急性呼吸窘迫综合征患者早期应用气道压力释放通气的疗效

目的探讨早期应用气道压力释放通气（APRV）对急性呼吸窘迫综合征（ARDS）患者的临床疗效。 方法将2017年9月至2019年6月收住在兰州大学第一医院ICU的71例ARDS患者分为APRV组（36例）和小潮气量（LTV）组（35例）。APRV组患者起初给予容量辅助控制通气模式，测量气道平台压后转为APRV模式；LTV组患者接受LTV通气，目标潮气量设置为6~8 mL/kg，依据ARDSnet协议调节呼气末正压（PEEP）水平、潮气量和呼吸频率。记录两组患者的一般资料，比较其机械通气第1天和第7天呼吸机参数、呼吸力学指标、血气功能指标、循环功能指标及预后情况；绘制Kaplan-Meier生存曲线，比较两组患者28 d生存情况。 结果机械通气第7天，APRV组和LTV组患者吸入氧浓度（FiO₂）[（47 ± 5）% vs.（66 ± 5）%，t = 3.746，P < 0.001]、呼吸频率[（24 ± 4）次/min vs.（18 ± 4）次/min，t = 3.453，P < 0.001]、PEEP[（5.6 ± 2.3）cmH₂O vs.（10.8 ± 4.4）cmH₂O，t = 3.011，P < 0.001]、气道峰压[23.9（18.5，29.6）cmH₂O vs. 25.1（11.3，31.8）cmH₂O，H = 2.736，P = 0.014]、气道平台压[22.2（18.7，24.3）cmH₂O vs. 19.6（17.2，22.4）cmH₂O，H = 2.154，P = 0.023]、平均气道压[23.8（22.1，24.3）cmH₂O vs. 15.4（13.9，19.4）cmH₂O，H = 2.814，P = 0.018]、肺顺应性[52.7（37.4，62.3）mL/cmH₂O vs. 41.8（31.5，57.6）mL/cmH₂O，H = 2.008，P = 0.034]、动脉血氧分压（PaO₂）[（89 ± 7）mmHg vs.（72 ± 7）mmHg，t = 2.324，P < 0.001]、PaO₂/FiO₂ [（201 ± 15）mmHg vs.（140 ± 12）mmHg，t = 2.743，P < 0.001]、动脉血氧饱和度（SaO₂）[（95.4 ± 2.1）% vs.（92.3 ± 1.8）%，t = 2.658，P < 0.001]、心率[（99 ± 9）次/min vs.（108 ± 9）次/min，t = 2.733，P = 0.014]及平均动脉压[（84 ± 11）mmHg vs.（74 ± 13）mmHg，t = 3.012，P = 0.011]比较，差异均有统计学意义。APRV组ARDS患者机械通气时间[（9.6 ± 2.2）d vs.（11.9 ± 2.9）d，t = 3.687，P < 0.001]、住ICU时间[（11.3 ± 3.1）d vs.（13.2 ± 2.7）d，t = 2.722，P = 0.008]、住院时间[（13.9 ± 2.5）d vs.（16.2 ± 2.4）d，t = 3.924，P = 0.004]均较LTV组显著缩短，拔管成功率[80.6%（29/36）vs. 54.3%（19/35），χ² = 5.592，P = 0.018]显著升高，肺复张[5.6%（2/36）vs. 48.6%（17/35），χ² = 16.753，P < 0.001]、俯卧位通气[11.1%（4/36）vs. 34.3%（12/35），χ² = 5.460，P = 0.019]、气胸发生率[8.3%（3/36）vs. 28.6%（10/35），χ² = 4.860，P = 0.028]及28 d住院病死率[13.9%（5/36）vs. 34.3%（12/35），χ² = 4.054，P = 0.044]均显著降低。Kaplan-Meier生存曲线结果显示，APRV组ARDS患者生存情况显著优于LTV组（χ² = 4.118，P = 0.015）。 结论与LTV组比较，早期应用APRV可显著改善ARDS患者的氧合功能和呼吸系统顺应性，提高拔管成功率，降低气胸发生率，并减少机械通气时间和住院时间。

Clinical efficacy of early application of airway pressure release ventilation on patients with acute respiratory distress syndrome

ObjectiveTo investigate the clinical effect of early application of airway pressure release ventilation (APRV) on patients with acute respiratory distress syndrome (ARDS). MethodsSeventy-one ARDS patients admitted to the Department of Intensive Care Medicine of the First Hospital of Lanzhou University from September 2017 to June 2019 were divided into a APRV group (n = 36) and a low tidal volume (LTV) group (n = 35). Patients in the APRV group were initially given a volume-assisted control ventilation mode and then changed to an APRV mode after measuring airway plateau pressure. At the same time, patients in the LTV group were given LTV ventilation. The target tidal volume was set to 6-8 mL/kg, and the positive end expiratory pressure (PEEP) level, tidal volume and respiratory rate were adjusted according to the ARDSnet protocol in the LTV group. The general data of patients in these two groups were recorded, and the ventilator parameters, respiratory mechanics indexes, blood gas indexes, circulation indexes and prognosis were compared after 1 and 7 days of mechanical ventilation. The Kaplan-Meier survival curves were drawn to compare 28-day survival between these two groups. ResultsAfter 7 days of mechanical ventilation, the fraction of inspiratory oxygen (FiO₂) [(47 ± 5)% vs. (66 ± 5)%, t = 3.746, P < 0.001], respiratory rate [(24 ± 4) breaths/min vs. (18 ± 4) breaths/min, t = 3.453, P < 0.001], PEEP [(5.6 ± 2.3) cmH₂O vs. (10.8 ± 4.4) cmH₂O, t = 3.011, P < 0.001], peak airway pressure [23.9 (18.5, 29.6) cmH₂O vs. 25.1 (11.3, 31.8) cmH₂O, H = 2.736, P = 0.014], airway platform pressure [22.2 (18.7, 24.3) cmH₂O vs. 19.6 (17.2, 22.4) cmH₂O, H = 2.154, P = 0.023], mean airway pressure [23.8 (22.1, 24.3) cmH₂O vs. 15.4 (13.9, 19.4) cmH₂O, H = 2.814, P = 0.018], lung compliance [52.7 (37.4, 62.3) mL/cmH₂O vs. 41.8 (31.5, 57.6) mL/cmH₂O, H = 2.008, P = 0.034], arterial partial pressure of oxygen (PaO₂) [(89 ± 7) mmHg vs. (72 ± 7) mmHg, t = 2.324, P < 0.001], PaO₂/FiO₂ [(201 ± 15) mmHg vs. (140 ± 12) mmHg,t = 2.743,P < 0.001], arterial oxygen saturation (SaO₂) [(95.4 ± 2.1)% vs. (92.3 ± 1.8)%, t = 2.658, P < 0.001], heart rate [(99 ± 9) beats/min vs. (108 ± 9) beats/min, t = 2.733, P = 0.014] and mean arterial pressure [(84 ± 11) mmHg vs. (74 ± 13) mmHg, t = 3.012, P = 0.011] were statistically significantly different between the APRV group and LTV group. Compared with the LTV group, the mechanical ventilation time [(9.6 ± 2.2) d vs. (11.9 ± 2.9) d, t = 3.687, P < 0.001], ICU stay [(11.3 ± 3.1) d vs. (13.2 ± 2.7) d, t = 2.722, P = 0.008], and hospital stay [(13.9 ± 2.5) d vs. (16.2 ± 2.4) d, t = 3.924, P = 0.004] were significantly shorter, and the successful extubation rate [80.6% (29/36) vs. 54.3% (19/35), χ² = 5.592, P = 0.018] significantly increased, while the lung recovery [5.6% (2/36) vs. 48.6% (17/35), χ² = 16.753, P < 0.001], ventilation in prone position [11.1% (4/36) vs. 34.3% (12/35) , χ² = 5.460, P = 0.019], aerothorax [8.3% (3/36) vs. 28.6% (10/35), χ² = 4.860, P = 0.028] and 28-day hospitalization mortality [13.9% (5/36) vs. 34.3% (12/35), χ² = 4.054, P = 0.044] significantly decreased in the APRV group. The Kaplan-Meier survival curve showed that the survival of ARDS patients in the APRV group was significantly better than that in the LTV group (χ² = 4.118, P = 0.015). ConclusionCompared with the LTV group, early application of APRV can improve oxygenation and respiratory compliance in patients with ARDS, improve their success rate of extubation and reduce their incidence of pneumothorax, duration of mechanical ventilation and length of hospital stay.