通过潮气量顺应性确定儿童最佳呼气末正压和潮气量：一项前瞻性观察研究。
Determining optimal positive end-expiratory pressure and tidal volume in children by intratidal compliance: a prospective observational study.
机构信息
Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
出版信息
Br J Anaesth. 2022 Jan;128(1):214-221. doi: 10.1016/j.bja.2021.09.024. Epub 2021 Oct 20.
BACKGROUND
Limited data exist regarding optimal intraoperative ventilation strategies for the paediatric population. This study aimed to determine the optimal combination of PEEP and tidal volume (V) based on intratidal compliance profiles in healthy young children undergoing general anaesthesia.
METHODS
During anaesthesia, infants (1 month-1 yr), toddlers (1-3 yr), and children (3-6 yr) were assigned serially to four ventilator settings: PEEP 8 cm HO/V 8 ml kg (PEEP8/V8), PEEP 10 cm HO/V 5 ml kg (PEEP10/V5), PEEP 10 cm HO/V 8 ml kg (PEEP10/V8), and PEEP 12 cm HO/V 5 ml kg (PEEP12/V5). The primary outcome was intratidal compliance profile, classified at each ventilator setting as horizontal (indicative of optimal alveolar ventilatory conditions), increasing, decreasing, or combinations of increasing/decreasing/horizontal compliance. Secondary outcomes were peak inspiratory, plateau, and driving pressures.
RESULTS
Intratidal compliance was measured in 15 infants, 13 toddlers, and 15 children (15/43 [35%] females). A horizontal compliance profile was most frequently observed with PEEP10/V5 (60.5%), compared with PEEP10/V8, PEEP8/V8, and PEEP12/V5 (23.3-34.9%; P<0.001). Decreasing compliance profiles were most frequent when V increased to 8 ml kg, PEEP increased to 12 cm HO, or both. Plateau airway pressures were lower at PEEP8/V8 (16.9 cm HO [2.2]) and PEEP10/V5 (16.7 cm HO [1.7]), compared with PEEP10/V8 (19.5 cm HO [2.1]) and PEEP12/V5 (19.0 cm HO [2.0]; P<0.001). Driving pressure was lowest with PEEP10/V5 (4.6 cm HO), compared with other combinations (7.0 cm HO [2.0]-9.5 cm HO [2.1]; P<0.001).
CONCLUSIONS
V 5 ml kg combined with 10 cm HO PEEP may reduce atelectasis and overdistension, and minimise driving pressure in the majority of mechanically ventilated children <6 yr. The effect of these PEEP and V settings on postoperative pulmonary complications in children undergoing surgery requires further study.
CLINICAL TRIAL REGISTRATION
NCT04633720.
背景
关于小儿患者术中通气策略的最佳选择，相关数据有限。本研究旨在确定在接受全身麻醉的健康幼儿中，根据潮气内顺应性曲线来确定最佳的 PEEP 和潮气量（V）组合。
方法
在麻醉期间，婴儿（1 个月至 1 岁）、幼儿（1-3 岁）和儿童（3-6 岁）被依次分配到四种呼吸机设置：PEEP8cmH2O/V8mlkg（PEEP8/V8）、PEEP10cmH2O/V5mlkg（PEEP10/V5）、PEEP10cmH2O/V8mlkg（PEEP10/V8）和 PEEP12cmH2O/V5mlkg（PEEP12/V5）。主要结局指标是潮气内顺应性曲线，在每个呼吸机设置下分类为水平（提示最佳肺泡通气条件）、增加、减少或增加/减少/水平顺应性的组合。次要结局指标是吸气峰压、平台压和驱动压。
结果
在 15 名婴儿、13 名幼儿和 15 名儿童（15/43[35%]女性）中测量了潮气内顺应性。与 PEEP10/V8、PEEP8/V8 和 PEEP12/V5（23.3%-34.9%；P<0.001）相比，PEEP10/V5 时最常观察到水平顺应性曲线（60.5%）。当 V 增加到 8mlkg、PEEP 增加到 12cmHO 或两者都增加时，顺应性曲线最常出现减少。与 PEEP10/V8（16.7cmHO[1.7]）和 PEEP12/V5（16.0cmHO[1.9]）相比，PEEP8/V8（16.9cmHO[2.2]）和 PEEP10/V5（16.7cmHO[1.7]）的平台气道压较低（P<0.001）。与其他组合（7.0cmHO[2.0]-9.5cmHO[2.1]；P<0.001）相比，PEEP10/V5 时驱动压最低（4.6cmHO）。
结论
在大多数接受机械通气的<6 岁儿童中，V 为 5mlkg 联合 10cmHO PEEP 可能减少肺不张和过度充气，并使驱动压最小化。这些 PEEP 和 V 设置对接受手术的儿童术后肺部并发症的影响还需要进一步研究。
临床试验注册号
NCT04633720。
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