Current application and advances in lung recruitment in ARDS

doi:10.3877/cma.j.issn.2096-1537.2024.02.005

Abstract

Abstract:

Mechanical ventilation (MV) is one of the most important management in acute respiratory distress syndrome (ARDS) patients, but also leading to ventilator-induced lung injury (VILI) when inappropriate applied. Lung recruitment is able to decrease atelectrauma and shear strain, but with the risk of volutrauma. For decades, randomized clinical trials (RCTs) on lung recruitment have not concluded to improve mortality in ARDS. This paper reviews pathophysiological mechanism, methods and monitoring during lung recruitment, which discovering that it is important to find recruitable ARDS patients. The factors affecting results of lung recruitment include etiology, severity and classification of ARDS. This article reviews current application and advances in lung recruitment in ARDS in order to find further research topics.

Key words: Acute respiratory distress syndrome, Lung recruitment, Recruitability, Primary factors

Nan Shi, Xueyan Yuan, Haibo Qiu. Current application and advances in lung recruitment in ARDS[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2024, 10(02): 118-126.

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URL: https://icu.cma-cmc.com.cn/EN/10.3877/cma.j.issn.2096-1537.2024.02.005

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纳入研究作者，发表年份	纳入标准	ARDS病因	干预组方法				对照组方法			结论	局限性
纳入研究作者，发表年份	纳入标准	ARDS病因	例数	肺复张方法	Vt<8 ml/kg	联合高PEEP	例数	Vt<8 ml/kg	PEEP策略	结论	局限性
Amato等^[33]，1998	LIS >2.5分，PCWP < 16 mmHg，机械通气时间<1周	肺源性为主	29	CPAP 35~40 cmH₂O，持续40 s	是	是	24	否，12	a	RM改善28 d病死率	常规组未进行小潮气量肺保护性通气
易丽等^[34]，2005	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	未说明	14	CPAP 40 cmH₂O，持续40 s	是	是	14	是	a	RM可改善氧合	-
王晓芝等^[35]2007	符合ARDS诊断，PaO₂/FiO₂<200 mmHg	肺外源性为主	14	CPAP 35 cmH₂O，持续35 s	是	否	14	是	b	RM改善氧合，不改善病死率	小样本量
Meade等^[36]，2008	符合ARDS诊断，发病48 h以内，PaO₂/FiO₂≤250 mmHg	肺源性为主	475	CPAP 40 cmH₂O，持续40 s	是	是	508	是	b	RM改善氧合，不改善病死率	不能区分高水平PEEP、高气道平压、RM和压力控制通气在肺保护中的作用
Huh等^[37]，2009	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺源性：肺外源性=2∶1	30	延长叹息法，Vt设置为基线的25%，PEEP最高达25 cmH₂O	是	是	27	是	b	RM改善氧合，不改善28 d病死率	1. 小样本量； 2. 氧合/力学指标评估肺复张不敏感，未评估塌陷肺泡复张的效果，复张压力可能不够
汪宗昱等^[38]2009	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺源性：肺外源性=1∶1	10	CPAP 40 cmH₂O，持续30 s	是	是	10	是	a	RM不改善氧合和EVLW	未评估RM反应性
Xi等^[39]，2010	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺炎，其他病因和脓毒血症	55	CPAP 40 cmH₂O，持续40 s	是	否	55	是	a	RM改善氧合和ICU病死率，不改善住院/28 d病死率	1. RM后PEEP水平较低； 2. RM压力和时间应用是否合适
杨国辉等^[40]，2011	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺源性：肺外源性=1∶1	19	CPAP 40 cmH₂O，持续30 s	是	是	19	是	b	RM改善氧合	-
Hodgson等^[41]，2011	符合ARDS诊断，发病72 h以内，PaO₂/FiO₂≤200 mmHg	肺源性为主	10	驱动压设置在15 cmH₂O，PEEP递增法至40 cmH₂O	是	是	10	是	b	RM改善氧合和炎症，不改善住院病死率	小样本量
Kacmarek等^[42]，2016	符合ARDS诊断，发病48 h以内，PaO₂/FiO₂≤200 mmHg	肺源性为主	99	驱动压设置在15 cmH₂O，PEEP递增法至35~45 cmH₂O	是	是	101	是	b	RM改善氧合，不改善病死率	1. 小样本量； 2. 液体管理未记录
Chung等^[43]，2017	符合ARDS诊断，发病48 h以内，PaO₂/FiO₂<200 mmHg	未说明	12	驱动压设置在15 cmH₂O，PEEP递增法至40 cmH₂O	是	是	12	是	b	RM改善氧合和EVLW，不改善病死率	1. 小样本量； 2. EVLW热稀释法存在局限性
Yu等^[44]，2017	符合ARDS诊断	肺源性为主	36	驱动压设置在15 cmH₂O，PEEP递增法至40 cmH₂O	是	是	38	是	b	RM改善氧合，不改善病死率	1. 高度异质性； 2. 肺内外源性病因均有，不能确定亚型的作用
ART^[30]，2017	符合ARDS诊断，发病72 h以内，PaO₂/FiO₂<200 mmHg	肺源性为主	501	驱动压设置在15 cmH₂O，PEEP递增法从25 cmH₂O至35~45 cmH₂O	是	是	509	是	b	RM增加28 d病死率和气压伤、气胸发生率	1. 对照组高死亡率反映人群因素影响结果；2. 操作前未评估肺可复张性，未进行表型分类；3. 持续时间长，方案变更一次；4. 干预措施复杂，涉及NMBA和液体准备，不可能将观察到的临床效应完全归因于RM和PEEP的直接效应
Kung等^[45]，2019	符合ARDS诊断，发病72h以内，PaO₂/FiO₂<250 mmHg	肺源性为主	60	驱动压设置在15 cmH₂O，PEEP递增法至气道峰压达到50 cmH₂O	是	是	60	是	b	RM改善脱离呼吸机和ICU时长，不改善28 d病死率	1. 小样本量； 2. RM组接受NMBA比例更高； 3. 未评估两组肺部形态学同质性
Hodgson等^[46]，2019	符合ARDS诊断，发病72 h以内，PaO₂/FiO₂<200 mmHg	肺源性为主	57	驱动压设置在15 cmH₂O，PEEP递增法从20 cmH₂O至40 cmH₂O	是	是	56	是	b	RM不改善病死率和脱离呼吸机天数，心律失常发生率增加	1. 小样本量； 2. 试验提前停止； 3. ART结果影响了随机化平衡
Constantin等^[32]，2019	符合ARDS诊断，发病12 h以内，PaO₂/FiO₂<200 mmHg	肺源性为主	89	CPAP 40 cmH₂O，持续40 s	是	是	204	是	b	RM未改善病死率，与肺部形态不一致的通气策略增加病死率	1. 21%肺部形态被错误分类；2. 肺部形态学不能替代定量分析以量化肺泡复张和过度充气；3. 仅通过随机化前的CT/X线进行分类，首次肺复张后再次判断的肺可复张性未纳入分类

纳入研究作者，发表年份	纳入标准	ARDS病因	干预组方法				对照组方法			结论	局限性
纳入研究作者，发表年份	纳入标准	ARDS病因	例数	肺复张方法	Vt<8 ml/kg	联合高PEEP	例数	Vt<8 ml/kg	PEEP策略	结论	局限性
Amato等^[33]，1998	LIS >2.5分，PCWP < 16 mmHg，机械通气时间<1周	肺源性为主	29	CPAP 35~40 cmH₂O，持续40 s	是	是	24	否，12	a	RM改善28 d病死率	常规组未进行小潮气量肺保护性通气
易丽等^[34]，2005	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	未说明	14	CPAP 40 cmH₂O，持续40 s	是	是	14	是	a	RM可改善氧合	-
王晓芝等^[35]2007	符合ARDS诊断，PaO₂/FiO₂<200 mmHg	肺外源性为主	14	CPAP 35 cmH₂O，持续35 s	是	否	14	是	b	RM改善氧合，不改善病死率	小样本量
Meade等^[36]，2008	符合ARDS诊断，发病48 h以内，PaO₂/FiO₂≤250 mmHg	肺源性为主	475	CPAP 40 cmH₂O，持续40 s	是	是	508	是	b	RM改善氧合，不改善病死率	不能区分高水平PEEP、高气道平压、RM和压力控制通气在肺保护中的作用
Huh等^[37]，2009	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺源性：肺外源性=2∶1	30	延长叹息法，Vt设置为基线的25%，PEEP最高达25 cmH₂O	是	是	27	是	b	RM改善氧合，不改善28 d病死率	1. 小样本量； 2. 氧合/力学指标评估肺复张不敏感，未评估塌陷肺泡复张的效果，复张压力可能不够
汪宗昱等^[38]2009	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺源性：肺外源性=1∶1	10	CPAP 40 cmH₂O，持续30 s	是	是	10	是	a	RM不改善氧合和EVLW	未评估RM反应性
Xi等^[39]，2010	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺炎，其他病因和脓毒血症	55	CPAP 40 cmH₂O，持续40 s	是	否	55	是	a	RM改善氧合和ICU病死率，不改善住院/28 d病死率	1. RM后PEEP水平较低； 2. RM压力和时间应用是否合适
杨国辉等^[40]，2011	符合ARDS诊断，PaO₂/FiO₂≤200 mmHg	肺源性：肺外源性=1∶1	19	CPAP 40 cmH₂O，持续30 s	是	是	19	是	b	RM改善氧合	-
Hodgson等^[41]，2011	符合ARDS诊断，发病72 h以内，PaO₂/FiO₂≤200 mmHg	肺源性为主	10	驱动压设置在15 cmH₂O，PEEP递增法至40 cmH₂O	是	是	10	是	b	RM改善氧合和炎症，不改善住院病死率	小样本量
Kacmarek等^[42]，2016	符合ARDS诊断，发病48 h以内，PaO₂/FiO₂≤200 mmHg	肺源性为主	99	驱动压设置在15 cmH₂O，PEEP递增法至35~45 cmH₂O	是	是	101	是	b	RM改善氧合，不改善病死率	1. 小样本量； 2. 液体管理未记录
Chung等^[43]，2017	符合ARDS诊断，发病48 h以内，PaO₂/FiO₂<200 mmHg	未说明	12	驱动压设置在15 cmH₂O，PEEP递增法至40 cmH₂O	是	是	12	是	b	RM改善氧合和EVLW，不改善病死率	1. 小样本量； 2. EVLW热稀释法存在局限性
Yu等^[44]，2017	符合ARDS诊断	肺源性为主	36	驱动压设置在15 cmH₂O，PEEP递增法至40 cmH₂O	是	是	38	是	b	RM改善氧合，不改善病死率	1. 高度异质性； 2. 肺内外源性病因均有，不能确定亚型的作用
ART^[30]，2017	符合ARDS诊断，发病72 h以内，PaO₂/FiO₂<200 mmHg	肺源性为主	501	驱动压设置在15 cmH₂O，PEEP递增法从25 cmH₂O至35~45 cmH₂O	是	是	509	是	b	RM增加28 d病死率和气压伤、气胸发生率	1. 对照组高死亡率反映人群因素影响结果；2. 操作前未评估肺可复张性，未进行表型分类；3. 持续时间长，方案变更一次；4. 干预措施复杂，涉及NMBA和液体准备，不可能将观察到的临床效应完全归因于RM和PEEP的直接效应
Kung等^[45]，2019	符合ARDS诊断，发病72h以内，PaO₂/FiO₂<250 mmHg	肺源性为主	60	驱动压设置在15 cmH₂O，PEEP递增法至气道峰压达到50 cmH₂O	是	是	60	是	b	RM改善脱离呼吸机和ICU时长，不改善28 d病死率	1. 小样本量； 2. RM组接受NMBA比例更高； 3. 未评估两组肺部形态学同质性
Hodgson等^[46]，2019	符合ARDS诊断，发病72 h以内，PaO₂/FiO₂<200 mmHg	肺源性为主	57	驱动压设置在15 cmH₂O，PEEP递增法从20 cmH₂O至40 cmH₂O	是	是	56	是	b	RM不改善病死率和脱离呼吸机天数，心律失常发生率增加	1. 小样本量； 2. 试验提前停止； 3. ART结果影响了随机化平衡
Constantin等^[32]，2019	符合ARDS诊断，发病12 h以内，PaO₂/FiO₂<200 mmHg	肺源性为主	89	CPAP 40 cmH₂O，持续40 s	是	是	204	是	b	RM未改善病死率，与肺部形态不一致的通气策略增加病死率	1. 21%肺部形态被错误分类；2. 肺部形态学不能替代定量分析以量化肺泡复张和过度充气；3. 仅通过随机化前的CT/X线进行分类，首次肺复张后再次判断的肺可复张性未纳入分类

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