结果： 1例军团菌病患者在肺复张中发生纵隔气肿；1例肺炎、胸腔积液患者因存在房间隔缺损，导致复张无效；1例急性重症胰腺炎患者，有效PEEP最高达到30厘米水柱而对血流动力学无明显影响；1例脑出血、肺炎患者，初次肺复张无效，经纤维支气管镜从左右主支气管、多处段支气管开口处吸出大量黄脓痰，再次肺复张有效；1例膀胱癌术后并发肺部感染患者初次肺复张失败，经扩容治疗，第二次肺复张有效；一例脑出血并颅内高压患者应用6厘米水柱的PEEP,导致血压急剧、严重降低达15分钟以上。
结论：肺复张术中PEEP应用水平、效果、副反应受诸多因素的影响，肺复张术的实施必须遵循个体化的原则。
关键词：PEEP;肺复张；低氧血症；机械通气
Analysis of six representative episodes of lung recruitment maneuver
YANG Zi-jian, ZHANG Xiang-yu*, SHEN Ju-fang, WANG Qi-xing, FAN Hai-rong, JIANG Xin, CHEN Liang.
Surgery Intensive Care Unit, Shanghai Tenth People’s Hospital, Tongji University, Shanghai 200072, China.
ABSTRACT
Objective: To analyze 6 representative episodes of lung recruitment maneuver in patients with mechanical ventilation.
Methods: To describe in relatively detail 6 typical episodes of lung recruitment maneuver(RM) in patients admitted to our department from July 2005 to October 2007 and to analyze the underlining disease, desired and undesired effects of lung recruitment maneuver. To elevate PEEP gradually and to keep the driving pressure at fixed level were the preferred methods to recruit the lung.
Results: One patient with legionares’disease developed pneumomediastinum. One patient with pneumonia and pleural effusion showed no effect due to an unrevealed patent foramen ovale. One patient with acute severe pancreatitis endured a maximal PEEP of 30 cmH2O without adverse effects on cardiovascular system. One patient with intracerebral hemorrhage and nosocomial pneumonia failed to respond to recruitment maneuver initially and showed desired effect after suction of large mount of secretion through bronchoscope. One patient with cystectomy responded unsatisfiedly at the first RM due to complicated hypotension and manifested desired effect after volume replacement therapy. One patient with intra-cerebral hemorrhage sustained dramatic and severe blood drop lasting for 15 minutes while receiving aggressive support of vasoconstrictive agents and volume replacement.
Conclusion: The desired and adverse effects of PEEP during lung recruitment maneuver are subject to a series of factors, so the principle of individuality must be followed in the clinical practice when performing recruitment maneuver.
Key words: PEEP;lung recruitment maneuver; hypoxemia; mechanical ventilation
肺复张术能有效改善氧合，是目前治疗急性呼吸窘迫综合征的主要措施之一。目前，已有大量的研究、报道[1,2]；但是，针对肺复张实施具体程的分析,报道少见。我们在临床实施肺复张术的过程中积累了部分资料，对此进行整理，已经针对肺复张术的疗效进行了报道[3]。其中，6例肺复张实施过程包含了值得借鉴的经验，故在此进行相对详细的报道。
1、 对象与方法
1.1对象： 我院SICU设有10张病床， 2005年7月—2007年10月期间，共收治各种需机械通气患者286例，其中6例肺复张术实施过程值得介绍。患者临床资料如简表。
1.2方法： 6名患者入院前、或在住院期间胸部X线或CT检查提示肺部不同程度渗出，伴低氧血症发生，积极进行呼吸道护理，胸部物理治疗，氧合改善仍然不明显，进行肺复张治疗。复张方法如下：肺复张采取固定驱动压，逐渐升高PEEP，每次升高2cmH2O，每次持续2 分钟左右，直至脉氧饱和度改善，或者出现副反应，终止复张术；在进行肺复张的过程中氧浓度维持在80%，以确保安全实施肺复张术。所有患者皆进行中心静脉压及有创动脉血压监测,左或右侧桡动脉；脑室内压监测,穿刺点——大脑中线旁开2厘米，前额发际后2厘米；进针方向——垂直外耳道连线；进针深度约5厘米。雅陪压力传感器/42584——赫士睿公司；压力显示器——飞利浦IntelliVue MP70。
2、6例肺复张术具体过程：
病例1：女，24岁，因军团菌感染（入院后经过细菌学，血清学，及市内多名专家会诊后确诊），两肺广泛浸润以右侧为主，伴有严重呼吸窘迫，动脉血氧分压/氧浓度＜50，心输出量严重降低,左室射血分数（＜30%），进行肺复张，保持驱动压为15cmH2O，逐步升高PEEP，PEEP达20cmH2O时，脉氧饱和度快速下降，伴颈部、前胸出现广泛皮下气肿且逐渐增加，床旁胸片提示纵隔气肿，进行引流处理，因并发循环功能衰竭，应用ECMO进行心、肺支持治疗3天，继续进行机械通气约3周、逐渐好转、脱机，转普通病房。
病例2 ： 女，73岁，因患急性重症胰腺炎，腹腔压力升高，胸片无明显渗出，在吸入80%氧浓度时伴有明显低氧血症，血气分析提示动脉血氧饱和度70%，提高PEEP 到20cmH2O后，氧饱和度显示出好转趋势，保持该PEEP水平，5分钟内脉氧饱和度内逐渐上升并稳定在98%，逐渐下调吸入氧浓度至40%，脉氧仪显示氧饱和度仍维持在98%左右；然后逐渐下调PEEP至10cmH2O，2分钟后脉氧仪显示氧饱和度轻度下降至96%左右，并能持续维持氧饱和度在该数值轻度波动，在提升PEEP中，不伴有血压下降。
5日后该患者机械通气支持力度逐渐增加，胸片提示两肺野弥漫渗出、血气分析提示动脉血氧分压/氧浓度＜120，ARDS形成。此时，因腹腔内压增高行腹腔切开减压，在吸入80%氧浓度时氧饱和度＜70％，进行肺复张术，肺复张术采用固定驱动压15cmH2O，逐渐升高PEEP，每次升高2cmH2O，3-5个通气周期后，伴有脉氧仪监测氧饱和度逐渐好转，当PEEP达到16cmH2O时，氧饱和度反而表现出下降趋势，伴随有创血压轻度下降，下调PEEP 5cmH2O，氧饱和度、血压回升，再次上调PEEP 至16cmH2O，无氧饱和度下降表现，氧饱和度继续改善。此后，每次上调PEEP2cmH2O，皆表现出短暂氧饱和度、血压下降，经过下调PEEP，氧饱和度回升后，继续提升PEEP，可以得到氧饱和度的改善，当PEEP达到30cmH2O，氧饱和度达到98%左右，血压稳定。逐渐下调吸入氧浓度至50%，脉氧仪显示氧饱和度轻度下降至97%左右，并能持续维持氧饱和度在该数值轻度波动。该患者最终死于MODS。
病例3： 男，78岁，多发伤、肺炎，右侧胸腔积液，机械通气过程中，表现为持续低氧血症，转入SICU时,在吸入氧浓度80%，PEEP为0的情况下，脉氧饱和度＜75%，经过吸痰，提高氧浓度，氧饱和度无明显好转，逐步升高PEEP，当PEEP达到6 cmH2O时，氧饱和度反而有下降趋势，经下调PEEP，氧饱和度可以少许回升，经过多次肺复张手法皆失败，床旁超声提示：房间隔缺损，3日后死于MODS。
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