Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI).
Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI).
复制标题
DOI：
10.1186/s40635-017-0121-x
复制
发表时间：
2017-12
影响因子：
3.5
通讯作者：
Gatto LA
中科院分区：
文献类型：
--
作者：
Nieman GF;Satalin J;Andrews P;Aiash H;Habashi NM;Gatto LA
研究表明，对于急性呼吸窘迫综合征 (ARDS) 患者或高危患者进行机械通气可能是一把双刃剑。如果机械呼吸设置不当，可能会加剧 ARDS 相关的肺损伤，导致继发性呼吸机相关性肺损伤 (VILI)。相反，可以调整机械呼吸以尽量减少 VILI，从而降低 ARDS 死亡率。目前旨在最大程度减少 VILI 的护理通气策略标准尝试通过将潮气量 (Vt) 降低至 6 cc/kg，并根据氧合变化指导的滑动量表调整呼气末正压 (PEEP)，从而减少肺泡过度扩张和复张-复张 (R/D)。因此，Vt 通常但并不总是设置为“一刀切”的方法，尽管 PEEP 通常任意设置为 5 cmH2O，但它可以根据生理参数（最常见的是氧合）的变化进行个性化设置。然而，有证据表明，氧合作为优化 PEEP 的方法与维持肺部开放和稳定所需的 PEEP 水平并不一致。因此，使用氧合作为生理反馈系统，最佳 PEEP 可能无法针对个体患者的肺部病理进行个性化。个性化 PEEP 的多种方法已经过测试，包括死腔、肺顺应性、肺应力和应变、使用计算机断层扫描 (CT) 或电阻抗断层扫描 (EIT) 的通气模式、压力/容量曲线 (P/V) 上的拐点以及使用气道压力释放通气 (APRV) 的呼气流量曲线的斜率。尽管许多研究表明个性化 PEEP 是可能的，但对于最佳技术尚未达成共识。本综述将评估用于个性化 PEEP 的各种方法，以生理参数为指导，根据肺病理生理学的渐进变化自适应调整呼吸机设置。
It has been shown that mechanical ventilation in patients with, or at high-risk for, the development of acute respiratory distress syndrome (ARDS) can be a double-edged sword. If the mechanical breath is improperly set, it can amplify the lung injury associated with ARDS, causing a secondary ventilator-induced lung injury (VILI). Conversely, the mechanical breath can be adjusted to minimize VILI, which can reduce ARDS mortality. The current standard of care ventilation strategy to minimize VILI attempts to reduce alveolar over-distension and recruitment-derecruitment (R/D) by lowering tidal volume (Vt) to 6 cc/kg combined with adjusting positive-end expiratory pressure (PEEP) based on a sliding scale directed by changes in oxygenation. Thus, Vt is often but not always set as a “one-size-fits-all” approach and although PEEP is often set arbitrarily at 5 cmH2O, it may be personalized according to changes in a physiologic parameter, most often to oxygenation. However, there is evidence that oxygenation as a method to optimize PEEP is not congruent with the PEEP levels necessary to maintain an open and stable lung. Thus, optimal PEEP might not be personalized to the lung pathology of an individual patient using oxygenation as the physiologic feedback system. Multiple methods of personalizing PEEP have been tested and include dead space, lung compliance, lung stress and strain, ventilation patterns using computed tomography (CT) or electrical impedance tomography (EIT), inflection points on the pressure/volume curve (P/V), and the slope of the expiratory flow curve using airway pressure release ventilation (APRV). Although many studies have shown that personalizing PEEP is possible, there is no consensus as to the optimal technique. This review will assess various methods used to personalize PEEP, directed by physiologic parameters, necessary to adaptively adjust ventilator settings with progressive changes in lung pathophysiology.