【罂粟摘要】使用电阻抗成像对急性呼吸窘迫综合征患者的呼气末正压和潮气量进行个体化管理：一项初步的可行性研究
使用电阻抗成像对急性呼吸窘迫综合征患者的呼气末正压和潮气量进行个体化管理：一项初步的可行性研究
贵州医科大学 高鸿教授课题组
翻译：吴学艳 编辑：佟睿 审校：曹莹
急性呼吸窘迫综合征(ARDS)患者机械通气中，电阻抗成像(EIT)提供了肺泡循环和过度扩张的信息，以及床边的招募能力评估；利用EIT获得关于招募能力、肺过度膨胀和肺泡循环的信息，研发一种个体化呼气末正压(PEEP)和潮气量(VT)管理方案;本研究目的是评估基于EIT方案是否允许在不导致肺过度扩张情况下的个性化呼吸机设置，并评估其对呼吸系统顺应性、氧合及肺泡循环的影响。
本研究纳入20例ARDS患者，最初根据ARDS管理指南，以VT6ml/kg潮气量进行机械通气，PEEP根据较低的PEEP/FiO2表调整；随后，基于EIT方案每30分钟调整一次呼吸机设置，持续时间为4小时。为了评估肺整体过度扩张，确定肺压力和张力是否分别保持在27mbar和2.0以下。
用EIT进行机械通气的前瞻性优化所致更高的PEEP水平(16.5 [14-18]mbar优化前是10 [8-10]mbar;p = 0.0001)；VT相似(5.7±0.92 ml/kg 优化前是5.8±0.47 ml/kg;p = 0.96)。所有患者整体肺应力均低于27 mbar, 20例患者中有19例的整体张力低于2.0；EIT优化后，依从性保持不变，氧合功能显著改善，肺泡循环减少。
使用基于EIT方案调整PEEP和VT使得呼吸机设置个体化，改善氧合，减少肺泡循环，而不促进整体过度扩张。
Becher T, Buchholz V, Hassel D,et al.Individualization of PEEP and tidal volume in ARDS patients with electrical impedance tomography: a pilot feasibility study.Ann Intensive Care 2021 Jun 02;11(1)
Individualization of PEEP and tidal volume in ARDS patients with electrical impedance tomography: a pilot feasibility study
Background: In mechanically ventilated patients with acute respiratory distress syndrome (ARDS), electrical impedance tomography (EIT) provides information on alveolar cycling and overdistension as well as assessment of recruitability at the bedside. We developed a protocol for individualization of positive end-expiratory pressure (PEEP) and tidal volume (VT) utilizing EIT-derived information on recruitability, overdistension and alveolar cycling. The aim of this study was to assess whether the EIT-based protocol allows individualization of ventilator settings without causing lung overdistension, and to evaluate its efects on respiratory system compliance, oxygenation and alveolar cycling.
Methods: 20 patients with ARDS were included. Initially, patients were ventilated according to the recommendations of the ARDS Network with a VT of 6 ml per kg predicted body weight and PEEP adjusted according to the lower PEEP/FiO2 table. Subsequently, ventilator settings were adjusted according to the EIT-based protocol once every 30 min for a duration of 4 h. To assess global overdistension, we determined whether lung stress and strain remained below 27 mbar and 2.0, respectively.
Results: Prospective optimization of mechanical ventilation with EIT led to higher PEEP levels (16.5 [14–18] mbar vs. 10 [8–10] mbar before optimization; p=0.0001) and similar VT (5.7±0.92 ml/kg vs. 5.8±0.47 ml/kg before optimization; p=0.96). Global lung stress remained below 27 mbar in all patients and global strain below 2.0 in 19 out of 20 patients. Compliance remained similar, while oxygenation was signifcantly improved and alveolar cycling was reduced after EIT-based optimization.
Conclusions: Adjustment of PEEP and VT using the EIT-based protocol led to individualization of ventilator settings with improved oxygenation and reduced alveolar cycling without promoting global overdistension.Trial registrationThis study was registered at clinicaltrials.gov (NCT02703012) on March 9, 2016 before including the first patient.
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