Department of ICU, Shaanxi Provincial People's Hospital, Xi'an, China.
Department of ICU, Shaanxi Provincial People's Hospital, Xi'an, China.
Heart Lung. 2023 Sep-Oct;61:127-135. doi: 10.1016/j.hrtlng.2023.05.009. Epub 2023 May 29.
Acute respiratory distress syndrome (ARDS) is a common disease in intensive critical care(ICU), and the use of positive end-expiratory pressure(PEEP) during mechanical ventilation can increase the right heart afterload and eventually cause right heart dysfunction. For these factors causing acute cor pulmonale(ACP), especially inappropriate mechanical ventilation settings, it is important to explore the effect of PEEP on right heart function.
To investigate the effects of three titration methods on right heart function and prognosis in patients with ARDS.
Observational, prospective study in which ARDS patients were enrolled into three distinct PEEP-titration strategies groups: guide, transpulmonary pressure-oriented and driving pressure-oriented. Prognostic indicators, right heart systolic and diastolic echocardiographic function indices, ventilatory parameters, blood gas analysis results, and respiratory mechanics Monitoring indices were collated and analyzed statistically by STATA 15 software.
A total of 62 ARDS patients were enrolled into guide (G) group (n=40) for whom titrated PEEP values were 9±2cm HO, driving pressure-oriented (DPO) group (n=12) with titrated PEEP values of 10±2cm HO and transpulmonary pressure-oriented (TPO) group (n=10) with titrated PEEP values of 12±3cm HO. Values were significantly higher for TPO than for G (p=0.616) or DPO (p=0.011). Compliance was significantly increased after 72 h in the TPO and DPO groups compared with the G group (p<0.001). Mean airway pressure at end-inspiratory obstruction (p=0.047), tricuspid annular plane systolic excursion (TAPSE, p<0.001) and right ventricular area change fraction (RVFAC, p=0.049) were all higher in the TPO and DPO groups than in the G group. E/A indices were significantly better in the TPO group than in the G or DPO groups (p=0.046). No significant differences in 28 day mortality were found among the three groups. Multivariate logistic regression analysis revealed that lung compliance and transpulmonary pressure-oriented PEEP titration method was negatively correlated to the increase in right ventricular systolic dysfunction.
Transpulmonary pressure-oriented PEEP titration improves oxygenation and pulmonary function and causes less right heart strain when compared to other PEEP-titration methods during mechanical ventilation of ARDS patients.
急性呼吸窘迫综合征（ARDS）是重症监护病房（ICU）中常见的疾病，机械通气时使用呼气末正压（PEEP）会增加右心后负荷，最终导致右心功能障碍。对于这些导致急性肺心病（ACP）的因素，尤其是不当的机械通气设置，重要的是要探讨 PEEP 对右心功能的影响。
探讨三种滴定方法对 ARDS 患者右心功能和预后的影响。
观察性、前瞻性研究，ARDS 患者被纳入三种不同的 PEEP 滴定策略组：指南、跨肺压导向和驱动压导向。通过 STATA 15 软件收集和分析预后指标、右心收缩和舒张超声心动图功能指标、通气参数、血气分析结果和呼吸力学监测指标。
共纳入 62 例 ARDS 患者，其中指南（G）组（n=40）的 PEEP 值为 9±2cm HO，驱动压导向（DPO）组（n=12）的 PEEP 值为 10±2cm HO，跨肺压导向（TPO）组（n=10）的 PEEP 值为 12±3cm HO。TPO 组的值明显高于 G 组（p=0.616）或 DPO 组（p=0.011）。与 G 组相比，TPO 和 DPO 组在 72 小时后顺应性显著增加（p<0.001）。吸气末气道阻塞时平均气道压（p=0.047）、三尖瓣环平面收缩期位移（TAPSE，p<0.001）和右心室面积变化分数（RVFAC，p=0.049）在 TPO 和 DPO 组均高于 G 组。TPO 组的 E/A 指数明显优于 G 组或 DPO 组（p=0.046）。三组 28 天死亡率无显著性差异。多变量逻辑回归分析显示，肺顺应性和跨肺压导向 PEEP 滴定法与右心室收缩功能障碍的增加呈负相关。
与其他 PEEP 滴定方法相比，跨肺压导向 PEEP 滴定可改善氧合和肺功能，减少机械通气时右心的压力。
