静脉-静脉体外膜肺氧合应用过程中的管理

近年静脉-静脉体外膜肺氧合（V-V ECMO）的应用迅速增加,随着新的技术、设备、治疗方法和研究证据的更新,应用过程中的管理也越来越成熟和规范。静脉-静脉体外膜肺的管理主要包括氧供与氧耗管理、机械通气策略、俯卧位治疗、清醒ECMO、早期康复和标准化撤机。     

体外膜肺氧合技术在重症呼吸衰竭患者治疗的应用进展

从体外膜肺氧合(ECMO)治疗的基本原理及其发展、ECMO 技术应用于重症呼吸衰竭的适应证等方面综述了体外膜肺氧合技术在重症呼吸衰竭患者治疗中的应用进展。体外膜肺氧合技术治疗 ARDS 有独特的优势和良好的效果,并且是一种简单、安全的技术,随着体外膜肺技术的成熟,其并发症逐渐减少。     

体外气体交换技术的现状与展望

体外气体交换技术是将血液引流至人工膜肺,进行氧合并排出CO2,再注入动脉或静脉系统实现肺气体交换替代功能.我们已经具备充足的临床经验与科学数据,应用体外膜肺氧合与超保护性肺通气策略作为极重度低氧血症ARDS患者一线治疗.随着体外气体交换技术的进步,不远的将来这项技术或可逐渐取代气管插管,应用于等待肺移植过程或COPD急性加重期患者的治疗.     

预防性静脉-动脉体外膜肺氧合支持下的经导管主动脉瓣植入术

经导管主动脉瓣植入术是治疗重度主动脉瓣狭窄的有效方法,当遇到诸如低射血分数的极高危患者,可能需要静脉-动脉体外膜肺氧合这样的机械设备的辅助治疗.现通过介绍1例成功在预防性静脉-动脉体外膜肺氧合应用下进行经导管主动脉瓣植入术的高危、低射血分数患者,进一步讨论当前国内外静脉-动脉体外膜肺氧合在经导管主动脉瓣植入术中的应用情...     

体外膜肺氧合辅助治疗妊娠期重症急性胰腺炎合并重度急性呼吸窘迫综合征1例报告

机械通气是治疗重度急性呼吸窘迫综合征(ARDS)的主要手段,然而即使采用包括保护性肺通气、肺复张手法、允许性高碳酸血症等策略,这类患者的病死率仍然高达30%～40%,并没有明显改善。可能的原因之一在于重度ARDS患者中难以做到既保护肺功能,又开放肺泡保证机体基本的氧摄取及CO2的排除。近年来体外膜肺氧合(ECMO)技术手段的进展,既能让已经严重受损的肺得到休息,     

ECMO在严重胸外伤抢救中的应用研究并2例病例报告

目的：探讨体外膜肺氧合在严重胸外伤抢救中的应用。方法：将我院2016年1月至2016年2月收治的严重胸外伤2例作为研究对象,两例患者均采用穿刺置管,由颈内静脉及股静脉置管,接MAQUET离心泵血液灌注系统(体外膜肺氧合) v一v模式治疗,对两例患者治疗前后血流动力学以及氧代谢指标进行监测。结果：与治疗前相比,经过体外膜肺氧合之后,患者混合静脉血分压、静脉血氧饱和度、动脉血氧分压、血氧饱和度明显改善,氧供与氧耗也明显增加,患者经过治疗后动脉血乳酸含量明显低于治疗前,氧摄取率也明显高于治疗前,经分析,数据差异明显,具有统计学意义（P<0.05）。在体外膜肺氧合前后,患者血流动力学无明显变化（P>0.05）。结论：对于胸外伤抢救患者采用体外膜肺氧合进行治疗,能够有效的降低氧血症的发生,对机体的氧代谢进行改善,提高组织的氧摄取率,从而赢得了治疗原发病的时间,有利于胸外伤的抢救。     

体外循环膜氧合支持下全肺灌洗治疗肺泡蛋白沉积症一例并文献复习

目的提高对肺泡蛋白沉积症(PAP)患者肺灌洗治疗过程中低氧血症危险性的认识。方法介绍1例经病理证实的PAP患者体外循环膜氧合下的全肺灌洗治疗过程，并复习相关文献。结果57岁男性患者，因咳嗽和进行性呼吸困难12个月入院，动脉血氧分压(PaO2)为46mmHg(1mmHg=0．133kPa)，脉搏容积血氧饱和度(SpO2)85％～88％。胸部CT、经纤维支气管镜支气管肺泡灌洗和肺活检病理检查符合PAP。在手术室常规静脉全麻后，经口腔插入双腔管，分隔为通气肺和灌洗肺。两肺机械通气SpO2为80％～90％；当右侧单侧肺机械通气SpO2为68％～80％。于右股动脉和右股静脉插管，建立体外循环通道，开始静脉-动脉体外循环膜氧合(ECMO)支持，右侧单侧肺机械通气SpO2为89％～97％。左侧肺用总计20800ml生理盐水灌洗，灌洗期间SpO2为80％～94％；灌洗后，患者无呼吸困难。28d后未用ECMO完成右肺灌洗。1个月后复查CT示双肺浸润影基本消失。结论当PAP患者全肺灌洗操作前出现顽固的低氧血症，应考虑使用ECMO支持，以避免患者在全肺灌洗治疗中的危险低氧血症。     

体外膜肺氧合在急性呼吸窘迫综合征的研究进展

体外膜肺氧合作为治疗重症急性呼吸衰竭的一种新型措施,常用于致死性低氧血症的治疗.目前被认为是在机械通气及其他治疗方法无效的情况下最后的选择,它可使患肺得到充分的休息和康复,为挽救急性呼吸窘迫综合征患者的生命提供了一个宝贵的契机.随着现代科学技术的发展,这项技术功能更强大,设备更先进,具有良好的临床实用价值.     

静脉-动脉体外膜肺氧合在心脏危重症中的救治

中国的心血管疾病负担较重,冠心病和心力衰竭等心脏疾病可导致心源性休克和心搏骤停。静脉-动脉体外膜肺氧合是救治心脏危急重症的重要手段。现通过1例体外膜肺氧合救治成功的心肌梗死合并心源性休克病例,引出体外膜肺氧合在心脏危急重症中救治的探讨,包括体外膜肺氧合机制、适应证与禁忌证、国内外研究进展、应用现状和展望等方面。     

体外膜肺氧合联合俯卧位通气治疗重症呼吸衰竭的新进展

摘要 近年来，体外膜肺氧合（ECMO）和俯卧位通气作为重症呼吸衰竭治疗中的两种重要手段，被广泛应用于临床实践中。本文就ECMO联合俯卧位通气在治疗重症呼吸衰竭中的原理，在改善氧合、减少机械通气时间、降低肺损伤等方面的作用机制和临床效果进行综述，分析目前该领域存在的问题，对未来的研究方向提出展望。     

Pumpless Extracorporeal Lung Assist for the Treatment of Severe,Refractory Status Asthmaticus

Background. Until recently, the only available lung-protective treatment option for carbon dioxide removal due to severe, refractory status asthmaticus has been extracorporeal pump-driven membrane oxygenation (ECMO). Pumpless extracorporeal lung assist (pECLA) may serve as an alternative therapy for these patients. Case Report. A 42-year-old woman presented with an acute exacerbation of asthma to our Emergency Department. Despite optimal pharmacological therapy, the patient developed respiratory failure requiring mechanical ventilation with elevated airway pressures. For severe ventilation-refractory hypercapnia and respiratory acidosis, ECMO was used initially and was later replaced by a pECLA device. The clinical condition continuously improved with sufficient pulmonary gas exchange. The pECLA was removed after 8 days, and the patient was successfully weaned from mechanical ventilation. Conclusions. This report suggests that pECLA is an alternative extracorporeal lung assist in patients with ventilation-refractory hypercapnia and respiratory acidosis due to severe, refractory status asthmaticus.     

Extrakorporale Lungenunterstützung beim hyperkapnischen Lungenversagen

In recent years the use of extracorporeal lung assist devices has rapidly increased in intensive care medicine. While venovenous extracorporeal membrane oxygenation (vv-ECMO) is applied as rescue therapy in patients with severe hypoxemic respiratory failure, extracorporeal CO₂ removal (ECCO₂R) can be applied in patients with hypercapnic respiratory failure. Especially in patients with acute on chronic hypercapnic respiratory failure treated with invasive mechanical ventilation, ventilator-associated side effects can lead to a poorer outcome. In these patients extracorporeal lung assist often enables lung protective ventilation and potentially ameliorates ventilator-associated side-effects. Moreover, by reducing the load on the respiratory muscle pump ECCO₂R may facilitate weaning from the ventilator and in individual patients with failure of non-invasive ventilation (NIV) may even help to avoid intubation. In selected patients with chronic lung disease listed for lung transplantation, the avoidance of invasive mechanical ventilation for acute decompensation by means of extracorporeal lung support may help to maintain the option for transplantation. The potential advantages of ECCO₂R must be weighed against the risks and complications.     

Adenovirus Pneumonia Complicated With Acute Respiratory Distress Syndrome: A Case Report

Severe adenovirus infection in children can manifest with acute respiratory distress syndrome (ARDS) and respiratory failure, leading to the need for prolonged mechanical support in the form of either mechanical ventilation or extracorporeal life support. Early extracorporeal membrane oxygenation (ECMO) intervention for children with ARDS should be considered if selection criteria fulfill.We report on a 9-month-old boy who had adenovirus pneumonia with rapid progression to ARDS. Real-time polymerase chain reaction tests of sputum and pleural effusion samples confirmed adenovirus serotype 7. Chest x-rays showed progressively increasing infiltrations and pleural effusions in both lung fields within 11 days. Because conventional ARDS therapies failed, we initiated ECMO with high-frequency oscillatory ventilation (HFOV) for 9 days. Chest x-rays showed gradual improvements in lung expansion.This patient was subsequently discharged after a hospital stay of 38 days. Post-ECMO and adenovirus sequelae were followed in our outpatient department.Adenovirus pneumonia in children can manifest with severe pulmonary morbidity and respiratory failure. The unique lung recruitment by HFOV can be a useful therapeutic option for severe ARDS patients when combined with sufficient lung rest provided by ECMO.     

Myocardial localization of coronavirus in COVID‐19 cardiogenic shock

We describe the first case of acute cardiac injury directly linked to myocardial localization of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in a 69‐year‐old patient with flu‐like symptoms rapidly degenerating into respiratory distress, hypotension, and cardiogenic shock. The patient was successfully treated with venous‐arterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation. Cardiac function fully recovered in 5 days and ECMO was removed. Endomyocardial biopsy demonstrated low‐grade myocardial inflammation and viral particles in the myocardium suggesting either a viraemic phase or, alternatively, infected macrophage migration from the lung.     

Akute respiratorische Insuffizienz

Acute respiratory distress syndrome (ARDS) is the clinical manifestation of an acute lung injury caused by a variety of direct and indirect injuries to the lung. The cardinal clinical feature of ARDS, refractory arterial hypoxemia, is the result of protein-rich alveolar edema with impaired surfactant function, due to vascular leakage and dysfunction with consequently impaired matching of ventilation to perfusion. Better understanding of the pathophysiology of ARDS has led to the development of novel therapies, pharmacological strategies, and advances in mechanical ventilation. However, protective ventilation is the only confirmed option in ARDS management improving survival, and few other therapies have translated into improved oxygenation or reduced ventilation time. The development of innovative therapy options, such as extracorporeal membrane oxygenation, have the potential to further improve survival of this devastating disease.     

Low‐flow veno‐venous extracorporeal carbon dioxide removal in the management of severe status asthmatics: a case report

Status asthmaticus is a life‐threatening condition that requires intensive care management. Most of these patients have severe hypercapnic acidosis that requires lung protective mechanical ventilation. A small proportion of these patients do not respond to conventional lung protective mechanical ventilation or pharmacotherapy. Such patients have an increased mortality and morbidity. Successful use of extracorporeal membrane oxygenation (ECMO) is reported in such patients. However, the use of ECMO is invasive with its associated morbidity and is limited to specialised centres. In this report, we report the use of a novel, minimally invasive, low‐flow extracorporeal carbon dioxide removal device in management of severe hypercapnic acidosis in a patient with life threatening status asthmaticus.     

An Update on Interventional Lung Assist Devices and Their Role in Acute Respiratory Distress Syndrome

In recent years, pumpless arteriovenous systems for extracorporeal gas exchange have become a new therapeutic option for the treatment of patients suffering from acute respiratory failure. Experiences with the pumpless extracorporeal membrane lung in animal experiments and in patients with adult respiratory distress syndrome published in the current literature are reviewed. In addition this article presents a case of varicella pneumonia with persistent hypoxemia and hypercapnia under mechanical ventilation that showed a significant improvement with treatment with a pumpless extracorporeal lung assist using an arteriovenous shunt for eight days. The patient made a complete recovery. This is the first report of a patient with a life-threatening varicella pneumonia successfully treated with pumpless extracorporeal lung assist device. This review provides an update on interventional lung assist devices and a critical discussion of their advantages and limitations.     

Two Cases of Severe COVID-19 Pneumonia Effectively Treated with Extracorporeal Membrane Oxygenation in Addition to Favipiravir and Corticosteroid

Case 1: A 65-year-old man with novel coronavirus infection (COVID-19) complicated with acute respiratory failure. On admission, the patient was started on favipiravir and corticosteroid. However, due to a lack of significant improvement, he was introduced to mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Although iliopsoas hematoma occurred as a complication, the patient recovered. Case 2: A 49-year-old man with COVID-19 had been started on favipiravir and corticosteroid. Due to progressive respiratory failure, the patient underwent mechanical ventilation and ECMO. The patient recovered without complications. We successfully treated these severe cases with a multimodal combination of pharmacological and non-pharmacological supportive therapy.