High PEEP in acute respiratory distress syndrome: quantitative evaluation between improved arterial oxygenation and decreased oxygen delivery.
High PEEP in acute respiratory distress syndrome: quantitative evaluation between improved arterial oxygenation and decreased oxygen delivery.
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DOI：
10.1093/bja/aew314
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发表时间：
2016-11
影响因子：
9.8
通讯作者：
Hardman JG
中科院分区：
文献类型：
--
作者：
Chikhani M;Das A;Haque M;Wang W;Bates DG;Hardman JG
呼气末正压 (PEEP) 广泛用于改善急性呼吸窘迫综合征 (ARDS) 机械通气患者的氧合并防止肺泡塌陷。尽管 PEEP 可预期改善动脉氧合，但高 PEEP 策略已证明对 ARDS 相关死亡率的改善效果不明确。 PEEP 对组织氧输送的影响知之甚少，并且难以在临床环境中量化或研究。我们使用高度集成的呼吸和心血管系统的新型高保真计算模型研究了 PEEP 对 ARDS 组织氧输送的影响。该模型被配置为复制已发表的关于 12 名 ARDS 患者对 PEEP 变化的反应的临床试验数据。这些虚拟患者在肺保护性通气策略（0-20 cm H2O）期间接受不断增加的 PEEP 水平。测量变量包括动脉氧合、心输出量、外周氧输送和肺泡应变。随着 PEEP 增加，尽管动脉氧张力增加（20 cm H2O PEEP 平均增加 6.7 kPa），但所有受试者的组织氧输送均减少（20 cm H2O PEEP 平均减少 25%）。受试者之间动脉氧合和组织氧输送的变化有所不同，但表现出一致的模式。随着 PEEP 增加，所有患者的静态和动态肺泡应变均下降。 ARDS 中增加 PEEP 似乎可以保护肺泡并改善动脉氧合，但由于心输出量减少，似乎也会显着损害组织氧输送。我们认为，这种权衡可能可以解释与高 PEEP 通气策略相关的死亡率改善不佳的原因。
Positive end-expiratory pressure (PEEP) is widely used to improve oxygenation and prevent alveolar collapse in mechanically ventilated patients with the acute respiratory distress syndrome (ARDS). Although PEEP improves arterial oxygenation predictably, high-PEEP strategies have demonstrated equivocal improvements in ARDS-related mortality. The effect of PEEP on tissue oxygen delivery is poorly understood and is difficult to quantify or investigate in the clinical environment. We investigated the effects of PEEP on tissue oxygen delivery in ARDS using a new, high-fidelity, computational model with highly integrated respiratory and cardiovascular systems. The model was configured to replicate published clinical trial data on the responses of 12 individual ARDS patients to changes in PEEP. These virtual patients were subjected to increasing PEEP levels during a lung-protective ventilation strategy (0–20 cm H2O). Measured variables included arterial oxygenation, cardiac output, peripheral oxygen delivery, and alveolar strain. As PEEP increased, tissue oxygen delivery decreased in all subjects (mean reduction of 25% at 20 cm H2O PEEP), despite an increase in arterial oxygen tension (mean increase 6.7 kPa at 20 cm H2O PEEP). Changes in arterial oxygenation and tissue oxygen delivery differed between subjects but showed a consistent pattern. Static and dynamic alveolar strain decreased in all patients as PEEP increased. Incremental PEEP in ARDS appears to protect alveoli and improve arterial oxygenation, but also appears to impair tissue oxygen delivery significantly because of reduced cardiac output. We propose that this trade-off may explain the poor improvements in mortality associated with high-PEEP ventilation strategies.
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影响因子：
9.8
作者：
Hardman, JG;Bedforth, NM;Aitkenhead, AR
通讯作者：
Aitkenhead, AR
DOI：
10.1186/s13054-014-0723-6
发表时间：
2015-01-12
期刊：
Critical care (London, England)
影响因子：
--
作者：
Das A;Cole O;Chikhani M;Wang W;Ali T;Haque M;Bates DG;Hardman JG
通讯作者：
Hardman JG
DOI：
10.1164/ajrccm.164.1.2007011
发表时间：
2001-07-01
影响因子：
24.7
作者：
Crotti, S;Mascheroni, D;Gattinoni, L
通讯作者：
Gattinoni, L
影响因子：
9.6
作者：
DANTZKER, DR;LYNCH, JP;WEG, JG
通讯作者：
WEG, JG
DOI：
10.1164/ajrccm.156.5.9604081
发表时间：
1997-11-01
影响因子：
24.7
作者：
Carvalho, CRR;Barbas, CSV;Amato, MBP
通讯作者：
Amato, MBP