摘要
目的探讨不同方式俯卧位通气(PPV)对高原重度急性呼吸窘迫综合征(ARDS)患者疗效的影响。方法回顾性选择高原地区青海省人民医院重症医学科2017年1月至2020年1月收治的符合柏林标准的重度ARDS患者。将实施经典PPV治疗(即俯卧-仰卧位交替、每日约16 h)的患者纳入间断PPV组;将实施改良PPV治疗(每4 h交替左、右侧俯卧位20°~30°、每日24 h持续治疗)的患者纳入持续PPV组。分析两组患者治疗前及治疗72 h时的氧合指数(PaO_(2)/FiO_(2))、呼吸力学、呼吸机参数以及机械通气时间、重症监护病房(ICU)住院时间和相关并发症等的差异。结果持续PPV治疗18例,间断PPV治疗20例。两组患者性别、年龄、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)以及治疗前PaO_(2)/FiO_(2)、肺顺应性、驱动压(ΔP)、呼气末正压(PEEP)等差异均无统计学意义。与治疗前相比,间断PPV组和持续PPV组治疗72 h PaO_(2)/FiO_(2)明显上升〔mmHg(1 mmHg=0.133 kPa):99.7±15.4比55.5±6.3,121.8±25.3比55.1±7.1,均P<0.05〕,肺顺应性明显改善(mL/cmH_(2)O:36.8±2.4比28.0±2.0,43.4±6.7比27.7±2.1,均P<0.05),ΔP明显下降〔cmH_(2)O(1 cmH_(2)O=0.098 kPa):10.5(10.0,12.0)比13.0(12.3,14.0),10.0(8.0,12.0)比13.0(12.0,14.0),均P<0.05〕,PEEP也随之下降〔cmH_(2)O:12(12,14)比14(13,14),10(8,10)比14(12,15),均P<0.05〕;并且持续PPV组各指标较间断PPV组改善更为显著〔PaO_(2)/FiO_(2)(mmHg):121.8±25.3比99.7±15.4,肺顺应性(mL/cmH_(2)O):43.4±6.7比36.8±2.4,ΔP(cmH_(2)O):10.0(8.0,12.0)比10.5(10.0,12.0),PEEP(cmH_(2)O):10(8,10)比12(12,14),均P<0.05〕。持续PPV组患者机械通气时间、ICU住院时间均较间断PPV组明显缩短〔d:6.0(5.0,7.3)比8.0(7.0,9.0),9.7±1.5比12.1±2.2,均P<0.01〕。在PPV治疗过程中,持续PPV组患者出现面颊部皮肤破损3例、耳部皮肤破损2例,间断PPV组出现面部皮肤破损3例,两组并发症发生率比较差异无统计学意义(χ^(2)=0.321,P=0.571);所有患者均于PPV结束后修复正常,未造成不良后果。结论持续PPV比间断PPV在治疗高原重度ARDS患者中疗效更显著,且未增加延长PPV时间带来的相关并发症。
Objective To investigate the therapeutic effect of different prone position ventilation(PPV)on patients with severe acute respiratory distress syndrome(ARDS)at high altitude.Methods The severe ARDS patients who met the Berlin standard admitted to the department of intensive care unit(ICU)of Qinghai Provincial People's Hospital from January 2017 to January 2020 were enrolled.The patients with classic PPV treatment(i.e.alternate prone supine position,about 16 hours per day)were included in the discontinuous PPV group;the patients with modified PPV treatment(i.e.alternate left and right prone positions 20°-30°,every 4 hours and continuous treatment for 24 hours per day)were included in the continuous PPV group.The oxygenation index(PaO_(2)/FiO_(2)),mechanics of breathing,ventilator parameters before treatment and 72 hours after treatment,and mechanical ventilation time,the length of ICU stay,and related complications between the two groups were analyzed.Results Eighteen cases were treated with continuous PPV and 20 cases were treated with discontinuous PPV.There were no significant differences in gender,age,acute physiology and chronic health evaluationⅡ(APACHEⅡ),PaO_(2)/FiO_(2),lung compliance,driving pressure(ΔP)and positive end expiratory pressure(PEEP)before treatment between the two groups.Compared with before treatment,PaO_(2)/FiO_(2) in discontinuous PPV group and continuous PPV group was increased significantly after 72-hour treatment[mmHg(1 mmHg=0.133 kPa):99.7±15.4 vs.55.5±6.3,121.8±25.3 vs.55.1±7.1,both P<0.05],lung compliance was improved significantly(mL/cmH_(2)O:36.8±2.4 vs.28.0±2.0,43.4±6.7 vs.27.7±2.1,both P<0.05),andΔP was decreased significantly[cmH_(2)O(1 cmH_(2)O=0.098 kPa):10.5(10.0,12.0)vs.13.0(12.3,14.0),10.0(8.0,12.0)vs.13.0(12.0,14.0),both P<0.05],PEEP was also decreased[cmH_(2)O:12(12,14)vs.14(13,14),10(8,10)vs.14(12,15),both P<0.05],and the indexes in continuous PPV group were improved more significantly than those in discontinuous PPV group[PaO_(2)/FiO_(2)(mmHg):121.8±25.3 vs.99.7±15.4,lung compliance(mL/cmH_(2)O):43.4±6.7 vs.36.8±2.4,ΔP(cmH_(2)O):10.0(8.0,12.0)vs.10.5(10.0,12.0),PEEP(cmH_(2)O):10(8,10)vs.12(12,14),all P<0.05].The duration of mechanical ventilation and the length of ICU stay in the continuous PPV group were significantly shorter than those in the intermittent PPV group[days:6.0(5.0,7.3)vs.8.0(7.0,9.0),9.7±1.5 vs.12.1±2.2,both P<0.01].During the PPV treatment,there were 3 cases of cheek skin damage and 2 cases of ear skin damage in the continuous PPV group,and 3 cases of facial skin damage in the intermittent PPV group.There was no significant difference in the incidence of complications between the two groups(χ^(2)=0.321,P=0.571).All patients were repaired normally after PPV,without adverse consequences.Conclusion Continuous PPV is more effective than discontinuous PPV in the treatment of severe ARDS patients at high altitude,and the related complications are did not increased in prolonged time of PPV.
作者
韩进海
马四清
孙斌
王皓
孙晓林
贾贵彬
Han Jinhai;Ma Siqing;Sun Bin;Wang Hao;Sun Xiaolin;Jia Guibin(Department of Intensive Care Unit,Qinghai Provincial People's Hospital,Xining 810007,Qinghai,China)
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2021年第2期161-164,共4页
Chinese Critical Care Medicine
基金
青海省科技厅重点研发与转化计划项目(2019-SF-132)
青海省科技创新创业团队(2020-66)。
关键词
急性呼吸窘迫综合征
高原
俯卧位通气
Acute respiratory distress syndrome
Plateau
Prone position ventilation
作者简介
通信作者:马四清,Email:siqing177@sina.com。
