【摘要】 目的评价气道压力释放通气（airway pressure release ventilation,APRV）对急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）患者的疗效并观察其是否可减轻呼吸机相关性肺损伤（ventilator-induced lung injury,VILI）。方法选择河北医科大学第一医院重症医学科2013年1月至2014年12月收治的ARDS患者,随机分为同步间歇指令通气（synchronized intermittent mandatory ventilation,SIMV）组32例和气道压力释放通气（airway pressure release ventilation,APRV）组30例,利用AVEA呼吸机"转折点（Pflex）程序",测定准静态P-V曲线的高、低位拐点（upper inflection point,UIP;lower inflection point,LIP）以及高低位拐点间三角区Pflex容积,据此设置呼吸机参数。SIMV组采用小潮气量+PEEP肺保护性通气策略,APRV组采用气道压力释放通气,通气24小时后复测准静态P-V曲线及高、低位拐点和三角区Pflex容积。分别于入组时、通气24小时和通气48小时留取静脉血检测肺表面活性蛋白D（surfactant protein D,SP-D）、KL-6浓度。组间数据、组内数据差异分别采用独立样本t检验、配对样本t检验进行分析。结果共73例患者符合标准入选,其中62例完成试验（SIMV组32例、APRV组30例）。两组患者的基本情况差异无显著性,通气24小时、48小时后氧合均明显改善,血流动力学指标无明显变化,APRV组P_mean明显高于SIMV组[（22.16±4.18）cmH₂Ovs（18.63±3.54）cmH₂O,P=0.003;（19.70±3.75）cmH₂O vs（18.63±2.92）cmH₂O,P=0.047]。通气24小时前后APRV组高、低位拐点间三角区Pflex容积增加比例高于SIMV组（90%vs 75%）。通气24小时后APRV组血清SP-D浓度呈升高趋势[（18.57±5.24）ng/ml vs（26.34±9.59）ng/ml]。结论相对于小潮气量+PEEP肺保护性通气策略,气道压力释放通气可改善急性呼吸窘迫综合征患者的氧合,更有效地进行肺复张,对血流动力学无明显影响,但会显著加重VILI。更多还原

【Abstract】 Objective To provide clinical practice’s evidence of APRV and discusses its possible mechanism. Method The patients with ALI/ARDS were selected. The patients were divided into two groups randomly: The APRV group: Airway pressure release ventilation pattern and the other is lung protection ventilation with lower tidal volume group. The mechanical ventilation parameters were detected basing on the quasistatic P-V curve. After 24 and 48 hours ventilation, the quasistatic P-V curve described again in order to compare with before results. Venous blood was extracted to measure SP-D and KL-6 in blood serum with ELISA. The count data were analyzed with a chi-square test and the normal distribution data were analyzed with a two-tailed Student’s t-test(mean values). Result The parameters in the 62 patients were similar. After 24 hours and 48 hours mechanical ventilation in two groups, the patients’ oxygenation was improved significantly, but there were no significant changes in hemodynamic parameters. The Pmean in the APRV group was higher than that in the other group obviously. After 24 hours ventilation, 27 patients in 30 APRV and 24 patients the other group increased Vdelta respectively. After 24 hours ventilation, the SP-D density in blood serum in APRV group had the tendency of increase, but that had the tendency of decrease in the other group. Conclusion With lung protective ventilation strategy, airway pressure release ventilation was similar in oxygenate. The higher Pmean pressure of APRV could recruit alveolar more effectively, which had not impact on blood stream dynamics,but the higher Pmean pressure had caused ventilator-induced lung injury.更多还原