Đang tải... (xem toàn văn)
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES NGO TRONG TOAN RESEARCH EFFECTS OF MECHANICAL VENTILATION WITH TIRATING POSITIVE EN[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES - NGO TRONG TOAN RESEARCH EFFECTS OF MECHANICAL VENTILATION WITH TIRATING POSITIVE ENDEXPIRATORY PRESSURE GUIDED BY ESOPHAGEAL PRSSURE IN PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME Speciality: Anesthesia Resuscitation Code: 62723301 ABSTRACT OF MEDICAL PHD THESIS Hanoi – 2022 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: Prof PhD Nguyen Thi Du Ass Prof PhD Dao Xuan Co Reviewer: This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year The thesis can be found at: National Library of Vietnam Library of 108 Institute Pharmaceutical Sciences of Clinical Medical and INTRODUCTION Acute respiratory distress syndrome (ARDS) is a syndrome with highly prevalent rate in intensive care units Despite recent therapeutic advances in patients with ARDS, in-hospital mortality rate remains unacceptably high from 14.2% to 84% according to each study, average of 40% Mechanical ventilation that to secure oxygenation for patient is very important to manage patients with ARDS Positive endexpiratory pressure (PEEP) is an important parameter of mechanical ventilation in treating ARDS patients Whereas low tidal volumes are clearly beneficial in patients with ARDS, how to choose a PEEP to obtain the best benefit is uncertain and has many opinions A new approach is that ideally, mechanical ventilation should provide sufficient transpulmonary pressure (plateau airway pressure minus pleural pressure) to maintain oxygenation while minimizing repeated alveolar collapse or overdistention leading to lung injury In critical illness, there is marked variability among patients in abdomal and pleural pressures; thus, for a given level of PEEP, transpulmonary pressures may vary unpredictably from patient to patient Pleural pressures can be estimated by using an esophageal balloon catheter PEEP are adjusted according to each patient’s lung and chest-wall mechanics In patients with high estimated pleural pressure who are undergoing ventilation with conventional ventilator settings, underinflation may cause hypoxemia In such patients, raising PEEP to maintain a positive transpulmonary pressure might improve aeration and oxygenation without causing overdistention Conversely, in patients with low pleural pressure, maintaining low PEEP would keep transpulmonary pressure low, preventing overdistention and minimizing the adverse hemodynamic effects of high PEEP On the world, using an esophageal balloon catheter to measure esophageal pressures then adjusting PEEP according to measured esophageal pressures has been studied by Talmor, Sarge, Fessler, Yang…These researchers showed some initial benefits of adjusting PEEP depending on esophageal pressures are However, in Vietnam studies about esophageal pressure and its use in treating patients with ARDS have been rare So the thesis “Research effects of mechanical ventilation with titrating positive end-expiratory pressure guided by esophageal pressure in patients with acute respiratory distress syndrome” has been conducted with two following purposes: Study change of esophageal pressure measured by adult esophageal balloon catheter set and correlation between esophageal pressure and lung mechanical indexes in ARDS patients Evaluate efficacy about improving arterial blood oxygenation of mechanical ventilation with titrating positive end-expiratory pressure guided by esophageal pressure in ARDS patients Chapter OVERVIEW 1.1 Acute respiratory distress syndrome 1.1.1 The Berlin definition of ARDS ACUTE RESPIRATORY CHARACTERISTICS DISTRESS SYNDROME Within week of a known clinical Timing insult or new/worsening respiratory symptoms Bilateral opacities-not fully explained Chest imaginga by effusions, lobar/lung collapse, or nodules Respiratory failure not fully explained by cardiac failure or fluid overload; Need objective assessment (e.g., Origin of edema echocardiography) to exclude hydrostatic edema if no risk factor present 200 0.05 14 - Characteristics of lung mechanics such as Ppeak, Pplat, Pmean, PEEP, CRS, Vte, Vte/IBWkg, breath frequency, inspiratory time of two groups at baseline were well matched 3.2 Change in esophageal pressure and correlation with some indexes of lung mechanics 3.2.1 Changes in PesENDin and PesENDex - PesENDin and PesENDex varied widely between different times on the same patient and between different patients PesENDin and PesENDex were relatively high PesENDin and PesENDex averaged 16.7 ± 5.4 cmH2O ; 12.7 ± 4.5 cmH2O, respectively 3.2.2 Correlation between esophageal pressure and some indexes of lung mechanics - PesENDin, PesENDex were not correlated with obesity as assessed by body mass index, r = 0.227; p = 0.220; n = 31 (figure 3.1) and r = -0.194; p = 0.296; n = 31 (figure 3.2), respectively - PesENDex was not correlated with Ccw (r = 0.13; p = 0.509; n = 28) (figure 3.3) - PesENDexTo was not correlated with PEEP at baseline (r = 0.01; p = 0.958; n = 32) (figure 3.4) - PesENDin was significantly correlated with Ppeak at baseline (r = 0.601; p < 0.001; n = 32) (figure 3.5) PesENDin = 4.022 + 0.415 × Ppeak Hình 3.1 Correlation between Hình 3.2 Correlation between 15 PesENDin and BMI PesENDex and BMI Hình 3.3 Correlation between PesENDex and Ccw Hình 3.4 Correlation between Hình 3.5 Correlation between PesENDex and PEEP PesENDin and Ppeak 16 3.3 Effects of EPVent2 in comparision with ARDSnet 3.3.1 Oxygenation improvement 3.3.1.1 FiO2 level Table 3.17 FiO2 level between two groups EPVent2 ARDSnet p MinMinX ±SD X ±SD Max Max To 0.4-1 0.78±0.18 (n=32) 0,4-1 0.74±0.16 (n=34) >0.05 T1 0.5-1 0.7±0.15 (n=31) 0,5-1 0.77±0.15 (n=34) >0.05 T2 0.4-1 0.65±0.2 (n=29) 0,5-1 0.74±0.14(n=21) >0.05 T3 0.4-0.9 0.57±0.16 (n=16) 0,3-1 0.68±0.2 (n=15) >0.05 T4 0.4-1 0.62±0.22 (n=12) 0,4-1 0.67±0.19 (n=10) >0.05 p1-0 0.05 p2-0 0.05 p p3-0 0.05 p4-0 0.05 Comment: - FiO2 was significantly reduced (with p < 0,05) at T1, T2, T3, T4 compared with T0 in EPVent2 group 3.3.1.2 PaO2 (mmHg) Table 3.18 PaO2 change in two groups EPVent2 ARDSnet p Min-Max Min-Max X ±SD X ±SD To 39-132 73.5±17 (n=33) 40-107 70.8±16.4 (n=34) >0.05 T1 54-354 122±63 (n=32) 46.5-123 77.5±21.7 (n=34) 0.05 Comment: - PaO2 at T1 and T2 in EPVent2 group was significantly higher (p < 0.05) in comparision with ARDSnet group Difference at T1 was 44.5 mmHg; at T2 was 41 mmHg 17 - PaO2 at T1, T2, T3, T4 increased significantly (p < 0.01 and 0.05) in comparision with T0 in EPVent2 group Average differences at T1, T2, T3 and in comparision with T0 were 48.1 mmHg, 57.3 mmHg, 49.5 mmHg, 21.7 mmHg respectively 3.3.1.3 PaO2/FiO2 Table 3.19 Change of PaO2/FiO2 in EPVent2 group and ARDSnet group Nhóm EPVent2 Min-Max To T1 56-153 54-504 T2 55-516 T3 113-525 T4 64-340 p Min-Max X ±SD X ±SD 100±26 (n=32) 54-199 101±34 (n=34) >0.05 186±103 (n=32) 46.5-205 111±46 (n=34) 0.000 214± 103 45-285 125±53 (n=21) 0.000 (n=30) 221±102 (n=17) 95.4-402 161±82 (n=15) >0.05 177±85 (n=13) p1-0