38例重症SARS患者临床救治回顾分析

目的：探讨ICU救治重症严重急性呼吸综合征(SARS)患者的临床特点以及经验。方法：回顾分析2002年12月一2003年4月38例入住ICU救治的重症SARS患者的临床资料。初步分析治疗与预后的因果关系。结果：38例重症SARS患者中，合并有基础疾病者8例(21．1％)。起病初期均给予抗病毒对症支持和器官保护治疗，发展至重症阶段均给予抗生素、糖皮质激素抗炎、营养支持、免疫调节、人工通气辅助等治疗措施。30例最终病愈出院(78．9％)，其中ll例出院时X线胸片示有轻微的肺纤维化改变(36．7％，11／30)；8例死亡(病死率21．1％)。结论：重症SARS病情发展迅速，除了提倡早诊断、早隔离、早治疗外，合理使用糖皮质激素和人工通气辅助效果理想。     

重症神经疾病患者早期康复临床研究

目的：探索建立重症神经疾病患者早期康复程序。方法：将ICU内收治重症监护患者30例非选择性纳入研究。男性21例，女性9例；年龄23—89岁；23例(70．6％)存在意识障碍；需要机械通气和／或气管切开者12例(40％)；接受开颅手术、微创手术、溶栓疗法等特殊治疗者16例(53．33％)。30例患者中4例患者因存在瞳孔改变、严重低氧血征、顽固性颅压增高等情况，入院时未实行早期康复，有2例开始康复时间分别后延至3—6天。其余26例患者在住入ICU或手术后48小时内开始早期康复治疗。结果：8例急症脑卒中患者经过早期积极治疗，神经功能缺损程度明显改善，在研究过程中发现6例接受静脉溶栓的急性脑梗塞患者偏瘫运动功能迅速恢复，一般在72小时内已出现分离性运动。本组重症神经疾病患者ADL能力也有显著进步。结论：康复医学工作者必须主动参与急性脑卒中与重症颅脑外伤的早期救治。积极探索制订重症神经疾病患者早期康复程序有重要的意义。     

机械通气并发耐甲氧西林金黄色葡萄球菌肺炎的临床和药敏分析

目的：探讨机械通气并发耐甲氧西林金黄色葡萄球菌(MRSA)肺炎的临床特点及药物敏感性分布情况。方法：回顾性分析32例机械通气过程中并发耐甲氧西林金黄色葡萄球菌肺炎患者的临床资料；通过纤支镜留取痰标本，用生化APR法作细菌鉴定及用纸片法作药敏测定。结果：患者均有严重的基础疾病，其中29例(90．7％)发生在机械通气7d之后，多有发热，痰黄稠，周围血白细胞升高。胸片表现与普通肺炎差别不大，少数患者(15．6％)可见渗出阴影中有多发囊状透亮区；药敏示32例均对万古霉素敏感，对夫西地酸钠、利福平、磺胺、氯霉素敏感性分别为100％、92．8％、83．4％、81．2％，对苯唑西林、庆大霉素、环丙沙星、克林霉素、红霉素等耐药率高。结论：机械通气并发MRSA肺炎细菌耐药率高，仅对万古霉素、夫西地酸钠等少数抗生素有效，治疗难度大，应引起临床医生的重视。     

严重急性呼吸综合征的后期并发症及其处理策略

目的 总结严重急性呼吸综合征(SARS)患者后期出现的并发症，分析其发生并发症的原因，并探讨其处理策略。方法 回顾性分析10例重症SARS患者的基础疾病状况、并发症、治疗经过和预后。结果 5例患者合并有慢性基础疾病，10例患者均长期使用糖皮质激素和广谱抗生素，所有患者都出现了急性呼吸功能衰竭；经抗感染、呼吸支持和其他综合治疗1个月左右，有4例患者仍然存在着急性呼吸功能衰竭，8例患者血清CD4和CD8水平低于正常范围，7例有继发高血糖表现，2例继发高血压；出现重度营养不良和严重电解质紊乱1例，精神行为异常者1例，气胸3例；8例患者发生了院内获得性肺炎(HAP)，其中3例发展为多器官功能障碍综合征；总的死亡率为30％(3／10)。结论 重症SARS患者后期并发症多；合并慢性基础疾病、机体免疫力受损、长期大剂量使用激素和广谱抗生素是SARS后期出现并发症的主要原因；合理使用糖皮质激素和抗生素、提高机体的免疫力、积极地处理合并症和并发症是治疗重症SARS后期患者的关键。     

人工机械通气在救治急性致死性呼吸衰竭中的作用

目的：探讨人工机械通气在救治急性致死性呼吸衰竭中的作用。方法：对36例急性致死性呼吸衰竭患者进行人工机械通气治疗。结果：成功救治29例（80．6％）,死亡7例（19．4％）,并发症5例（13．9％）,结论：人工机械通气是救治急性致死性呼吸衰竭唯一有效的方法,值得临床医师推广应用。     

对重症SARS预警因子和高危因素的探讨

目的 对2003年12月前广东省严重急性呼吸综合征（SARS）临床数据库采用决策树方法重新评价重症诊断标准，探讨预警因子并筛选高危因素。方法 首先选取按国家卫生部SARS诊断标准确诊的患者402例，其中358例符合重症标准。358例中，再选取进行有创机械通气、无创机械通气、或死亡者作为明确重症患者，余44例作为明确非重症患者。将氧合指数（OI）按病程中的最差值划分为3个等级，≤200mmHg（1mmHg=0．133kPa）为1；200～300mmHg为2；〉300mmHg为3，初步评价OI等级划分对重症SARS患者的预测作用，并进一步筛选临床的高危因素。结果 利用OI≤300mmHg作为判别规则对明确重症患者和明确非重症患者进行分类，错判率只有6．800%，由OI≤300mmHg所筛选的重症患者与按国家卫生部重症诊断标准（剔除OI≤300mmHg的部分）所筛选的患者以Logistic回归比较了病死概率和并发症，提示以OI≤300mmHg为标准划分的重症患者临床风险更高、预后更差。结论OI≤300mmHg即急性肺损伤的诊断标准更符合现行重症SARS的诊断要求，可作为重症SARS的预警指标之一。     

机械通气患者应用丙泊酚镇静治疗的观察与护理

我们通过选用丙泊酚用于机械通气患者镇静治疗的观察与护理取得满意的效果，现报道如下。 1对象和方法 1．1对象 选择2006—01／2006—12我院ICU收治的实施机械通气神志清醒的危重患者26例。其中男18例，女8例。年龄19～73岁。体重50～78kg。颅脑损伤8例；急性肺损伤6例；心源性肺水肿1例；重症胰腺炎3例；重症肌无力2例；复合外伤6例。     

人工机械通气在急性致死性肺水肿抢救中的作用

目的：探讨人工机械通气救治急性重症肺水肿的疗效。方法：对38例急性重症肺水肿(心源性和非心源性)患者在传统常规治疗同时加用人工机械通气辅助呼吸，呼吸机经鼻、口插管或气管切开进行气道正压通气治疗，观察通气前后动脉血气中pH、PaO2、PaCO2、SaO2的变化以及患者心率(HR)、呼吸频率(RR)、血压(BP)和临床征象的变化。结果：通气治疗后，35例患者临床症状明显改善，pH、PaO2、PaCO2、SaO2等参数与治疗前比较有显著性差异(P＜0．01)，顺利脱机。抢救成功率为92．1％，死亡3例，死亡率7．9％。结论：人工机械通气治疗急性重症肺水肿，能迅速改善患者症状和低纸血症，是抢救急性重症肺水肿的一种安全有效的辅助治疗方法。     

有创通气在重症严重急性呼吸综合征患者中的应用

目的探讨有创机械通气在重症严重急性呼吸综合征(SARS)中的应用效果.方法对2002年11月至2003年4月佛山市第一人民医院ICU收治的6例重症SARS患者有创机械通气的疗效和隔离防护的效果进行回顾性分析.结果6例重症SARS患者均成功撤离呼吸机,痊愈出院,无一例死亡;机械通气撤离时低氧血症和氧合指数较实施前均明显改善(P＜0.001),气道峰压(P=0.002)和气道均压(P=0.004)显著降低,所需呼吸末正压水平亦明显减少(P＜0.001);发生呼吸机相关性肺炎5例;与SIMV通气相比较,采用PRVC通气时所用镇静剂用量较小,通气时间较短;无医务人员、患者和患者家属发生SARS院内感染.结论对重症SARS患者实施肺保护性通气策略和有效的隔离防护,能降低死亡率,减少机械通气时间,减少SARS院内感染.     

乌司他丁对大鼠呼吸机相关性肺损伤的预防作用及机制研究

机械通气是治疗重危患者的可靠手段之一,据统计30%的重症加强治疗病房(ICU)患者需要进行机械通气,但不适当的应用会导致严重的并发症如呼吸机相关性肺损伤(VILI).     

Rhabdomyolysis associated with acute renal failure in patients with severe acute respiratory syndrome

An outbreak of severe acute respiratory syndrome (SARS) occurred in Taiwan in 2003. SARS complicated with rhabdomyolysis has rarely been reported. This study reported three cases of rhabdomyolysis developing during the clinical course of SARS. Thirty probable SARS patients were admitted to the isolation wards at Linkou Chang Gung Memorial Hospital between 4 April and 4 June 2003. Thirty patients, including four men and 26 women aged from 12 to 87 years (mean age 40). Eleven (36.7%) patients had respiratory failure and required mechanical ventilation with paralytic therapy; three (10%) patients had rhabdomyolysis complicated with acute renal failure and one received haemodialysis; four (13.3%) patients died. Three cases with rhabdomyolysis all received sedative and paralytic therapy for mechanical ventilation. Haemodialysis was performed on one patient. Two patients died from multiple organ failure, and one patient fully recovered from rhabdomyolysis with acute renal failure. SARS is a serious respiratory illness, and its aetiology is a novel coronavirus. Rhabdomyolysis resulting from SARS virus infection was strongly suspected. Immobilisation under paralytic therapy and steroids may also be important in developing rhabdomyolysis.     

早期控制呼吸在重度颅脑损伤患者中的应用

目的:探讨重度颅脑损伤患者早期控制呼吸的效果和护理方法。方法:对本组49例重度颅脑损伤患者,早期行机械通气,有自主呼吸存在的患者,清除人机对抗现象,根据血气分析结果调整呼吸机参数。结果:45例于8~26d自主呼吸平稳,顺利脱机,32例在20~32d神志转清醒,2例患者因就诊时多脏器功能衰竭死亡,2例患者放弃治疗。结论:早期控制呼吸,快速建立机械通气,加强呼吸道护理可避免并发症发生及降低病死率。     

Intensive care for seriously ill patients affected by novel coronavirus sars - CoV – 2: Experience of the Crema Hospital,Italy

AimsIn this work, the survival and mortality data of 54 consecutive patients admitted to the Intensive Care Unit (ICU) and suffering from severe respiratory insufficiency imputable to viral SARS - CoV - 2 infection were analyzed and shared, after a critical review of the evidence in order to optimize the most dedicated clinical and treatment strategy, for a future ‘targeted’ management in the care of the possible return flu outbreak.MethodsAt our Emergency Department of the Crema Hospital, from the beginning of the pandemic until the end of June 2020, 54 consecutive patients admitted to ICU suffering from severe acute respiratory infection (SARI) and severe respiratory distress (ARDS) attributable to viral SARS - CoV - 2 infection were recruited. The recruitment criterion was based on refractory hypoxia, general condition and clinical impairment, comorbidities and CT images. The incoming parameters of the blood chemistry and radiology investigations and the timing of the gold - tracheal intubation were compared. Medical therapy was based on the application of shared protocols.ResultsThe onset of symptoms was varyng, i.e. within the range of 1–14 days. The average time from the admission to the emergency room to the admission to intensive care was approximately 120 h. The average number of days of hospitalization in the ICU was 28 days. With a majority of male patients, the most significant age group was between 60 and 69 years. There were 21 deaths and, compared to the survivors, the deceased ones were older at an average age of about 67 years (vs an average age of the survivors of about 59 years). From the available data entering the ICU, the surviving patients presented average better values of oximetry and blood gas analysis, with a lower average dosage of D-Dimer than the deceased. Ones with a presence of bilateral pneumonia in all patients, the worsening of the ARDS occurred in 31 patients. 9 out of 25 patients early intubated died, while 12 out of 23 patients died when intubation was performed after 24 h of non-invasive ventilation. The presence of multiple comorbidities was shown in 17 of 28 patients and revealed an additional adverse prognostic factor. Also, more than one complication in the same patient were detected; after respiratory worsening, renal failure was more frequently found in 16 patients. Some particular complications such as lesions induced by ventilation with barotrauma mechanism (VILI), ischemic heart disease and the appearance of central and peripheral neurological events were detected too.ConsiderationsSARS - CoV - 2 disease is caused by a new coronavirus that has its main route of transmission through respiratory droplets and close contact, resulting in a sudden onset of the clinical syndrome with acute respiratory infection (SARI) and severe respiratory distress (ARDS). But it can also appear with other symptoms such as gastrointestinal or neurological events, as to be considered as a disease with multisystem phenotype. This pathology evolves towards a serious form of systemic disease from an acute lung damage to venous and arterial thromboembolic complications and multi-organ failure, mostly associated with high mortality. All patients received empirical or targeted antibiotic therapy for prevention and control of infections of potential pathogens, together with low molecular weight heparin therapy. The majority of patients was subjected to the off - label protocol with antivirals and hydroxychloroquine therapy, we used cortisone support therapy under surveillance and in 3 cases the protocol with anti - IL6 monoclonal antibody (Tolicizumab). In a simplified classification of the tomographic examination of the chest, mostly 3D and 2C lesions were found in the deceased patients with a prevalence of severe and moderate forms, whilst in the survivors the distribution appears with a prevalence of medium and moderate forms. Among the intubated patients, 21 patients, all suffering from worsening ARDS, died whilst there was no mortality in patients subjected to non-invasive ventilation it so. The heterogeneity of the respiratory syndromes and the presence of multiple comorbidities represent an unfortunate prognostic factor. Among the complications, besides the respiratory worsening, renal failure, liver failure and the state of sepsis were most frequently found; less frequent complications were lesions induced by ventilation with a barotrauma mechanism, ischemic heart disease, the appearance of central neurological events of sensory alterations, meningo - encephalitis and cerebral hemorrhage, and peripheral neurological events with polyneuro - myopathies. Mechanical ventilation can adversely affect the prognosis due to lung damage induced, protective ventilation remains the necessary treatment during severe hypoxia in patients with SARS - CoV - 2. The essential prerequisite remains the search for optimal ‘customized’ values since conditions can vary from patient to patient and, in the same patient, during different times of ventilation.ConclusionsIn these extraordinary circumstances, our reality was among the most affected and was able to hold the impact thanks to the immediate great response set in place by the operators, although it costed us an effort especially the one to try to guarantee a high quality level of assistance and care compared to the huge wave of patients in seriously bad conditions. Further research on this heterogeneous pathology and data sharing could help identify a more dedicated clinical decision-making and treatment pathway that, together with a resource planning, would allow us to better face any new disease outbreak.     

160例呼吸衰竭患者的诊治研究

目的探讨呼吸衰竭的临床特点,总结诊断和治疗的要点。方法对160例呼吸衰竭患者诊治过程进行回顾性分析。结果160例患者中,急性呼吸衰竭74例,其中严重肺部感染所致10例,胸部外伤严重累及呼吸肌或肺组织14例,尿毒症或肺癌胸膜腔积液短期内大量增多18例,自发性气胸8例,心源性肺水肿6例,重度中枢神经系统感染累及呼吸中枢6例,其他病因12例;慢性呼吸衰竭86例,其中慢性阻塞性肺病（COPD）64例,间质性肺疾病8例,硅肺、石棉肺6例,其他疾病8例。动脉气血分析：Pa02〈8.00kPa、PaC02正常为I型呼吸衰竭者70例;Pa02〈8.00kPa、PaC02〉6.67kPa为Ⅱ型呼吸衰竭者90例。160例患者经积极救治后6例死亡（4例严重胸部外伤、肺挫裂伤,2例尿毒症、全身多器官功能衰竭）,病死率为3.75％。其余154例均存活。结论呼吸衰竭的诊断依赖于疾病的临床表现、动脉气血分析、呼吸功能检查及胸部影像学检查等。呼吸衰竭的治疗应依呼吸衰竭的类型和病因个性化治疗。     

Noninvasive ventilation in acute respiratory failure

BACKGROUND: Noninvasive ventilation has assumed an important role in the management of respiratory failure in critical care units, but it must be used selectively depending on the patient's diagnosis and clinical characteristics. DATA: We review the strong evidence supporting the use of noninvasive ventilation for acute respiratory failure to prevent intubation in patients with chronic obstructive pulmonary disease exacerbations or acute cardiogenic pulmonary edema, and in immunocompromised patients, as well as to facilitate extubation in patients with chronic obstructive pulmonary disease who require initial intubation. Weaker evidence supports consideration of noninvasive ventilation for chronic obstructive pulmonary disease patients with postoperative or postextubation respiratory failure; patients with acute respiratory failure due to asthma exacerbations, pneumonia, acute lung injury, or acute respiratory distress syndrome; during bronchoscopy; or as a means of preoxygenation before intubation in critically ill patients with severe hypoxemia. CONCLUSION: Noninvasive ventilation has assumed an important role in managing patients with acute respiratory failure. Patients should be monitored closely for signs of noninvasive ventilation failure and promptly intubated before a crisis develops. The application of noninvasive ventilation by a trained and experienced intensive care unit team, with careful patient selection, should optimize patient outcomes.     

机械通气治疗开胸术后急性呼吸衰竭

目的总结机械通气治疗开胸术后急性呼吸衰竭的经验. 方法开胸术后并发急性呼吸衰竭21例,给予机械通气治疗,同时治疗原发疾病,采用抗生素和营养支持. 结果治愈16例,死亡5例. 结论开胸术后并发急性呼吸衰竭,应及时机械通气治疗,并积极治疗原发疾病,采用有效抗生素和营养支持.     

Ventilator strategies for posttraumatic acute respiratory distress syndrome: airway pressure release ventilation and the role of spontaneous breathing in critically ill patients

PURPOSE OF REVIEW: Patients who experience severe trauma are at increased risk for the development of acute lung injury and acute respiratory distress syndrome. The management strategies used to treat respiratory failure in this patient population should be comprehensive. Current trends in the management of acute lung injury and acute respiratory distress syndrome consist of maintaining acceptable gas exchange while limiting ventilator-associated lung injury. RECENT FINDINGS: Currently, two distinct forms of ventilator-associated lung injury are recognized to produce alveolar stress failure and have been termed low-volume lung injury (intratidal alveolar recruitment and derecruitment) and high-volume lung injury (alveolar stretch and overdistension). Pathologically, alveolar stress failure from low- and high-volume ventilation can produce lung injury in animal models and is termed ventilator-induced lung injury. The management goal in acute lung injury and acute respiratory distress syndrome challenges clinicians to achieve the optimal balance that both limits the forms of alveolar stress failure and maintains effective gas exchange. The integration of new ventilator modes that include the augmentation of spontaneous breathing during mechanical ventilation may be beneficial and may improve the ability to attain these goals. SUMMARY: Airway pressure release ventilation is a mode of mechanical ventilation that maintains lung volume to limit intra tidal recruitment /derecruitment and improves gas exchange while limiting over distension. Clinical and experimental data demonstrate improvements in arterial oxygenation, ventilation-perfusion matching (less shunt and dead space ventilation), cardiac output, oxygen delivery, and lower airway pressures during airway pressure release ventilation. Mechanical ventilation with airway pressure release ventilation permits spontaneous breathing throughout the entire respiratory cycle, improves patient comfort, reduces the use of sedation, and may reduce ventilator days.     

肺切除术后危重患者机械通气的应用肺切除术后危重患者机械通气的应用肺切除术后危重患者机械通气的应用

目的总结机械通气治疗肺切除术后患者呼吸功能不全的经验.方法回顾分析2001-05～2006-03我科肺切除术后并发呼吸功能不全25例患者的临床资料,均采用机械通气,同时对因治疗、控制肺部感染和营养支持. 结果 治愈20例,死亡3例,自动出院2例.结论肺切除术后并发呼吸功能不全,应及时给予机械通气治疗,合理选择呼吸机参数,注意无菌操作,在呼吸功能改善的同时对因治疗,并积极控制肺部感染,采用有效抗生素和营养支持.     

呼吸道管理在老年肺癌患者围手术期的护理探讨

目的：探讨低肺功能老年肺癌患者围手术期呼吸道管理的方法。方法：在肺癌患者围手术期护理的基础上，对低肺功能老年肺癌患者，加强术前、术后有效的呼吸道管理。结果：40例70岁以上低肺功能老年肺癌患者中，1例因术前伴有重度通气功能障碍，术后发生呼吸衰竭合并肺部感染死亡。结论：加强围手术期呼吸道管理，可有效的预防和减少术后并发症的发生，提高低肺功能老年肺癌患者术后的生活质量。     

32例严重胸腹部复合伤并发急性呼吸窘迫综合征患者的救治

目的探讨严重胸腹部复合伤并发急性呼吸窘迫综合征的有效救治方法。方法回顾性分析32例患者严重胸腹部复合伤并发急性呼吸窘迫综合征的急救方法及治疗效果。结果32例均有胸腹部的严重复合伤,均合并多发肋骨骨折或肺挫伤而致急性呼吸窘迫综合征,均行抗休克、合理补充血容量、合理的机械通气及急诊外科手术抢救治疗。临床治愈26例,死亡6例,死亡率18．75%。结论早期诊断、及时抗休克、合理补充血容量和处理胸腹部外伤以及尽早正确采用机械通气,是治疗严重胸腹部复合伤并发急性呼吸窘迫综合征的关键,也是降低死亡率的有效措施。