绵羊急性呼吸窘迫综合征开放肺压力安全性的实验研究

目的观察在绵羊急性呼吸窘迫综合征（ARDS）模型上利用控制性肺膨胀法（SI）实施肺复张策略对血流动力学及肺组织结构的影响，以期找到实施SI的理想压力及时间范围。方法14只绵羊在全麻下行纤维支气管镜温生理盐水肺泡灌洗建立ARDS模型，低流速法描记准静态压力-容积（P—V）曲线，寻找P—V曲线的上拐点（UIP）以及下拐点（LIP）。以UIP下5cm H2O（1cm H2O=0．098kPa）、UIP、UIP上10cm H2O和UIP上20cm H2O将14只绵羊随机分为4组（U-5、U＋0、U＋10、U＋20组），并作为SI的峰压进行肺复张，持续时间为60s，记录每次复张过程中及复张后连续血流动力学参数和氧合指数变化，维持至2h后实验结束，行CT、肺组织病理学检查。结果U＋20组在SI过程中出现气胸，导致绵羊死亡；其余各组肺复张过程中，对血流动力学均有明显影响。U＋10组肺复张10s即出现中心静脉压（CVP）升高，心排血量（CO）、心脏指数（CI）、平均血压（MBP）明显下降，复张后CI恢复缓慢；U＋0组及U-5组可完成整个肺复张过程，CVP轻度升高，CO、CI下降，U-5组在复张结束后15s、U＋0组在复张结束后30s恢复至复张前水平。肺组织病理学观察仍见U＋0组有肺大泡形成。结论对ARDS实施肺复张，应充分考虑压力对血流动力学及肺组织的损害；肺复张压力应选择在UIP或UIP下5cm H2O，此时对血流动力学没有明显影响。     

Low flow inflation pressure-time curve in patients with acute respiratory distress syndrome

OBJECTIVE: In mechanically ventilated patients with ARDS, determination of the lower (LIP) and upper (UIP) inflection points of the static pressure-volume curve (P-V) is crucial for planning ventilatory strategies. Recently, a simple new method was proposed for measuring the P-V curve by inflating the lung with constant low flow [14]. We hypothesized that during low flow inflation LIP and UIP might be determined using the pressure-time curve (P-T) instead of P-V. METHODS: Eleven paralyzed patients with ARDS were studied. During volume control ventilation the patients were allowed to reach passive functional residual capacity (FRC) and then ventilator frequency, inspiratory to total breath duration ratio and tidal volume (VT) were set to 5 breaths/ min, 80% and 500 or 1,500 ml, respectively. With these settings, constant inspiratory flow (V'I) was administered for 9.6 s and ranged, depending on VT, between 0.05 and 0.15 l/s. P-V and P-T were obtained at two levels of positive end-expiratory pressure (PEEP; 0 and 10 cm H2O), with V'I being achieved either fast (< 0.1 s, minimum delay) or slowly (0.4 s, maximum delay). RESULTS: With minimum flow delay for a given experimental condition, the shape of the P-T did not differ from that of P-V. In all cases P-T correctly identified the presence of LIP and UIP, which did not differ significantly between P-T and P-V. With maximum flow delay, compared to P-V, the initial part of P-T was significantly shifted to the left. P-T did not identify the presence of UIP and LIP in one and two cases, respectively. CONCLUSIONS: Provided that constant flow is given relatively fast, P-T accurately determines the shape of P-V, as well as the LIP and UIP. Flow delay causes a leftward shift of the initial part of P-T, masking the presence of LIP and UIP in some cases.     

控制性肺膨胀对急性呼吸窘迫综合征家兔的肺力学和肺损伤影响

目的　探讨控制性肺膨胀 (SI)对急性呼吸窘迫综合征 (ARDS)家兔的肺力学和肺损伤影响。方法　利用肺泡灌洗法建立家兔ARDS模型 ,30只ARDS家兔随机分为SI组和非SI组。观察SI后 2h ,家兔肺力学及肺损伤的改变。结果　与非SI组相比 ,SI组在实施SI后 10、 30min ,1、 2h的平均气道压均明显降低。SI组 2h时的峰值气道压亦明显低于非SI组。与SI前比较 ,SI组实施SI后动态肺顺应性 (Cdyn)显著增加 ,SI前Cdyn为 (0 82± 0 11)ml/cmH2 O ,SI结束时达到最大 [(2 2 3± 0 4 )ml/cmH2 O],SI后 3h[(1 0 0± 0 0 6 )ml/cmH2 O]仍显著高于SI前水平。与非SI组比较 ,SI组 2h、 3h和 4h的Cdyn 均明显增加。非SI组肺损伤评分为 6 7± 2 6 ,SI组肺损伤评分显著降低 (5 0± 2 2 ,P <0 0 1)。结论　SI具有改善ARDS肺顺应性、防止肺损伤的作用     

小潮气量结合控制性肺膨胀对肿瘤术后早期急性呼吸窘迫患者的疗效

目的 观察小潮气量结合控制性肺膨胀(SI)对肿瘤术后早期呼吸窘迫(ARD)患者的疗效及可能出现的不良反应.方法 选择中国医学科学院肿瘤医院和北京协和医院2007年1月至2009年12月收治的肿瘤术后早期ARD患者51例,术后循环稳定,因ARD而不能脱离机械通气.监测并记录其持续无创血压(NBP)、脉搏血氧饱和度(SPO2),实行肺保护性通气,予SI治疗,记录SI前及SI后10 min、24 h和48 h的呼吸末正压通气(PEEP)水平及吸入氧浓度(Fi02);监测呼吸频率(F)、气道平台压(Pplat)、吸入峰值压(Ppeak)、潮气量(VT)、呼吸系统静态顺应性(Cst)及动脉血气分析(ABG).结果应用SI后,51例肿瘤术后ARD患者Fi02、PEEP减低(F值分别为66.05、241.28,P均＜0.01);VT、Cst增加(F值分别为262.40、118.28,P均＜0.01);Ppeak、Pplat、呼吸频率下降(F值分别为88.96、83.05、57.55,P均＜0.01),动脉血气分析改善,未发生各种不良事件.结论 SI在肺保护性通气的基础上可改善肿瘤术后ARD患者的氧合.     

严重创伤并发急性呼吸窘迫综合征的临床特点

目的：探讨严重创伤并发急性呼吸窘迫综合征（ＡＲＤＳ）的临床特点。方法：对１６２例严重创伤、创伤严重度评分（ＩＳＳ）≥１６分者进行回顾性分析,４６例并发ＡＲＤＳ,均发生了全身炎症反应综合征,其中３１例发生多脏器衰竭（ＭＯＦ）。并对４６例ＡＲＤＳ发生率为７１．８％,显著高于ＩＳＳ１６～２５分者（２８．２％）。发生ＭＯＦ患者血浆ＥＴ－１、ＡＤＭ、ＴＭＦ－α显著增高,且死亡组高于存活组。结论：创伤严重程度     

控制性肺膨胀对急性呼吸窘迫综合征家兔肺外器官炎症反应的影响

目的 研究控制性肺膨胀(SI)对急性呼吸窘迫综合征(ARDS)家免肺外器官炎症反应的影响。方法 生理盐水肺泡灌洗法复制ARDS家兔模型。实验动物随机分为对照组、ARDS组、小潮气量(VT) 最佳呼气末正压组(LVBP组)和SI组。机械通气4 h后,逆转录-聚合酶链反应(RT-PCR)检测肝、肠组织肿瘤坏死因子-α(TNF-α)和自细胞介素-10(IL-10)mRNA表达;酶联免疫吸附法检测肝、肠组织TNF-α和IL-10浓度,同时测定髓过氧化物酶(MPO)和丙二醛(MDA)含量。结果 SI组肝、肠组织TNF-α mRNA表达明显低于ARDS组和LVBP组(P均<0.05);肝、肠组织IL-10 mRNA表达均显著低于ARDS组和LVBP组(P均<0.05)。各组间肝、肠组织TNF-α、IL-10、MPO和MDA含量比较无统计学差异。结论 SI可抑制ARDS家免肺外器官细胞因子mRNA的表达,下调肺外器官炎症反应。     

控制性肺膨胀对急性呼吸窘迫综合征绵羊肺力学和肺损伤的影响

目的：探讨控制性肺膨胀（SI）与肺保护性通气策略联合应用时,对急性呼吸窘迫综合征（ARDS）的肺泡复张作用及其安全性。方法：利用内毒秀导的绵羊ARDS模型,观察实施SI[2.94kPa(1kPa=10.20cmH2O),屏气时间20秒]后绵羊的肺力学和组织病理学改变。结果：实施SI后,绵羊的动态肺顺应性和肺容积显著增加,气道峰值压、平台压和平均气道压均显著降低（P均＜0．05）,并可维持3－4小时。与未应用SI的绵羊比较,实施SI后的绵羊肺损伤减轻,肺不张改善。结论：SI具有肺复张和肺保护作用,是肺保护性通气策略的重要补充。     

无创正压通气治疗创伤性湿肺的临床研究

目的 观察无创正压通气（NIPPV）治疗创伤性湿肺的疗效。方法 选择30例行无创正压通气治疗的创伤性湿肺患者为治疗组，24例未用NIPPV治疗的创伤性湿肺患者为对照组，通过对2组患者进行心电监测、血氧饱和度、呼吸频率、血气分析等指标的监测，比较2组患者呼吸频率和动脉血气参数、肺部病变吸收时间、气管插管率、ICU住院时间及预后。结果 30例创伤性湿肺患者经NIPPV治疗后动脉血气指标与临床表现明显改善（P〈0．01）；与对照组相比，NIPPV治疗组患者临床症状改善时间、肺部病变吸收时间、ICU住院时间明显缩短（P〈0．01），肺实变率显著减低（P〈0．05），但2组患者气管插管率和病死率差异却无显著性。结论 NIPPV通过调节压力支持与呼吸末正压水平，早期应用可明显改善创伤性湿肺患者病情及缩短病程，但并不能改善其预后。     

急性呼吸窘迫综合征患者早期行持续肾脏替代治疗的临床研究

目的 观察早期行持续肾脏替代治疗(CRRT)对急性呼吸窘迫综合征(ARDS)患者血管外肺水指数(EVLWI)、动脉血乳酸(Lac)等的影响和临床意义.方法 36例ARDS患者随机分为常规治疗组(A组,18例)和常规治疗+CRRT组(B组,18例).B组明确诊断后即行CRRT治疗.通过脉搏指示连续心排监测仪(PICCO)监测确诊即刻及治疗后2 h、1 d、3 d、7 d EVLWI变化,在相同时间点监测Lac、氧合指数(PaO2/FiO2)、pH值及呼气末正压(PEEP),并进行比较.比较两组患者机械通气时间、呼吸机相关性肺炎(VAP)发生率和死亡率.结果 B组pH值、PaO2/FiO2在治疗后2 h即开始显著上升,EVLWI、Lac、PEEP则在治疗后1 d开始显著下降(P均<0.05);而A组pH值、PaO2/FiO2显著上升及EVLWI、Lac、PEEP显著下降的时间点分别为治疗后1 d和治疗后3 d,均晚于B组,且两组相同时间点各指标比较差异有统计学意义(P均＜0.05).A组、B组机械通气时间分别为(14.5±1.0)d和(9.2±0.8)d(P＜0.05),VAP发生率分别为50%和17%(P＜0.05),死亡率分别为38.9%和22.2%(P＞0.05).结论 对ARDS患者进行常规治疗的同时早期进行CRRT治疗,能有效降低EVLWI、Lac及PEEP,改善氧合状态,缩短机械通气时间,降低VAP发生率.     

肺挫伤致急性呼吸窘迫综合征患者肺循环变化的临床研究

目的 用Swan-Ganz导管及脉搏指示连续心排血量(PiCCO)技术分析肺挫伤致急性呼吸窘迫综合征(ARDS)患者肺循环变化规律及意义.方法 采用前瞻性随机对照临床研究,选择2009年8月至2011年8月肺挫伤致ARDS患者(挫伤组,18例)和无肺挫伤且无ARdS的多发伤患者(对照组,22例),记录两组患者置管即刻及伤后12、24、36、48、60、72 h肺动脉收缩压(PAS)、肺动脉舒张压(PAD)、肺动脉楔压(PAWP)、肺动脉舒张压与肺动脉楔压梯度(PAD-PA WP)和血管外肺水指数(ELWI).比较各参数在组内和组间的差异.结果 肺挫伤致ARDS存活患者PAS、PAD和PAD-PAWP较对照组明显增高,之后逐渐回落,其中PAS、PAD于伤后60h,PAD-PAWP于伤后48 h恢复至对照组水平;而对照组PAS、PAD自置管即刻至伤后72 h无显著变化,PAD-PAWP伤后72 h较48 h增高.肺挫伤组ELWI较对照组明显升高,至12h达峰值后逐渐回落,于伤后60h恢复至对照组水平,对照组伤后60h及72 h较48 h降低.肺挫伤组PAWP开始较对照组降低,于伤后48 h恢复至对照组水平;对照组自置管即刻至伤后72 h无显著变化.相关性分析显示,挫伤组置管即刻至伤后48 h,PAS、PAD、PAD-PAWP与ELWI均呈正相关(r值分别为0.554、0.498、0.629,均P＜0.01).结论 PAS、PAD、PAD-PAWP和ELWI的变化规律可指导肺挫伤致ARDS患者的液体治疗、机械通气和评估病情.     

Protective ventilation of patients with acute respiratory distress syndrome

In a recent issue of the British Journal of Anaesthesia, Moloney and Griffiths reviewed clinically pertinent issues surrounding the management of the acute respiratory distress syndrome (ARDS) patient, particularly as it pertains to the treatment of ventilator induced/associated lung injury (VILI). In addition to highlighting the important observations that have contributed to further our understanding of the relationship between the mechanical ventilator and inflammatory lung injury, the authors also offer a concise reappraisal of the clinical strategies used to minimize VILI in ARDS. Special emphasis is placed on the theory of biotrauma, which attempts to explain how multi-organ failure may develop in patients who ultimately succumb to this syndrome.     

Protective ventilation of patients with acute respiratory distress syndrome

In a recent issue of the British Journal of Anaesthesia, Moloney and Griffiths reviewed clinically pertinent issues surrounding the management of the acute respiratory distress syndrome (ARDS) patient, particularly as it pertains to the treatment of ventilator induced/associated lung injury (VILI). In addition to highlighting the important observations that have contributed to further our understanding of the relationship between the mechanical ventilator and inflammatory lung injury, the authors also offer a concise reappraisal of the clinical strategies used to minimize VILI in ARDS. Special emphasis is placed on the theory of biotrauma, which attempts to explain how multi-organ failure may develop in patients who ultimately succumb to this syndrome.     

风险护理干预应用于急性呼吸窘迫综合征患者的临床效果

目的 探讨风险护理干预用于急性呼吸窘迫综合征患者的临床效果。 方法 选取2016年2月-2017年3月本院治疗的急性呼吸窘迫综合征患者86例作为研究对象,采用随机数字表法将其分为对照组和观察组各43例。对照组给予常规护理,观察组给予风险护理干预。比较2组护理质量、患者舒适度和并发症情况。 结果 观察组熟练技能、质量控制、护理满意度评分均高于对照组(t=7.835,P=0.017; t=7.014,P=0.023; t=8.682,P=0.012),护理投诉率低于对照组(χ²=8.444,P=0.004);观察组舒适度的社会维度、心理维度、生理维度、环境维度评分高于对照组;观察组并发症发生率低于对照组(χ²=9.550,P=0.023)。 结论 急性呼吸窘迫综合征患者接受风险护理干预,有助于提高护理质量和患者舒适度,降低护理投诉率,改善并发症情况。     

控制性肺膨胀对急性呼吸窘迫综合征肺静态顺应性曲线低位转折点的影响

目的 :探讨控制性肺膨胀 (SI)对急性呼吸窘迫综合征 (ARDS)肺静态顺应性曲线低位转折点压力(Pinf)的影响。方法 :30只家兔利用肺泡灌洗法建立 ARDS模型 ,并随机分为 SI组和非 SI组 ,观察 SI后 2小时动物的 Pinf、肺气体交换和肺机械力学特征改变。结果 :SI组动物 SI前 Pinf为〔(0 .90± 0 .14 ) k Pa,1k Pa=10 .2 0 cm H2 O〕,SI 2小时后 Pinf降到 (0 .6 1± 0 .14 ) k Pa(P=0 .0 2 0 ) ;非 SI组机械通气 2小时前后 Pinf无明显改变 ,P>0 .0 5。 SI组动物机械通气 2小时后动脉血氧分压 (Pa O2 )和氧饱和度 (Sa O2 )分别为 (2 4 .2 0±8.79) k Pa(1k Pa=7.5 m m Hg)和 0 .96 7± 0 .0 2 4 ,显著高于非 SI组〔分别为 (10 .80± 1.13) k Pa和 0 .76 8±0 .0 76 ,P<0 .0 5〕。 SI组动物机械通气 2小时后动态肺顺应性 (Cydn)为 (12 .2 4± 1.5 3) ml/k Pa,显著高于非 SI组〔(9.80± 0 .82 ) ml/k Pa〕。结论 :SI具有促进肺泡复张、降低 Pinf水平的效应 ,实施 SI后应重新调整呼气末正压 (PEEP)水平。     

Antioxidant status in patients with acute respiratory distress syndrome

Objectives: Reactive oxygen species (ROS) have been implicated in the pathophysiology of ARDS. We investigated the pattern of antioxidants in plasma and ROS production by neutrophils in patients with ARDS over 6 days. Design: Observational study. Blood samples were taken when the diagnosis was made (D0) and after 3 (D3) and 6 days (D6) during therapy. Setting: Intensive care units at a University Hospital. Patients: Eight patients with ARDS were investigated, 17 healthy volunteers served as controls. Measurements and results: Plasma levels of ascorbate, α-tocopherol, retinol, β-carotene, selenium and lipid peroxidation products (MDA) were determined and the activities of the antioxidative enzymes catalase (CAT), superoxide dismutase (SOD) and glutathione-peroxidase (GSH-PX) in erythrocytes were measured. In addition, ROS production (superoxide anion and hydrogen peroxide) in activated neutrophils was assessed. Plasma levels of α-tocopherol, ascorbate, β-carotene and selenium were reduced from the onset of illness. MDA plasma levels were increased throughout the illness. ROS generation from neutrophils was normal on D0 and decreased to D6 in ARDS patients. Conclusion: The antioxidative system is severely compromised in patients with ARDS. Plasma levels of α-tocopherol, ascorbate, β-carotene and selenium are decreased. Elevated MDA levels provide further evidence of massive oxidative stress. The routine replacement of micronutrients according to recommended daily allowances was inadequate to compensate for the increased requirements. Received: 8 April 1998 Final revision received: 22 September 1998 Accepted: 5 October 1998     

急性呼吸窘迫综合征预后的影响因素分析

目的急性呼吸窘迫综合征（ARDS）预后的影响因素分析。方法纳入2009年1月至2012年2月在温州医学院附属第二医院重症医学科就诊的ARDS患者151例,其中死亡49例。对患者年龄、性别、血压、血糖、人体质量指数（BMI）、ARDS分级、急性病生理学和长期健康评价（APACHE）11评分、序贯器官衰竭估计（SOFA）评分、前降钙素原（PCT）、血管活性药物使用等相关因素进行单因素Logistic回归分析,选择有统计学意义的变量进行多因素Logistic回归分析。结果单因素Logistic分析发现,性别、血压、血糖对ARDS患者预后无统计学意义,而年龄、BMI、ARDS分级、APACHEII评分、SOFA评分、PCT、血管活性药物7个指标均影响ARDS患者的预后（P均〈0．05）。多因素logistic回归分析发现,影响ARDS患者预后的危险因素为ARDS分级（OR=6．895,95％CI=1．447～32．860）、年龄（OR=3．633,95％C1=1．333～9．906）APACHEU评分（OR=1．210,95％CI：1．033～1．417）及SOFA评分（O尺=1．676,95％CI=1．253～2．242）,而BMI是保护因素（OR=0．379,95％CI：0．168～0．856）。结论ARDS分级、APACHEII评分、SOFA评分及年龄是ARDS患者预后的不利因素,而BMI是保护因素。     

Prone positioning in patients with acute respiratory distress syndrome

Prone positioning is a technique used to treat patients with acute respiratory distress syndrome (ARDS). Nurses are ideally placed to initiate and manage prone positioning. This article examines the aetiology of ARDS and how nurses can identify this condition. Patient groups that benefit most from prone positioning are considered as well as the research evidence on the use of prone positioning in the treatment of ARDS. This article addresses nurse involvement in delivering therapy and suggests that nurses alert members of the multidisciplinary team to the possible use of this therapy.     

Effects of sustained inflation and postinflation positive end-expiratory pressure in acute respiratory distress syndrome: focusing on pulmonary and extrapulmonary forms

OBJECTIVE: To investigate whether the response to sustained inflation and postinflation positive end-expiratory pressure varies between acute respiratory distress syndrome with pulmonary (ARDS(exp)) and extrapulmonary origin (ARDS(exp)). DESIGN: Prospective clinical study. SETTING: Multidisciplinary intensive care unit in a university hospital. PATIENTS: A total of 11 patients with ARDS and 13 patients with ARDS. INTERVENTIONS: A 7 ml/kg tidal volume, 12-15 breaths/min respiratory rate, and an inspiratory/expiratory ratio of 1:2 was used during baseline ventilation. Positive end-expiratory pressure levels were set according to the decision of the primary physician. Sustained inflation was performed by 45 cm H2O continuous positive airway pressure for 30 secs. Postinflation positive end-expiratory pressure was titrated decrementally, starting from a level of 20 cm H2O to keep the peripheral oxygen saturation between 92% and 95%. Fio2 was decreased, and baseline tidal volume, respiratory rate, inspiratory/expiratory ratio were maintained unchanged throughout the study period. MEASUREMENTS AND MAIN RESULTS: Blood gas, airway pressure, and hemodynamic measurements were performed at the following time points: at baseline and at 15 mins, 1 hr, 4 hrs, and 6 hrs after sustained inflation. After sustained inflation, the Pao2/Fio2 ratio improved in all of the patients both in ARDS(p) and ARDS(exp). However, the Pao2/Fio2 ratio increased to >200 in four ARDS(p) patients (36%) and in seven ARDS(p) patients (54%). In two of those ARDS patients, the Pao2/Fio2 ratio was found to be <200, whereas none of the ARDS(p) patients revealed Pao2/Fio2 ratios of <200 at the 6-hr measurement. Postinflation positive end-expiratory pressure levels were set at 16.7 +/- 2.3 cm H O in ARDS(p) and 15.6 +/- 2.5 cm H2O in ARDS. The change in Pao /Fio ratios was found statistically significant in patients with ARDS(p) (p =.0001) and with ARDS(p) (p =.008). Respiratory system compliance increased in ARDS patients (p =.02), whereas the change in ARDS was not statistically significant. CONCLUSIONS: Sustained inflation followed by high levels of postinflation positive end-expiratory pressure provided an increase in respiratory system compliance in ARDS; however, arterial oxygenation improved in both ARDS forms.     

改良叹气法肺复张对急性呼吸窘迫综合征疗效的影响

目的 在小潮气量通气策略基础上,对急性呼吸窘迫综合征患者实施改良叹气法肺复张治疗,观察改良叹气法肺复张对急性呼吸窘迫综合征的疗效,为改良叹气法肺复张的应用提供依据.方法 选择2006-11～2008-11我院ICU收治的30例ARDS患者.采用压力控制辅助通气模式,限制吸气压≤30 cm H2O,潮气量为6～8 mL/kg.研究分三期:基础期2 h(小潮气量通气+呼气末正压)、叹气期1 h(小潮气量通气+呼气末正压+叹气)、叹气后期1 h(小潮气量通气+呼气末正压).记录并比较各期患者的氧合情况、通气及酸碱情况、呼吸力学指标、血流动力学指标、气压伤的发生情况等.结果 ①氧合指数(PaO2/FiO2)明显改善,差异有统计学意义(P<0.05).但是随着叹气的结束又恢复到叹气前的水平.②二氧化碳分压(PaCO2)有所降低,差异有统计学意义(P<0.05).但是随着叹气的结束又恢复到叹气前水平.③静态顺应性明显改善,差异有统计学意义(P<0.05).但是随着叹气结束又恢复到叹气前的水平.④心率、平均动脉压及中心静脉压变化差异无统计学意义(P均>0.05).⑤未发生气压伤.结论 持续的改良叹气能明显改善患者的氧合状态及胸肺顺应性,且安全易行,对血流动力学干扰较小,但疗效的维持时间不稳定.