烟雾吸入性损伤致急性呼吸窘迫综合征发展的动力学变化：对长时间现场救治的影响。

Dynamics of acute respiratory distress syndrome development due to smoke inhalation injury: Implications for prolonged field care.

机构信息

From the The Geneva Foundation (A.I.B., J.H.C.), Tacoma, Washington; Unites States Army Institute of Surgical Research (A.I.B., J.H.C., D.B., B.S.J., C.N., L.C.C.), JBSA Ft. Sam Houston, Texas, West Florida Hospital, Department of Internal Medicine (R.W.), Pensacola, Florida; Pulmonary/Critical Care Service, Department of Medicine (S.E.B.), Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia; Department of Medicine (M.J.M., K.K.C.), Brooke Army Medical Center, JBSA Ft. Sam Houston, Texas.

出版信息

J Trauma Acute Care Surg. 2019 Jul;87(1S Suppl 1):S91-S100. doi: 10.1097/TA.0000000000002227.

DOI:10.1097/TA.0000000000002227

PMID:31246912

Abstract

BACKGROUND

Smoke inhalation injury (SII) causes 30% to 40% mortality and will increase as a cause of death during prolonged field care. We used a combat relevant model of acute respiratory distress syndrome due to SII to study temporal changes in ventilation-perfusion (V/Q) matching, computed tomography (CT) scan data, and histopathology and hypothesized that SII leads to increase in shunt (Qshunt), V/Q mismatch, lung consolidation, and diffuse alveolar damage.

METHODS

Swine received severe SII and airway pressure release ventilation (APRV, n = 6), or conventional ARDSNet mechanical ventilation (MV) (CMV, n = 8). A control group without injury received volume controlled MV (CTRL, n = 6), The multiple inert gas elimination technique and CT were performed at baseline (BL), 0.5 hours, 1 hours, 2 hours, 24 hours, and 48 hours after injury. Diffuse alveolar damage scoring was performed post mortem. Significance at p less than 0.05: APRV versus CTRL; CMV versus CTRL; APRV versus CMV*; denotes changes versus BL.

RESULTS

(1) SII caused increases in Qshunt more so in APRV than CMV group. Qshunt did not change in CTRL. (2) PaO2-to-FIO2 ratio (PFR) was lower in APRV versus CTRL at 2 hours (375 ± 62‡ vs. 549 ± 40) and 24 hours (126 ± 34‡* vs. 445 ± 5) and 48 hours (120 ± 41‡& vs. 430 ± 13). In CMV animals, PFR was lower versus CTRL and BL at 24 hours (238 ± 33) and 48 hours (98 ± 27). Qshunt correlated with PFR (r = 0.75, p < 0.0001, APRV and (r = 0.65, p < 0.0001, CMV). CT showed decrease in normally aerated lung, while poorly and nonaerated lung increased.

CONCLUSION

Smoke inhalation injury leads to early development of shunt, V/Q mismatch, lung consolidation, and diffuse alveolar damage. These data substantiate the need for new point of injury interventions in the prolonged field care setting.

LEVEL OF EVIDENCE

Animal research.

摘要

背景

烟雾吸入性损伤（SII）导致 30%-40%的死亡率，并将随着延长野外护理时间而增加死亡原因。我们使用与战场相关的 SII 引起的急性呼吸窘迫综合征模型来研究通气-灌注（V/Q）匹配、计算机断层扫描（CT）扫描数据和组织病理学的时间变化，并假设 SII 导致分流（Qshunt）增加、V/Q 不匹配、肺实变和弥漫性肺泡损伤。

方法

猪遭受严重的 SII 和气道压力释放通气（APRV，n=6）或常规 ARDSNet 机械通气（MV）（CMV，n=8）。无损伤的对照组接受容量控制 MV（CTRL，n=6）。在损伤后 0.5 小时、1 小时、2 小时、24 小时和 48 小时进行多次惰性气体消除技术和 CT。死后进行弥漫性肺泡损伤评分。p<0.05 表示有统计学意义：APRV 与 CTRL；CMV 与 CTRL；APRV 与 CMV*；表示与 BL 相比的变化。

结果

（1）SII 导致分流增加，APRV 组比 CMV 组更明显。CTRL 组的 Qshunt 没有变化。（2）APRV 组的 PaO2 与 FIO2 比值（PFR）在 2 小时（375±62‡ 与 549±40）和 24 小时（126±34‡* 与 445±5）和 48 小时（120±41‡& 与 430±13）时均低于 CTRL。在 CMV 动物中，PFR 在 24 小时（238±33）和 48 小时（98±27）时低于 CTRL 和 BL。Qshunt 与 PFR 相关（r=0.75，p<0.0001，APRV 和（r=0.65，p<0.0001，CMV）。CT 显示正常充气肺减少，而充气不良和非充气肺增加。