Effects and Efficacy Evaluation of Modified Prone Ventilation Combined with Bronchoscopic Alveolar Lavage on Respiratory Mechanics and Hemodynamics in Children with ARDS
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摘要:
目的 探讨改良式俯卧位通气联合支气管镜肺泡灌洗治疗对ARDS患儿呼吸力学和血流动力学影响以及临床治疗效果评价。 方法 选取2021年1月至2023年12月在昆明市儿童医院急诊重症监护病房的96例接受机械通气治疗的ARDS患儿为对象，按随机数字法分为A、B、C 三组。A组为传统俯卧位通气组（n = 32）、B组改良式俯卧位通气组（n = 32）、C组为改良式俯卧位通气联合支气管镜肺泡灌洗治疗组（n = 32）。比较三组治疗前及治疗后以下参数的变化，氧合指标：动脉血氧分压（PaO2）、动脉氧合指数（PaO2/FiO2）；呼吸力学指标： 肺顺应性、气道平均压、气道平台压、气道总阻力；血流动力学指标：心输出量、心指数、总外周阻力指数，平均动脉压；临床疗效指标： 啰音消失时间，机械通气时间，住院时间；并发症发生率：心律失常、气道阻塞、压力性损伤、导管脱落总发生率、胃内容物反流。 结果 C组治疗后的氧合指标优于A组和B组（P < 0.05）。C组治疗后的呼吸力学指标优于A组和B组（P < 0.05）。血流动力学方面：C组治疗后心输出量、心指数、平均动脉压三项指标与A、B组比较，差异无统计学意义（P > 0.05）；C组治疗后总外周阻力指数指标优于A组和B组（P < 0.05）。C组治疗后的临床疗效指标优于A组和B组（P < 0.05）。C组治疗后的并发症发生率较A组、B组无明显差异（P > 0.05）。 结论 改良式俯卧位通气联合支气管镜肺泡灌洗治疗方案较传统治疗方法有更好的治疗效果，对患儿氧合及呼吸力学指标及血流总外周阻力指数有较好改善，值得临床推广。 Abstract:Objective To explore the effects of modified prone ventilation combined with bronchoscopic alveolar lavage on respiratory mechanics and hemodynamics in children with Acute Respiratory Distress Syndrome （ARDS）, as well as to evaluate the clinical treatment efficacy. Methods A total of 96 ARDS children receiving mechanical ventilation treatment in the emergency intensive care unit of Kunming Children's Hospital from January 2021 to December 2023 were selected and randomly assigned into three groups: Group A （prone ventilation group, n = 32 ）, Group B （modified prone ventilation group, n = 32）, and Group C （modified prone ventilation combined with bronchoscopic alveolar lavage group, n = 32）. The changes in the following parameters before and after treatment among the three groups were compared: oxygenation indicators: arterial oxygen partial pressure （PaO2）, arterial oxygenation index （PaO2/FiO2）; respiratory mechanics indicators: lung compliance, mean airway pressure, plateau airway pressure, and total airway resistance; hemodynamic indicators: cardiac output, cardiac index, systemic vascular resistance index, and mean arterial pressure; clinical efficacy indicators time to disappearance of rales, mechanical ventilation duration, and length of hospital stay; and incidence of complications: arrhythmia, airway obstruction, pressure injuries, total incidence of catheter dislodgment, and gastric content reflux. Results The oxygenation indicators in Group C after treatment were superior to those in Groups A and B （P < 0.05）. The respiratory mechanics indicators in Group C after treatment were also better than those in Groups A and B （P < 0.05）. In terms of hemodynamics, there were no statistically significant differences in cardiac output, cardiac index, and mean arterial pressure among Groups A, B, and C after treatment （P > 0.05）. However, the SVRI in Group C was better than that in Groups A and B （P < 0.05）. Curative effect for Group C were also better than those for Groups A and B （P < 0.05）.The incidence of complications in Group C showed no significant difference compared to Groups A and B （P > 0.05）. Conclusion The modified prone ventilation combined with bronchoscopic alveolar lavage treatment scheme demonstrates better therapeutic effects compared to traditional treatment methods, significantly improving oxygenation and respiratory mechanics indicators as well as the systemic vascular resistance index in children, and is worthy of clinical promotion. -
Key words:
- Modified prone ventilation /
- Bronchoscopic alveolar lavage /
- ARDS /
- Respiratory mechanics /
- Hemodynamics
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表 1 A、B和C组患儿基线资料比较[（$ \bar x \pm s $）/n（%）]
Table 1. Comparison of general data in the three groups[（$ \bar x \pm s $）/n（%）]
基线资料 A组（n = 32） B组（n = 32） C组（n = 32） χ2/F P 年龄（岁） 5.81 ± 1.54 6.05 ± 0.63 5.91 ± 1.85 0.046 0.913 性别 1.228 0.711 男 16（50.0） 17（53.13） 14（43.75） 女 16（50.0） 15（46.88） 18（56.25） 体重（kg） 18.93 ± 2.15 19.01 ± 2.33 18.32 ± 2.17 0.418 0.734 儿童危重病例评分 63.93 ± 2.15 60.63 ± 3.15 61.27 ± 2.89 0.392 0.593 合并症 心功能不全 6（18.75） 4（12.5） 8（25.0） 0.432 0.807 脓毒症 3（9.38） 5（15.63） 2（6.25） 0.554 0.721 
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表 2 A、B和C组患儿氧合参数比较（$ \bar x \pm s $）
Table 2. Comparison of oxygenation indicators in the three groups（$ \bar x \pm s $）
组别 n PaO2（mmHg） PaO2/FiO2（mmHg） T0 T1 T0 T1 A组 32 53.81 ± 7.69 91.90 ± 5.33 237.98 ± 12.16 301.35 ± 18.19 B组 32 54.23 ± 8.16 92.33 ± 4.57 235.89 ± 13.15 313 ± 17.64 C组 32 52.33 ± 7.22 97.67 ± 4.55 236 ± 14.89 364.43 ± 18.90 F 0.029 143.820 0.032 133.123 P 0.989 0.033* 0.916 0.041* *P < 0.05 。
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表 3 A、B和C组患儿呼吸力学指标比较（$ \bar x \pm s $）
Table 3. Comparison of respiratory mechanics indicators in the three groups （$ \bar x \pm s $）
组别 n 肺顺应性
L/cmH2O气道平均压
cmH2O气道平台压
cmH2O气道总阻力
cmH2O/L/sT0 T1 T0 T1 T0 T1 T0 T1 A组 32 14.44 ± 3.2 26.5 ± 5.2 18.57 ± 2.4 14.7 ± 2.4 19.1 ± 3.5 13.1 ± 3.5 15.2 ± 4.1 14.2 ± 3.1 B组 32 13.98 ± 4.1 27.2 ± 6.1 18.36 ± 1.8 13.6 ± 1.9 20.3 ± 4.7 11.4 ± 3.1 14.7 ± 3.3 12.7 ± 2.6 C组 32 14.21 ± 5.7 31.8 ± 6.7 19.19 ± 3.6 11.8 ± 1.8 20.67 ± 5.2 10.5 ± 2.9 15.8 ± 4.6 9.3 ± 2.4 F 0.064 41.576 0.132 21.675 0.034 32.546 0.056 33.123 P 0.875 0.003* 0.768 0.014* 0.932 0.009* 0.901 0.007* *P < 0.05。
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表 4 A、B和C组患儿血流动力学指标比较（$ \bar x \pm s $）
Table 4. Comparison of hemodynamic indicators in the three groups （$ \bar x \pm s $）
组别 n CO
（L/min）CI
（min·m2）MAP
（mmHg）SVRI
dym/（s·cm5·m2）T0 T1 T0 T1 T0 T1 T0 T1 A组 32 2.5 ± 1.2 2.8 ± 0.7 3.6 ± 1.4 5.7 ± 2.4 55 ± 10 54.1 ± 3.5 1208 ± 23.11190 ± 41.5B组 32 2.7 ± 0.8 3.0 ± 1.1 3.1 ± 0.4 5.3 ± 1.9 53 ± 8 58.74 ± 3.1 1320 ± 33.51087 ± 37.3C组 32 2.6 ± 1.5 2.9 ± 1.3 3.3 ± 1.7 5.9 ± 1.7 57 ± 6 57.5 ± 2.9 1218 ± 28.5803 ± 33.7 F 0.047 0.064 0.035 0.076 0.041 0.961 0.0354 52.016 P 0.973 0.886 0.987 0.745 0.993 0.351 0.93 0.005* *P < 0.05。
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表 5 A、B和C组患儿临床疗效比较[（$ \bar x \pm s $），d]
Table 5. Comparison of clinical efficacy in the three groups[（$ \bar x \pm s $），d]
组别 n 啰音消失时间 机械通气时间 住院时间 A组 32 9.19 ± 2.33 9.71 ± 1.21 16.56 ± 2.37 B组 32 7.76 ± 2.85 7.88 ± 1.47 13.34 ± 2.81 C组 32 5.14 ± 2.54 6.67 ± 1.33 11.09 ± 2.09 F 37.588 43.871 19.030 P 0.018* 0.013* 0.021* *P < 0.05。
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表 6 A、B和C组患儿并发症发生率比较 [n（%）]
Table 6. Comparison of incidence of complications in the three groups [n（%）]
组别 n 气道阻塞 压力性损伤 导管脱落 胃内容物反流 心律失常 总发生率 A组 32 1（3.13） 2（6.25） 0（0） 2（6.25） 0（0） 5（15.63） B组 32 0（0） 1（3.13） 0（0） 2（6.25） 1（3.13） 4（12.5） C组 32 1（3.13） 2（6.25） 0（0） 1（3.13） 0（0） 4 （12.5） χ2 0.003 P 0.950
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