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中华危重症医学杂志(电子版) ›› 2018, Vol. 11 ›› Issue (03) : 168 -173. doi: 10.3877/cma.j.issn.1674-6880.2018.03.005

所属专题： 文献；

论著

食道压法设置呼气末正压在急性Stanford A型主动脉夹层术后低氧血症中的应用
孙芳1, 章文豪1, 章淬1, 赵谊1, 祁祥1, 陈永铭1, 穆心苇1,†()   
  1. 1. 210006　南京，南京医科大学附属南京医院重症医学科
  • 收稿日期:2017-08-06 出版日期:2018-06-01
  • 通信作者: 穆心苇
  • 基金资助:
    南京市医学科技发展项目(ZKX14036)

Esophageal pressure-guided ventilation in postoperative hypoxemia patients with acute Stanford type A aortic dissection

Fang Sun1, Wenhao Zhang1, Cui Zhang1, Yi Zhao1, Xiang Qi1, Yongming Chen1, Xinwei Mu1,†()   

  1. 1. Department of Intensive Care Unit, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
  • Received:2017-08-06 Published:2018-06-01
  • Corresponding author: Xinwei Mu
  • About author:
    Corresponding author: Mu Xinwei, Email:
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引用本文：

孙芳, 章文豪, 章淬, 赵谊, 祁祥, 陈永铭, 穆心苇. 食道压法设置呼气末正压在急性Stanford A型主动脉夹层术后低氧血症中的应用[J]. 中华危重症医学杂志(电子版), 2018, 11(03): 168-173.

Fang Sun, Wenhao Zhang, Cui Zhang, Yi Zhao, Xiang Qi, Yongming Chen, Xinwei Mu. Esophageal pressure-guided ventilation in postoperative hypoxemia patients with acute Stanford type A aortic dissection[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2018, 11(03): 168-173.

目的

探讨食道压监测调整呼气末正压的方法在改善急性Stanford A型主动脉夹层术后低氧血症中的疗效。

方法

将2016年1月至2017年2月南京医科大学附属南京医院重症医学科收住的40例急性Stanford A型主动脉夹层术后低氧血症患者分为食道压监测组和常规治疗组，每组各20例。记录两组患者的一般资料及预后状况，比较两组患者气体交换及呼吸力学指标，包括呼气末正压、氧合指数、呼气末跨肺压、吸气末跨肺压、肺驱动压、肺弹性阻力、胸壁驱动压、胸壁弹性阻力、呼吸系统驱动压及呼吸系统弹性阻力。

结果

两组急性Stanford A型主动脉夹层术后低氧血症患者入组时、入组24 h和入组48 h的呼气末正压、动脉血氧合指数、呼气末跨肺压、肺驱动压和肺弹性阻力比较，差异均有统计学意义（F=9.583、9.544、17.806、4.799、6.830，P=0.004、0.004、< 0.001、0.035、0.013），进一步两两比较发现，食道压监测组患者入组24 h和入组48 h的呼气末正压、动脉血氧合指数及呼气末跨肺压均较常规治疗组显著升高（P均< 0.05），而肺驱动压和肺弹性阻力均较常规治疗组显著降低（P均< 0.05）。与常规治疗组比较，食道压监测组患者机械通气时间明显降低[（68 ± 20）h vs.（55 ± 16）h，t=2.261，P=0.030]明显缩短；而两组患者住ICU时间[（101 ± 26）h vs.（92 ± 24）h，t=1.226，P=0.228]及和28 d病死率（10% vs. 5%，χ2=0.360，P=0.548）比较，差异均无统计学意义。

结论

根据食道压监测调整呼气末正压可以明显改善急性Stanford A型主动脉夹层术后低氧血症患者的氧合指数，降低肺驱动压及肺弹性阻力，缩短患者机械通气时间。

关键词: 食道压, 急性Stanford A型主动脉夹层, 低氧血症, 呼气末正压, 肺驱动压
Objective

To investigate the clinical effect of positive end-expiratory pressure guided by esophageal pressure on postoperative hypoxemia patients with acute Stanford A aortic dissection.

Methods

From January 2016 to February 2017, 40 patients with hypoxemia after acute Stanford A aortic dissection in Nanjing Hospital Affiliated to Nanjing Medical University were divided into the esophageal pressure monitoring group and routine treatment group, 20 cases in each group. The general data and prognosis of patients in the two groups were recorded. The indexes of gas exchange and respiratory mechanics including positive end-expiratory pressure, oxygenation index, end-expiratory transpulmonary pressure, end-inspiratory transpulmonary pressure, pulmonary driving pressure, pulmonary elastic resistance, chest wall driving pressure, chest wall elastic resistance, respiratory system drive pressure and respiratory system elastic resistance were compared between the two groups.

Results

The positive end-expiratory pressure, arterial blood oxygenation index, end-expiratory transpulmonary pressure, pulmonary driving pressure and pulmonary elastic resistance were significantly different between postoperative hypoxemia patients with acute Stanford A aortic dissection in the two groups at the admission, 24 h and 48 h after admission (F=9.583, 9.544, 17.806, 4.799, 6.830; P=0.004, 0.004, < 0.001, 0.035, 0.013). Further comparison showed that the positive end-expiratory pressure, arterial blood oxygenation index and end-expiratory transpulmonary pressure were significantly higher in the esophageal pressure monitoring group than in the routine treatment group at 24 h and 48 h after admission respectively (all P < 0.05), while the pulmonary driving pressure and pulmonary elastic resistance were significantly lower (all P < 0.05). Compared with the routine treatment group, the mechanical ventilation time in the esophageal pressure monitoring group significantly decreased [(68 ± 20) h vs. (55 ± 16) h; t=2.261, P=0.030]. However, there were no significant differences in the length of stay in ICU [(101 ± 26) h vs. (92 ± 24) h; t=1.226, P=0.228] and 28 d mortality (10% vs. 0.5%, t=0.360, P=0.548) between the two groups.

Conclusion

Adjusting positive end-expiratory pressure according to esophageal pressure monitoring can significantly improve the oxygenation index, reduce the pulmonary driving pressure and pulmonary elastic resistance, and shorten the mechanical ventilation time of patients with hypoxemia after acute Stanford A aortic dissection.

Key words: Esophageal pressure, Acute Stanford type A aortic dissection, Hypoxemia, Positive end-expiratory pressure, Pulmonary driving pressure
表1 两组急性Stanford A型主动脉夹层术后低氧血症患者一般资料的比较（±s）
组别 例数 年龄（岁） 性别比（例，男/女） 体质量（kg） 体质量指数（kg/m2） APACHEⅡ评分（分） 主动脉阻断时间（min）
常规治疗组 20 51 ± 15 14/6 65.3 ± 6.4 25 ± 4 17 ± 4 146 ± 32
食道压监测组 20 54 ± 12 16/4 65.2 ± 4.7 27 ± 4 16 ± 4 135 ± 26
t/χ2值 ? 0.811 0.533 0.056 1.644 1.446 1.289
P值 ? 0.445 0.716 0.955 0.108 0.157 0.247
组别 例数 体外循环时间（min） 停循环时间（min） 动脉血酸碱度 PaO2（mmHg） PCO2（mmHg） 动脉血氧合指数（mmHg） 乳酸（mmol/L）
常规治疗组 20 243 ± 33 18.2 ± 1.0 7.40 ± 0.03 71 ± 6 40.0 ± 2.3 144 ± 26 4.8 ± 1.8
食道压监测组 20 232 ± 27 18.3 ± 1.4 7.41 ± 0.03 70 ± 6 39.1 ± 2.6 138 ± 21 5.7 ± 1.9
t/χ2值 ? 1.176 0.346 1.012 1.215 0.830 0.740 1.430
P值 ? 0.205 0.731 0.318 0.801 0.412 0.464 0.161
表2 两组急性Stanford A型主动脉夹层术后低氧血症患者气体交换指标的比较（±s）
组别 例数 呼气末正压（cmH2O） 动脉血氧合指数（mmHg）
入组时 入组24 h 入组48 h 入组时 入组24 h 入组48 h
常规治疗组 20 5.0 ± 0.0 9.1 ± 2.4 6.7 ± 1.7 142 ± 28 182 ± 34 206 ± 28
食道压监测组 20 5.0 ± 0.0 11.6 ± 1.7 8.1 ± 1.8 136 ± 20 205 ± 29 246 ± 20
F值 ? ? 9.583 ? ? 9.544 ?
P值 ? ? 0.004 ? ? 0.004 ?
组别 例数 呼气末跨肺压（cmH2O） 吸气末跨肺压（cmH2O）
入组时 入组24 h 入组48 h 入组时 入组24 h 入组48 h
常规治疗组 20 -5.0 ± 2.4 -0.5 ± 2.2 -0.9 ± 2.0 4.3 ± 1.5 7.0 ± 2.1 6.6 ± 3.1
食道压监测组 20 -4.2 ± 1.8 1.7 ± 0.4 1.5 ± 0.5 4.5 ± 0.8 7.1 ± 2.4 7.3 ± 2.1
F值 ? ? 17.806 ? ? 0.305 ?
P值 ? ? <0.001 ? ? 0.585 ?
表3 两组急性Stanford A型主动脉夹层术后低氧血症患者呼吸力学指标的比较（±s）
组别 例数 肺驱动压（cmH2O） 肺弹性阻力（cmH2O/L） 胸壁驱动压（cmH2O）
入组时 入组24 h 入组48 h 入组时 入组24 h 入组48 h 入组时 入组24 h 入组48 h
常规治疗组 20 9.3 ± 2.8 7.8 ± 3.6 8.1 ± 3.2 23 ± 7 19 ± 9 20 ± 9 4.7 ± 3.4 6.9 ± 2.5 5.9 ± 1.8
食道压监测组 20 9.0 ± 2.3 5.8 ± 2.7 5.4 ± 2.2 20 ± 7 13 ± 8 12 ± 6 5.2 ± 2.7 7.0 ± 2.8 6.6 ± 0.9
F值 ? ? 4.799 ? ? 6.830 ? ? 0.484 ?
P值 ? ? 0.035 ? ? 0.013 ? ? 0.491 ?
组别 例数 胸壁弹性阻力（cmH2O/L） 呼吸系统驱动压（cmH2O） 呼吸系统弹性阻力（cmH2O/L）
入组时 入组24 h 入组48 h 入组时 入组24 h 入组48 h 入组时 入组24 h 入组48 h
常规治疗组 20 12 ± 9 17 ± 7 15 ± 5 18.3 ± 4.2 14.7 ± 4.5 14.0 ± 3.8 34 ± 11 37 ± 12 36 ± 11
食道压监测组 20 12 ± 7 16 ± 8 15 ± 4 16.8 ± 5.2 12.8 ± 4.0 12.0 ± 2.1 31 ± 14 30 ± 13 27 ± 8
F值 ? ? 0.102 ? ? 2.268 ? ? 2.446 ?
P值 ? ? 0.794 ? ? 0.140 ? ? 0.126 ?
表4 两组急性Stanford A型主动脉夹层术后低氧血症患者预后指标的比较（±s）
组别 例数 机械通气时间（h） 住ICU时间（h） 28 d病死率[例（%）]
常规治疗组 20 68 ± 20 101 ± 26 2（10）
食道压监测组 20 55 ± 16 92 ± 24 1（5）
t/χ2值 ? 2.261 1.226 0.360
P值 ? 0.030 0.228 0.548
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