开腹手术中低呼气末正压与高呼气末正压时的呼吸系统力学：PROVHILO随机对照试验的一项子研究
Respiratory System Mechanics During Low Versus High Positive End-Expiratory Pressure in Open Abdominal Surgery: A Substudy of PROVHILO Randomized Controlled Trial.
作者信息
D'Antini Davide, Huhle Robert, Herrmann Jacob, Sulemanji Demet S, Oto Jun, Raimondo Pasquale, Mirabella Lucia, Hemmes Sabrine N T, Schultz Marcus J, Pelosi Paolo, Kaczka David W, Vidal Melo Marcos Francisco, Gama de Abreu Marcelo, Cinnella Gilda
机构信息
From the Department of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy.
Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.
出版信息
Anesth Analg. 2018 Jan;126(1):143-149. doi: 10.1213/ANE.0000000000002192.
BACKGROUND
In the 2014 PROtective Ventilation using HIgh versus LOw positive end-expiratory pressure (PROVHILO) trial, intraoperative low tidal volume ventilation with high positive end-expiratory pressure (PEEP = 12 cm H2O) and lung recruitment maneuvers did not decrease postoperative pulmonary complications when compared to low PEEP (0-2 cm H2O) approach without recruitment breaths. However, effects of intraoperative PEEP on lung compliance remain poorly understood. We hypothesized that higher PEEP leads to a dominance of intratidal overdistension, whereas lower PEEP results in intratidal recruitment/derecruitment (R/D). To test our hypothesis, we used the volume-dependent elastance index %E2, a respiratory parameter that allows for noninvasive and radiation-free assessment of dominant overdistension and intratidal R/D. We compared the incidence of intratidal R/D, linear expansion, and overdistension by means of %E2 in a subset of the PROVHILO cohort.
METHODS
In 36 patients from 2 participating centers of the PROVHILO trial, we calculated respiratory system elastance (E), resistance (R), and %E2, a surrogate parameter for intratidal overdistension (%E2 > 30%) and R/D (%E2 < 0%). To test the main hypothesis, we compared the incidence of intratidal overdistension (primary end point) and R/D in higher and lower PEEP groups, as measured by %E2.
RESULTS
E was increased in the lower compared to higher PEEP group (18.6 [16…22] vs 13.4 [11.0…17.0] cm H2O·L; P < .01). %E2 was reduced in the lower PEEP group compared to higher PEEP (-15.4 [-28.0…6.5] vs 6.2 [-0.8…14.0] %; P < .05). Intratidal R/D was increased in the lower PEEP group (61% vs 22%; P = .037). The incidence of intratidal overdistension did not differ significantly between groups (6%).
CONCLUSIONS
During mechanical ventilation with protective tidal volumes in patients undergoing open abdominal surgery, lung recruitment followed by PEEP of 12 cm H2O decreased the incidence of intratidal R/D and did not worsen overdistension, when compared to PEEP ≤2 cm H2O.
背景
在2014年的高呼气末正压与低呼气末正压保护性通气（PROVHILO）试验中，与采用低呼气末正压（0 - 2 cmH₂O）且无肺复张通气策略的方法相比，术中采用低潮气量通气联合高呼气末正压（呼气末正压 = 12 cmH₂O）及肺复张策略并未降低术后肺部并发症的发生率。然而，术中呼气末正压对肺顺应性的影响仍知之甚少。我们推测，较高的呼气末正压会导致潮气量内过度扩张占主导，而较低的呼气末正压会导致潮气量内复张/萎陷（R/D）。为验证我们的假设，我们使用了容量依赖性弹性指数%E2，这是一种呼吸参数，可用于无创且无辐射地评估主导性过度扩张和潮气量内R/D。我们在PROVHILO队列的一个亚组中，通过%E2比较了潮气量内R/D、线性扩张和过度扩张的发生率。
方法
在来自PROVHILO试验2个参与中心的36例患者中，我们计算了呼吸系统弹性（E）、阻力（R）和%E2，%E2是潮气量内过度扩张（%E2 > 30%）和R/D（%E2 < 0%）的替代参数。为验证主要假设，我们比较了通过%E2测量的高呼气末正压组和低呼气末正压组中潮气量内过度扩张（主要终点）和R/D的发生率。
结果
与高呼气末正压组相比，低呼气末正压组的E升高（18.6 [16…22] vs 13.4 [11.0…17.0] cmH₂O·L；P <.01）。与高呼气末正压组相比，低呼气末正压组的%E2降低（-15.4 [-28.0…6.5] vs 6.2 [-0.8…14.0] %；P <.05）。低呼气末正压组的潮气量内R/D增加（61% vs 22%；P =.037）。两组间潮气量内过度扩张的发生率无显著差异（6%）。
结论
在接受开腹手术患者进行保护性潮气量机械通气期间，与呼气末正压≤2 cmH₂O相比，先进行肺复张然后采用12 cmH₂O呼气末正压可降低潮气量内R/D的发生率，且不会加重过度扩张。
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