超保护机械通气减少重症急性呼吸窘迫综合征患者静脉-静脉体外膜肺氧合的生物损伤
Introduction: Ventilator settings for patients with severe acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation are currently set arbitrarily. The impact on serum and pulmonary biotrauma markers of the transition to ultra-protective ventilation settings following extracorporeal membrane oxygenation implantation, and different mechanical ventilation strategies while on extracorporeal membrane oxygenation were investigated.
前言：目前，严重急性呼吸窘迫综合征患者在静脉-静脉体外膜氧合支持下的呼吸机设置是随意的。本研究探讨了体外膜肺氧合植入术后过渡到超保护性通气对血清和肺组织生物标志物的影响，以及体外膜肺氧合期间不同机械通气策略。
Design: Randomized clinical trial.
设计：随机临床试验。
Settings: Nine-month monocentric study.
背景：九个月单中心研究。
Patients: Severe acute respiratory distress syndrome patients on venovenous extracorporeal membrane oxygenation.
患者：重症急性呼吸窘迫综合征患者行体外膜肺氧合。
Interventions: After starting extracorporeal membrane oxygenation, patients were switched to the bi-level positive airway pressure mode with 1 second of 24cm H2O high pressure and 2 seconds of 12cm H2O low pressure for 24 hours. A computer-generated allocation sequence randomized patients to receive each of the following three experimental steps: 1) high pressure 24cm H2O and low pressure 20cm H2O (very high positive end-expiratory pressure–very low driving pressure); 2) high pressure 24cm H2O and low pressure 5cm H2O (low positive end-expiratory pressure–high driving pressure); and 3) high pressure 17cm H2O and low pressure 5cm H2O (low positive end-expiratory pressure–low driving pressure). Plasma and bronchoalveolar lavage soluble receptor for advanced glycation end-products, plasma interleukin-6,and monocyte chemotactic protein-1 were sampled preextracorporeal membrane oxygenation and after 12 hours at each step.
干预措施：体外膜肺氧合开始后，将患者转入双水平气道正压通气模式，高压24cmH2O，1秒，低压12cmH2O，2秒，持续24小时。患者根据计算机生成的分配序列随机分为以下三个实验步骤：1）高压24cmH2O和低压20cmH2O（非常高的呼气末正压-非常低的驱动压力）；2）高压24cmH2O和低压5cmH2O（非常低的呼气末正压-非常高的驱动压力压力）；和3）高压17cmH2O和低压5cmH2O（低呼气末正压-低驱动压力）。在体外膜氧合前和每一步骤12小时后获取血浆和支气管肺泡灌洗液中可溶性晚期糖基化终产物受体、血浆白细胞介素-6和单核细胞趋化蛋白-1。
Measurements and Main Results: Sixteen patients on ECMO after 7 days (1–11 d) of mechanical ventilation were included. “Ultraprotective” mechanical ventilation settings following ECMO initiation were associated with significantly lower plasma sRAGE,interleukin-6, and monocyte chemotactic protein-1 concentrations. Plasma sRAGE and cytokines were comparable within each on-ECMO experimental step, but the lowest bronchoalveolar lavage sRAGE levels were obtained at minimal driving pressure.
测量和主要结果：包括16例进行ecmo机械通气7天后（1-11天）的患者。ECMO启动后的“超保护性”机械通气设置与显着降低的血浆sRAGE、白细胞介素-6和单核细胞趋化蛋白-1浓度相关。在ECMO应用期间的每个实验步骤中，血浆sRAGE和细胞因子是可比较的，但在最小驱动压力下获得最低的支气管肺泡灌洗sRAGE水平。
Conclusions: ECMO allows ultra- protective ventilation, which combines significantly lower plateau pressure, tidalvolume, and driving pressure. This ventilation strategy significantly limited pulmonary biotrauma, which couldtherefore decrease ventilatorinduced lung injury. However, the optimal ultra-protective ventilation strategy once ECMO is initiated remains undetermined and warrants further investigations.
结论：ECMO期间允许低平台压、低潮气量及低驱动压的超保护性通气。这种通气策略明显限制了肺生物损伤，从而减少了机械通气相关肺损伤。然而，一旦ECMO启动，最佳的超保护性通气策略仍不确定，需要进一步研究。
【临床研究】每日一读：超保护机械通气减少重症急性呼吸窘迫综合征患者静脉-静脉体外膜肺氧合的生物损伤
