目的:本研究旨在评估使用经肺驱动压力滴定呼气末正压(PEEP)的肺保护性通气策略对预后的影响[机械通气持续时间,住院,28天死亡率和呼吸机相关性肺炎(VAP)的发生率,急性呼吸窘迫综合征(ARDS)患者的生存结果]。
方法:将105例ARDS患者随机分为对照组(n=51)或研究组(n=53)。对照组接受基于潮气量的PEEP滴定[潮气量为6mL/kg,流量30-60升/分钟,16-20次呼吸/分钟的频率,恒定流速,吸气与呼气比为1:1至1:1.5,平台压力≤30-35cmH2O。调整PEEP以保持氧饱和度(SaO2)在90%或以上,考虑到血压],而研究组接受了基于经肺驱动压的PEEP滴定(使用连接到呼吸机的食管压力测量导管测量食管压力作为胸膜压力的替代。根据观察到的吸气末和呼气末跨肺压调整潮气量和PEEP,旨在在机械通气期间将经肺驱动压保持在15cmH2O以下。每天进行2-4次调整)。对肺功能指标[氧合指数(OI),动脉血氧张力(PaO2),动脉二氧化碳张力(PaCO2)]以及其他措施,如心率,平均动脉压,两组患者机械通气48h后中心静脉压。28天死亡率,机械通气的持续时间,住院时间,比较两组呼吸机相关性肺炎(VAP)发生率。进行60天的随访以记录患者的生存状态。
结果:在对照组中,平均年龄(55.55±10.51)岁,有33名女性和18名男性。ICU前住院时间为(32.56±9.89)小时。平均急性生理学和慢性健康评估(APACHE)II评分为(19.08±4.67),平均Murray急性肺损伤评分为(4.31±0.94)。在研究小组中,平均年龄(57.33±12.21)岁,有29名女性和25名男性。ICU前住院时间为(33.42±10.75)小时。平均APACHEⅡ评分为(20.23±5.00)分,平均Murray急性肺损伤评分为(4.45±0.88)。它们呈现均匀的分布(均P>0.05)。干预之后,与干预前相比,观察到PaO2和OI显著改善.与对照组相比,研究组表现出明显更高的PaO2和OI,差异均有统计学意义(均P<0.05)。干预后,与干预前水平(34.19±5.39mmHg)相比,研究组的PaCO2(43.69±6.71mmHg)显著升高.研究组PaCO2高于对照组(42.15±7.25mmHg),但差异无统计学意义(P>0.05)。干预后两组血流动力学指标比较差异均无统计学意义(均P>0.05)。研究组的机械通气时间和住院时间明显缩短,而28天死亡率和呼吸机相关性肺炎(VAP)发生率无显著差异.Kaplan-Meier生存分析显示,在60天的随访中,研究组的生存结果明显更好(HR=0.565,95%CI:0.320-0.999)。
结论:经肺驱动压力滴定PEEP肺保护性机械通气可有效改善肺功能,减少机械通气时间和住院时间,并提高ARDS患者的生存结局。然而,需要进一步研究以促进更广泛地采用这种方法。
OBJECTIVE: This study aimed to assess the impact of a lung-protective ventilation strategy utilizing transpulmonary driving pressure titrated positive end-expiratory pressure (PEEP) on the prognosis [mechanical ventilation duration, hospital stay, 28-day mortality rate and incidence of ventilator-associated pneumonia (VAP), survival outcome] of patients with Acute Respiratory Distress Syndrome (ARDS).
METHODS: A total of 105 ARDS patients were randomly assigned to either the control group (n = 51) or the study group (n = 53). The control group received PEEP titration based on tidal volume [A tidal volume of 6 mL/kg, flow rate of 30-60 L/min, frequency of 16-20 breaths/min, constant flow rate, inspiratory-to-expiratory ratio of 1:1 to 1:1.5, and a plateau pressure ≤ 30-35 cmH2O. PEEP was adjusted to maintain oxygen saturation (SaO2) at or above 90%, taking into account blood pressure], while the study group received PEEP titration based on transpulmonary driving pressure (Esophageal pressure was measured as a surrogate for pleural pressure using an esophageal pressure measurement catheter connected to the ventilator. Tidal volume and PEEP were adjusted based on the observed end-inspiratory and end-expiratory transpulmonary pressures, aiming to maintain a transpulmonary driving pressure below 15 cmH2O during mechanical ventilation. Adjustments were made 2-4 times per day). Statistical analysis and comparison were conducted on lung function indicators [oxygenation index (OI), arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2)] as well as other measures such as heart rate, mean arterial pressure, and central venous pressure in two groups of patients after 48 h of mechanical ventilation. The 28-day mortality rate, duration of mechanical ventilation, length of hospital stay, and ventilator-associated pneumonia (VAP) incidence were compared between the two groups. A 60-day follow-up was performed to record the survival status of the patients.
RESULTS: In the control group, the mean age was (55.55 ± 10.51) years, with 33 females and 18 males. The pre-ICU hospital stay was (32.56 ± 9.89) hours. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was (19.08 ± 4.67), and the mean Murray Acute Lung Injury score was (4.31 ± 0.94). In the study group, the mean age was (57.33 ± 12.21) years, with 29 females and 25 males. The pre-ICU hospital stay was (33.42 ± 10.75) hours. The mean APACHE II score was (20.23 ± 5.00), and the mean Murray Acute Lung Injury score was (4.45 ± 0.88). They presented a homogeneous profile (all P > 0.05). Following intervention, significant improvements were observed in PaO2 and OI compared to pre-intervention values. The study group exhibited significantly higher PaO2 and OI compared to the control group, with statistically significant differences (all P < 0.05). After intervention, the study group exhibited a significant increase in PaCO2 (43.69 ± 6.71 mmHg) compared to pre-intervention levels (34.19 ± 5.39 mmHg). The study group\'s PaCO2 was higher than the control group (42.15 ± 7.25 mmHg), but the difference was not statistically significant (P > 0.05). There were no significant differences in hemodynamic indicators between the two groups post-intervention (all P > 0.05). The study group demonstrated significantly shorter mechanical ventilation duration and hospital stay, while 28-day mortality rate and incidence of ventilator-associated pneumonia (VAP) showed no significant differences. Kaplan-Meier survival analysis revealed a significantly better survival outcome in the study group at the 60-day follow-up (HR = 0.565, 95% CI: 0.320-0.999).
CONCLUSIONS: Lung-protective mechanical ventilation using transpulmonary driving pressure titrated PEEP effectively improves lung function, reduces mechanical ventilation duration and hospital stay, and enhances survival outcomes in patients with ARDS. However, further study is needed to facilitate the wider adoption of this approach.