Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury
Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury
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DOI：
10.1164/ajrccm.164.1.2001078
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发表时间：
2001-07-01
影响因子：
24.7
通讯作者：
Mutz, N
中科院分区：
文献类型：
--
作者：
Putensen, C;Zech, S;Mutz, N
与受控机械通气相比，在气道压力释放通气（APRV）自发呼吸过程中观察到气体交换的改善。本研究旨在确定在有急性呼吸窘迫综合征（ARDS）风险的患者中，与初始受控机械通气相比，使用APRV合并自主呼吸作为初级通气支持方式是否能更好地预防心肺功能恶化。30例多发外伤患者随机分为两组，一组使用APRV进行自主呼吸（APRV组）（n = 15），另一组接受压力控制、时间循环机械通气（PCV组）72小时后使用APRV进行脱机（n = 15）。患者在APRV期间持续输注舒芬太尼和咪达唑仑维持自主呼吸（Ramsay镇静评分[RSS]为3）。采用舒芬太尼、咪达唑仑（RSS为5）和神经肌肉阻断术诱导自发性呼吸缺失（PCV组）。首次使用APRV与呼吸系统顺应性（C(RS)）、动脉氧张力（Pa(O2)）、心脏指数（CI）和氧输送（Do(2)）增加（p < 0.85）相关，与静脉混合(（Q) / dot VA/(Q) / dot T）和氧提取降低（p < 0.05）相关。相比而言，接受72 h PCV治疗的患者C（RS）、Pa(O2) CI、Do(2)和(Q) / dot A/(Q) / dot T值较低（p < 0.05），需要较高剂量的舒芬太尼（p < 0.05）、咪达唑仑（p < 0.05）、去甲肾上腺素（p = 0.05）和多巴酚丁胺（p < 0.05）。C（RS）、Pa（O2）、CI和Do(2)最低（p < 0.05）， (Q) / dot VA/(Q) / dot T最高（p < 0.05）。首次使用APRV与较短的通气支持时间（APRV组：15 +/- 2天[平均+/- SEM]； PCV组：21 +/- 2天）（p < 0.05）和重症监护病房（ICU）住院时间（APRV组：23 +/- 2天；PCV组：30 +/- 2天）一致相关（p < 0.05）。这些发现表明，在APRV期间维持自主呼吸需要较少的镇静并改善心肺功能，可能是通过增加非通气肺单元，需要更短的通气支持时间和ICU住院时间。
Improved gas exchange has been observed during spontaneous breathing with airway pressure release ventilation (APRV) as compared with controlled mechanical ventilation. This study was designed to determine whether use of APRV with spontaneous breathing as a primary ventilatory support modality better prevents deterioration of cardiopulmonary function than does initial controlled mechanical ventilation in patients at risk for acute respiratory distress syndrome (ARDS). Thirty patients with multiple trauma were randomly assigned to either breathe spontaneously with APRV (APRV Group) (n = 15) or to receive pressure-controlled, time-cycled mechanical ventilation (PCV) for 72 h followed by weaning with APRV (PCV Group) (n = 15). Patients maintained spontaneous breathing during APRV with continuous infusion of sufentanil and midazolam (Ramsay sedation score [RSS] of 3). Absence of spontaneous breathing (PCV Group) was induced with sufentanil and midazolam (RSS of 5) and neuromuscular blockade. Primary use of APRV was associated with increases (p < 0.85) in respiratory system compliance (C(RS)), arterial oxygen tension (Pa(O2)), cardiac index (CI), and oxygen delivery (Do(2)), and with reductions (p < 0.05) in venous admixture ((Q) over dot VA/(Q) over dot T), and oxygen extraction. In contrast, patients who received 72 h of PCV had lower C(RS), Pa(O2) CI, Do(2), and (Q) over dot A/(Q) over dot T values (p < 0.05) and required higher doses of sufentanil (p < 0.05), midazolam (p < 0.05), noradrenalin (p = 0.05), and dobutamine (p < 0.05). C(RS), Pa(O2), CI and Do(2) were lowest (p < 0.05) and (Q) over dot VA/(Q) over dot T was highest (p < 0.05) during PCV. Primary use of APRV was consistently associated with a shorter duration of ventilatory support (APRV Group: 15 +/- 2 d [mean +/- SEM]; PCV Group: 21 +/- 2 d) (p < 0.05) and length of intensive care unit (ICU) stay (APRV Group: 23 +/- 2 d; PCV Group: 30 +/- 2 d) (p < 0.05). These findings indicate that maintaining spontaneous breathing during APRV requires less sedation and improves cardiopulmonary function, presumably by recruiting nonventilated lung units, requiring a shorter duration of ventilatory support and ICU stay.