PURPOSE: 目的

Experimental animal models of acute respiratory distress syndrome (ARDS) have shown that the updated airway pressure release ventilation (APRV) methodologies may significantly improve oxygenation, maximize lung recruitment, and attenuate lung injury, without circulatory depression. This led us to hypothesize that early application of APRV in patients with ARDS would allow pulmonary function to recover faster and would reduce the duration of mechanical ventilation as compared with low tidal volume lung protective ventilation (LTV).

ARDS動物模型表明，最新的氣道壓力釋放通氣(APRV)能夠顯著改善氧合，促進(jìn)肺復(fù)張，減輕肺損傷，且不影響循環(huán)功能。因此，我們假設(shè)，與小潮氣量肺保護(hù)性通氣(LTV)相比，ARDS患者早期使用APRV可能加速肺功能恢復(fù)，縮短機(jī)械通氣時(shí)間。

METHODS: 方法

A total of 138 patients with ARDS who received mechanical ventilation for <48 h between="" may="" 2015="" to="" october="" 2016="" while="" in="" the="" critical="" care="" medicine="" unit="" (icu)="" of="" the="" west="" china="" hospital="" of="" sichuan="" university="" were="" enrolled="" in="" the="" study.="" patients="" were="" randomly="" assigned="" to="" receive="" aprv="" (n =" 71)" or="" ltv="" (n =" 67)." the="" settings="" for="" aprv="" were:="" high="" airway="" pressure="">_high) set at the last plateau airway pressure (P_plat), not to exceed 30 cmH₂O) and low airway pressure ( P_low) set at 5 cmH₂O; the release phase (T_low) setting adjusted to terminate the peak expiratory flow rate to ≥ 50%; release frequency of 10-14 cycles/min. The settings for LTV were: target tidal volume of 6 mL/kg of predicted body weight; P_plat not exceeding 30 cmH₂O; positive end-expiratory pressure (PEEP) guided by the PEEP-FiO₂ table according to the ARDSnet protocol. The primary outcome was the number of days without mechanical ventilation from enrollment to day 28. The secondary endpoints included oxygenation, P_plat, respiratory system compliance, and patient outcomes.

從2015年5月至2016年10月，四川大學(xué)華西醫(yī)院ICU收治的138名接受機(jī)械通氣不足48小時(shí)的ARDS患者入選此研究?；颊弑浑S機(jī)分為APRV組(n = 71)或LTV組(n = 67)。APRV設(shè)置如下：氣道高壓 (P_high) 設(shè)置為最近的平臺壓 (P_plat) 水平，且不超過30 cmH₂O，氣道低壓(P_low) 設(shè)置為5 cmH₂O；壓力釋放時(shí)間 (T_low) 設(shè)置為呼氣末流量相當(dāng)于呼氣峰流量 ≥ 50%；釋放頻率 10-14 次/分。LTV的設(shè)置為：目標(biāo)潮氣量 6 mL/kg理想體重；P_plat 不超過 30 cmH₂O；根據(jù)ARDSnet方案的PEEP-FiO₂ 表格設(shè)置PEEP。

RESULTS: 結(jié)果

Compared with the LTV group, patients in the APRV group had a higher median number of ventilator-free days {19 [interquartile range (IQR) 8-22] vs. 2 (IQR 0-15); P < 0.001}. this="" finding="" was="" independent="" of="" the="" coexisting="" differences="" in="" chronic="" disease.="" the="" aprv="" group="" had="" a="" shorter="" stay="" in="" the="" icu="" (p =" 0.003)." the="" icu="" mortality="" rate="" was="" 19.7%="" in="" the="" aprv="" group="" versus="" 34.3%="" in="" the="" ltv="" group="" (p =" 0.053)" and="" was="" associated="" with="" better="" oxygenation="" and="" respiratory="" system="" compliance,="" lower="">_plat, and less sedation requirement during the first week following enrollment (P < 0.05, repeated-measures="" analysis="" of="">

與LTV組相比，APRV組患者無機(jī)械通氣中位天數(shù)顯著增加{19 [四分位區(qū)間 (IQR) 8-22] vs. 2 (IQR 0-15); P < 0.001}。這一結(jié)果與合并的慢性疾病無關(guān)。aprv組icu住院日縮短(p = 0.003)。aprv組患者icu病死率19.7%，ltv組為34.3% (p ="">_plat 更低，需要鎮(zhèn)靜藥物更少（P <>

CONCLUSIONS: 結(jié)論

Compared with LTV, early application of APRV in patients with ARDS improved oxygenation and respiratory system compliance, decreased P_plat and reduced the duration of both mechanical ventilation and ICU stay.

與LTV相比，ARDS患者早期使用APRV能夠改善氧合及呼吸系統(tǒng)順應(yīng)性，降低P_plat，縮短機(jī)械通氣時(shí)間及ICU住院日。