肺部超聲在急性呼吸窘迫綜合征肺復(fù)張過程中的應(yīng)用
發(fā)布時間：2018-07-27 20:29
【摘要】：研究目的： 1.建立溫鹽水灌洗家兔ARDS模型及肺部超聲評價方法。 2.驗證肺復(fù)張過程中超聲再氣化評分的指導(dǎo)意義。 3.探索肺部超聲指導(dǎo)下的肺復(fù)張PEEP滴定調(diào)整方案。 研究方法： 第一部分：12只新西蘭家兔隨機分為兩組,超聲法指導(dǎo)肺復(fù)張組和氧合法指導(dǎo)肺復(fù)張組,建立溫鹽水灌洗家兔ARDS模型及相應(yīng)的肺部超聲評價方法,在模型建立過程中同步進行肺部超聲評價。實施PEEP遞增法肺復(fù)張,氧合法指導(dǎo)組以PaO2+PaCO2400mmHg為復(fù)張終點,超聲法指導(dǎo)組以連續(xù)兩次再氣化評分相同為復(fù)張終點,比較兩組復(fù)張終點的肺部超聲評價結(jié)果、氧合水平、呼吸力學(xué)指標(biāo),以及肺組織Smith病理評分及濕干比。第二部分：6只新西蘭家兔建立溫鹽水灌洗家兔ARDS模型,壓力控制法肺復(fù)張后以2cmH2O為間隔進行最佳維持PEEP的滴定,以PaO2+PaCO2380mmHg為滴定終點。同步進行肺部超聲評價,比較氧合法和超聲法確定的不同滴定終點間的肺部超聲評價結(jié)果和氧合水平。第三部分：以動物實驗研究結(jié)論為基礎(chǔ),觀察臨床ARDS患者最大氧合法肺復(fù)張后最佳維持PEEP滴定過程中的肺部超聲征象改變及再氣化評分變化,提出超聲指導(dǎo)下的肺復(fù)張后PEEP滴定調(diào)整方案。 實驗結(jié)果： 第一部分： 1.肺部超聲方法能夠有效評價溫鹽水灌洗家兔ARDS模型建立過程的通氣水平改變。根據(jù)超聲評價結(jié)果,家兔ARDS模型建立過程中首先出現(xiàn)雙肺后部實變,同時伴有前中部肺組織通氣水平不同程度下降。 2.模型建立成功后試驗性給予PEEP5cmH2O可顯著改善氧合水平(50±10mmHgv.s.93±40mmHg,p0.05)、動態(tài)順應(yīng)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),但基于超聲評價的肺通氣水平改善程度并不明顯,且局限在前中部。 3.肺復(fù)張過程中各組動物模型均達到相應(yīng)的復(fù)張終點。氧合法指導(dǎo)組和超聲法指導(dǎo)組的肺開放壓(18.7±2.1cmH2O vs.23.4±3.4cmH2O, p0.05)和動脈氧分壓(465±57mmHg vs.552±77mmHg, p0.05)存在顯著差異。超聲法動物組肺復(fù)張終點的再氣化評分顯著增加(6.5±1.6vs.13.8±3.0分),提示肺通氣水平得到了進一步改善。而肺順應(yīng)性和死腔分流比兩組間無顯著性差異,Smith病理評分和肺濕干比亦無顯著性差異。 第二部分： 1.以PaO2+PaCO2380mmHg為滴定終點的最大氧合法能夠?qū)ふ壹彝脺佧}水灌洗ARDS模型的維持PEEP。滴定過程中再氣化評分逐漸降低,而在氧合法確定的維持PEEP水平下可再次出現(xiàn)肺實變。 2.在滴定過程中再氣化評分在下降過程中均存在一個明顯的突躍(下降≥50%),且對應(yīng)的PEEP在氧合法確定的維持PEEP之上(再氣化評分突躍前PEEP vs.氧合法最佳維持PEEP:12.0±2.2cmH2Ovs.9.3±2.1cmH2O,p0.05)。 第三部分： 1.研究共納入7例ALI/ARDS患者。與動物實驗部分所見類似,在臨床ARDS患者最大氧合法滴定PEEP過程中,再氣化評分同樣出現(xiàn)了一個較為明顯的下降過程；且多數(shù)(4/7例)出現(xiàn)在氧合法滴定終點前(再氣化評分突躍前PEEP vs.氧合法最佳維持PEEP:14.1±1.0cmH2Ovs.12.4±2.3cmH2O,p0.05)。 主要結(jié)論： 1.肺部超聲方法能夠有效評價家兔ARDS模型在模型建立、肺復(fù)張和最佳維持PEEP滴定過程中的肺通氣水平改變。 2.模型建立成功后給予5cmH2O PEEP可顯著改善氧合水平,但超聲評價改善程度不明顯,且局限在前中部。 3.與最大氧合法指導(dǎo)肺復(fù)張相比,超聲指導(dǎo)肺復(fù)張復(fù)張終點較高的肺開放壓水平帶來了氧合水平和再氣化評分的增加,提示肺泡通氣水平的進一步改善,而呼吸力學(xué)指標(biāo)和肺損傷病理指標(biāo)并未提示肺損傷有所加重。 4.與最大氧合法相比,超聲指導(dǎo)下肺復(fù)張在各個肺區(qū)的再氣化水平均有明顯提升,提示ALI/ARDS市部病變的不均一性得到了有效改善。 5.在最大氧合法滴定最佳維持PEEP過程中,肺部超聲再氣化評分逐漸降低,在終點PEEP之上再氣化評分存在一個突躍過程(下降50%),提示肺泡通氣水平在滴定至氧合法最佳維持PEEP之前已明顯降低。 6.以本研究結(jié)論為基礎(chǔ)提出并初步臨床驗證的肺復(fù)張后滴定維持PEEP新方法有望在臨床工作中得到進一步應(yīng)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.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R445.1;R563.9
本文編號：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.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R445.1;R563.9
【共引文獻】
相關(guān)期刊論文 前4條
1 黃鋒;周勝華;潘家義;王振河;白中樂;;危重患者院際遠程轉(zhuǎn)送的安全策略[J];臨床薈萃;2010年24期
2 陳莉;呂發(fā)金;張麗娟;李劍秋;姚開情;勒都曉蘭;;胸腔積液量的多層螺旋CT定量研究[J];臨床放射學(xué)雜志;2012年06期
3 王峰;趙洪東;;肺復(fù)張策略在ARDS患者中應(yīng)用現(xiàn)狀[J];吉林醫(yī)學(xué);2013年31期
4 李晨;徐軍;于學(xué)忠;;肺部超聲評估血管外肺水研究進展[J];臨床急診雜志;2013年11期
相關(guān)碩士學(xué)位論文 前1條
1 麻宵萍;胸部CT聯(lián)合計算機輔助設(shè)計技術(shù)對胸腔積液定量研究的初步應(yīng)用[D];山東大學(xué);2008年
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