肺部超声在急性呼吸窘迫综合征肺复张过程中的应用
发布时间：2018-07-27 20:29
【摘要】：研究目的： 1.建立温盐水灌洗家兔ARDS模型及肺部超声评价方法。 2.验证肺复张过程中超声再气化评分的指导意义。 3.探索肺部超声指导下的肺复张PEEP滴定调整方案。 研究方法： 第一部分：12只新西兰家兔随机分为两组,超声法指导肺复张组和氧合法指导肺复张组,建立温盐水灌洗家兔ARDS模型及相应的肺部超声评价方法,在模型建立过程中同步进行肺部超声评价。实施PEEP递增法肺复张,氧合法指导组以PaO2+PaCO2400mmHg为复张终点,超声法指导组以连续两次再气化评分相同为复张终点,比较两组复张终点的肺部超声评价结果、氧合水平、呼吸力学指标,以及肺组织Smith病理评分及湿干比。第二部分：6只新西兰家兔建立温盐水灌洗家兔ARDS模型,压力控制法肺复张后以2cmH2O为间隔进行最佳维持PEEP的滴定,以PaO2+PaCO2380mmHg为滴定终点。同步进行肺部超声评价,比较氧合法和超声法确定的不同滴定终点间的肺部超声评价结果和氧合水平。第三部分：以动物实验研究结论为基础,观察临床ARDS患者最大氧合法肺复张后最佳维持PEEP滴定过程中的肺部超声征象改变及再气化评分变化,提出超声指导下的肺复张后PEEP滴定调整方案。 实验结果： 第一部分： 1.肺部超声方法能够有效评价温盐水灌洗家兔ARDS模型建立过程的通气水平改变。根据超声评价结果,家兔ARDS模型建立过程中首先出现双肺后部实变,同时伴有前中部肺组织通气水平不同程度下降。 2.模型建立成功后试验性给予PEEP5cmH2O可显著改善氧合水平(50±10mmHgv.s.93±40mmHg,p0.05)、动态顺应性(0.8±0.2ml/cmH2Ov.s.1.1±0.3ml/cmH2O)及死腔分流比(0.87±0.05vs.0.79±0.06,p0.05),但基于超声评价的肺通气水平改善程度并不明显,且局限在前中部。 3.肺复张过程中各组动物模型均达到相应的复张终点。氧合法指导组和超声法指导组的肺开放压(18.7±2.1cmH2O vs.23.4±3.4cmH2O, p0.05)和动脉氧分压(465±57mmHg vs.552±77mmHg, p0.05)存在显著差异。超声法动物组肺复张终点的再气化评分显著增加(6.5±1.6vs.13.8±3.0分),提示肺通气水平得到了进一步改善。而肺顺应性和死腔分流比两组间无显著性差异,Smith病理评分和肺湿干比亦无显著性差异。 第二部分： 1.以PaO2+PaCO2380mmHg为滴定终点的最大氧合法能够寻找家兔温盐水灌洗ARDS模型的维持PEEP。滴定过程中再气化评分逐渐降低,而在氧合法确定的维持PEEP水平下可再次出现肺实变。 2.在滴定过程中再气化评分在下降过程中均存在一个明显的突跃(下降≥50%),且对应的PEEP在氧合法确定的维持PEEP之上(再气化评分突跃前PEEP vs.氧合法最佳维持PEEP:12.0±2.2cmH2Ovs.9.3±2.1cmH2O,p0.05)。 第三部分： 1.研究共纳入7例ALI/ARDS患者。与动物实验部分所见类似,在临床ARDS患者最大氧合法滴定PEEP过程中,再气化评分同样出现了一个较为明显的下降过程；且多数(4/7例)出现在氧合法滴定终点前(再气化评分突跃前PEEP vs.氧合法最佳维持PEEP:14.1±1.0cmH2Ovs.12.4±2.3cmH2O,p0.05)。 主要结论： 1.肺部超声方法能够有效评价家兔ARDS模型在模型建立、肺复张和最佳维持PEEP滴定过程中的肺通气水平改变。 2.模型建立成功后给予5cmH2O PEEP可显著改善氧合水平,但超声评价改善程度不明显,且局限在前中部。 3.与最大氧合法指导肺复张相比,超声指导肺复张复张终点较高的肺开放压水平带来了氧合水平和再气化评分的增加,提示肺泡通气水平的进一步改善,而呼吸力学指标和肺损伤病理指标并未提示肺损伤有所加重。 4.与最大氧合法相比,超声指导下肺复张在各个肺区的再气化水平均有明显提升,提示ALI/ARDS市部病变的不均一性得到了有效改善。 5.在最大氧合法滴定最佳维持PEEP过程中,肺部超声再气化评分逐渐降低,在终点PEEP之上再气化评分存在一个突跃过程(下降50%),提示肺泡通气水平在滴定至氧合法最佳维持PEEP之前已明显降低。 6.以本研究结论为基础提出并初步临床验证的肺复张后滴定维持PEEP新方法有望在临床工作中得到进一步应用。
[Abstract]:The purpose of the study is:
1. establish the rabbit model of ARDS with warm saline water and evaluate the lung ultrasound.
2. to verify the guiding significance of ultrasound re gasification score during lung recruitment.
3. explore the PEEP titration adjustment plan under the guidance of lung ultrasound.
Research methods:
The first part: 12 New Zealand rabbits were randomly divided into two groups. The ultrasonic method was used to guide the pulmonary rehabilitation group and the oxygen therapy to guide the pulmonary rehabilitation group. The ARDS model and the corresponding pulmonary ultrasonic evaluation method were set up in the warm saline lavage rabbits. The lung ultrasonic evaluation was carried out synchronously during the establishment of the model. The pulmonary re extension method was carried out by the PEEP increasing method, and the guidance group of oxygen was PaO2+PaC O2400mmHg was the endpoint of re extension. The ultrasound guided group took two consecutive re gasification scores for the same end point, compared the pulmonary ultrasound evaluation results of the two groups of endpoints, oxygenation level, respiratory mechanics index, and lung tissue Smith pathological score and wet dry ratio. The second part: 6 New Zealand rabbits were set up ARDS model of warm saline lavage rabbits, pressure The best maintenance PEEP titration was carried out at 2cmH2O interval after the force control method. PaO2+PaCO2380mmHg was used as the end point of titration. The pulmonary ultrasound evaluation was carried out synchronously. The pulmonary ultrasound evaluation results and the oxygenation level between the different titration end points determined by oxygen and ultrasound were compared. The third parts were based on the animal experimental research conclusions. The optimal pulmonary echocardiographic changes and the change of the re gasification score during the PEEP titration of the clinical ARDS patients were best maintained after the maximum oxygenation of the lung, and the PEEP titration adjustment scheme was proposed under the guidance of the echocardiography.
Experimental results:
Part one:
1. the pulmonary ultrasound method can effectively evaluate the change of ventilation level in the process of establishing ARDS model in warm saline saline lavage rabbits. According to the results of ultrasonic evaluation, the first appearance of two lungs in the process of the establishment of rabbit ARDS model, accompanied by a decrease in the level of ventilation in the anterior central lung tissue.
After the 2. model was established, PEEP5cmH2O could significantly improve the oxygenation level (50 + 10mmHgv.s.93 + 40mmHg, P0.05), dynamic compliance (0.8 + 0.2ml/cmH2Ov.s.1.1 + 0.3ml/cmH2O) and dead lumen shunt ratio (0.87 + 0.05vs.0.79 + 0.06, P0.05), but the improvement of lung ventilation level based on ultrasonic evaluation was not obvious, and was limited in the anterior central region.
There were significant differences in the open pressure of lung (18.7 + 2.1cmH2O vs.23.4 + 3.4cmH2O, P0.05) and arterial oxygen pressure (465 + 57mmHg vs.552 + 77mmHg, P0.05) in the oxygen legal guidance group and the ultrasound guidance group. The re gasification score of the pulmonary re extension end of the ultrasonic method was significantly increased. (6.5 + 1.6vs.13.8 + 3), the level of lung ventilation was further improved, but there was no significant difference between the two groups in the lung compliance and the dead chamber shunt ratio, and there was no significant difference between the Smith pathological score and the lung wet dry ratio.
The second part:
1. the maximum oxygen method with PaO2+PaCO2380mmHg as the end point of the titration can find the ARDS model of warm saline lavage in rabbits and the regasification score gradually decreases during the PEEP. titration process, while the pulmonary consolidation can occur again at the level of the maintenance of PEEP.
2. in the process of titration, there is a significant jump (decrease > 50%) during the decline of the re gasification score, and the corresponding PEEP is above the maintenance of PEEP (PEEP vs. oxygen method best maintains PEEP:12.0 + 2.2cmH2Ovs.9.3 + 2.1cmH2O, P0.05).
The third part:
The 1. study included 7 cases of ALI/ARDS patients. Similar to the animal experiment part, the re gasification score also appeared a more obvious decline process in the clinical ARDS patient's maximum oxygen titration PEEP process; and most (4/7 cases) appeared before the end of the oxygen titration end (the best PEEP vs. oxygen method to maintain PEEP: before the re gasification score was leaped. " 14.1 + 1.0cmH2Ovs.12.4 + 2.3cmH2O, P0.05).
The main conclusions are as follows:
1. the lung ultrasound method can effectively evaluate the change of pulmonary ventilation level in the rabbit model of ARDS during the establishment of lung remodeling and the best maintenance PEEP titration.
2. 5cmH2O PEEP can significantly improve oxygenation level after successful establishment of the model, but the improvement of ultrasound evaluation is not obvious, and is limited to the anterior central part.
3. compared with the pulmonary re extension guided by maximum oxygen, the higher level of open pressure in the lung of the pulmonary complex at the Zhang Fuzhang end of the lung caused the increase of oxygenation level and the increase of the re gasification score, suggesting the further improvement of the alveolar ventilation level, while the respiratory mechanics and the pathological indexes of lung injury did not suggest that the lung injury was aggravated.
4. compared with the maximum oxygen method, the level of the re gasification of the lung under the guidance of ultrasound in each lung area has been significantly improved, suggesting that the inhomogeneity of the lesions in the ALI/ARDS city has been effectively improved.
5. during the best maintenance of PEEP with maximum oxygen titration, the lung ultrasonic re gasification score gradually decreased, and there was a sudden jump process (down 50%) on the re gasification score above the end of the end PEEP, suggesting that the alveolar ventilation level had been significantly reduced before the titration to the best maintenance of PEEP.
6. based on the conclusions of this study, a new method of titration maintenance PEEP after lung recruitment after initial clinical verification is expected to be further applied in clinical work.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R445.1;R563.9
本文编号：2149049
[Abstract]:The purpose of the study is:
1. establish the rabbit model of ARDS with warm saline water and evaluate the lung ultrasound.
2. to verify the guiding significance of ultrasound re gasification score during lung recruitment.
3. explore the PEEP titration adjustment plan under the guidance of lung ultrasound.
Research methods:
The first part: 12 New Zealand rabbits were randomly divided into two groups. The ultrasonic method was used to guide the pulmonary rehabilitation group and the oxygen therapy to guide the pulmonary rehabilitation group. The ARDS model and the corresponding pulmonary ultrasonic evaluation method were set up in the warm saline lavage rabbits. The lung ultrasonic evaluation was carried out synchronously during the establishment of the model. The pulmonary re extension method was carried out by the PEEP increasing method, and the guidance group of oxygen was PaO2+PaC O2400mmHg was the endpoint of re extension. The ultrasound guided group took two consecutive re gasification scores for the same end point, compared the pulmonary ultrasound evaluation results of the two groups of endpoints, oxygenation level, respiratory mechanics index, and lung tissue Smith pathological score and wet dry ratio. The second part: 6 New Zealand rabbits were set up ARDS model of warm saline lavage rabbits, pressure The best maintenance PEEP titration was carried out at 2cmH2O interval after the force control method. PaO2+PaCO2380mmHg was used as the end point of titration. The pulmonary ultrasound evaluation was carried out synchronously. The pulmonary ultrasound evaluation results and the oxygenation level between the different titration end points determined by oxygen and ultrasound were compared. The third parts were based on the animal experimental research conclusions. The optimal pulmonary echocardiographic changes and the change of the re gasification score during the PEEP titration of the clinical ARDS patients were best maintained after the maximum oxygenation of the lung, and the PEEP titration adjustment scheme was proposed under the guidance of the echocardiography.
Experimental results:
Part one:
1. the pulmonary ultrasound method can effectively evaluate the change of ventilation level in the process of establishing ARDS model in warm saline saline lavage rabbits. According to the results of ultrasonic evaluation, the first appearance of two lungs in the process of the establishment of rabbit ARDS model, accompanied by a decrease in the level of ventilation in the anterior central lung tissue.
After the 2. model was established, PEEP5cmH2O could significantly improve the oxygenation level (50 + 10mmHgv.s.93 + 40mmHg, P0.05), dynamic compliance (0.8 + 0.2ml/cmH2Ov.s.1.1 + 0.3ml/cmH2O) and dead lumen shunt ratio (0.87 + 0.05vs.0.79 + 0.06, P0.05), but the improvement of lung ventilation level based on ultrasonic evaluation was not obvious, and was limited in the anterior central region.
There were significant differences in the open pressure of lung (18.7 + 2.1cmH2O vs.23.4 + 3.4cmH2O, P0.05) and arterial oxygen pressure (465 + 57mmHg vs.552 + 77mmHg, P0.05) in the oxygen legal guidance group and the ultrasound guidance group. The re gasification score of the pulmonary re extension end of the ultrasonic method was significantly increased. (6.5 + 1.6vs.13.8 + 3), the level of lung ventilation was further improved, but there was no significant difference between the two groups in the lung compliance and the dead chamber shunt ratio, and there was no significant difference between the Smith pathological score and the lung wet dry ratio.
The second part:
1. the maximum oxygen method with PaO2+PaCO2380mmHg as the end point of the titration can find the ARDS model of warm saline lavage in rabbits and the regasification score gradually decreases during the PEEP. titration process, while the pulmonary consolidation can occur again at the level of the maintenance of PEEP.
2. in the process of titration, there is a significant jump (decrease > 50%) during the decline of the re gasification score, and the corresponding PEEP is above the maintenance of PEEP (PEEP vs. oxygen method best maintains PEEP:12.0 + 2.2cmH2Ovs.9.3 + 2.1cmH2O, P0.05).
The third part:
The 1. study included 7 cases of ALI/ARDS patients. Similar to the animal experiment part, the re gasification score also appeared a more obvious decline process in the clinical ARDS patient's maximum oxygen titration PEEP process; and most (4/7 cases) appeared before the end of the oxygen titration end (the best PEEP vs. oxygen method to maintain PEEP: before the re gasification score was leaped. " 14.1 + 1.0cmH2Ovs.12.4 + 2.3cmH2O, P0.05).
The main conclusions are as follows:
1. the lung ultrasound method can effectively evaluate the change of pulmonary ventilation level in the rabbit model of ARDS during the establishment of lung remodeling and the best maintenance PEEP titration.
2. 5cmH2O PEEP can significantly improve oxygenation level after successful establishment of the model, but the improvement of ultrasound evaluation is not obvious, and is limited to the anterior central part.
3. compared with the pulmonary re extension guided by maximum oxygen, the higher level of open pressure in the lung of the pulmonary complex at the Zhang Fuzhang end of the lung caused the increase of oxygenation level and the increase of the re gasification score, suggesting the further improvement of the alveolar ventilation level, while the respiratory mechanics and the pathological indexes of lung injury did not suggest that the lung injury was aggravated.
4. compared with the maximum oxygen method, the level of the re gasification of the lung under the guidance of ultrasound in each lung area has been significantly improved, suggesting that the inhomogeneity of the lesions in the ALI/ARDS city has been effectively improved.
5. during the best maintenance of PEEP with maximum oxygen titration, the lung ultrasonic re gasification score gradually decreased, and there was a sudden jump process (down 50%) on the re gasification score above the end of the end PEEP, suggesting that the alveolar ventilation level had been significantly reduced before the titration to the best maintenance of PEEP.
6. based on the conclusions of this study, a new method of titration maintenance PEEP after lung recruitment after initial clinical verification is expected to be further applied in clinical work.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R445.1;R563.9
【共引文献】
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