Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, München, Germany.
PLoS One. 2018 Mar 14;13(3):e0193654. doi: 10.1371/journal.pone.0193654. eCollection 2018.
Appropriate mechanical ventilation and prevention of alveolar collaps is mainly dependent on transpulmonary pressure TPP. TPP is assessed by measurement of esophageal pressure EP, largely influenced by pleural and intraabdominal pressure IAP. Consecutively, TPP-guided ventilation might be particularly useful in patients with high IAP. This study investigates the impact of large volume paracentesis LVP on TPP, EP, IAP as well as on hemodynamic and respiratory function in patients with liver cirrhosis and tense ascites.
We analysed 23 LVP-procedures in 11 cirrhotic patients ventilated with the AVEA Viasys respirator (CareFusion, USA) which is capable to measure EP via an esophageal tube.
LVP of a mean volume of 4826±1276 mL of ascites resulted in marked increases in inspiratory (17.9±8.9 vs. 5.4±13.3 cmH2O; p<0.001) as well as expiratory TPP (-3.0±4.7 vs. -15.9±10.9 cmH2O; p<0.001; primary endpoint). In parallel, the inspiratory (2.4±8.7 vs. 14.1±14.5 cmH2O; p<0.001) and expiratory EP (12.4±6.0 vs. 24.9±11.3 cmH2O; p<0.001) significantly decreased. The effects were most pronounced for the release of the first 500 mL of ascites. LVP evoked substantial decreases in IAP and central venous pressure CVP. By contrast, mean arterial pressure, cardiac index, global end-diastolic volume index, extravascular lung water index and systemic vascular resistance index did not change. Among the respiratory parameters we observed an increase in paO2/FiO2 (247.7±60.9 vs. 208.3±46.8 mmHg; p<0.001) and a decrease in Oxygenation Index OI (4.8±2.0 vs. 5.8±3.1 cmH2O/mmHg; p = 0.002). Tidal volume (510±100 vs. 452±113 mL; p = 0.008) and dynamic respiratory system compliance Cdyn (46.8±15.9 vs. 35.1±14.6 mL/cmH20; p<0.001) increased, whereas paCO2 (47.3±10.7 vs. 51.2±12.3mmHg; p = 0.046) and the respiratory rate decreased (17.1±7.3 vs. 19.6±7.8 min-1; p = 0.010).
In mechanically ventilated patients with decompensated cirrhosis, intraabdominal hypertension resulted in a substantially decreased TPP despite PEEP-setting according to the ARDSNet. In these patients LVP markedly increased TPP and improved respiratory function in parallel with a decline of EP. Furthermore, LVP induced a decrease in IAP and CVP, while other hemodynamic parameters did not change.
适当的机械通气和肺泡塌陷的预防主要依赖于跨肺压（TPP）。通过测量食管压力（EP）来评估 TPP，而 EP 很大程度上受到胸内压和腹腔内压（IAP）的影响。因此，在 IAP 较高的患者中，TPP 指导通气可能特别有用。本研究旨在探讨大量腹腔穿刺（LVP）对 TPP、EP、IAP 以及肝硬化伴张力性腹水患者血流动力学和呼吸功能的影响。
我们分析了 11 例肝硬化患者在 AVEA Viasys 呼吸机（CareFusion，美国）下进行的 23 次 LVP 操作，该呼吸机能够通过食管管测量 EP。
LVP 排出腹水的平均体积为 4826±1276mL，导致吸气（17.9±8.9 比 5.4±13.3cmH2O；p<0.001）和呼气 TPP（-3.0±4.7 比-15.9±10.9cmH2O；p<0.001；主要终点）明显增加。同时，吸气（2.4±8.7 比 14.1±14.5cmH2O；p<0.001）和呼气 EP（12.4±6.0 比 24.9±11.3cmH2O；p<0.001）显著降低。前 500mL 腹水释放时效果最为明显。LVP 引起 IAP 和中心静脉压（CVP）的显著下降。相比之下，平均动脉压、心指数、全心舒张末期容积指数、血管外肺水指数和全身血管阻力指数没有变化。在呼吸参数方面，我们观察到 paO2/FiO2（247.7±60.9 比 208.3±46.8mmHg；p<0.001）增加和氧合指数（OI）（4.8±2.0 比 5.8±3.1cmH2O/mmHg；p = 0.002）降低。潮气量（510±100 比 452±113mL；p = 0.008）和动态呼吸系统顺应性（Cdyn）（46.8±15.9 比 35.1±14.6mL/cmH20；p<0.001）增加，而 paCO2（47.3±10.7 比 51.2±12.3mmHg；p = 0.046）和呼吸频率降低（17.1±7.3 比 19.6±7.8min-1；p = 0.010）。
在失代偿性肝硬化机械通气患者中，尽管根据 ARDSNet 设置了 PEEP，但腹腔内高压导致 TPP 明显降低。在这些患者中，LVP 显著增加了 TPP，并改善了呼吸功能，同时 EP 下降。此外，LVP 引起 IAP 和 CVP 下降，而其他血流动力学参数没有变化。
