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中华重症医学电子杂志 ›› 2016, Vol. 02 ›› Issue (04) : 277 -284. doi: 10.3877/cma.j.issn.2096-1537.2016.04.012

所属专题: 文献

临床研究

神经调节辅助通气对AECOPD患者呼吸功的影响
夏飞萍1, 刘玲1,()   
  1. 1. 210009 南京,东南大学附属中大医院重症医学科
  • 收稿日期:2016-10-26 出版日期:2016-11-28
  • 通信作者: 刘玲
  • 基金资助:
    江苏省临床医学科技专项(BL2013030); 急性呼吸窘迫综合征的规范化诊疗研究及示范应用(BL2013030)

Efffect of neurally adjusted ventilatory assist on work of breathing in patients with acute exacerbation of chronic obstructive pulmonary disease

Feiping Xia1, Ling Liu1,()   

  1. 1. Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing 210009, China
  • Received:2016-10-26 Published:2016-11-28
  • Corresponding author: Ling Liu
  • About author:
    Corresponding author: Liu Ling, Email:
引用本文:

夏飞萍, 刘玲. 神经调节辅助通气对AECOPD患者呼吸功的影响[J]. 中华重症医学电子杂志, 2016, 02(04): 277-284.

Feiping Xia, Ling Liu. Efffect of neurally adjusted ventilatory assist on work of breathing in patients with acute exacerbation of chronic obstructive pulmonary disease[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2016, 02(04): 277-284.

目的

探讨不同外源性呼气末正压(extrinsic positive end expiratory pressure,PEEPe)条件下,神经调节辅助通气(neurally adjusted ventilatory assist,NAVA)对慢性阻塞性肺疾病急性加重(acute exacerbation of chronicobstructive pulmonary disease,AECOPD)患者呼吸功及触发功的影响。

方法

以2012年5月至2013年5月入住东南大学附属中大医院ICU、静态内源性呼气末正压(intrinsic positive end-expiratory pressure,PEEPi)(PEEPi_stat)≥5 cm H2O(1 cm H2O=0.098 kPa)的AECOPD患者为研究对象。本研究方案已通过东南大学附属中大医院伦理委员会批准(批准号:2010ZDLL018.0),并与患者签署了知情同意书。将控制通气下PEEPe由0升至40%PEEPi_stat,总呼气末正压(total-PEEP)不增加的患者作为呼气流速受限(expiratory flow limitation,EFL)组,增加的患者为呼气阻力(expiratory resistance,Re)增高组。共纳入AECOPD患者12例,其中EFL组6例,Re组6例。患者分组后调节镇静深度至Ramsay3分,在PEEPe设定为0、40%、80%、120%PEEPi_stat条件下,随机进行支持力度相同压力支持通气(pressure support ventilation,PSV)及NAVA通气。通过NAVA压力限定实现NAVA与PSV支持水平的等效性。监测食道内压(esophageal pressure,Pes)、膈肌电活动(electrical activity diaphragm,EAdi),采集流速、压力波形并计算呼吸功(PTPes_ins)和触发功(PTPes_tri)。测量参数在通气模式和PEEPe水平之间的比较采用两因素的重复测量方差分析。在NAVA或PSV模式下,不同PEEPe水平之间的多重比较采用SNK检验。

结果

2组患者年龄与急性生理与慢性健康评分II(acute physidogy and chronic health evaluation,APACHE II)等一般情况无显著差异。① NAVA与PSV支持水平的等效性:NAVA通气时可以获得与PSV通气类似的方波压力-时间曲线,且与PSV相比NAVA通气时呼吸频率、吸气时间、气道峰值压、平均气道压均无显著差异(t=0.720,0.817,0.621,1.579,均P>0.05)。② NAVA对呼吸功影响:在相同PEEPe水平下NAVA通气时呼吸功明显低于PSV通气(t=3.816,3.117,2.758,2.572,均P<0.05)。PEEPe由0逐渐增至120%PEEPi_stat时,在NAVA及PSV模式下,EFL组患者呼吸功均显著下降(t=4.629,4.431,4.165,5.082,均P<0.05);RE组患者呼吸功无显著变化(F=8.12,7.64,均P>0.05)。③ NAVA对触发功的影响:相同PEEPe水平下,NAVA通气触发功明显低于PSV通气(t=4.624,4.431,4.165,5.082,均P<0.05)。PEEPe由0逐渐增至120%PEEPi_stat时,NAVA模式下EFL组及RE组患者触发功均无显著变化(F=5.71,5.93,均P>0.05);PSV模式下,EFL组患者触发功显著下降(F=16.21,P<0.05);RE组患者随着PEEPe增加触发功无明显变化(F=6.12,P>0.05)。

结论

与PSV相比,NAVA通气显著降低AECOPD患者的呼吸功及触发功。NAVA通气时触发功不受PEEPe的影响,PSV通气时增加PEEPe可降低呼气流速受限患者的触发功。

Objective

To assess if the work of breath in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is affected by different extrinsic positive end-expiratory pressure (PEEPe) levels during (neurally adjusted ventilatory assist, NAVA).

Methods

From May 2012 to May 2013, 12 AECOPD patients who were admitted to the ICU of Nanjing Zhong-da hospital with an static intrinsic positive end-expiratory pressure (PEEPi_stat more than 5 cmH2O were enrolled in this study.The EFL group was defined as no increase in total-PEEP when we elevated PEEPe from 0 PEEPi_stat to 40% of PEEPi_stat and the Re group defined as the opposite. Being titrated to a level of Ramsay 3 sedation, 12 AECOPD patients were randomized to undergo pressure support ventilation (PSV) or NAVA with four different levels of PEEPe (0, 40%, 80%, 120% of PEEPi_stat). NAVA pressure limit was used to assure the equivalence of supporting pressure between NAVA and PSV. Air flow and airway pressure, esophageal pressure, and EAdi were continuously recorded.PTPes_ins and PTPes_tri at different PEEP levels in each group were calculated offline. We opted for comparison of measured parameters in the ventilation mode and PEEPe using repetitive measure analysis of variance. In NAVA or PSV mode, multiple comparison between different PEEPe level using SNK test.

Results

There were 6 patients in EFL group and 6 in Re group. we found no significant difference in patients age, acute physiology and chronic health evaluation II between these two groups.①The equivalence of NAVA with PSV: no significant difference was found in pressure-time wave, respiratory rate, peak airway pressure and mean airway pressure (t=0.720, 0.817, 0.621, 1.579, P>0.05).② Effects of NAVA on work of breath: at each PEEPe level, PTPes_ins was significantly lower in NAVA patients than in PSV patients (t=3.816, 3.117, 2.758, 2.572, P<0.05). When elevating PEEPe from 0 to 120% of PEEPi_stat in FEL group, PTPes_ins decreased significantly both in NAVA patients and in PSV patients (F=9.78, 10.26, P<0.05) , no significant effect on PTPes_ins was found in RE group (F=8.12, 7.64, P>0.05). ③Effects of PEEPe on work of triggering: at each PEEPe levels, PTPes_tri was significantly lower in NAVA patients than in PSV patients (t=4.624, 4.431, 4.165, 5.082, P<0.05). PTPes_tri was not significantly different among each PEEPe conditions in NAVA patients of both groups (F=5.71, 5.93, P> 0.05). There was a PTPes decrease in EFL patients using PSV when PEEP was elevated, but not in RE patients.

Conclusions

NAVA significantly reduced work of breath and triggering in AECOPD patients compared with PSV. The work of triggering was not impacted by PEEPe in NAVA, while increased PEEPe may decrease triggering work in EFL patients with PSV.

表1 2组慢性阻塞性肺疾病急性加重患者一般情况(x±s)
表2 不同外源性呼吸正压水平下NAVA与PSV呼吸形式的比较(x±s,n=12)
图1 不同外源性呼气末正压水平下NAVA/PSV通气时食管压吸气时间乘积的变化
图2 不同外源性呼气末正压水平下NAVA/PSV通气时膈肌电活动吸气时间乘积比较
图3 不同外源性呼气末正压水平下NAVA/PSV食管压触发时间乘积的变化
图4 不同外源性呼气末正压水平下NAVA/PSV通气时膈肌电活动触发时间乘积比较
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