腹內高壓對病患呼吸的影響與呼吸照護策略的介紹

The Effect of Intra-Abdominal Hypertension on Patients' Breathing and Introduction of Respiratory Care Strategies

呂學哲(Hsueh-Che Lu) ； 曾雪英(Hsueh-Ying Tseng) ； 吳岱容(Dai-Rong Wu) ； 陳慧華(Hui-Hua Chen)

《呼吸治療》 20卷1期 (2021/01) Pp. 1-12

https://doi.org/10.6269/JRT.202101_20(1).0001

摘要

腹內高壓（intra-abdominal hypertension, IAH）是重症加護病房患者之常見併發症，其發生率高達65%，並會引發腹部腔室症候群，近年逐漸受到臨床重視與討論。由於腹內高壓患者接受機械通氣後的呼吸治療策略並無一致性，致使臨床因應與策略選擇面對一大考驗，尤以呼吸器設定為重。因此，以文獻搜尋將「腹內高壓」與「機械通氣」的相關研究進行分析後，發現腹內高壓病患之呼吸照護策略有：（1）.使用壓力支持（Pressure support）模式能改善氧合、減少肺泡塌陷。（2）.採保護性肺通氣（lung protective ventilation），使用低潮氣量6-8 ml/kg及最大驅使壓力≦14 cmH_2O。（3）.經肺壓差＜25cmH_2O。（4）.以ATT（abdominal-thoracic transmission）約為50％，修正後平原壓力為目標平原壓（cmH_2O）-7 + IAP（mmHg）* 0.7。（5）.最佳吐氣末正壓（Positive end expiratory pressure, PEEP）可設在50%IAP（cmH_2O）有最佳肺順應性（compliance, Cs）。（6）.使用肺泡再擴張術（recruitment maneuvers, RM）在IAH病患身上須謹慎評估，有可能產生併發症如低血壓。（7）.俯臥與鎮靜藥物對IAH病患會有幫助，能降低腹內壓。經本文彙整結果，冀望可提供呼吸治療師臨床工作之參考，進而提升呼吸照護專業品質。

關鍵字

腹內高壓 ； 呼吸治療 ； 機械通氣

並列摘要

Intraabdominal hypertension (IAH) is a common complication of patients in the intensive care unit, and its incidence is as high as 65%, and it can cause abdominal cavity syndrome. IAH is associated with high morbidity and mortality. Therefore, IAH has received growing attention and discussions in recent years. Because a universal standard has not been established on the respiratory therapy strategy for patients with IAH who have received mechanical ventilation, respiratory therapists are facing challenges in selecting clinical responses and strategies, particularly those related to ventilator settings. Therefore, this study searched for relevant studies by using two keywords, namely ＂Intraabdominal hypertension＂ and ＂mechanical ventilation,＂ and analyzed these studies to reveal the following care strategies for patients with IAH: (1). Using pressure support (PS) mode improved oxygenation and decreased alveolar collapse. (2). Lung protective ventilation should be adopted with a low tidal volume at 6-8 ml/kg and the maximum driving pressure set at ≦14 cmH_2O. (3). Transpulmonary pressure set at ＜25 cmH_2O. (4.) The abdominal-thoracic transmission should be set at approximately 50%, and the modified plateau pressure to be: target plateau pressure (cmH_2O) - 7 + IAP(mmHg) * 0.7. (5). The best positive end-expiratory pressure (PEEP) is set at 50% IAP (cmH_2O) to have the best lung compliance (Cs). (6). The applicability of recruitment maneuvers to patients with IAH should be meticulously evaluated to avoid potential comorbidities (e.g. hypotension). (7). The prone position and sedatives are effective in reducing the abdominal pressure in patients with IAH. The results of this article, hoping can provide a reference for the clinical work of respiratory therapists, thereby improving the professional quality of respiratory care.

並列關鍵字

intraabdominal hypertension (IAH) ； respiratory therapy ； mechanical ventilation