摘要

Importance:An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain.
Objective:To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP.
Design, Setting, and Participants:Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018.
Interventions:Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight.
Main Outcomes and Measures:The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute).
Results:Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P 

译文

重要性: 术中更高水平的呼气末正压 (PEEP) 和肺泡复张策略可以改善接受手术的肥胖患者的呼吸功能,但是对临床结果的影响还不确定。
目的: 确定较高水平的 PEEP 与较低水平的 PEEP 相比,较高水平的 PEEP 与肺泡复张策略是否能减少接受手术的肥胖患者的术后肺部并发症。
设计、设置和参与者: 2013年的成人随机临床试验,其体重指数为 35 或以上,并具有在全身麻醉下进行非心脏、非神经外科手术的术后肺部并发症的实质性风险。该试验于 2014年7月至 2018 在 23 个国家的 77 个地点进行; 最终随访: 2018年5月。
干预: 患者被随机分配到高水平的 PEEP 组 (n = 989), 由 12厘米 H2O 的 PEEP 水平加上肺泡补充动作 (潮气量和最终 PEEP 的逐步增加) 或 PEEP 组的低水平 (n =) 组成, 由 4厘米 H2O 的 PEEP 水平组成。所有患者均接受容量控制通气,潮气量为预计体重的 7 mL/kg。
主要结果和措施: 主要结果是术后 5 天内肺部并发症的复合,包括呼吸衰竭、急性呼吸窘迫综合征、支气管痉挛、新的肺部浸润、肺部感染, 吸入性肺炎、胸水、肺不张、心肺水肿和气胸。在 9 个预先确定的次要结果中,3 个是术中并发症,包括低氧血症 (血氧饱和度 ≤ 92%> 1 分钟)。
结果: 在 2013 名随机成年人中,1976 (98.2%) 完成了试验 (平均年龄 48.8 岁; 1381 [69.9%] 女性; 1778 [90.1%] 接受了腹部手术)。在意向治疗分析中,主要结果发生在高水平 PEEP 组的 211 名患者中的 989 名 (21.3%),而 233 名患者中的 987 名 (23.6%) 在低水平的 PEEP 组 (差异,-2.3% [95% CI,-5.9% 至 1.4%]; 风险比,0.93 [95% CI,0.83 到 1.04]; p   =  .23)。在 9 个预先指定的次要结果中,6 个在 PEEP 的高水平和低水平组之间没有显著差异,3 个有显著差异, 包括较少的低氧血症患者 (高水平 PEEP 组为 5.0%,而低水平 PEEP 组为 13.6%; 差异,-8.6% [95% CI,-11.1% 到 6.1%]; p  

positive end expiratory pressure

重症 通气治疗 治疗方法
概述  :  

患者出现呼吸衰竭时,可以发生严重的动态肺过度通气(DPH)和高水平的内生呼吸末正压(PEEPi),损害心功能,增加气压伤危险,降低吸气肌收缩效率和异常增加无效呼吸功能。机械通气时加用外源性PEEP,可对抗动态气道受压,以下游阻力平衡PEEPi的上游阻力,只要加用的PEEP水平小于PEEPi,就不会影响呼气流速和肺容量。PEEP可增加肺顺应性,减小呼吸肌作功,过高潮气量或高水平PEEP都可使肺泡过度扩张而形成肺大泡产生气胸的可能。所以临床应用时,尤其是对于可能合并肺气肿的患者而言,更应严格掌握

positive 英 [ ˈpɒzətɪv ] 美 [ ˈpɑ:zətɪv ]  

释义   adj. 积极的;[数] 正的,[医][化学] 阳性的;确定的,肯定的;实际的,真实的;绝对的 ;n. 正数;[摄] 正片

例句   So no matter what you do, be positive.

所以无论你做什么,都要积极。

 

expiratory 英 [ eks'paɪrət(ə)rɪ ] 美 [ ɛks'paɪərətəri ]   

释义   adj. [生理] 呼气的;吐气的

例句   In order to measure the changing expiratory flow correctly, the sensor must meet the undistorted measurement requirement within its working frequency range.

为了正确测量呼气流量的变化,传感器必须在其工作频率范围内满足不失真的测量要求。

 

Pressure 英 [ ˈpreʃə(r) ] 美 [ ˈpreʃər ]  

释义   n. 压力;压迫,[物] 压强 ;vt. 迫使;密封;使……增压

例句   He would not knuckle down under their pressure.

他不会屈服于他们的压力。


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