Lung Recruitment in Obese Patients with Acute Respiratory Distress Syndrome
Lung Recruitment in Obese Patients with Acute Respiratory Distress Syndrome
复制标题
DOI：
10.1097/aln.0000000000002638
复制
发表时间：
2019-05-01
期刊：
影响因子：
8.8
通讯作者：
Zhao, Jing
中科院分区：
文献类型：
--
作者：
Fumagalli, Jacopo;Santiago, Roberta R. S.;Zhao, Jing
背景资料：肥胖患者的特征是正常的胸壁弹性和高胸膜压力，并且已被排除在评估急性呼吸窘迫综合征（ARDS）中设置呼气末正压（PEEP）的最佳策略的试验之外。作者假设严重肥胖的ARDS患者存在高度的肺萎陷，在肺复张操作之前通过滴定PEEP可以逆转。方法：严重肥胖的ARDS患者参加了一项生理交叉研究，评估按以下顺序应用的三种PEEP滴定策略的效果：（1）PEEP ARDSNET：低PEEP/Fio（2）ARDSnet表;（2）PEEP INCREMENTAL：PEEP水平设置，以确定一个积极的呼气末跨肺压;和（3）PEEP递减：PEEP水平设置，以确定最低的呼吸系统弹性在递减PEEP试验后，招募操作呼吸力学，区域肺萎陷，过度膨胀根据电阻抗断层扫描和气体exchanges.Results：14例患者进行了研究程序。在PEEP ARDSNET（13 +/- 1 cm H2O）时，呼气末跨肺压为负（-5 +/- 5 cm H2O），肺弹性为27 +/- 12 cm H2O/L，PaO 2/Fio（2）为194 +/- 111 mmHg。与PEEP ARDSNET相比，在PEEP增量水平（22 +/- 3 cm H2O）肺容量增加（977 +/- 708 ml），肺弹性降低（23 +/- 7 cm H2O/l），肺萎陷减少（18 +/- 10%），通气均匀性增加，因此氧合增加（251 +/- 105 mmHg），尽管过度扩张水平较高（16 +/- 12%），但所有值与PEEP ARDSnet相比P < 0.05。根据肺复张操作后的PEEP DECREMENTAL试验设置PEEP（21 +/- 4 cm H2O，P = 0.99 vs. PEEP增量）进一步降低肺弹性（19 +/- 6 cm H2O/l）和氧合增加（329 +/- 82 mmHg），同时减少肺萎陷（9 +/- 2%）和过度扩张（11 +/- 2%），所有值与PEEP ARDSnet和PEEP INCREMENTAL相比P < 0.05。所有患者维持滴定PEEP水平长达24 h，无血流动力学或通气相关的并发症。结论：在PEEP滴定策略测试，设置PEEP根据PEEP递减试验之前的招聘机动获得最佳的肺功能，减少肺过度膨胀和塌陷，恢复肺弹性，氧合提示肺组织招聘。
Background: Obese patients are characterized by normal chest-wall elastance and high pleural pressure and have been excluded from trials assessing best strategies to set positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS). The authors hypothesized that severely obese patients with ARDS present with a high degree of lung collapse, reversible by titrated PEEP preceded by a lung recruitment maneuver.Methods: Severely obese ARDS patients were enrolled in a physiologic crossover study evaluating the effects of three PEEP titration strategies applied in the following order: (1) PEEP ARDSNET : the low PEEP/Fio(2) ARDSnet table; (2) PEEP INCREMENTAL : PEEP levels set to determine a positive end-expiratory transpulmonary pressure; and (3) PEEP DECREMENTAL : PEEP levels set to determine the lowest respiratory system elastance during a decremental PEEP trial following a recruitment maneuver on respiratory mechanics, regional lung collapse, and overdistension according to electrical impedance tomography and gas exchange.Results: Fourteen patients underwent the study procedures. At PEEP ARDSNET (13 +/- 1 cm H2O) end-expiratory transpulmonary pressure was negative (-5 +/- 5 cm H2O), lung elastance was 27 +/- 12 cm H2O/L, and PaO2/Fio(2) was 194 +/- 111 mmHg. Compared to PEEP ARDSNET, at PEEP INCREMENTAL level (22 +/- 3 cm H2O) lung volume increased (977 +/- 708 ml), lung elastance decreased (23 +/- 7 cm H2O/l), lung collapse decreased (18 +/- 10%), and ventilation homogeneity increased thus rising oxygenation (251 +/- 105 mmHg), despite higher overdistension levels (16 +/- 12%), all values P < 0.05 versus PEEP ARDSnet. Setting PEEP according to a PEEP DECREMENTAL trial after a recruitment maneuver (21 +/- 4 cm H2O, P = 0.99 vs. PEEP INCREMENTAL) further lowered lung elastance (19 +/- 6 cm H2O/l) and increased oxygenation (329 +/- 82 mmHg) while reducing lung collapse (9 +/- 2%) and overdistension (11 +/- 2%), all values P < 0.05 versus PEEP ARDSnet and PEEP INCREMENTAL. All patients were maintained on titrated PEEP levels up to 24 h without hemodynamic or ventilation related complications.Conclusions: Among the PEEP titration strategies tested, setting PEEP according to a PEEP DECREMENTAL trial preceded by a recruitment maneuver obtained the best lung function by decreasing lung overdistension and collapse, restoring lung elastance, and oxygenation suggesting lung tissue recruitment.