Effects of recruiting maneuvers in patients with acute respiratory distresss syndrome ventilated with protective ventilatory strategy
Effects of recruiting maneuvers in patients with acute respiratory distresss syndrome ventilated with protective ventilatory strategy
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DOI：
10.1097/00000542-200204000-00005
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发表时间：
2002-04-01
期刊：
影响因子：
8.8
通讯作者：
Ranieri, VM
中科院分区：
文献类型：
--
作者：
Grasso, S;Mascia, L;Ranieri, VM
工作背景：低潮气量（V-T）肺保护性通气策略已被提出用于急性呼吸窘迫综合征（ARDS）。肺泡去募集可能发生在使用肺保护性呼吸策略期间，并且可以通过募集策略来预防。本研究检验了这一假设，即肺和胸壁的弹性特性会影响ARDS患者的复张策略改善氧合的有效性。方法：在使用ARDSNet肺保护性复张策略期间，研究了22例ARDS患者：V-T设定为6 ml/kg预测体重，呼气末正压（PEEP）和吸气氧分数（FIO 2）设定为获得90- 100%的动脉氧饱和度。95%和/或动脉血氧分压（Pao（2））为60-80 mmHg（基线）。Pao（2）/FIO 2、静态容积-压力曲线、复张容积（容积-压力曲线的垂直位移）、胸壁和肺弹性（Est（W）和Est（L）：食管压力）在呼气末压力为零、基线、复张操作（40 cm H2O持续气道正压40 s）后2 min和20 min进行测量。心输出量（经食管多普勒）和平均动脉压测量之前，期间，并立即在招募策略。结果：在无反应者中，招募策略使Pao（2）/FIO 2增加了20 +/- 3%（n = 11），在反应者中增加了175 +/- 23%（n = 11;平均值+/-标准差）。在零呼气末压时，无应答者的Est（L）（28.4 +/- 2.2 vs. 24.2 +/- 2.9 cm H2O/I）和Est（W）（10.4 +/- 1.8 vs. 5.6 +/- 0.8 cm H2O/I）高于应答者（P < 0.01）。无应答者的通气时间长于应答者（7 +/- 1 vs. 1 +/- 0.3天; P < 0.001）。无应答者的心输出量和平均动脉压分别下降31 +/- 2和19 +/- 3%，应答者分别下降2 +/- 1和2 +/- 10%（P < 0.01）。肺复张策略的应用仅在早期ARDS患者中改善氧合，这些患者没有胸壁力学损伤，并且具有很大的肺复张潜力，如Est的低值所示。
Background: A lung-protective ventilatory strategy with low tidal volume (V-T) has been proposed for use in acute respiratory distress syndrome (ARDS). Alveolar derecruitment may occur during the use of a lung-protective ventilatory strategy and may be prevented by recruiting maneuvers. This study examined the hypothesis that the effectiveness of a recruiting maneuver to improve oxygenation in patients with ARDS would be influenced by the elastic properties of the lung and chest wall.Methods: Twenty-two patients with ARDS were studied during use of the ARDSNet lung-protective ventilatory strategy: V-T was set at 6 ml/kg predicted body weight and positive end-expiratory pressure (PEEP) and inspiratory oxygen fraction (FIO2) were set to obtain an arterial oxygen saturation of 90-95% and/or an arterial oxygen partial pressure (Pao(2)) of 60-80 mmHg (baseline). Measurements of Pao(2)/FIO2, static volume-pressure curve, recruited volume (vertical shift of the volume-pressure curve), and chest wall and lung elastance (Est(W) and Est(L): esophageal pressure) were obtained on zero end-expiratory pressure, at baseline, and at 2 and 20 min after application of a recruiting maneuver (40 cm H2O of continuous positive airway pressure for 40 s). Cardiac output (transesophageal Doppler) and mean arterial pressure were measured Immediately before, during, and immediately after the recruiting maneuver. Patients were classified a priori as responders and nonresponders on the basis of the occurrence or nonoccurrence of a 50% increase in Pao(2)/FIO2 after the recruiting maneuver.Results: Recruiting maneuvers increased Pao(2)/FIO2 by 20 +/- 3% in nonresponders (n = 11) and by 175 +/- 23% (n = 11; mean +/- standard deviation) in responders. on zero end-expiratory pressure, ESt(L) (28.4 +/- 2.2 vs. 24.2 +/- 2.9 cm H2O/I) and Est(W) (10.4 +/- 1.8 vs. 5.6 +/- 0.8 cm H2O/I) were higher in nonresponders than in responders (P < 0.01). Nonresponders had been ventilated for a longer period of time than responders (7 +/- 1 vs. 1 +/- 0.3 days; P < 0.001). Cardiac output and mean arterial pressure decreased by 31 +/- 2 and 19 +/- 3% in nonresponders and by 2 +/- 1 and 2 +/- 10% in responders (P < 0.01).Conclusions: Application of recruiting maneuvers improves oxygenation only in patients with early ARDS who do not have impairment of chest wall mechanics and with a large potential for recruitment, as indicated by low values of Est,.