VIETNAM MEDICAL JOURNAL N°1 - JANUARY - 2017
NGHIEN Cl^U s y THAY 0 0 1 KHI MAU 6" BENH NHAN THONG KHI NHAN TAO VOI TIT THE NAM S A P
T O M TAT
B^t van de: Benh nhan (BN) suy ho hiip cap tien trien (ARDS) du'dc thong khi nhan tao (TKPJT) t i l the nam sap cai thien oxy mau, gop phan lam cai thien t / le tu* vong. Myc tieu: Danh gia hieu qua cai thien oxy mau cua tu' the nam siip trong th6ng khi nhSn tao d benh nhan suy ho hap cap tien trien. Phu'dng phap:
Nghifin ciili tien ciTu m6 ta so sanh tru'dc va sau can thiep (thd may tu' the nam sap) tren 26 bfinh nhan ARDS ed PaOa/FiOj < 100 hoSc PaOz/FiOz < 150 nhung dang giam vdi PEEP > 5 va ROj > 60%. Cac bfinh nhan du'dc thd may theo hu'dng dan cua ARDSNet d ca khi nSm ngu'a va nam sap. Tieu chuan cai thi?n oxy mau khi Pa02/Fi02 tang tren 20% so vdi tru'dc khi benh nh§n nSm sap. Ket qua: Ty le BN cd cai thien oxy mau la 80,8%. Oxy mau cai thien sau nam sap 1 gid va tiep tuc tang len trong nhij'ng gid tiep theo. r^ng do E1O2 dirpc giam dan trong thdi gian benh nhan nam sap. Ket luSn: Thong khi nhan tao tu"
the nSm sSp c6 tac dung cai thien oxy mau trong dieu tri BN ARDS.
Td khoa: Jhdng khi nhan tao tu'the nim sap, hpi ChiTng suy ho hap cap tien trien, ARDS.
SUMMARY
IMPROVEMENT OF OXYGENATION D U R I N G PRONE P O S I T I O N I N MECHANICALLY VENTILATED PATIENTS W I T H ACUTE RESPIRATORY DISTRESS SYNDROME Introduction: Prone position during mechanical ventilation has been increasingly used In patients with acute respiratory distress syndrome (ARDS). This maneuver has now been considered as a simple and safe technique to Improve oxygenation and respiratory mechanics. Furthermore, it helped improve survival among patients with ARDS. Objectives: To evaluate the effectiveness of prone position in improving oxygenation during ventilation for ARDS patients.
Methods: This is a prospective observatory study. We assigned 26 patients with ARDS. The Pa02/Fi02 ratio was less than 100 or 150 and on decrease on PEEP >
5, FIOz > 60%. All of patients were implemented a
* Kho? Cap cuti A9, Benh vien Bach Mai
**Khoa HSCC Benh vien Da khoa Thai Binh Chiu trach nhiem chinh: Nguyen Van Chi Email; [email protected] Ngay nhan bai: 15.10.2016 Ngay phan bien khoa hoc: 5.12.2016 Ngay duyet bai: 12.12.2016
Nguyin Van Chi*, D§ Mmh Phu-ffngl
protective ventilation strategy following ARDSNeJ^
both supine and prone position. Imprcn^
oxygenation when PaOz/FIOz ratio increased ,20% a ^ over in comparison to the baseline. Results: The percentage of patients with Improving oxygenatfciif, was 80.8%. The saturation of oxygen {Sa02)' increased after 1 hour and during prone p o ^ o n . FiOj was decreased during prone position. Conclusions: Prone ventilation improved oxygenation in ARDS patients. fl
Keywords: prone ventilation, acute respiratoty/
distress syndrome, ARDS.
I. OAT VAN o l
Ty le tCr vong chung cda hpi chu?ig suy ho hap cap tien trien (ARDS) td 30 - 6 0 % , trong do tCr vong d nhdm BN nang la 8 0 % [ 2 ] . Bieu hien dac tru'ng cua benh la t o n thu'dng lan tda mang ptie nang mao mach gay nen tinh trang giam oxy mau tram trong [ 7 ] . Phu'dng phap TKNT tu'.tiie nam sap trong dieu trj benh nhan ARDS du'dc Piehl ap dung td nam 1976 [ 3 ] . I^lot trong nhiJng tac dung cua phu'dng phap nay la lam md cac phe nang d vung phu thupc, tCr dd lam ,tang dong bp ty le thong khi/tu'dl mau (V/Q) nen lam cai thien oxy mau. Nhieu nghien cull sau do clio thay TKNT tu' the nam sap cd tac dung lam dii thien oxy mau ti!r 70 - 8 0 % cac tru'dng hdp va lam giam ton thu'dng phoi do t h d may [2]. Vl vay nghien cu'u nham muc tieu; Danh gia hieu qua cai thien Sxy^mau cua td the nam sap ti'ong thong khf nhan tao d benh nhan suy ho hap cap tien trien.
II. 0 6 1 T i r p N G VA PHU'aNG PHAP NGHIEN COU 2 . 1 . Doi tu'dng nghiSn cu'u
Gom 26 berih nhan ARDS cd PaOs/FiOs < 150 dddc dieu tri tai khoa Cap cdu, khoa Hoi sdctfcfi cdc benh vien Bach Mai tii thang 11/2013 den thang 1/2016.
2.1.1. Tiiu chuin lu'a chpn Bfi
* Cac benh nhan cd d u tieu chuan ARDS theo, djnh nghta Berlin nam 2012 [ 4 ]
- Thdi gian: Xay ra cap tinh, trong vdng 1 tuan cda benh hoac cac trieu chutig ho hap nang len hay mdi xuat hien,
- Hinh anh X quang phoi: m d lan tda hai phoi khdng do tran djch hay xep phdi.
76
TAP CHi Y Hpc VlgT NAM TAP 450 -THANG 1 - S 0 1 - 2017
- SUy ho hap khong do suy tim hay qua tai
Ijch. Sieu am tim de loai trir phu phoi cap huyet long neu khong cd yeu to nguy cd.
' * Benh nhan du'dc TKNT theo ARDSNet [6] va luy dpng phecoang trang vong 24 gid ma oxy nau khong cai thien: Ty- le Pa02/Fi02 < 100 nmHg hoac PaQz/FiO^ 5 150 mmHg nhu'ng cd :u hu'dng tiep tuc giam vdi PEEP > 5 cmH20,
•iOz > 60%.
2,1.2. Tiiu chuan loai ^u"ijinh nhin
- Benh nhan du'di 16 tuoi.- Gia dinh benh nhan khong dong y tham gia ighien culi
Pa02/FI02 < 150 nhu'ng dang cai thien ihanh va co xu hu'dng tang len.
- Benh nhan cd chong chi dinh vdi tu'the nam sap:
• Chan thu'dng sp nao, chan thu'dng cot
>ong, chan thu'dng ham mat.
• Gay xu'dng chau, xu'dng su'dn mdi phau ihuat viJng bung, ngu'c.
• Soc hoac ban nliip tim nang de dpa b'nh mang.
^ • Benh nhan dang loc mau lien tuc.
• Phu niJcd thai.
2.2. Phu'dng phap nghien cili'u 2.2.1. Thiet ke nghien cu'u: Nghien CUXJ tien cull mo ta so sanh tru'dc sau.
2.2.2. TiSn hanh nghien cu'u:
* BN dit^: tiling khi nhan tao xam nh$p theo ARDSNet l^]
- Cai dat thong so may tiid:
+ Phu'dng thu'c thd: VCV, VC+, PCV + Vt = 6 - 8 ml/kg can nang ly- tu'dng (PBW) + Tan so thd f < 35 Ian/phut de dat thong khi phut can thiet
+ Ty le thdi gian thd vao, thd ra I:E = 1:1 den 1:3
+ Cai dat PEEP va FiOztheo bang hu'dng din cua ARDSNet
- Muc tieu can dat;
+ SpOztCr 88-95% hay PaOatLT 55-80 mmHg.
1. T^ le benh nhan co cai thien 6xy mi&u
+ pH mau DM tir 7,3 - 7,45.
+ Ppiat ^ 30 cm H2O.
* Binh nhan du'dc huy dgng phe nang vdi md'c CPAP 40 cmHzO ttvng 40 giay.
* Ven hanh TKNT tW the nam sap:
- Ttidi diem thu'c hien thay doi tu' the benh
nhan nam sap: Trong vong 24 gid tilr khi BN du'dc chan doan la ARDS va dap uTig du cac tieu chuan iLTa chon.
- Duy tri TKNT tu' the nam sap toi da la 16 - 17 gid/ngay khi oxy mau cai thien va khdng cd bien chu'ng nguy hiem nhu* tut huyet ap, ngilrng tim, tuot npi khi quan...
- Sau khi benh nhan nam ngda trd lai 7 - 8 gid thi danh gia lai tinh trang benh nhan, neu Pa02/F!02 van trong tieu chuan lu^ chpn va khong cd chong chi djnh thi tiSp tuc cho benh nhan nam sap. Thdi gian thiTc hien trong vdng 5 ngay (Day la glai doan cap cua ARDS).
- Dij'ng TKNT tu' the nam sap:
+ Khi oxy mau khong cai thien sau 3 - 4 gid hoac cd bien chOTng nguy hiem nhu': tac, tuot NKQ, ngifng tuan hoan, tut HA.
+ Benh nhan khong con chi dinh: Pa02/Fi02
> 150 vdi PEEP < 10, Fi02 < 60% ^ - TKNT trong khi benh nhan nam sap: Ttieo ARDSNet nhu* khi nam ngu'a.
- Theo doi mach, huyet ap, Sp02 lien tuc. Xet nghiem khi mau dpng mach, do cd hpc phoi tru'dc va sau khi thay doi id the nam sap 1 gid va each 6 gid mpt lan.
- Tieu chuan xac dmh cai thien oxy mau khi Pa02/Fi02 tang len 20% so vdi tru'dc nam sap
III. KETQUA
Tuoi trung binh cua benh nhan la 40,8 ± 17,3, thap nhat la 16, cao nhat la 68. Ty Ie nam la 69,2%. Diem Apache II la 25,2 ± 4,4, cao nhat la 32, thap nhat la 17.
Khdng chl thi^n oxy
Bieu dio 1; Ty le benh nhan tang oxy mau
VIETHAM MEDICAL JOURHAL N°1 - JAHUARY - 2017
Nhin xei: Cd 21 benh nhan (80,8%) tang oxy mau sau l(hi TKtJT tU the nam sap 2. Thay doi khi mau dong mach
Bang 1: Thay doi khi mau dgng mach
Tru'dc NS N S l h Nseh NS12h NS sau 12h Nam ngu'a pH 7,38 ± 0,1 7,33 ± 0,1 7,37 ± 0,1 7,38 ± 0,1 7,41 ± 0,1 7,36 ± 0,1
49 ± 14 56 + 24 50 ± 1 3 48 ± 12 48 ±19
PaOz 66 ± 17 92 ± 1 7 112 ± 26 113 ± 4 9 109 ± 21
HCO328 ± 6 28 ± 6 27 ± 5 27 ± 5 26 ± 1 27 ± 2 PaOz/FiOz I 91 ±32 I 129 ± 9 9 ' " ' I 132 ± 45 | 162 ± 86 I 168 ± 47 I 164 ± IVS: nam sap; (*): so vdi tntdc nam sip vdip < 0,05; (**); so Vdi tru'dc nam sip vdip < 0,01
Nhin xet: PaOz/FiOz tang len sau khi benli nhan nam sap 1 gid (p<0,05) va tiep tuc cai thien d cac thcfi diem tiep theo. PaC02tang len khi BN nam sap 1 gid nhu^g sau do giam dan so vcfl trifdc khi nam sap.
3. Ty le PaOz/FiOz d nhom cai thien dxy va nhom khdng cai thien oxy Bing 2: Ty' le PaOz/FIOz d nhdm cai thiin oxy va khdng cai thien dxy
PaOz/FiOz (mmHg)
Cai thien dxy (n==21)
Khong cai thien oxy (n=5)"
Tru'dc NS > 0,05 J
NS 1 gift <0,05
NS 6 gia
Nhin xit:Ty le PaOJi=i02 d nhom cai thien oxy tang cao hdn nhdm Ithong cai thien dxy sau 1 gid 4. Thay ddi ndng do SPO2 vaFlO?,
ZH NS 12 gift
• Sp02 ^Fi02 Nam ngu'a
Bieu dS 2: Nong do SpOz va FiOz (°/o) IV. BAN LUAN
Chung toi da ap dung phu'dng phap thong khi nhan tao tu' the nam sap tren 26 benh nhan du'dc chan doan ARDS vdi PaOz/FiOz < 100 hoac PaOz/FIOz < 150 nhu'ng dang co xu hu'dng glani.
Diem Apache II la 25,2 ± 4,4; cao nhat la 32, thap nhat la 17. Trong khi nam sap, benh nhan tiep tuc du'dc thd may theo hu'dng dan cua ARDSNet va dieu tri nhu' khi nam ngiiS [6],
Ty le bSnh nhan cai thien oxy mau;
Trong nghien ciJu cua chung toi cd 21 BN cai thien ve oxy mau trong khi nam sap chlem 80,8% (bieu do 1), tu'dng tiT nhu' nghien cifu ciia Romero [5]. Nguyen nhan ciia cai thien oxy mau khi BN nam sap la do tang huy dpng phe nan" d viing phoi phu thuoc (phia luYig), dac biet la su' dong bo ve ty le thong khi/tu'dl mail (V/Q) giifa
cac viing phoi. Theo cac tac gia tren the gidi thi TKNT tu' the nam sap cd tac dung lam tai phan bo djch tir viing phoi phia lutig (viing phu thuoc) sang phia xu'dng ii'c (viing khong phu thupc) va bai xuat dich ra ngoai tot hdn. Ngoai ra TKNTtiJ:
the nam sap con lam giam de ep ciia tim va cac teng trong 6' bung len viing phoi phia lu'ng nen cung lam cho viing phoi nay du'dc thong khi Int hdn [2]. Nhi?ng tac dung nay lam tang thong khi d viing phSi phia lu'ng. l»lat khac thi viec tirtSi mau d vung phoi phia lulig thi luon cao hdn viing phoi phfa xu'dng ifc khi BN du'dc nam, sSp;"
nen lam tang ty ie thong khi tifdi mau (V/Q).
Oieu nay cd vai trd quyet djnh den cai thien oxy
mau khi BN nam sap [1]. r Thay doi khi mau dong mach; Khi phan>
tich khi mau dong mach d nhdm co cai thi^n^.
TAP CHl Y HOC VIJT NAM TAP 450 - THAHG 1 - SO 1 - 2017 oxy, chiing toi thay sau khi benh nhan du'cfc
chuyen sang tu" the nam sap i gicJ thi ty le PaOj/FiOa tang t i r 91 ± 32 len 129 ± 99 mmHg, vcfi p < 0.05 (bang 1). Ty le PaOj/ROj tiep tuc du'dc cai thien d cac thcfi diem tiep theo va khi chuyen benh nhan ve td the nam ngu^ thi t y le Pa02/Fi02 van cao hdn mu'c ban dau vdi p <
0,01. Ket qua nghien cdu ciia chung toi cung b/dng t i / nghien culJ cua Romero va cong su"
cung cho thay cac benh nhan nam sap co cai thien oxy mau tu" 1 - 2 gid dau va tiep tyc tang len d nhuTig gid tiep theo [ 5 ] .
Nong do PaCO; tang Ien khi mdi chuyen BN sang tu" the nam sap nhuTig sau do PaCO^ giam clan so vcfl tru'dc khi nam sap. Tuy nhien mu'c thay doi PaCOz la khong nhieu nen pH mau van du'dc duy tri d mu'c cho phep theo hu'dng dan cua ARDSNet [ 6 ] . Nguyen nhan tang PaC02c6 le do vEing phoi phia lutig chu'a du'dc md het khi BN mdi nam sap nhuYig sau do viJng phoi nay du'dc Cid va thong khi tang len nen lam giam PaC02.
T y le P a O z / F i O z d n h o m cai t h i e n o x y v a n h o m k h o n g cai t h i e n o x y : Mac du so lu'dng BN con ft nhuYig chung toi thay khong co siJ khac biet ve Ty le Pa02/Fi02 d nhom cai thien oxy va nhdm khong cai thien oxy tru'dc khi BN nam sap. Sau 1 gid thi Ty le Pa02/Fi02 d nhom cai thien oxy tang cao hc^ nhdm khdng cai thien oxy vdi p < 0,05. Ket qua nay cDng tu'dng tu" d thdi diem sau 6 gid (bang 2). Nhom BN khong cai thien oxy thi t y le Pa02/Fi02 cung khong bi giam di khi d tu' the nam sap. Tuy nhien sd cai thien oxy mau d BN cang kho cd the tien lu'dng du'dc tu" tru'dc khi nam sap vi cd the lien quan den hinh thai va cau true cua phoi. Cac tac gia tren the gidi cung cho rang can cho BN nam sap sdm trong 24 gid dau tiJr khi BN bj ARDS de dat hieu qua cao hdn [ 1 ] , [ 5 ] .
N o n g d o S p O i va Fi02: Sp02 cung cd xu hu'dng cai thien ngay khi benh nhan nam sap 1 gid va duy tri on djnh trong suot thdi gian benh nhan nam sap (bleu do 2). Tuy nhien khi oxy mau du'dc cai thien thi chung toi cung giam dan nong dp oxy khf t h d vao (Fi02) va dieu chinh mu'c PEEP theo hu'dng dan cua ARDSNet de duy tri nong do oxy can thiet [ 6 ] . BN ARDS can phai thd may vdi nong do RO2 cao nen co nguy cd va giam nguy cd xep phoi hap phu. Vi vay khi theo doi Sp02 lien tuc tren monitor gii!ip cho viec danh gia nhanh chdng su" cai thien oxy mau cua BN va
cd the dieu chinh hong dp Fi02 sdm de han che ton thu'dng phoi.
V . KET LUAN
Nghien cu'u thong khf nhan tao tu" the nam sap cho 26 benh nhan ARDS tai khoa Cap culi, khoa Hoi su'c tich cdc benh vien Bach Mai td thang 11/2013 den thang 1/2016 chung toi bu'de dau ket luan;
- Ty le benh nhan cai thien oxy mau d tu* the nam sap la 80,8%.
- Oxy mau du'dc cai thien sau khi benh nhan nam sap 1 gid vdi p<0,05 va tiep tuc cai thien trong cac thdi diem tiep theo. Khi chuyen benh nhan ve tu* the nam ngu^a thi oxy giam di nhuVig van cao hdn ban dau vdi p < 0 , 0 1 .
- Nong dp Fi02 du'dc giam dan trong thdi gian benh nhan nam sap.
TAI L i g u T H A M KHAO
1 . Guerin C, Reignier 3, Richard 3, et al (2013).
"Prone Positioning in Severe Acute Respiratory Distress Syndrome". N Engl J Med, iX)!:
10.1056/NBMoal214103.
1. Mancebo 3, Fernandez R, Blanch L, et al (2006). "A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome". Am J Respir Crit Care Med, 173:1233 - 9.
3. Piehl MA, Brown RS (1975). "Use of extreme position changes in acute respiratory failure", Qit Care Med, 4(1):13 -14.
4. Ranieri VM, Rubenfeld GD, Thompson BT, et a l . (2012) "Acute respiratory distress syndrome: the Berlin Definition", JAMA, 307:2526-33.
5. Romero CM, Cornejo RA, Galvez LR, et al (2009). "Extended prone position ventilation in severe acute respiratory distress syndrome: a pilot feasibility study". J Crit Care, 24(l):81-88.
6. The Acute Respiratory Distress Syndrome Network (2000). "Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome". NBM, vol 342, No 18,1301- 1308.
7. Ware LB, Mathay MA (2000). 'The acute respiratory distress syndrome". N EngiJ Med, Vol 342 No. 18, 1334 -1348.