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Objective To explore the effect of cognitive education and behavioral intervention in solid-state high resolution esophageal manometry (HRM) examination. Methods From April 2016 to June 2017, 60 patients with solid-state HRM in the gastrointestinal motility room at the First Affiliated Hospital of Jiaotong University were as the research object. The 60 patients were divided into control group and experimental group with 30 cases each by the method of random numbers. The conventional methods was used in control group to conduct informed counseling before the examination and the coordination guidance in the examination. The conventional methods and cognitive behavioral intervention was used in experimental group at the same time. The successful rate of intubation, the time used for the examination, discomfort symptoms during intubation, the patient's satisfaction in the whole check process and self-evaluation of intubation pain experience in two groups of patients were compared. Results The time used in the experimental group examination was (28.50±8.75) min, and the control group was (33.13± 5.49) min. The difference between the two groups was statistically significant (t=2.584, P=0.015). In the experimental group, the number of nausea, vomiting, and coughing in the intubation process was 11, 0, and 1, respectively, and the control group was 20, 6, and 7, respectively. The difference was statistically significant (χ2=5.406, 4.630, 5.192, all P<0.05). In the experimental group, the scores of the 2, 3, 4, 5, 7, 8, 10, 11, 12, and 13 items of the intubation pain experience self-evaluation in the examination process were (1.00 ± 0.64), (1.37 ± 0.85), (2.80 ± 0.96), (1.50 ± 0.51), (0.87 ± 0.63), (0.77 ± 0.50), (0.60 ± 0.56), (1.07 ± 0.25), (0.57 ± 0.57), (1.50 ± 0.63) points, and the 2, 3, 4, 5, 7, 8, 10, 11, 12 and 13 scores of the control group they were (1.50 ± 0.51), (2.03 ± 0.76), (3.50 ± 0.82), (2.03 ± 0.76), (1.20 ± 0.61), (1.03 ± 0.41), (0.83 ± 0.53), (1.23 ± 0.43), (0.87 ± 0.57), (2.00 ± 1.05) points, respectively. The difference was statistically significant (t=-4.130--2.140, all P<0.05). Conclusions HRM is an important test before the clinical application of a wide range of clinical applications for the detection of esophageal motility disorders and gastroesophageal reflux disease. The degree of patient cooperation with the operation directly affects the high-resolution esophageal manometry test results and self-experience. Medical staff can give patients cognitive education and behavioral intervention before examination, which can effectively reduce the symptoms and pain caused by intubation, improve patient compliance, shorten the time for examinations, improve work efficiency, and improve patient satisfaction. It is worth further promotion and application in clinical examination.
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Acute respiratory distress syndrome (ARDS) is a common disease in intensive care unit. ARDS has attracted wide attention of clinicians for its high in-hospital mortality and high incidence of long-term mortality. This expert opinion reviews the available clinical evidence and adjuvant treatment of ventilator support. Based on clinical evidence and experience,we provide suggestions for the management of patients with ARDS. We interpret this expert opinion and some experience in children was added,hoping to provide suggestions for the treatment of children with ARDS.
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Esophageal pressure monitoring provides a minimally invasive method to assess the pleural pressure, which can be used to differentiate the lung and chest wall mechanics. The information of transpulmonary pressure, work of breathing, intrinsic positive end-expiratory pressure and respiratory muscle performance can facilitate the proper setting of mechanical ventilation. Esophageal pressure monitoring is still not routinely used in the clinical setting because of difficulty in esophageal balloon catheter placement and data interpretation due to esophageal pressure monitoring has certain technical requirements, and the measurement results are influenced by many factors such as airbag volume, location, esophageal wall elasticity and mediastinal organ weight. In this review, we introduced technique for esophageal pressure measurement and calculation of transpulmonary pressure aiming to promote the clinical application of esophageal pressure monitoring.
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Objective To evaluate the effect of positive end-expiratory pressure (PEEP) ventilation guided by esophageal pressure (Pes) on pulmonary function after laparoscopic surgery in elderly patients.Methods Sixty American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients of both sexes,aged ≥ 65 yr,with body mass index of 16-28 kg/m2,scheduled for elective laparoscopic radical resection of colorectal cancer,were divided into 2 groups (n =30 each) using a random number table method:PEEP group (group P) and Pes-guided PEEP group (group PP).After induction of anesthesia,the patients were tracheally intubated and mechanically ventilated.The fresh gas flow of oxygen was set at 2 ml/L,tidal volume (VT) was 8 ml/kg,inspiratory/expiratory ratio was 1.0:(1.5-2.0),fraction of inspired oxygenwas 60％,the respiratory rate was adjusted,and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg.PEEP was set at 5 cmH2O in group P.PEEP was set according to Pes to maintain 5 mmHg ≤ transpulmonary end-expiratory pressure ≤ 10 mmHg in group PP.Forced expiratory volume first second,forced vital capacity,and maximum ventilatory volume were determined after admission to the operating room and at 1,3 and 5 days after operation.Blood samples were collected from the radial artery for blood gas analysis,PaO2 and PaCO2 were recorded,and oxygenation index (PaO2/FiO2) was calculated.Clinical Pulmonary Infection Score was assessed.The development of postoperative pulmonary complications such as pulmonary atelectasis,pneumothorax,respiratory failure,aspiration pneumonia,respiratory infections,pleural effusion and bronchial asthma was recorded.Results Compared with group P,forced expiratory volume first second,forced vital capacity,and maximum ventilatory volume,PaO2 and PaO2/FiO2 were significantly increased at 1,3 and 5 days after operation,and the Clinical Pulmonary Infection Score and incidence of pulmonary atelectasis and respiratory infections were decreased in group PP (P＜0.05).Conclusion Pes-guided PEEP can improve pulmonary function after laparoscopic surgery and decrease pulmonary complications in elderly patients.
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Objective To evaluate the safety and feasibility of injection test which is used to locate esophageal balloon catheter.Methods A prospective study was conducted. The patients undergoing invasive mechanical ventilation (MV) admitted to general intensive care unit (ICU) of Beijing Tiantan Hospital Affiliated to Capital Medical University from May 2015 and March 2017 were enrolled. The commercially available esophageal balloon catheter was modified to perform injection test. The catheter was withdrawn step by step and the injection test was repeated until the presence disturbance wave presented, which indicated that the balloon had just entered the esophagus. The position where disturbance wave appears was named 0 cm. End-expiratory occlusions were performed at the positions of+15,+10,+5, 0, -5, -10 and -15 cm, respectively, and the changes of esophageal pressure (Pes) and airway pressures (Paw) were measured in the spontaneous breathing and passive ventilation, and the ratio between the changes (ΔPes/ΔPaw) was calculated.Results A total of 20 patients were enrolled, of which 15 patients finished both the spontaneous and the passive ventilation parts, and 2 patients finished only the spontaneous part and 3 patients finished only passive part. ① Disturbance waves could be induced by injection test in all patients. The average depth of disturbance wave in spontaneous breathing was deeper than that in passive ventilation (cm: 42.4±3.8 vs. 41.8±3.3), but there was no significant difference between the two ventilation settings (P = 0.132). No adverse events occurred during the study period. ② Pes increased with the stepwise withdraw of esophageal catheter, reached the maximal value at+5 cm, and then decreased when the catheter was further withdrawn, no matter in the spontaneous or the passive ventilation. In spontaneous breathing, the ΔPes/ΔPaw was within the ideal range (0.8-1.2) at the positions of 0, -5 and -10 cm. The ΔPes/ΔPaw was closest to unity at the positions of 0 cm (0.98±0.15). The ΔPes/ΔPaw at -15 cm (0.66±0.26) was significantly lower than that at 0 cm (P < 0.05). For passive ventilation, the ΔPes/ΔPaw was within the ideal range at the positions of -5 cm and -10 cm, and the ΔPes/ΔPaw was closest to unity at the positions of-10 cm (0.94±0.12). The ΔPes/ΔPaw at 0 cm and -5 cm was significantly higher than that at -10 cm (1.43±0.31 and 1.12±0.14, respectively); while the ΔPes/ΔPaw at -15 cm (0.68±0.23) was significantly lower than that at -10 cm (allP < 0.01).Conclusions Ideal position of the esophageal balloon catheter could be determined quickly and easily by using injection test. The method is safe and clinically feasible.Clinical Trial Registration Clinical Trials, NCT02446938.
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Esophageal pressure(Pes)is usually measured via a catheter with an air - filled thin - walled latex balloon inserted nasally or orally. To validate Pes measurement,a dynamic occlusion test measures the ratio of change in Pes to change in Paw during inspiratory efforts against a closed airway. This report summarizes current physiological and technical knowledge on esophageal pressure measurements in patients receiving mechanical ventilation. The respiratory changes in Pes are representative of changes in pleural pressure. The difference between airway pressure(Paw)and Pes is a valid estimate of transpulmonary pressure. Because of the nonuniformity of lesion of pulmonary in patient with acute respiratory distress syndrome,Paw and volume can not represent the stress to expand the pulmonary. How to adjust posi-tive end expiratory pressure(PEEP)is still lack of gold standard. The use of Pes for PEEP titration may help improve oxygenation and compliance,or even has the possibility to improve the patient outcome.
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Objective To evaluate the value of transpulmonary pressure (Ptp) guided optimal positive end-expiratory pressure (PEEP) selection in patients with early acute respiratory distress syndrome (ARDS).Methods A prospective randomized self-control study was conducted.ARDS patients in the early stage (onset ≤3 days) undergoing intubation and mechanical ventilation admitted to intensive care unit (ICU) of Jiangsu Provincial Subei People's Hospital from December 2013 to December 2015 were enrolled.The PEEP level was regulated to 30 cmH2O (1 cmH2O =0.098 kPa) after recruitment maneuver,and then it was gradually decreased to 0 with lowering by 3 cmH2O every 5 minutes.The optimal PEEP was titrated by Ptp,lowest dead space fraction (VD/VT),highest static lung compliance (Cst),and optimal oxygenation,respectively.Parameters of respiratory mechanics and gas exchange were observed.Results Totally 28 patients with ARDS (including 17 male and 11 female) were included with the average age of (45 ± 12) years old,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score was 21 ± 9,oxygenation index (PaO2/FiO2) was (165 ± 76) mmHg (1 mmHg =0.133 kPa).① During decremental PEEP titration,Ptp was gradually decreased,and expiratory Ptp (Ptp-e) was more than zero [(1.3±0.3) cmH2O] when PEEP was (9.6 ± 2.3) cmH2O.Cst was initially improved until reaching a peak,and then deteriorated.Cst was highest [(50 ± 8) mL/cmH2O] when PEEP was (11.5 ± 2.4) cmH2O.PaO2/FiO2 reached the maximum [(312 ± 99) mmHg] at PEEP level of (18.0 ± 2.5) cmH2O.Compared with Ptp-e 3.00-5.99 cmH2O,PaO2/FiO2 was significantly decreased when Ptp-e became negative (all P ＜ 0.05).VD/VT was lowest (0.52 ±0.05) when PEEP was (10.1 ± 2.2) cmH2O.When compared with ventilation [inspiratory Ptp (Ptp-i) 0-2.99 cmH2O],it was significantly higher during high (Ptp-i ≥ 15 cmH2O,all P ＜ 0.05).② There were no statistically significant differences in the levels of optimal PEEP,Ptp-i and Ptp-e among Ptp,lowest VD/VT and highest Cst methods (all P ＞ 0.05),but they were significantly less than optimal oxygenation method (all P ＜ 0.05).Compared with baseline and the method of optimal oxygenation,Cst in other three PEEP titration methods including Ptp,lowest VD/VT and highest Cst was improved obviously (mL/cmH2O:46± 7,47±9,50± 8 vs.30± 8,35 ± 10,all P ＜ 0.05).PaO2/FiO2 (mmHg) in the method of Ptp and lowest VD/VT were higher than the baseline (252 ± 86,258 ± 72 vs.165 ± 76,both P ＜ 0.05),but significantly lower than that of optimal oxygenation method (312 ± 99,both P ＜ 0.05),and did not significantly differ from that of highest Cst (268± 85,both P ＞ 0.05).Compared with baseline and the method of optimal oxygenation,VD/Vr improved significantly in ventilated patients on PEEP targeting with Ptp and lowest VD/VT (0.53±0.05,0.52±0.05 vs.0.59±0.05,0.58±0.04,all P ＜ 0.05).Conclusion Titration the optimal PEEP level with the method of Ptp could promote collapse alveolar recruitment,improve oxygenation and lung compliance,decrease dead space ventilation,and will not cause alveolar excessive inflation in patients who undergoing mechanical ventilation with early ARDS.
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Objective To study the effect of mechanical ventilation guided by esophageal pressure on hemodynamics and oxygen metabolism of severe acute pancreatitis (SAP) swine model with intra-abdominal hypertension (IAH) Methods By self-controlled study,SAP model was made by infusing sodium taurocholate (5％) into the pancreatic duct in 6 domestic swine.Mechanical ventilator mode was volumeassist control with tidal volume 10 ml/kg ; FiO2 40％ and PEEP 5 cm H2O (routine ventilation) given to SAP model swine.After 3 h ventilation,pneumo-peritoneum was made with N2 gas to increase the intraabdominal pressure (IAP) to 25 mm Hg in SAP swine.Three more hours later,PEEP was adjusted as the measurement of esophageal pressure (Pes guided ventilation) to such a level that trans-pulmonary pressure stayed above 0 cm H2O during end-expiratory occlusion.During the investigation period,heart rate (HR),cardiac output index (CI),central venous pressure (CVP),mean arterial pressure (MAP) and pulmonary arterial wedge pressure (PAWP) were continuously recorded with the aid of Swan-Ganz catheter and ECG monitor,and oxygen partial pressure of artery (PaO2) and carbon dioxide partial pressure of artery (PaCO2) were measured by blood-gas analysis.In addition,systemic oxygen delivery (DO2) and systemic oxygen consumption (VO2) were calculated by using the data of blood-gas analysis of arterial and central venous blood.Results No swine model was subjected to barotrauma.After routine mechanical ventilation,there were significant differences in HR,CI,MAP,CVP,PAWP,Ppeak,Pplat,Pes,pulmonary compliance (Cstat),PaO2,and DO2 between SAP and IAH in swine (all P ＜ 0.05).Compared with routine ventilation,however,PaO2 and Cstat improved significantly with lower CI and increased Pplat after PEEP adjusted according to measurements of esophageal pressure (all P ＜ 0.05).The lactate decreased significantly after esophageal pressure guided ventilation (all P ＜ 0.05).There were no significant changes in PaCO2,HR,MAP,CVP and PAWP in IAH swine after mechanical ventilation with routine parameters (all P ＞ 0.05).Conclusions There were remarkable effects on oxygen metabolism in response to mechanical ventilation guided by esophageal pressure.In case of clinical application of mechanical ventilation,the results of this study are in favor of setting transpulmonary pressure according to measurements of esophageal pressure in SAP patients with IAH in an early stage.
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To investigate the relationship between esophageal motility and GI hormones in patients suffering from gastroesophageal reflux disease (GERD), the esophageal motility in 20 GERD patients with esophagitis and 25 GERD patients without esophagitis was examined by means of SGY-3 Digestive Tract Motility Measuring Instrument. Meanwhile,Serum gastrin,motilin,glucagon,estradiol were measured with RIA.The data from 15 healthy volunteers served as control.The results showed that ①GERD patients without esophagitis had lower LESP(2 12?1 00kPa) than control(3 23?0 72kPa P