急性呼吸窘迫综合征患者的辅助通气：肺扩张压力与患者-呼吸机相互作用

Assisted Ventilation in Patients with Acute Respiratory Distress Syndrome: Lung-distending Pressure and Patient-Ventilator Interaction.

作者信息

Doorduin Jonne, Sinderby Christer A, Beck Jennifer, van der Hoeven Johannes G, Heunks Leo M A

机构信息

From the Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands (J.D., J.G.v.d.H., L.M.A.H.); Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada (C.A.S.); Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada (J.B.); and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada (C.A.S., J.B.).

出版信息

Anesthesiology. 2015 Jul;123(1):181-90. doi: 10.1097/ALN.0000000000000694.

DOI:10.1097/ALN.0000000000000694

PMID:25955983

Abstract

BACKGROUND

In patients with acute respiratory distress syndrome (ARDS), the use of assisted mechanical ventilation is a subject of debate. Assisted ventilation has benefits over controlled ventilation, such as preserved diaphragm function and improved oxygenation. Therefore, higher level of "patient control" of ventilator assist may be preferable in ARDS. However, assisted modes may also increase the risk of high tidal volumes and lung-distending pressures. The current study aims to quantify how differences in freedom to control the ventilator affect lung-protective ventilation, breathing pattern variability, and patient-ventilator interaction.

METHODS

Twelve patients with ARDS were ventilated in a randomized order with assist pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA). Transpulmonary pressure, tidal volume, diaphragm electrical activity, and patient-ventilator interaction were measured. Respiratory variability was assessed using the coefficient of variation of tidal volume.

RESULTS

During inspiration, transpulmonary pressure was slightly lower with NAVA (10.3 ± 0.7, 11.2 ± 0.7, and 9.4 ± 0.7 cm H2O for PCV, PSV, and NAVA, respectively; P < 0.01). Tidal volume was similar between modes (6.6 [5.7 to 7.0], 6.4 [5.8 to 7.0], and 6.0 [5.6 to 7.3] ml/kg for PCV, PSV, and NAVA, respectively), but respiratory variability was higher with NAVA (8.0 [6.4 to 10.0], 7.1 [5.9 to 9.0], and 17.0 [12.0 to 36.1] % for PCV, PSV, and NAVA, respectively; P < 0.001). Patient-ventilator interaction improved with NAVA (6 [5 to 8] % error) compared with PCV (29 [14 to 52] % error) and PSV (12 [9 to 27] % error); P < 0.0001.

CONCLUSION

In patients with mild-to-moderate ARDS, increasing freedom to control the ventilator maintains lung-protective ventilation in terms of tidal volume and lung-distending pressure, but it improves patient-ventilator interaction and preserves respiratory variability.

摘要

背景

在急性呼吸窘迫综合征（ARDS）患者中，辅助机械通气的使用存在争议。辅助通气相较于控制通气具有优势，如保留膈肌功能和改善氧合。因此，在ARDS中，更高水平的呼吸机辅助“患者控制”可能更可取。然而，辅助模式也可能增加高潮气量和肺扩张压力的风险。本研究旨在量化呼吸机控制自由度的差异如何影响肺保护性通气、呼吸模式变异性以及患者-呼吸机相互作用。

方法

12例ARDS患者按随机顺序接受辅助压力控制通气（PCV）、压力支持通气（PSV）和神经调节通气辅助（NAVA）通气。测量跨肺压、潮气量、膈肌电活动和患者-呼吸机相互作用。使用潮气量变异系数评估呼吸变异性。

结果

吸气期间，NAVA时跨肺压略低（PCV、PSV和NAVA分别为10.3±0.7、11.2±0.7和9.4±0.7 cmH₂O；P<0.01）。各模式间潮气量相似（PCV、PSV和NAVA分别为6.6[5.7至7.0]、6.4[5.8至7.0]和6.0[5.6至7.3]ml/kg），但NAVA时呼吸变异性更高（PCV、PSV和NAVA分别为8.0[6.4至10.0]、7.1[5.9至9.0]和17.0[12.0至36.1]%；P<0.001）。与PCV（误差29[14至52]%）和PSV（误差12[9至27]%）相比，NAVA改善了患者-呼吸机相互作用（误差6[5至8]%）；P<0.0001。