Zhao Yang, Zhang Shengxuan, Liu Chengjiang, Wang Xiaoxia
Shandong University of Traditional Chinese Medicine, Jinan, China.
Zhejiang Chinese Medical University, Hangzhou, China.
World J Surg. 2025 Sep;49(9):2361-2373. doi: 10.1002/wjs.12676. Epub 2025 Jul 25.
Acute respiratory distress syndrome (ARDS) secondary to severe acute pancreatitis (SAP) presents significant management challenges with high mortality rates. This study aimed to investigate the application value of an individualized lung-protective ventilation strategy guided by esophageal pressure (Pes) monitoring in patients with ARDS associated with SAP.
This randomized controlled trial included 124 patients with SAP-related ARDS admitted to our hospital from January 2023 to December 2023, and they were randomized to a conventional lung protective ventilation group (conventional group, n = 62) and an esophageal pressure monitoring-guided group (EPM-guided group, n = 62). The conventional group adopted a conventional lung protective ventilation strategy; whereas, the EPM-guided group received the individualized ventilation strategy based on EPM. The EPM indicators, respiratory mechanics parameters, oxygenation indicators, and clinical outcomes were compared between the two groups.
After treatment, the EPM-guided group showed significantly lower transpulmonary pressure (PL) [(16.82 ± 2.46) versus. (22.41 ± 3.23) cmH2O, p = 0.006], transpulmonary driving pressure (ΔPL) [(12.36 ± 1.83) versus. (16.52 ± 2.37) cmH2O, p = 0.007], and driving pressure (ΔP) [(11.43 ± 1.83) versus. (14.52 ± 2.24) cmH2O, p = 0.008] than the conventional group, whereas static compliance (Cst) [(37.82 ± 4.46) versus. (29.41 ± 5.23) mL/cmH2O, p = 0.009] and the PaO2/FiO2 ratio [(268.82 ± 32.46) versus. (195.41 ± 28.23) mmHg, p = 0.008] were significantly higher. The EPM-guided group had shorter mechanical ventilation duration [(12.32 ± 3.24) versus. (16.83 ± 4.52) d, p = 0.013] and intensive care nit (ICU) length of stay [(18.53 ± 4.62) versus. (23.72 ± 5.83) d, p = 0.018] compared to the conventional group, along with a lower VAP incidence (14.52% vs. 25.81% and p = 0.038) and a 28-day mortality rate (19.35% vs. 32.26% and p = 0.042). Multivariate logistic regression analysis showed that ΔPL at 72 h (OR 1.56, 95% CI 1.25-2.01, p < 0.001) was an independent predictor of a 28-day mortality rate. ROC curve analysis showed that ΔPL had a good diagnostic value for predicting a 28-day mortality rate (AUC = 0.832 and 95% CI 0.760-0.904). Correlation analysis showed that ΔPL at 72 h was significantly negatively correlated with the PaO2/FiO2 ratio (r = -0.71 and p < 0.001) and static compliance (r = -0.69 and p < 0.001).
Individualized lung protective ventilation strategy guided by EPM can more accurately assess the actual lung inflation pressure, optimize the setting of ventilation parameters, and improve clinical outcomes of patients with SAP-related ARDS.
重症急性胰腺炎（SAP）继发的急性呼吸窘迫综合征（ARDS）给治疗带来了重大挑战，死亡率很高。本研究旨在探讨食管压力（Pes）监测指导下的个体化肺保护通气策略在与SAP相关的ARDS患者中的应用价值。
本随机对照试验纳入了2023年1月至2023年12月我院收治的124例与SAP相关的ARDS患者，将他们随机分为传统肺保护通气组（传统组，n = 62）和食管压力监测指导组（EPM指导组，n = 62）。传统组采用传统肺保护通气策略；而EPM指导组则根据EPM接受个体化通气策略。比较两组的EPM指标、呼吸力学参数、氧合指标和临床结局。
治疗后，EPM指导组的跨肺压（PL）显著低于传统组[（16.82±2.46）对（22.41±3.23）cmH₂O，p = 0.006]、跨肺驱动压（ΔPL）[（12.36±1.83）对（16.52±2.37）cmH₂O，p = 0.007]和驱动压（ΔP）[（11.43±1.83）对（14.52±2.24）cmH₂O，p = 0.008]，而静态顺应性（Cst）[（37.82±4.46）对（29.41±5.23）mL/cmH₂O，p = 0.009]和PaO₂/FiO₂比值[（268.82±32.46）对（195.41±28.23）mmHg，p = 0.008]显著更高。与传统组相比，EPM指导组的机械通气时间更短[（12.32±3.24）对（16.83±4.52）天，p = 0.013]，重症监护病房（ICU）住院时间更短[（18.53±4.62）对（23.72±5.83）天，p = 0.018]，呼吸机相关性肺炎（VAP）发生率更低（14.52%对25.81%，p = 0.038），28天死亡率更低（19.35%对32.26%，p = 0.042）。多因素logistic回归分析显示，72小时时的ΔPL（OR 1.56，95%CI 1.25 - 2.01，p < 0.001）是28天死亡率的独立预测因素。ROC曲线分析显示，ΔPL对预测28天死亡率具有良好的诊断价值（AUC = 0.832，95%CI 0.760 - 0.904）。相关性分析显示，72小时时的ΔPL与PaO₂/FiO₂比值（r = -0.71，p < 0.001）和静态顺应性（r = -0.69，p < 0.001）显著负相关。
EPM指导下的个体化肺保护通气策略能够更准确地评估实际肺膨胀压力，优化通气参数设置，改善与SAP相关的ARDS患者的临床结局。
