摘要
目的比较跨肺压法与最佳氧合法选择最佳呼气末正压通气(PEEP),对急性呼吸窘迫综合征(ARDS)模型猪肺损伤作用的影响。方法 12只普通家猪随机分为跨肺压组和最佳氧合组,均给予有创通气、留置股动脉导管接PiCCO仪监测血流动力学及留置右颈内静脉导管测中心静脉压(CVP),稳定30 min后,行0.9%氯化钠溶液肺泡灌洗复制猪ARDS模型。模型成功后,在充分肺复张的基础上,两组分别使用跨肺压法和最佳氧合法设置最佳PEEP,并以此维持通气4 h。观察并记录基础状态(PEEP 5 cm H_2O)(Tbase)、ARDS模型稳定(PEEP 5 cm H_2O)(T0)和最佳PEEP维持机械通气4 h期间(T1-T4)的肺毛细血管通透性指数(PVPI)、血管外肺水指数(EVLWI)及呼吸力学变化,并在Tbase、T0、T4 3个时间点采集血标本,酶联免疫吸附剂测定法(ELISA)测定血白介素1β(IL-1β)、白介素6(IL-6)炎症因子表达水平。实验结束处死动物,留取猪右上肺、右下肺背侧、右下肺腹侧,行免疫组化测肺组织核转录因子kappa B(NF-κB)、IL-1β、IL-6水平,比色法测肺组织抗髓过氧化物酶(MPO)活性,同时观察病理改变及测湿干比反应肺水含量。结果呼吸力学方面:跨肺压组最佳PEEP、Pm、Paw-exp、Ptrans-exp明显低于最佳氧合组(P<0.05),而跨肺压组Ptrans-ins在最佳PEEP通气第3小时、第4小时明显低于最佳氧合组(P<0.05)。炎症反应方面:右肺上叶肺组织NF-κB、右全肺肺组织IL-6、右肺下叶背侧及右全肺MPO表达跨肺压组均明显低于最佳氧合组(P<0.05)。肺水肿指标方面:两组最佳PEEP通气4h后PVPI、EVLWI以及各部位湿干比(W/D)差异无统计学意义(P>0.05)。病理方面:跨肺压组右肺上叶、下叶背侧及右全肺损伤病理评分低于最佳氧合组(P>0.05)。结论通过跨肺压法设置最佳PEEP能够在维持肺泡开放状态的同时,减少肺炎症反应发生,预防肺损伤,达到肺保护作用。
ObjectiveTo investigate the effect of positive end expiratory pressure (PEEP) guided by transpulmonary pressure compared with the optimal oxygenation-directed PEEP on lung injury in a pig model with acute respiratory distress syndrome(ARDS) .MethodsTwelve ordinary pigs were randomly divided into a transpulmonary pressure group (n=6) and an optimal oxygenation group (n=6) . Both groups were given invasive mechanical ventilation. Their hemodynamics was monitored, and catheterization of the right internal jugular vein was done to test CVP. The hemodynamics was stable 30 minutes after the operation. The pigs were given lung lavage with normal saline to induce ARDS. The optimal PEEP was set by transpulmonary pressure titration or optimal oxygenation after lung recruitment. Thereafter, ventilation continued for 4 hours. PVPI, EVLWI and respiratory mechanics changes were recorded before lung lavage with saline (PEEP 5 cmH2O) (Tbase), after stabilization of ARDS (PEEP 5 cmH2O) (T0) and after using optimal PEEP for 0, l, 2, 3 and 4 hours (T1-T4) . At the time of Tbase, T0 and T4, blood was collected to detect interleukin-1β and -6. At the end the experiment, the right upper, right lower ventral, right lower dorsal lung tissues were taken for immunohistochemical test of NF-ΚB, IL-1β and IL-6. Lung homogenates were prepared to detect myeloperoxidase (MPO) . At the same time, lung tissue was taken to observe pathological changes and record the lung wet/dry weight ratio (W/D) .Results The levels of PEEP, Pm, Paw-exp, and Ptrans-exp in the transpulmonary pressure group were significantly lower than those in the optimal oxygenation group (P<0. 05), and the levels of Ptrans-ins at T3 and T4 were also significantly lower than those in the optimal oxygenation group (P<0. 05) . The levels of NF-κB in the right upper lung tissue, IL-6 in the right lung tissue and MPO in the right lower dorsal lung tissue were significantly lower in the transpulmonary pressure group than those in the optimal oxygenation group (P<0. 05) . After mechanical ventilation set by optimal PEEP in the two groups, the levels of PVPI, EVLWI and W/D were not significantly different between the two groups (P>0. 05) . The pathological scores of the right upper, right lower dorsal, and right lung tissues were all significantly lower in the transpulmonary pressure group than those in the optimal oxygenation group (P>0. 05) .ConclusionPEEP guided by transpulmonary pressure can open the alveoli, reduce the inflammatory response, prevent the ventilator-associated lung injury, and then reach the effect of lung protection.
出处
《中华重症医学电子杂志》
2016年第1期-,共9页
Chinese Journal Of Critical Care & Intensive Care Medicine(Electronic Edition)
基金
江苏省"333高层次人才培养工程"基金(2011-15)
扬州市科技攻关-社会发展科技攻关(2012133)
关键词
急性呼吸窘迫综合征
机械通气
肺损伤
Acute respiratory distress syndrom
Mechanical ventilation
Lung injury
