Yang Yingying, Li Hantian, Chi Yi, Frerichs Inéz, Zhao Zhanqi, Li Yuan, Zhang Chunyang, Chu Huiwen, He Huaiwu, Long Yun
State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
4+4 Medical Doctor Program, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China.
Physiol Meas. 2025 Jan 29;13(1). doi: 10.1088/1361-6579/ada8f1.
Prone positioning has been established as a therapeutic strategy for severe acute respiratory distress syndrome (ARDS). In COVID-19-associated ARDS (CARDS), the application of prone position has shown varying responses, influenced by factors such as lung recruitability and SARS-CoV-2-induced pulmonary endothelial dysfunction. This study aimed to compare the early impact of pronation on lung ventilation-perfusion matching (VQmatch) in CARDS and non-COVID-19 ARDS patients (non-CARDS).This was a two-center, prospective study comparing between CARDS and non-CARDS. Electrical impedance tomography (EIT) was used to compare the VQmatch between supine and early-stage prone positions (∼2 h). The study identified the areas of Deadspace, shunt, and VQmatch. Within the defined VQmatch region, the global inhomogeneity index (VQmatch-GI) was computed to evaluate the degree of heterogeneity. Paired Wilcoxon signed-rank test and Chi-square test were used in statistical analysis.15 CARDS patients and 14 non-CARDS patients undergoing mechanical ventilation were included. In comparison to the non-CARDS group, the CARDS group exhibited a higher prevalence of diffuse lung disease (15 [100%] vs. 4 [28.6%], CARDS vs. Non-CARDS,< 0.001), along with elevated SOFA score, PCO, PEEP, and Ppeak. Among non-CARDS patients, 11/14 demonstrated improved oxygenation, whereas only 5/15 CARDS patients exhibited oxygenation improvement in prone ventilation. In 13/29 patients with oxygenation improvement (defined as above 20% increase in SpO/FiO), there was a significant decreased deadspace (21.3 [11.5, 33.1] vs. 9.7 [7.3, 16.9],= 0.039), and VQmatch showed an upward trend. When comparing prone ventilation to supine ventilation, non-CARDS patients showed a significant improvement in overall VQmatch (Supine 65.7 [49.7, 68.5] vs. Prone 67.4 [60.8, 72.6],= 0.019). CARDS patients had a notable decrease in ventral VQmatch (VQmatch_Ventral: Supine 35.0 [26.9, 42.0] vs. Prone 22.7 [12.4, 32.9],= 0.003), and an improvement in dorsal VQmatch (VQmatch_Dorsal: Supine 33.4 [20.4, 39.4] vs. Prone 46.4 [37.4, 48.4],= 0.031), leading to no significant improvement in overall VQmatch. Ten CARDS patients with no improvement in VQmatch had increased shunting and VQmatch-GI.In non-CARDS patients, the improvement in oxygenation and VQmatch following prone positioning exhibits a consistent pattern. Conversely, in CARDS patients, the impact of prone positioning reveals considerable individual variability. This study indicates that the response to short-time prone ventilation can vary in ARDS patients with different etiologies.NCT05816928, 04/17/2023, retrospectively registered. Ventilation-Perfusion Matching in Early-stage Prone Position Ventilation, NCT05816928. Registered 17 April 2023 - Retrospectively registered,https://clinicaltrials.gov/study/NCT05816928.
俯卧位通气已被确立为治疗重症急性呼吸窘迫综合征（ARDS）的一种策略。在新型冠状病毒肺炎相关ARDS（CARDS）中，俯卧位通气的应用显示出不同的反应，这受到肺可复张性和严重急性呼吸综合征冠状病毒2（SARS-CoV-2）诱导的肺内皮功能障碍等因素的影响。本研究旨在比较俯卧位通气对CARDS患者和非新型冠状病毒肺炎ARDS患者（非CARDS）肺通气-灌注匹配（VQmatch）的早期影响。
这是一项在两个中心开展的前瞻性研究，对CARDS组和非CARDS组进行比较。采用电阻抗断层成像（EIT）比较仰卧位和早期俯卧位（约2小时）之间的VQmatch。该研究确定了无效腔、分流和VQmatch区域。在定义的VQmatch区域内，计算总体不均匀性指数（VQmatch-GI）以评估异质性程度。统计分析采用配对Wilcoxon符号秩检验和卡方检验。
纳入了15例接受机械通气的CARDS患者和14例非CARDS患者。与非CARDS组相比，CARDS组弥漫性肺疾病的患病率更高（15例[100%] vs. 4例[28.6%]，CARDS组 vs. 非CARDS组，P<0.001），同时序贯器官衰竭评估（SOFA）评分、二氧化碳分压（PCO）、呼气末正压（PEEP）和气道峰压（Ppeak）升高。在非CARDS患者中，11/14例患者氧合改善，而在俯卧位通气时，CARDS患者中只有5/15例患者氧合改善。在13/29例氧合改善的患者（定义为动脉血氧饱和度/吸入氧浓度[SpO/FiO]增加20%以上）中，无效腔显著减少（21.3[11.5, 33.1] vs. 9.7[7.3, 16.9]，P=0.039），VQmatch呈上升趋势。与仰卧位通气相比，非CARDS患者总体VQmatch有显著改善（仰卧位65.7[49.7, 68.5] vs. 俯卧位67.4[60.8, 72.6]，P=0.019）。CARDS患者腹侧VQmatch显著降低（腹侧VQmatch：仰卧位35.0[26.9, 42.0] vs. 俯卧位22.7[12.4, 32.9]，P=0.003），背侧VQmatch改善（背侧VQmatch：仰卧位33.4[20.4, 39.4] vs. 俯卧位46.4[37.4, 48.4]，P=0.031），总体VQmatch无显著改善。10例VQmatch无改善的CARDS患者分流增加，VQmatch-GI升高。
在非CARDS患者中，俯卧位通气后氧合和VQmatch的改善呈现出一致的模式。相反，在CARDS患者中，俯卧位通气的影响显示出相当大的个体差异。本研究表明，不同病因的ARDS患者对短时间俯卧位通气的反应可能不同。
NCT05816928，2023年4月17日，回顾性注册。早期俯卧位通气时的通气-灌注匹配，NCT05816928。于2023年4月17日注册——回顾性注册，https://clinicaltrials.gov/study/NCT05816928 。
