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Moderate and Severe Acute Respiratory Distress Syndrome: Hemodynamic and Cardiac Effects of an Open Lung Strategy With Recruitment Maneuver Analyzed Using Echocardiography
背景与目的
肺复张⼿法的肺开放策略对急性呼吸窘迫综合征（ARDS）患者具有重要意义，但其可引起⽓道压⼒的升⾼并引发⼼脏功能障碍，从⽽限制其治疗效果。本研究探讨肺复张⼿法以及递减式呼⽓末正压通⽓（PEEP）对⼼脏功能的影响。
方 法
对确诊ARDS的20名患者施⾏逐步肺复张⼿法，同时进⾏呼吸评估和⼼功能的超声⼼动图评估。 肺复张开始时，将初始PEEP设置为25cmH2O，驱动压（DP）15cmH2O。然后以每2分钟5cmH2O的速度逐渐增加PEEP直⾄达到40 cmH2O（达到40 cm H2O时，持续时间为3到4分钟以记录超声⼼动图图像），同时保持15 cmH2O的DP。在PEEP达到峰值后，施加25cmH2O的PEEP和15cmH2O的DP，然后以每4分钟2cmH2O逐步减少PEEP。当氧饱和度或顺应性分别降低2或2mL/cmH2O时，终⽌PEEP⽔平的降低。当氧饱和度或顺应性分别降低2或2mL/cmH2O时，停⽌降低PEEP⽔平。⼀旦达到最低⽔平并确认减少氧合作⽤，则再次进⾏肺复张（重新进⾏肺开放），然后将PEEP直接降低到最低⽔平之前的PEEP⽔平，并将此⽔平指定为最佳PEEP⽔平，即最佳PEEP⽔平为⽐
最低PEEP⽔平⾼2cmH2O时的⽔平。
结 果
在施⾏肺复张⼿法呼⽓末正压达到峰值时，动脉压、⼼排⾎量、左⼼室容积减⼩，右⼼室容积增加。左⼼室射⾎分数从60%±13%降⾄48%±18%（p = 0.05）。左⼼室和右⼼室整体纵向应变均受损（分别为-15.8%±4.5%⾄-11%±4.7%和-19%±5%⾄-14%±6% [p = 0.05]）。最佳呼⽓末正压为14±5 cmH2O（基线时为11±4cmH2O）,PaO2/FiO2⽐值从111±25增加到197±89 mmHg（p <0.0001）。尽管有较⾼的呼⽓末正压，但在施⾏肺复张⼿法后所有⾎流动⼒学变量都恢复到其基线值。
结 论
逐步增加PEEP的肺复张策略有利于中重度ARDS患者氧合功能的改善；肺复张⼿法可产⽣轻度可逆的⼼脏功能障碍，但不会明显损伤⼼脏功能。
原始文献摘要
Mercado P, Maizel J, Kont ar L, et al. Moderat e and Severe Acute Respiratory Distress Syndrome: Hemodynamic and Cardiac Effects of an Open Lung Strategy With Recruitment Maneuver Analyzed Using Echocardiography. Crit Care Med. 2018 Oct ;46(10):1608-1616. doi: 10.1097/CCM.0000000000003287.
Objectives: Open lung ventilation with a recruitment maneuver could be beneficial for acute respiratory distress syndrome patients. However, the increased airway pressures resulting f rom the recruitment maneuver may induce cardiac
dysf unction, limiting the benefit of this maneuver. We analyzed the effect of a recruitment maneuver and decremental positive end-expiratory pressure titration on cardiac function.
Settings: Medical ICU Amiens, France.
Patients: Twenty patients with moderate to severe acute respiratory distress syndrome.
Interventions: Patients underwent a stepwise recruitment maneuver with respiratory evaluation and echocardiography assessment of cardiac function including longitudinal strain at baseline, peak positive end-expiratory pressure of recruitment maneuver (positive end-expiratory pressure 40 cm H2O), and at“optimal” positive end-expiratory pressure. The patients were divided into two groups based on change on the Pao2/Fio2 ratio (nonresponders< 50%; responders ≥ 50%).
Measurements and Main Results: At peak positive end-expiratory pressure during the recruitment maneuver, the arterial pressure,cardiac output, left ventricular size decreased and right ventricularsize increased. The left ventricular ejection fraction decreased f rom 60% ± 13% to 48% ± 18% (p =0.05). Both left and right ventricular global longitudinal strain were impaired (–15.8% ± 4.5% to –11% ± 4.7% and – 19% ± 5% to –14% ± 6% [p = 0.05] respectively). Fifty percent of patients were nonresponders and demonstrated a lower hemodynamic tolerance to the mrecruitment maneuver than responders. Optimal positive end-expiratory pressure was 14 ± 5cm H2O (vs 11 ± 4 cm H2O at baseline), and Pao2/Fio2 ratio increased f rom 111± 25 to 197 ± 89 mm Hg (p < 0.0001). All hemodynamic variables returned to their baseline value af ter the recruitment maneuver despite a higher positive endexpiratory pressure.
Conclusions: An open lung strategy with a stepwise recruitment maneuver permitted a higher positive end-expiratory pressure and improved oxygenation without any cardiac impairment. The recruitment maneuver was associated with mild and transient, cardiac dysf unction, with nonresponders demonstrating poorer tolerance.
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