Clinical effect of high positive end expiratory pressure ventilation in treatment of children with severe high altitude pulmonary edema

doi:10.3877/cma.j.issn.1673-5250.2019.03.010

Objective

To investigate the clinical effect of high end-expiratory positive pressure (PEEP) ventilation in treatment of children with severe plateau pulmonary edema (HAPE).

Methods

From January 2010 to June 2017, a total of 42 children with severe HAPE who received synchronized intermittent mandatory ventilation (SIMV) combined with PEEP ventilation in the Pediatric Intensive Care Unit, Ganzi Tibetan Autonomous Prefecture People′s Hospital were selected as research subjects. According to the order of admission, these 42 children were randomly divided into low PEEP ventilation group (n=21) and high PEEP ventilation group (n=21). The initial PEEP of ventilator in low PEEP ventilation group and high PEEP ventilation group was set as <5 cmH₂O (1 cmH₂O=0.098 1 kPa) and 5-7 cmH₂O, respectively. The heart rate and respiratory rate (RR), blood oxygen saturation (SpO₂), arterial blood gas analysis index, length of mechanical ventilation treatment, length of hospital stay and acute physiology and chronic health evaluation (APACHE) Ⅱ score before and after treatment in two groups were compared by independent-samples t test, and pairwise t test was used to compare within each group. The guardians of all severe HAPE children signed the informed consent for clinical research. The procedures followed in this study were consistent with the standards of Ethic Committee of Human Beings in Ganzi Tibetan Autonomous Prefecture People′s Hospital, and this study was approved by this committee (Approval No. 2010-K-12).

Results

①There were no statistically significant differences between two groups in the general clinical data, such as age, APACHE Ⅱ score before treatment, and onset time of serve HAPE (P>0.05). ②After receiving treatment of SIMV combined with PEEP ventilation, 40 cases survived and 2 cases gave up treatment among these 42 cases of children with severe HAPE. ③After 2 h of mechanical ventilation treatment, the heart rate and RR of children in high PEEP ventilation group were significantly lower than those in low PEEP ventilation group, while the SpO₂ was significantly higher than that in low PEEP ventilation group, and all the differences were statistically significant (t=4.062, P<0.001; t=4.392, P<0.001; t=-3.219, P=0.006). In low PEEP ventilation group, the heart rate and RR after 2 h of treatment were significantly lower than those before treatment, and the differences were statistically significant (t=24.646, 20.125; P<0.001). After 2 h of treatment, the heart rate and RR of high PEEP ventilation group were significantly lower than those before treatment, while SpO₂ was significantly higher than that before treatment, and all the differences were statistically significant (t=31.159, 19.913, -8.022; P<0.001). ④After mechanical ventilation treatment for 24 h, the oxygenation index partial pressure of oxygen (PaO₂)/ fraction of inspired oxygen (FiO₂), serum pH value and partial pressure of carbon dioxide (PaCO₂) of the children in low PEEP ventilation group and high PEEP ventilation group were significantly improved compared with those within group before treatment, and all the differences were statistically significant (low PEEP ventilation group: t=-17.374, -7.607, 12.338, P<0.001; high PEEP ventilation group: t=-13.645, -12.262, 17.949, P<0.001). After mechanical ventilation treatment for 24 h, PaO₂/FiO₂ in high PEEP ventilation group was significantly higher than that in low PEEP ventilation group, while PaCO₂ was significantly lower than that in low PEEP ventilation group, and the differences between two groups were statistically significant (t=2.820, P=0.013; t=3.230, P=0.006). ⑤The length of mechanical ventilation treatment, length of hospital stay and APACHE Ⅱ score after treatment in children of high PEEP ventilation group were (36.7±2.8) h, (14.0±0.4) d, (16.9±7.9) points, respectively, which all were significantly lower than (40.2±4.0) h, (18.4 ±0.5) d, (18.6±2.2) points, respectively in low PEEP ventilation group, and all the differences were statistically significant (t=2.316, P=0.035; t=5.985, P<0.001; t=2.499, P=0.025).

Conclusions

The effect of invasive mechanical ventilation method of SIMV combined with PEEP ventilation in treatment of children with severe HAPE is a good. High PEEP ventilation (with initial PEEP of ventilator set as 5-7 cmH₂O) is relatively safe and can better improve the clinical efficacy of children with severe HAPE.

Key words: Pulmonary edema, Altitude sickness, Intermittent positive-pressure breathing, Ventilators, mechanical, Positive-pressure respiration, Blood gas analysis, Severe high altitude pulmonary edema, Child

表1 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿一般临床资料比较

组别	例数	年龄(岁，±s)	治疗前APACHEⅡ评分(分，±s)	HAPE发病时间[d，M(P₂₅～P₇₅)]
低PEEP通气组	21	5.0±0.7	21.2±1.8	3.0(1.2～5.0)
高PEEP通气组	21	5.3±0.7	20.8±1.7	2.0(1.0～3.8)
检验值	?	t＝－1.261	t＝0.678	Z＝－0.941
P值	?	0.222	0.508	0.347

表1 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿一般临床资料比较

组别	例数	年龄(岁，±s)	治疗前APACHEⅡ评分(分，±s)	HAPE发病时间[d，M(P₂₅～P₇₅)]
低PEEP通气组	21	5.0±0.7	21.2±1.8	3.0(1.2～5.0)
高PEEP通气组	21	5.3±0.7	20.8±1.7	2.0(1.0～3.8)
检验值	?	t＝－1.261	t＝0.678	Z＝－0.941
P值	?	0.222	0.508	0.347

表2 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗前、后心率、RR、SpO₂比较(±s)

组别	例数	心率(次/min)		RR(次/min)		SpO₂(%)
组别	例数	治疗前	治疗2 h后	治疗前	治疗2 h后	治疗前	治疗2 h后
低PEEP通气组	21	124.0±5.1	95.1±3.6	31.2±1.9	22.2±1.4	93.5±1.9	94.3±3.4
高PEEP通气组	21	126.6±4.9	89.3±2.6	30.9±1.8	20.5±1.1	92.3±1.2	97.7±2.4
t值	?	－1.214	4.062	0.374	4.392	2.643	－3.219
P值	?	0.244	<0.001	0.713	<0.001	0.018	0.006

表2 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗前、后心率、RR、SpO₂比较(±s)

组别	例数	心率(次/min)		RR(次/min)		SpO₂(%)
组别	例数	治疗前	治疗2 h后	治疗前	治疗2 h后	治疗前	治疗2 h后
低PEEP通气组	21	124.0±5.1	95.1±3.6	31.2±1.9	22.2±1.4	93.5±1.9	94.3±3.4
高PEEP通气组	21	126.6±4.9	89.3±2.6	30.9±1.8	20.5±1.1	92.3±1.2	97.7±2.4
t值	?	－1.214	4.062	0.374	4.392	2.643	－3.219
P值	?	0.244	<0.001	0.713	<0.001	0.018	0.006

表3 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗前、后动脉血气分析指标比较(±s)

组别	例数	PaO₂/FiO₂(mmHg)		血清pH值		PaCO₂(mmHg)
组别	例数	治疗前	治疗24 h后	治疗前	治疗24 h后	治疗前	治疗24 h后
低PEEP通气组	21	102.6±6.7	129.6±1.9	7.25±0.06	7.37±0.01	54.4±4.9	39.6±1.1
高PEEP通气组	21	99.0±6.5	133.9±5.9	7.27±0.03	7.38±0.01	54.4±3.9	37.6±1.8
t值	?	1.961	－2.820	－1.252	－1.954	0.000	3.230
P值	?	0.069	0.013	0.230	0.070	1.000	0.006

表3 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗前、后动脉血气分析指标比较(±s)

组别	例数	PaO₂/FiO₂(mmHg)		血清pH值		PaCO₂(mmHg)
组别	例数	治疗前	治疗24 h后	治疗前	治疗24 h后	治疗前	治疗24 h后
低PEEP通气组	21	102.6±6.7	129.6±1.9	7.25±0.06	7.37±0.01	54.4±4.9	39.6±1.1
高PEEP通气组	21	99.0±6.5	133.9±5.9	7.27±0.03	7.38±0.01	54.4±3.9	37.6±1.8
t值	?	1.961	－2.820	－1.252	－1.954	0.000	3.230
P值	?	0.069	0.013	0.230	0.070	1.000	0.006

表4 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗时间、住院时间及治疗后APACHEⅡ评分比较(±s)

组别	例数	机械通气治疗时间(h)	住院时间(d)	治疗后APACHEⅡ评分(分)
低PEEP通气组	21	40.2±4.0	18.4±0.5	18.6±2.2
高PEEP通气组	21	36.7±2.8	14.0±0.4	16.9±7.9
t值	?	2.316	5.985	2.499
P值	?	0.035	<0.001	0.025

表4 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗时间、住院时间及治疗后APACHEⅡ评分比较(±s)

组别	例数	机械通气治疗时间(h)	住院时间(d)	治疗后APACHEⅡ评分(分)
低PEEP通气组	21	40.2±4.0	18.4±0.5	18.6±2.2
高PEEP通气组	21	36.7±2.8	14.0±0.4	16.9±7.9
t值	?	2.316	5.985	2.499
P值	?	0.035	<0.001	0.025

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