Application of right heart protective ventilation in acute respiratory distress syndrome patients: a prospective randomized controlled trail

doi:10.3877/cma.j.issn.1674-6880.2023.06.004

Abstract

Abstract:

Objective

To investigate the effect of right heart protective ventilation strategy on right heart function and prognosis in patients with acute respiratory distress syndrome (ARDS).

Methods

Using a prospective randomized controlled trial (RCT) method, 83 patients with ARDS who were hospitalized in Shaanxi Provincial People's Hospital from January 2021 to September 2022 were selected and randomly divided into a control group (n = 41) and a observation group (n = 42). The control group was treated with conventional lung protective ventilation, and the observation group was treated with right heart protective ventilation. Echocardiography was performed to evaluate right heart systolic and diastolic function. The ventilator parameters, blood gas analysis results, and prognostic indicators such as 28-day mortality, duration of mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and prone position ratio and time were recorded respectively.

Results

After 72 hours of mechanical ventilation, the respiratory compliance, tidal volume, respiratory rate, peak airway pressure, plateau pressure, driving pressure, Tei index, right ventricular fractional area change (RVFAC), right/left ventricular end-diastolic diameter (R/L) in the observation group were all improved as compared with the basal values (all P < 0.05). The plateau pressure, driving pressure, Tei index, and tissue Doppler velocities of the tricuspid annulus (E/e') were significantly lower, while the tricuspid annular plane systolic excursion (TAPSE), RVFAC, tricuspid annular motion (TAM), and Doppler velocities of the transtricuspid flow (E/A) were higher in the observation group than in the control group (all P < 0.05). The duration of mechanical ventilation in the observation group was shorter than that in the control group [(10 ± 3) d vs. (14 ± 6) d, t = 2.306, P = 0.026]. The 28-day mortality [38.1% (16/42) vs. 63.4% (26/41), χ² = 2.805, P = 0.099], ICU stay [(17 ± 6) d vs. (17 ± 7) d, t = 0.152, P = 0.873], amount of fluid [2 876.8 (1 062.9, 3 399.6) mL vs. 1 458.7 (-150.2, 3 821.4) mL, Z = 0.364, P = 0.750], proportion of prone position [47.6% (20/42) vs. 41.5% (17/41), χ² = 0.660, P = 0.360], ECMO [40.5% (17/42) vs. 31.7% (13/41), χ² = 1.850, P = 0.177], and proportion of vasoactive drug use [40.5% (17/42) vs. 48.8% (20/41), χ² = 1.122, P = 0.289] in the observation group and control group showed no statistically significant difference.

Conclusions

The right heart protective ventilation strategy given to ARDS patients is consistent with the effectiveness of the conventional lung protective ventilation strategy. It can reduce the incidence of right heart disorders, and has a protective effect on right heart function with less impact on both systolic and diastolic function.

Key words: Acute respiratory distress syndrome, Right heart protective ventilation strategy, Right heart function, Prognosis

Daoran Dong, Yuan Zong, Yan Wang, Chengqiao Jing, Jiawei Ren. Application of right heart protective ventilation in acute respiratory distress syndrome patients: a prospective randomized controlled trail[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2023, 16(06): 461-468.

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Figures/Tables 4

References 33

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组别	例数	年龄（岁）	性别（例，男/女）	体质量（kg）	APACHEⅡ评分[分，M（P₂₅，P₇₅）]	心率（次/min）	平均动脉压（mmHg）	潮气量（mL）	基础血气分析
组别	例数	年龄（岁）	性别（例，男/女）	体质量（kg）	APACHEⅡ评分[分，M（P₂₅，P₇₅）]	心率（次/min）	平均动脉压（mmHg）	潮气量（mL）	PaO₂（mmHg）	PaCO₂（mmHg）	乳酸[mmol/L，M（P₂₅，P₇₅）]	pH值
对照组	41	57 ± 18	24/17	63 ± 20	23（12，38）	107 ± 30	81 ± 22	377 ± 120	85 ± 32	44 ± 12	2.2（1.7，8.7）	7.41 ± 0.20
观察组	42	50 ± 17	22/20	68 ± 22	26（14，34）	110 ± 25	73 ± 14	405 ± 130	79 ± 31	44 ± 10	2.2（1.7，6.4）	7.34 ± 0.15
t/χ²/Z值		0.511	0.035	0.726	0.176	0.292	1.356	0.961	1.474	0.176	0.842	1.148
P值		0.219	0.851	0.473	0.864	0.771	0.182	0.471	0.513	0.862	0.402	0.255
组别	例数	发病原因[例（%）]								ARDS严重程度[例（%）]
组别	例数	肺部感染	误吸	肺内其他原因	脓毒症	胰腺炎	休克	创伤	肺外其他原因	轻度	中度	重度
对照组	41	21（51.2）	3（7.3）	4（9.8）	4（9.8）	2（4.9）	2（4.9）	0（0.0）	5（12.2）	7（17.1）	24（58.5）	10（24.4）
观察组	42	24（57.1）	1（2.4）	2（4.8）	6（14.3）	2（4.8）	4（9.5）	1（2.4）	2（4.8）	10（23.8）	19（45.2）	13（31.0）
t/χ²/Z值		5.980								4.439
P值		0.545								0.410

组别	例数	年龄（岁）	性别（例，男/女）	体质量（kg）	APACHEⅡ评分[分，M（P₂₅，P₇₅）]	心率（次/min）	平均动脉压（mmHg）	潮气量（mL）	基础血气分析
组别	例数	年龄（岁）	性别（例，男/女）	体质量（kg）	APACHEⅡ评分[分，M（P₂₅，P₇₅）]	心率（次/min）	平均动脉压（mmHg）	潮气量（mL）	PaO₂（mmHg）	PaCO₂（mmHg）	乳酸[mmol/L，M（P₂₅，P₇₅）]	pH值
对照组	41	57 ± 18	24/17	63 ± 20	23（12，38）	107 ± 30	81 ± 22	377 ± 120	85 ± 32	44 ± 12	2.2（1.7，8.7）	7.41 ± 0.20
观察组	42	50 ± 17	22/20	68 ± 22	26（14，34）	110 ± 25	73 ± 14	405 ± 130	79 ± 31	44 ± 10	2.2（1.7，6.4）	7.34 ± 0.15
t/χ²/Z值		0.511	0.035	0.726	0.176	0.292	1.356	0.961	1.474	0.176	0.842	1.148
P值		0.219	0.851	0.473	0.864	0.771	0.182	0.471	0.513	0.862	0.402	0.255
组别	例数	发病原因[例（%）]								ARDS严重程度[例（%）]
组别	例数	肺部感染	误吸	肺内其他原因	脓毒症	胰腺炎	休克	创伤	肺外其他原因	轻度	中度	重度
对照组	41	21（51.2）	3（7.3）	4（9.8）	4（9.8）	2（4.9）	2（4.9）	0（0.0）	5（12.2）	7（17.1）	24（58.5）	10（24.4）
观察组	42	24（57.1）	1（2.4）	2（4.8）	6（14.3）	2（4.8）	4（9.5）	1（2.4）	2（4.8）	10（23.8）	19（45.2）	13（31.0）
t/χ²/Z值		5.980								4.439
P值		0.545								0.410

组别	例数	氧合指数（mmHg）		PaCO₂（mmHg）		呼吸系统顺应性（mL/cmH₂O）		PaO₂（mmHg）		FiO₂（%）		呼气末正压（cmH₂O）
组别	例数	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h
对照组	41	102 ± 43	173 ± 42^a	44 ± 12	43 ± 6	33 ± 6	38 ± 8^a	85 ± 32	107 ± 18	77 ± 15	65 ± 18^a	10.2 ± 2.2	10.8 ± 4.1^a
观察组	42	129 ± 73	170 ± 67	44 ± 10	46 ± 7	29 ± 10	36 ± 9^a	79 ± 31	103 ± 31	72 ± 14	65 ± 11	10.9 ± 2.8	9.7 ± 3.1
t值		1.118	0.148	0.176	1.616	1.333	0.931	1.474	0.473	0.962	0.141	0.793	0.979
P值		0.147	0.886	0.862	0.119	0.183	0.352	0.513	0.635	0.345	0.889	0.439	0.336
组别	例数	潮气量（mL）		呼吸频率（次/min）		气道峰压（cmH₂O）		平均气道压（cmH₂O）		平台压（cmH₂O）		驱动压（cmH₂O）
组别	例数	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h
对照组	41	440 ± 86	399 ± 61	33 ± 5	19 ± 5^a	36 ± 4	28 ± 4^a	24 ± 4	24 ± 4	27.4 ± 1.1	28.7 ± 5.5	17.1 ± 6.0	18.0 ± 3.5
观察组	42	463 ± 69	377 ± 61^a	33 ± 8	17 ± 3^a	35 ± 4	27 ± 4^a	23 ± 5	24 ± 4	29.6 ± 5.1	24.8 ± 3.3^a	18.5 ± 5.8	15.0 ± 2.6^a
t值		0.961	1.132	0.204	1.277	0.758	0.885	0.172	0.097	0.131	2.789	0.769	3.197
P值		0.345	0.269	0.831	0.207	0.454	0.384	0.862	0.929	0.197	0.008	0.441	0.003

组别	例数	氧合指数（mmHg）		PaCO₂（mmHg）		呼吸系统顺应性（mL/cmH₂O）		PaO₂（mmHg）		FiO₂（%）		呼气末正压（cmH₂O）
组别	例数	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h
对照组	41	102 ± 43	173 ± 42^a	44 ± 12	43 ± 6	33 ± 6	38 ± 8^a	85 ± 32	107 ± 18	77 ± 15	65 ± 18^a	10.2 ± 2.2	10.8 ± 4.1^a
观察组	42	129 ± 73	170 ± 67	44 ± 10	46 ± 7	29 ± 10	36 ± 9^a	79 ± 31	103 ± 31	72 ± 14	65 ± 11	10.9 ± 2.8	9.7 ± 3.1
t值		1.118	0.148	0.176	1.616	1.333	0.931	1.474	0.473	0.962	0.141	0.793	0.979
P值		0.147	0.886	0.862	0.119	0.183	0.352	0.513	0.635	0.345	0.889	0.439	0.336
组别	例数	潮气量（mL）		呼吸频率（次/min）		气道峰压（cmH₂O）		平均气道压（cmH₂O）		平台压（cmH₂O）		驱动压（cmH₂O）
组别	例数	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h
对照组	41	440 ± 86	399 ± 61	33 ± 5	19 ± 5^a	36 ± 4	28 ± 4^a	24 ± 4	24 ± 4	27.4 ± 1.1	28.7 ± 5.5	17.1 ± 6.0	18.0 ± 3.5
观察组	42	463 ± 69	377 ± 61^a	33 ± 8	17 ± 3^a	35 ± 4	27 ± 4^a	23 ± 5	24 ± 4	29.6 ± 5.1	24.8 ± 3.3^a	18.5 ± 5.8	15.0 ± 2.6^a
t值		0.961	1.132	0.204	1.277	0.758	0.885	0.172	0.097	0.131	2.789	0.769	3.197
P值		0.345	0.269	0.831	0.207	0.454	0.384	0.862	0.929	0.197	0.008	0.441	0.003

组别	例数	心指数		Tei指数		TAPSE（cm）		RVFAC（%）		TAM（cm/s）
组别	例数	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h
对照组	41	3.1 ± 0.7	2.4 ± 0.6^a	0.33 ± 0.05	0.53 ± 0.12^a	20.2 ± 3.5	14.2 ± 2.5^a	63 ± 11	52 ± 10^a	14.9 ± 2.4	12.1 ± 1.7^a
观察组	42	3.2 ± 0.7	2.8 ± 0.7	0.32 ± 0.04	0.39 ± 0.13^a	18.9 ± 4.4	16.8 ± 3.8	65 ± 6	61 ± 5^a	15.5 ± 2.9	14.3 ± 3.1
t/Z值		0.392	1.527	0.408	3.463	1.089	2.468	0.818	4.096	0.741	2.802
P值		0.691	0.136	0.682	0.001	0.288	0.019	0.412	< 0.001	0.460	0.008
组别	例数	下腔静脉内径变化率（%）		RVEDA（cm²）		R/L[M（P₂₅，P₇₅）]		E/A[M（P₂₅，P₇₅）]		E/e'[M（P₂₅，P₇₅）]
组别	例数	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h	基础值	机械通气72 h
对照组	41	29 ± 14	21 ± 9^a	11.1 ± 3.5	12.6 ± 2.9	0.58（0.56，0.63）	0.72（0.65，0.77）^a	0.9（0.8，1.0）	0.7（0.6，0.8）^a	5.22（3.80，6.47）	7.20（6.62，7.71）^a
观察组	42	30 ± 15	26 ± 13	10.4 ± 3.0	11.5 ± 2.5	0.61（0.56，0.68）	0.68（0.63，0.73）^a	1.0（0.9，1.1）	0.9（0.8，1.1）	5.35（4.56，7.36）	4.88（4.34，5.54）
t/Z值		0.095	1.377	0.688	1.315	0.145	1.910	0.751	3.020	0.909	4.422
P值		0.924	0.170	0.490	0.198	0.207	0.148	0.455	0.002	0.490	< 0.001

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