A patient with chronic obstructive pulmonary disease underwent a single-lung transplant. Pneumonia has developed in the transplanted left lung, requiring mechanical ventilatory support. A double-lumen tube is inserted to ventilate each lung separately.
Which of the following is the most important strategy for setting up the two ventilators?
A. Tidal volume settings should be 6 mL/kg ideal body weight in each lung.
B. Positive end-expiratory pressure should be equal in both lungs.
C. Respiratory rate should be synchronized in the two lungs.
D. A plateau pressure of 30 cmH2O should be maintained in both lungs.
管理每侧肺中肺力学明显不同的患者会带来重大问题，因为该患者接受了单次左肺移植，导致左侧肺明显僵硬，右侧气道狭窄的高顺应性肺。当采用单一通气支持策略治疗时，可能会导致不良气体分布和通气-灌注关系。呼气末正压(PEEP)的应用可能存在问题，因为PEEP在水肿性僵硬肺中是可取的，但在已经过度膨胀的阻塞性肺中显然是不可取的。
为了解决这个问题，双腔插管允许在每侧肺中设置独立的通气参数。在设置这些呼吸机时，每侧肺的通气模式和PEEP可滴定至特定的临床目标。由于任何通气策略的主要目标是预防过度膨胀和呼吸机诱导的肺损伤。将肺中的吸气末（最大）伸展压力（平台压）限制在30-35 cm H2O以下可降低该风险。差异PEEP是独立肺通气的目标之一。水肿肺需要PEEP，而肺气肿肺不需要。两个肺中的呼吸频率设置不需要同步。
References:
- Anantham D, Jagadesan R, Tiew PE. Clinical review: independent lung ventilation in critical care. Crit Care. 2005;9(6):594-600.
- Gravazzeni V, Iapichino G, Mascheroni D, et al. Prolonged intependent lung respiratory treatment after single lung transplantation in pulmonary emphysema. Chest. 1993 Jan;103(1):96-100.
- Powner DJ. Differential lung ventilation during adult donor care. Prog Transplant. 2010 Sep;20(3):262-267.
- [No authors listed]. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000 May 4;342(18):1301-1308
D
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