Departement d'Anesthesie Reanimation Chirurgicale, Centre Hospitalo-Universitaire de Caen Normandie, Caen, France.
Unite de sante publique, Centre Hospitalo-Universitaire de Caen Normandie, Caen, France.
Respir Care. 2024 Nov 18;69(12):1499-1507. doi: 10.4187/respcare.11948.
Determining which patients with ARDS are most likely to benefit from lung recruitment maneuvers is challenging for physicians. The aim of this study was to assess whether the single-breath simplified decremental PEEP maneuver, which evaluates potential lung recruitment, may predict a subject's response to lung recruitment maneuvers, followed by PEEP titration.
We conducted a pilot prospective single-center cohort study with a 3-step protocol that defined sequential measurements. First, potential lung recruitment was assessed by the single-breath maneuver in the volume controlled mode. Second, the lung recruitment maneuver was performed in the pressure controlled mode, with a fixed driving pressure of 15 cm HO and a maximum PEEP of 30 cm HO. Third, the lung recruitment maneuver was followed by decremental PEEP titration to determine the optimal PEEP, defined as the lowest driving pressure. Responders to the lung recruitment maneuver were defined by an improvement in [Formula: see text]/[Formula: see text] > 20% between the baseline state and the end of the PEEP titration phase.
Forty-two subjects with moderate-to-severe ARDS were included. The mean ± SD lung recruitment was 149 ± 104 mL. A threshold lung recruitment of 195 mL (area under the receiver operator characteristic curve 0.62, 95% CI 0.43-0.80) predicted a positive response to the maximal lung recruitment maneuver. The lung recruitment maneuver, followed by PEEP titration, resulted in a modification of PEEP in 74% of the subjects. PEEP was increased in more than two thirds of the responders and decreased in almost half of the non-responders to the lung recruitment maneuver. In addition, a decrease in driving pressure and an increase in respiratory system compliance were reported in 62% and 67% of the subjects, respectively.
The single-breath maneuver for evaluating lung recruitability predicted, with poor accuracy, the subjects who responded to the lung recruitment maneuver based on [Formula: see text]/[Formula: see text] improvement. Nevertheless, the lung recruitment maneuver, followed by PEEP titration, improved ventilator settings and respiratory mechanics in a majority of subjects.
对于医生来说，确定哪些 ARDS 患者最有可能从肺复张手法中获益是具有挑战性的。本研究的目的是评估单口气简化递减 PEEP 手法（评估潜在肺复张的手法）是否可以预测患者对肺复张手法的反应，随后进行 PEEP 滴定。
我们进行了一项具有 3 步方案的前瞻性单中心队列研究，该方案定义了顺序测量。首先，在容量控制模式下通过单口气手法评估潜在的肺复张。其次，在压力控制模式下进行肺复张手法，固定驱动压力为 15 cm H2O，最大 PEEP 为 30 cm H2O。第三，在递减 PEEP 滴定后进行肺复张手法，以确定最佳 PEEP，定义为最低驱动压力。肺复张手法的反应者定义为[Formula: see text]/[Formula: see text]改善>基线状态和 PEEP 滴定阶段结束时的 20%。
共纳入 42 例中重度 ARDS 患者。平均 ± 标准差肺复张为 149 ± 104 mL。阈值肺复张 195 mL（受试者工作特征曲线下面积 0.62，95%置信区间 0.43-0.80）预测对最大肺复张手法的阳性反应。肺复张手法，随后进行 PEEP 滴定，导致 74%的患者修改 PEEP。肺复张手法的反应者中超过三分之二的患者 PEEP 增加，近一半的非反应者 PEEP 减少。此外，报告了 62%和 67%的患者的驱动压力降低和呼吸系统顺应性增加。
用于评估肺可复张性的单口气手法预测，准确性较差，根据[Formula: see text]/[Formula: see text]改善对肺复张手法有反应的患者。尽管如此，大多数患者通过肺复张手法和 PEEP 滴定，改善了呼吸机设置和呼吸力学。
