Patient-Ventilator Interaction During Acute Lung Injury, and the Role of Spontaneous Breathing: Part 2: Airway Pressure Release Ventilation
Patient-Ventilator Interaction During Acute Lung Injury, and the Role of Spontaneous Breathing: Part 2: Airway Pressure Release Ventilation
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DOI：
10.4187/respcare.00968
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发表时间：
2011-02-01
期刊：
影响因子：
2.5
通讯作者：
Kallet, Richard H.
中科院分区：
文献类型：
--
作者：
Kallet, Richard H.
气道压力释放通气（APRV）和双水平气道正压通气（BIPAP）旨在充分减少患者呼吸功（WOB）并消除与患者-呼吸机同步相关的问题，以便在急性肺损伤（ALI）的整个过程中维持自主呼吸。因此，APRV/BIPAP 应减少镇静和肌肉麻痹的需求，从而减少机械通气的持续时间。只有 17 项人类、动物或肺模型研究直接或间接检验了这些说法。大多数并不针对 ALI 患者。关于镇静剂使用的研究存在严重的方法学局限性。其他研究发现 APRV/BIPAP 要么增加 WOB 和异步性，要么对能量消耗没有影响。为了补充 ALI 中 APRV/BIPAP 期间患者 WOB 的讨论，4 个临床实例显示患者 WOB 显着升高和广泛变化。一种合理的解释是自主呼吸叠加在机械通气模式上。因此，在 APRV/BIPAP 期间存在多种“呼吸环境”，这些环境对患者 WOB 和呼吸驱动产生不同的影响，并且可能是不可预测的。 APRV/BIPAP 的这一特性使得 WOB 与传统模式的比较存在问题。此外，当肺保护性通气用于每分钟通气量需求较高的 ALI 患者时，APRV 在控制患者 WOB 方面的理论上的益处似乎特别有限。未来的研究应重点关注 WOB 和同步性问题，以便设计合理的通气方案来测试传统模式的临床结果。迄今为止，低水平证据表明，用 APRV/BIPAP 促进自主呼吸可能不适合相对严重的 ALI/ARDS 患者。
Airway pressure release ventilation (APRV) and bi-level positive airway pressure (BIPAP) are proposed to reduce patient work of breathing (WOB) sufficiently and to obviate issues related to patient-ventilator synchrony, so that spontaneous breathing can be maintained throughout the course of acute lung injury (ALI). Thus, APRV/BIPAP should reduce requirements for sedation and muscle paralysis, and thereby reduce the duration of mechanical ventilation. Only 17 human, animal, or lung-model studies have examined these claims, either directly or indirectly. Most did not target patients with ALI. Studies on sedation use have serious methodological limitations. Other studies found that APRV/BIPAP either increased WOB and asynchrony, or had no effect on energy expenditure. To supplement the discussion of patient WOB during APRV/BIPAP in ALI, 4 clinical examples showed marked elevation and wide variation in patient WOB. One plausible explanation is that spontaneous breathing is superimposed upon the mechanical ventilation pattern. Thus a variety of "breathing environments" exist during APRV/BIPAP that affect patient WOB and respiratory drive differently and perhaps unpredictably. This characteristic of APRV/BIPAP makes WOB comparisons with traditional modes problematic. Furthermore, the theoretical benefits of APRV, in terms of controlling patient WOB, appear particularly limited when lung-protective ventilation is used for ALI patients with high minute ventilation demand. Future research should focus on issues of WOB and synchrony, so that reasonable ventilation protocols can be devised to test clinical outcomes against traditional modes. To date, low-level evidence suggests that promoting spontaneous breathing with APRV/BIPAP may not be appropriate in patients with relatively severe ALI/ARDS.