Hemodynamic effects of lung recruitment maneuvers in acute respiratory distress syndrome.
Hemodynamic effects of lung recruitment maneuvers in acute respiratory distress syndrome.
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DOI：
10.1186/s12890-017-0369-7
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发表时间：
2017-02-08
影响因子：
3.1
通讯作者：
Bates DG
中科院分区：
文献类型：
--
作者：
Das A;Haque M;Chikhani M;Cole O;Wang W;Hardman JG;Bates DG
到目前为止，临床试验未能确定招募策略（RMs）对急性呼吸窘迫综合征（ARDS）患者死亡率的明确有益结果，RMs对心血管系统的影响仍然知之甚少。一个高度整合肺部和心血管系统的计算模型被配置来复制来自临床试验的静态和动态心肺数据。在23例不同程度ARDS严重程度和初始心输出量的计算机患者中进行了招募操作（RMs）。记录并分析多个临床变量，包括动脉氧合、心输出量、外周氧输送和肺泡应变。最大复吸策略（MRS）操作，在呼气末正压（PEEP）滴定后逐渐增加呼气末正压（PEEP），在所有23例硅患者中产生了PF比，二氧化碳消除和动态应变的改善。中度和轻度硅性ARDS患者心输出量减少导致RM期间氧输送显著下降（分别平均减少423 ml min - 1和526 ml min - 1）。然而，在患有严重急性呼吸窘迫综合征的硅患者中，尽管心输出量平均下降超过31min - 1，但在RM期间，显著改善的气体交换导致氧输送平均增加89 ml min - 1。RM后的氧输送增加仅在严重ARDS患者中观察到。在高基线心输出量（>6.5 l min - 1）的患者中，氧输送从未低于700 ml min - 1。我们的研究结果支持这样的假设，即严重的ARDS患者和大量的肺泡单位可用于再生，可能从RMs中获益更多。我们的研究结果还表明，高于正常的初始心输出量可能提供保护，防止与RMs相关的高胸内压对心功能的潜在负面影响。来自轻度或中度急性呼吸窘迫综合征患者的结果表明，RMs对心输出量的有害影响可能超过肺泡增氧对氧合的积极影响，导致组织氧输送的总体减少。本文的在线版本（doi:10.1186/s12890-017-0369-7）包含补充材料，可供授权用户使用。
Clinical trials have, so far, failed to establish clear beneficial outcomes of recruitment maneuvers (RMs) on patient mortality in acute respiratory distress syndrome (ARDS), and the effects of RMs on the cardiovascular system remain poorly understood. A computational model with highly integrated pulmonary and cardiovascular systems was configured to replicate static and dynamic cardio-pulmonary data from clinical trials. Recruitment maneuvers (RMs) were executed in 23 individual in-silico patients with varying levels of ARDS severity and initial cardiac output. Multiple clinical variables were recorded and analyzed, including arterial oxygenation, cardiac output, peripheral oxygen delivery and alveolar strain. The maximal recruitment strategy (MRS) maneuver, which implements gradual increments of positive end expiratory pressure (PEEP) followed by PEEP titration, produced improvements in PF ratio, carbon dioxide elimination and dynamic strain in all 23 in-silico patients considered. Reduced cardiac output in the moderate and mild in silico ARDS patients produced significant drops in oxygen delivery during the RM (average decrease of 423 ml min−1 and 526 ml min−1, respectively). In the in-silico patients with severe ARDS, however, significantly improved gas-exchange led to an average increase of 89 ml min−1 in oxygen delivery during the RM, despite a simultaneous fall in cardiac output of more than 3 l min−1 on average. Post RM increases in oxygen delivery were observed only for the in silico patients with severe ARDS. In patients with high baseline cardiac outputs (>6.5 l min−1), oxygen delivery never fell below 700 ml min−1. Our results support the hypothesis that patients with severe ARDS and significant numbers of alveolar units available for recruitment may benefit more from RMs. Our results also indicate that a higher than normal initial cardiac output may provide protection against the potentially negative effects of high intrathoracic pressures associated with RMs on cardiac function. Results from in silico patients with mild or moderate ARDS suggest that the detrimental effects of RMs on cardiac output can potentially outweigh the positive effects of alveolar recruitment on oxygenation, resulting in overall reductions in tissue oxygen delivery. The online version of this article (doi:10.1186/s12890-017-0369-7) contains supplementary material, which is available to authorized users.