ARDS诊治进展优质PPT.ppt

1、15;176（8）:795-804.,例：ARDS患者在不同通气条件下的变化,在（day1）时间点 FiO20.5+PEEP 10，30min条件下重新分类为ARDS,ALI,ARF,29%ARDS患者PAWP18mmHg（或CVP升高）,而其中97%PAWP升高的ARDS患者中有正常的心脏功能。结论：PAWP或CVP升高不能作为ARDS的排除标准。,Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.N Engl J Med.2006 May 25;354（21）:22

2、13-24.,CVP,PAWP,例：ARDS与PAWP、CVP,8,18,Berlin Definition 2012 柏林定义,Berlin Definition of ARDS,ARDS的治疗策略？,ARDS的治疗原则,（一）原发病治疗：积极治疗原发病是遏制ARDS发展的必要措施。全身性感染、创伤、休克、烧伤、SAP等是导致ARDS的常见原因。全身性感染患者有25-50%发生ARDS，而且在感染、创伤等导致的MODS中肺是最早发生衰竭的器官。控制原发病，遏制其诱导的全身失控性炎症反应，是预防和治疗ARDS的必要措施。,急性呼吸窘迫综合征诊断和治疗指南（2015）,延误使用有效抗生素增加重症

3、肺炎死亡率,Kumar et al Crit Care Med 2006;34:1589-1596,延误使用有效抗生素1小时，死亡率增加 12%,ARDS的治疗原则,呼吸支持治疗：包括氧疗、机械通气。1.氧疗：治疗目的是改善低氧血症，PaO260-80mmHg；根据低氧血症改善的程度和治疗反应调整氧疗方式，首先使用鼻导管，当需要较高吸氧浓度时，可采用可调节氧浓度的文丘里面罩或带贮氧袋的非重吸收式氧气面罩；ARDS患者往往低氧血症严重，常规的氧疗难以奏效，机械通气是最主要的呼吸支持手段！,急性呼吸窘迫综合征诊断和治疗指南（2015）,ARDS的治疗原则,2.无创机械通气 预计病情能够在短期缓解的

4、早期ARDS患者可考虑应用无创机械通气。合并免疫功能低下的ARDS患者早期可首先试用无创机械通气。应用无创机械通气治疗ARDS应严密监测患者的生命体征及治疗反应。神志不清、休克、气道自洁能力障碍者不宜应用无创机械通气。,急性呼吸窘迫综合征诊断和治疗指南（2015）,ARDS的治疗原则,3.有创机械通气,传统机械通气的肺损伤？,Ventilator Induced Lung Injury，VILI,Overdistention 过度扩张 Barotrauma压力伤 Volutrauma容量伤 Recruitment/Derecruitment Injury（Atlectrauma）剪切伤/萎陷伤

5、 Translocation of Cells 细胞形态移位 Biotrauma 生物伤 Oxidant Injury 氧中毒,OverdistentionBarotrauma&Volutrauma,“Shear”,Recruitment/Derecruitment Injury,跨肺压,若用30cmH2O的正压通气，则跨肺压约35cmH2O。两个肺单位之间产生高达140cmH2O的切变力。,Biotruama,Mechanical Ventilation,Slutsky,Tremblay Am J Resp Crit Care Med.1998;157:1721-5,ARDS的保护性通气策略

6、？,Oxidant injury-keep FiO2 60 Barotrauma-keep alveolar inflation pressures 35 cm H2OVolutrauma-Baby lung concept or stretch injuryAtelectrauma-repeated opening and closingBiotrauma-release of inflammatory mediators and bacterial translocationOPEN GENTLY AND KEEP THEM OPEN温柔的打开肺泡，并保持开放,Principle原则,Wh

7、itehead T,Slutsky AS.Thorax.2002;57:636,传统的肺保护性通气策略,小潮气量（6 mlkg理想体重）允许性高碳酸血症（PHC）控制气道平台压30 cmH 2O 使用合适的PEEP,是迄今为止少有的被大规模随机对照研究证实，能降低ARDS患者死亡率的治疗措施。,LUNG PROTECTIVE VENTILATION WITH LOW TIDAL VOLUME,N Engl J Med 2000;342:1301-1308,提高治疗干预强度,轻度ARDS,中度ARDS,严重ARDS,小潮气量通气,更高水平PEEP,无创通气,低-中水平PEEP,俯卧位通气,神经肌

8、肉阻滞剂,高频振荡通气,ECCO2-R,ECMO,300 250 200 150 100 50,提纲：临床探讨的通气模式与参数,Tidal volume Plateau pressurespHPEEPVC vs PCVRecruitment maneuversHigh-frequency oscillatoryProne positioningECMO,潮气量平台压允许性高碳酸血症呼气末正压定容与定压手法复张高频振荡通气俯卧位通气体外膜氧合,肺通气保护策略在儿童ARDS中的应用,2000年 NEJM，861名成人ARDS患者治疗组：小潮气量（4-6ml/kg）,限制压力（平台压30cmH2O）

9、，允许性高碳酸血症但保持pH大于7.3 显著改善预后病死率 39.8%31%自主呼吸天数 10天12天首次为小潮气量通气模式提供可靠的循证医学证据,小潮气量 Low Tidal Volume,ARDS Net.2000,36,平台压的调整策略（跨肺压、驱动压）,787 patients from ARDS Network study,平台压,死亡率,PEEP：较高的呼气末正压（Meta）,Briel M,Meade M,Mercat A,et al.Higher vs lower positive end-expiratory pressure in patients with acute l

10、ung injury and acute respiratory distress syndrome.JAMA 2010;303（9）:86573.,医院死亡率 ICU死亡率 气胸 气胸后死亡 脱机时间,39,H值的调整策略,Ventilation Using the Best PEEPPrevention of Atelectrauma（最佳PEEP）,VCV vs PCV 定容与定压,没有定论，各有优劣！,RECRUITMENT 肺复张,A recent systematic review analyzed 40 studies that evaluated RMs;（4 were RCT

11、s,32 prospective studies,and 4 retrospective cohort studies）The sustained inflation method 45%：CPAP of 3550 cm H2O for 2040 seconds 23%：high pressure control20%：incremental PEEP10%：high VT/sigh,Fan E,Wilcox ME,Brower RG,et al.Recruitment maneuvers for acute lung injury.Am J Respir Crit Care Med 2008

12、;178（11）:115663.,RECRUITMENT MANEUVER,Driving pressure:15 cm H2O,Best V/PBest pO2/FIO2,Umbrello M,et al.Int J Mol Sci 2017;18:64,A ventilation strategy that included recruitment manoeuvres in participants with ARDS reduced intensive care unit mortality without increasing the risk of barotrauma but had no effect on 28-day and hospital mortality.We downgraded the quality of the evidence to low.Cochrane Database Syst Rev 2016;11:CD006667,Variations in Patients:Some Need Higher PEEP Than Others,Current evidence suggests that that RMs shou