CN112914526A - Special evaluation method for pulse pressure variation degree of respiratory mechanics correction - Google Patents
Special evaluation method for pulse pressure variation degree of respiratory mechanics correction Download PDFInfo
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- CN112914526A CN112914526A CN202110091438.5A CN202110091438A CN112914526A CN 112914526 A CN112914526 A CN 112914526A CN 202110091438 A CN202110091438 A CN 202110091438A CN 112914526 A CN112914526 A CN 112914526A
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- 230000035485 pulse pressure Effects 0.000 title claims abstract description 63
- 230000000241 respiratory effect Effects 0.000 title claims abstract description 12
- 238000011156 evaluation Methods 0.000 title claims abstract description 7
- 238000012937 correction Methods 0.000 title claims description 7
- 206010001052 Acute respiratory distress syndrome Diseases 0.000 claims abstract description 21
- 201000000028 adult respiratory distress syndrome Diseases 0.000 claims abstract description 19
- 239000012530 fluid Substances 0.000 claims abstract description 19
- 208000013616 Respiratory Distress Syndrome Diseases 0.000 claims abstract description 16
- 230000004043 responsiveness Effects 0.000 claims abstract description 8
- 238000000034 method Methods 0.000 claims description 17
- 230000008859 change Effects 0.000 claims description 9
- 230000029058 respiratory gaseous exchange Effects 0.000 claims description 2
- 239000007788 liquid Substances 0.000 abstract description 11
- 230000009257 reactivity Effects 0.000 abstract description 3
- 208000028399 Critical Illness Diseases 0.000 abstract description 2
- 230000006872 improvement Effects 0.000 description 5
- 238000005259 measurement Methods 0.000 description 4
- 230000036316 preload Effects 0.000 description 4
- 230000000747 cardiac effect Effects 0.000 description 3
- 238000010586 diagram Methods 0.000 description 3
- 230000004872 arterial blood pressure Effects 0.000 description 2
- 238000004364 calculation method Methods 0.000 description 2
- 210000004283 incisor Anatomy 0.000 description 2
- 239000000463 material Substances 0.000 description 2
- 238000005399 mechanical ventilation Methods 0.000 description 2
- 238000012544 monitoring process Methods 0.000 description 2
- 230000035945 sensitivity Effects 0.000 description 2
- 230000004075 alteration Effects 0.000 description 1
- 230000000903 blocking effect Effects 0.000 description 1
- 230000002612 cardiopulmonary effect Effects 0.000 description 1
- 238000006243 chemical reaction Methods 0.000 description 1
- 238000007796 conventional method Methods 0.000 description 1
- 230000007423 decrease Effects 0.000 description 1
- 238000003745 diagnosis Methods 0.000 description 1
- 238000009826 distribution Methods 0.000 description 1
- 239000003814 drug Substances 0.000 description 1
- 230000009977 dual effect Effects 0.000 description 1
- 230000000694 effects Effects 0.000 description 1
- 210000003238 esophagus Anatomy 0.000 description 1
- 230000003434 inspiratory effect Effects 0.000 description 1
- 230000010354 integration Effects 0.000 description 1
- 230000003993 interaction Effects 0.000 description 1
- 210000004072 lung Anatomy 0.000 description 1
- 238000012986 modification Methods 0.000 description 1
- 230000004048 modification Effects 0.000 description 1
- 210000003928 nasal cavity Anatomy 0.000 description 1
- 230000001681 protective effect Effects 0.000 description 1
- 230000004044 response Effects 0.000 description 1
- 238000006467 substitution reaction Methods 0.000 description 1
- 238000002560 therapeutic procedure Methods 0.000 description 1
- 238000009423 ventilation Methods 0.000 description 1
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B5/00—Measuring for diagnostic purposes; Identification of persons
- A61B5/02—Detecting, measuring or recording pulse, heart rate, blood pressure or blood flow; Combined pulse/heart-rate/blood pressure determination; Evaluating a cardiovascular condition not otherwise provided for, e.g. using combinations of techniques provided for in this group with electrocardiography or electroauscultation; Heart catheters for measuring blood pressure
- A61B5/021—Measuring pressure in heart or blood vessels
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B2560/00—Constructional details of operational features of apparatus; Accessories for medical measuring apparatus
- A61B2560/02—Operational features
- A61B2560/0223—Operational features of calibration, e.g. protocols for calibrating sensors
Abstract
The invention discloses a special evaluation method for pulse pressure variation degree corrected by respiratory mechanics, which comprises the following operation steps: measuring the pulse pressure variation degree (delta PP) and the intrathoracic pressure variation (delta Ppl) value of a patient; ② the value obtained by dividing the patient's delta PP by delta Ppl is used for predicting the acute respiratory distress syndrome patient fluid responsiveness. Compared with the prior art, the invention has the advantages that: the liquid reactivity of the critically ill patients is accurately judged to be a foundation for treatment. The delta PP is an important tool for predicting FR commonly used in clinic, but the predicting efficiency of the ARDS patient is poor, the predicting accuracy of the ARDS patient can be remarkably improved by correcting esophageal pressure (Pes) by the technology, and the feasibility and the reliability of clinical application of the parameter are greatly enhanced by introducing the gray zone, so that the technology has great clinical value for guiding the ARDS patient to manage clinical liquid and implement precise individualized liquid treatment.
Description
Technical Field
The invention relates to the field of medicine, in particular to a special evaluation method for pulse pressure variation degree of respiratory mechanics correction.
Background
Fluid Responsiveness (FR) is defined as the ability of a patient's heart to increase Stroke Volume (SV) or Cardiac Output (CO) after a fluid load, and a patient is considered positive if the SV or CO increases by more than or equal to 15% from baseline after a given amount of fluid load (also known as volume expansion). Pulse pressure variation (Δ PP) based on cardiopulmonary interaction is the most common and studied indicator in clinical practice, and more high-quality evidence indicates that Δ PP can accurately predict FR in mechanically ventilated patients with tidal Volume (VT) >8 ml/kg. I.e. if Δ PP > -13% the patient will respond to the liquid; otherwise, no reaction occurred (FIG. 1). However, in patients receiving protective ventilation of the lungs, especially ARDS patients, the use of Δ PP is greatly limited; mainly represented by lower ROC curve area and higher false negatives (lower Δ PP in the liquid reactor) and no significant improvement in the predicted efficacy of Δ PP after timely Vt correction. This is clearly very unfortunate, as accurate fluid therapy appears to be particularly important for ARDS patients due to its complex course and higher mortality. We correct for Δ PP using respiratory mechanics factors that may have an effect on it, thereby significantly improving its predictive ability for FR in ARDS patients.
Disclosure of Invention
The invention aims to solve the technical problem of providing a method for evaluating the liquid responsiveness of pulse pressure variation corrected by esophageal pressure (Pes) to patients with acute respiratory distress syndrome.
In order to solve the technical problems, the technical scheme provided by the invention is as follows: the special evaluation method for the pulse pressure variation degree of respiratory mechanics correction comprises the following operation steps:
measuring values of delta PP and delta Ppl of a patient;
② the value obtained by dividing the patient's delta PP by delta Ppl is used for predicting the acute respiratory distress syndrome patient fluid responsiveness.
Compared with the prior art, the invention has the advantages that: the liquid reactivity of the critically ill patients is accurately judged to be a foundation for treatment. The delta PP is an important tool for predicting FR commonly used in clinic, but the predicting efficiency of the ARDS patient is poor, the predicting accuracy of the ARDS patient can be remarkably improved by the technology through the correction of the Pes, and the feasibility and the reliability of the clinical application of the parameter are greatly enhanced by the introduction of the gray zone, so that the technology has great clinical value for guiding the ARDS patient to manage clinical liquid and implement precise individualized liquid treatment. Moreover, with the integration of the Pes monitoring function with some ventilators, the measurement of Pes can now be performed safely and satisfactorily at the ICU bedside, increasing the feasibility of clinical popularization of this technology.
As an improvement, Δ PP in the step (r) is a Pulse pressure variation (Pulse pressure variation).
As an improvement, said step ② this Δ Ppl is the intrathoracic pressure change.
As an improvement, the special assessment method is used to assess the Fluid Responsiveness (FR) in patients with Acute Respiratory Distress Syndrome (ARDS).
As an improvement, the Δ Ppl may be obtained by a difference between esophageal pressures at the time of inhalation block (Pes, eio) and exhalation block (Pes, eeo), and is expressed as follows ═ Pes, eio-Pes, eeo.
As a refinement, the Δ PP may be calculated from the maximum (PPmax, at the end of inspiration) and minimum (PPmin, at the end of expiration) of the Pulse Pressure (PP) over one respiratory cycle of the breath, with the formula Δ PP (%) ═ PPmax-PPmin/[ (PPmax + PPmin)/2] x 100.
Drawings
FIG. 1 is a graph of Frank-Starling curves (reflecting cardiac preload and stroke volume [ SV ]) versus pulse pressure variability (. DELTA.PP) for patients without ARDS.
Figure 2 is a graph of the area under the working characteristic curve (AUC) of subjects comparing the ability of each parameter to predict fluid responsiveness (fluid-induced cardiac output increase > 15%) across the population of acute respiratory distress syndrome (n-96).
Fig. 3 is a gray-scale graph of pulse pressure variability (Δ PP) and Δ PP corrected for intrathoracic pressure changes (Δ Ppl) determined in ARDS patients under normal fluid strategies (misclassified cost ratio, R ═ 1).
FIG. 4 is a graphical representation of invasive arterial blood pressure versus time(s).
Fig. 5 is a schematic diagram of airway pressure versus time(s).
Fig. 6 is a graph of a measurement calculation method of the intrathoracic pressure change (Δ Ppl).
Figure 7 is a diagrammatic illustration of esophageal balloon placement.
Detailed Description
The present invention will be described in further detail with reference to the accompanying drawings.
In the specific implementation of the invention, FIG. 1: the Δ PP from patients with non-ARDS reflects primarily the slope of the Frank-Starling curve. Specifically, fluid treatment when in the steep portion of the Frank-Starling curve (patients 1a-b) resulted in a large change in SV following a change in preload (Δ SV1, a fluid responder), while the patient had a large Δ PP before fluid treatment (a); whereas fluid treatment resulted in a smaller change in SV following preload change (Δ SV2, belonging to fluid non-responders) when the patient's heart worked and the flat portion of the Frank-Starling curve (patients 2c-d), in which case the patient had a smaller Δ PP before fluid treatment (c).
FIG. 2: for the pulse pressure variability (Δ PP,%) corrected by the intrathoracic pressure changes (Δ Ppl, cmH2O), the AUC was significantly higher than the AUC value for Δ PP alone (P <0.001), whereas the AUC value for Δ PP alone was statistically insignificant (P >0.05) compared to the tidal volume (Vt, L) corrected Δ PP.
FIG. 3: the gray zone method (both methods) will determine two cutoff values, the region between them, i.e., the gray zone, and the diagnosis of liquid reactivity is not determinable if the measured value of the parameter falls within the gray zone. The method comprises the following steps: the histogram (A, C) describes the 1000 best cutoff distributions for the 1000 resampled populations. The gray area (i.e., 95% CI of the optimal truncation point) is shown as a shaded area. The vertical dashed line shows the median of the 1000 best truncation points. The second method comprises the following steps: the two graphs B and D are dual ROC curves, i.e. the sensitivity (Se; open circle, dashed line) and specificity (Sp; open circle, solid line) of each parameter (DeltaPP [ B ] and DeltaPP/DeltaPpl [ D ]) are related to the parameter cutoff value; the uncertainty area is indicated by shading. The maximum ash area is determined as the final ash area range by two methods. Fig. A, B shows that the Δ PP gray zone is 7% to 12%, and more than 45% of patients fall into the gray zone. In contrast, the gray zone of Δ PP/Δ Ppl was narrow (1.94-2.1), including only 3.1% of patients (FIGS. 3, C and D).
FIG. 4 FIG. 5: measurement and calculation of the pulse pressure variation degree (. DELTA.PP). The upper and lower charts are respectively the relationship schematic diagram of the invasive artery blood pressure, the airway pressure and the time(s).
FIG. 6: the graphs in the 3 columns from top to bottom are respectively the Flow rate (Flow), airway pressure (Paw), and esophageal pressure (Pes) versus time. The esophageal pressure after respiratory block is Pes, eio, the esophageal pressure after respiratory block is Pes, eeo, and the difference between the two is delta Ppl.
FIG. 7: the left panel is a standard adult esophageal pressure (Pes) monitoring kit used in the present technology, with one end entering the middle and lower esophageal segment and the other end connected to a ventilator. The right figure is a schematic diagram of the esophageal balloon placement position.
The working principle of the invention is as follows: in ARDS patients, Δ PP decreases in ability to predict FR, primarily because a lower intrathoracic pressure change (Δ Ppl) resulting from a lower tidal volume (Vt) of mechanical ventilation will not produce a sufficient preload change, and therefore Δ PP is lower (false negative) even in fluid responders. Therefore we correct Δ PP with Δ Ppl, and generate a new parameter (Δ PP/Δ Ppl) that can reduce or avoid the occurrence of false negatives; the sensitivity, specificity and area under the Receiver Operating Characteristic (ROC) curve [ AUC ] of the FR predicted by delta PP/delta Ppl >2 are obviously improved and are respectively 92.3%, 93.2% and 0.94 (figure 2). Moreover, the gray zone range of Δ PP/Δ Ppl was 1.94-2.1 (FIG. 3), which contained only 3.1% of the total population, i.e., accurate determination of whether there was a liquid response in nearly 97% of patients with ARDS was possible using the gray zone range of Δ PP/Δ Ppl.
Δ PP can be calculated from the maximum (PPmax, at the end of inspiration) and minimum (PPmin, at the end of expiration) of the Pulse Pressure (PP) over one respiratory breathing cycle, with the formula Δ PP (%) - (PPmax-PPmin)/[ (PPmax + PPmin)/2] x 100, see fig. 4.Δ Ppl can be obtained by the difference between esophageal pressure at inspiratory block (Pes, eio) and expiratory block (Pes, eeo) (fig. 6). Is expressed as follows
ΔPpl＝Pes,eio–Pes,eeo
Wherein the measurement of esophageal pressure Pes is obtained by placing an esophageal balloon. All patients routinely placed esophageal balloons (fig. 7), measured esophageal pressure (Pes, esophageal pressure), which reflected intrathoracic pressure (Ppl), and the esophageal balloon catheter entered the gradual esophagus from the nasal cavity to 60cm from the incisors to measure intragastric pressure, and then the catheter was withdrawn with its distal end 40cm from the incisors, and after connecting the proximal end of the catheter to the viasys avea ventilator, the esophageal pressure (Pes) of the patient during mechanical ventilation was measured. The correct position of the catheter is crucial to accurately measuring Pes, and a conventional method is adopted for judging whether the position of the catheter is correct. After the esophageal balloon catheter is correctly positioned, the airway is blocked for 3-5s at the end of inspiration and the end of expiration respectively, and the esophageal blocking pressure at the end of inspiration (Pes. eio) and the end of expiration (Pes, eeo) can be measured.
Furthermore, the terms "first", "second" and "first" are used for descriptive purposes only and are not to be construed as indicating or implying relative importance or implicitly indicating the number of technical features indicated. Thus, a feature defined as "first" or "second" may explicitly or implicitly include one or more of that feature, and in the description of the invention, "plurality" means two or more unless explicitly specifically defined otherwise.
In the present invention, unless otherwise specifically stated or limited, the terms "mounted," "connected," "fixed," and the like are to be construed broadly and may, for example, be fixedly connected, detachably connected, or integrally connected; can be mechanically or electrically connected; they may be connected directly or indirectly through intervening media, or they may be interconnected between two elements. The specific meanings of the above terms in the present invention can be understood by those skilled in the art according to specific situations.
In the present invention, unless otherwise expressly stated or limited, "above" or "below" a first feature means that the first and second features are in direct contact, or that the first and second features are not in direct contact but are in contact with each other via another feature therebetween. Also, the first feature being "on," "above" and "over" the second feature includes the first feature being directly on and obliquely above the second feature, or merely indicating that the first feature is at a higher level than the second feature. A first feature being "under," "below," and "beneath" a second feature includes the first feature being directly above and obliquely above the second feature, or simply meaning that the first feature is at a lesser level than the second feature.
In the description herein, reference to the terms "one embodiment," "some embodiments," "an example," "a specific example," or "some examples" or the like means that a particular feature, structure, material, or characteristic described in connection with the embodiment or example is included in at least one embodiment or example of the invention. In this specification, the schematic representations of the terms used above do not necessarily refer to the same embodiment or example. Furthermore, the particular features, structures, materials, or characteristics described may be combined in any suitable manner in any one or more embodiments or examples.
Although embodiments of the present invention have been shown and described above, it is understood that the above embodiments are exemplary and should not be construed as limiting the present invention, and that variations, modifications, substitutions and alterations can be made in the above embodiments by those of ordinary skill in the art without departing from the principle and spirit of the present invention.
Claims (6)
1. The special evaluation method for the pulse pressure variation degree of respiratory mechanics correction comprises the following operation steps:
measuring values of delta PP and delta Ppl of a patient;
② the value obtained by dividing the patient's delta PP by delta Ppl is used for predicting the acute respiratory distress syndrome patient fluid responsiveness.
2. The method of claim 1, wherein the method comprises: the Δ PP in the step (i) is a Pulse Pressure Variation (Pulse Pressure Variation).
3. The method of claim 1, wherein the method comprises: the step (ii) is such that Δ Ppl is the intrathoracic pressure change.
4. The method of claim 1, wherein the method comprises: the specific evaluation method is used to evaluate the Fluid Responsiveness (FR) of patients with Acute Respiratory Distress Syndrome (ARDS).
5. The method of claim 1, wherein the method comprises: the Δ Ppl may be obtained by a difference between esophageal pressures at the time of inhalation block (Pes, eio) and exhalation block (Pes, eeo), and is expressed as follows ═ Pes, eio-Pes, eeo.
6. The method of claim 1, wherein the method comprises: the Δ PP can be calculated from the maximum (PPmax, at the end of inspiration) and minimum (PPmin, at the end of expiration) of the Pulse Pressure (PP) over one respiratory breathing cycle, with the formula Δ PP (%) - (PPmax-PPmin)/[ (PPmax + PPmin)/2] x 100.
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