A clinical study of lung protective ventilation and sequential lung recruitment maneuver for treatment of severe acute pancreatitis complicated with acute respiratory distress syndrome / 中国中西医结合急救杂志

ABSTRACT

Objective To investigate the clinical therapeutic effects of lung protective ventilation and sequential recruitment maneuver (RM) on treatment of patients with severe acute pancreatitis (SAP) complicated with acute respiratory distress syndrome (ARDS). Methods Sixty patients with SAP complicated with ARDS admitted to the Department of Critical Care Medicine of the First Affiliated Hospital of Nanchang University from April 2014 to March 2016 were enrolled. They were divided into control group and experimental group by random number table, 30 patients in each group. On the basis of comprehensive treatment, the patients in control group were treated with lung protective ventilation mode low tidal volume ventilation (6 mL/kg) + optimal end-expiratory positive pressure (PEEP) ventilation mode, when the intra-abdominal pressure (IAP) was essentially returned to a normal level (Ⅰ grade intra-abdominal hypertension), the patients in experimental group were treated by the combination with RM therapy, and the rest treatment was the same as the control group. Under the two types of ventilation strategies, the clinical effects, respiratory mechanics, hemodynamics and arterial blood gas indexes were compared between the two groups. Results The mechanical ventilation time (days 13.82±4.40 vs. 19.87±7.40), the length of ICU stay (days22.67±4.40 vs. 26.43±5.39) and incidence of ventilator associated pneumonia [VAP 16.67% (5/30) vs. 26.67% (8/30)] of the experimental group were lower than those of the control group (all P < 0.05), the mortality rate of the experimental group was slightly lower than that of the control group [26.67% (8/30) vs. 30.00% (9/30)] without statistical significance (P > 0.05). Plateau pressure (Pplat) and the peak airway pressure (PIP) at each time point were decreased after treatment in both groups, while the static lung compliance (Cst), the arterial partial pressure of oxygen (PaO2) and oxygenation index (PaO2/FiO2) were increased compared with those before treatment, especially the changes at 72 hours after recruitment in the experimental group were more significant than those in the control group [Pplat (cmH2O, 1 cmH2O = 0.098 kPa)15.6±4.0 vs. 21.2±5.6, PIP (cmH2O) 18.3±5.0 vs. 25.1±5.4, Cst (mL/cmH2O) 41.2±4.8 vs. 31.2±6.0, PaO2 (mmHg, 1 mmHg = 0.133 kPa) 90.93±6.45 vs. 80.27±4.51, PaO2/FiO2 (mmHg) 238.33±18.31 vs. 185.83±11.14]. Heart rate [HR (bpm) 110.23±7.92 vs. 98.23±8.44] and the central venous pressure [CVP (mmHg) 8.62±1.52 vs. 6.32±1.42] were significantly higher than those before treatment, the mean arterial pressure [MAP (mmHg) 86.74±7.65 vs. 94.92±10.93] and cardiac output [CO (L/min) 5.32±1.36 vs. 6.42±1.32] were significantly reduced compared with those before treatment (all P < 0.05). The values of HR, MAP, CVP, CO at 5 minutes after recruitment were (97.87±5.77) bpm, (94.54±6.87) mmHg, (6.33±1.44) mmHg, (6.32±1.41) L/min, respectively. The changes of these parameters were not significant when compared with those of the basal conditions (P > 0.05) Conclusions Based on the lung protective ventilation in the early stage, sequential RM is applied in treatment of patients with SAP complicated with ARDS, after the IAP is essentially returned to a normal, which is beneficial to improving lung compliance, promoting oxygenation, shortening the time of mechanical ventilation, reducing the length of ICU stay, and decreasing the incidence of VAP without any obvious hemodynamic influence.