无创正压通气治疗急性呼吸窘迫综合征早期的临床分析

目的分析无创正压通气(NPPV)的影响因素,进一步探讨NPPV治疗急性呼吸窘迫综合征(ARDS)早期的临床疗效。方法将88例ARDS早期患者随机分为NPPV组和标准氧疗组。NPPV组采用德国Drager呼吸机,经口鼻面罩辅助通气,模式IPPV或BIPAP,PEEP 5~8cmH2O,FiO240%~60%。标准氧疗组采用文丘里吸氧面罩,FiO240%~60%。比较两组治疗0.5、1h动脉血气分析、氧合指数,失败率(治疗失败改气管插管呼吸机辅助呼吸)等。分析比较治疗失败组和治疗成功组的血流动力学及血气分析情况。结果 NPPV组治疗后血气分析较标准氧疗组有明显改善,PaO2明显升高(P0.05),氧合指数增加(P0.05),治疗失败率明显低于标准氧疗组(P0.05)。休克,严重低氧血症和代谢性酸中毒是NIPPV和标准氧疗治疗失败的相关影响因素。结论早期ARDS可使用NPPV和标准氧疗,NPPV组优于标准氧疗组。     

无创正压通气治疗急性肺损伤/急性呼吸窘迫综合征研究进展

1994年美国和欧洲呼吸与重症医学学者首次统一急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）的定义及诊断标准。在2000年中华医学会呼吸病学分会也讨论通过了中国内地的急性肺损伤（acute lung injury,ALI）/ARDS的诊断标准（草案）：有发病的高危因素;②急性起病：呼吸频数和/或呼吸窘迫;③低氧血症;ALI时动脉血氧分压（PaO2）/吸入氧气浓度（Fi O2）≤300（1mmHg=0.133kPa）;ARDS时PaO2/Fi O2≤200;④胸部X线检查两肺浸润阴影;⑤肺毛细血管前楔压（PCWP）≤18mmHg或临床上能除外心源性     

成人急性肺损伤和急性呼吸窘迫综合征患者的无创和有创通气治疗新进展

<正>急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)是指心源性以外的各种肺内外致病因素所导致的急性进行性缺氧性呼吸衰竭,以肺容积减少、肺顺应性降低、严重的通气/血流比例失调为共同的病理生理特征。临床上表现为呼吸窘迫、顽固性低氧血症,肺部影像学上表现为非均一性的渗出性病变〔1〕。起病急、病情重、病死率高达31.0%～86.4%。随着人们对     

无创正压通气在严重急性呼吸综合征呼吸衰竭中的应用

临床实践表明，有23％～32％的严重急性呼吸综合征（SARS）患者可能合并急性肺损伤和（或）急性呼吸窘迫综合征的呼吸衰竭，需机械通气辅助呼吸。应用低潮气量的肺通气保护策略进行有创机械通气治疗SARS呼吸衰竭已得到广泛认同。但无创正压通气（NPPV）的应用价值在国际上尚存争议。在SARS暴发早期，中华医学会出版的相关指南中推荐尽早应用NPPV以改善患者的缺氧状态。     

无创机械通气治疗急性呼吸窘迫综合征的临床观察

目的 观察无创机械通气治疗急性呼吸窘迫综合征(ARDS)的临床疗效.方法 72例急性呼吸窘迫综合征患者在常规治疗(药物治疗+吸氧)基础上加用无创机械通气,观察患者治疗前后临床症状和动脉血气分析.结果 给予无创机械通气后患者呼吸困难症状明显改善,pH、SaO2、PaO2、PaO2/FiO2等指标上升明显,与治疗前相比差异有统计学意义(P<0.05);呼吸频率、心率、血压、PaCO2,等指标明显下降,与治疗前相比差异有统计学意义(P<0.05).动脉血气PaO2明显上升(P<0.05),PaCO2下降明显(P<0.05).结论 无创机械通气治疗能有效缓解急性呼吸窘迫综合征患者的临床症状,并改善患者的各项血气指标,值得在临床中推广应用.     

肾移植术后合并急性呼吸窘迫综合征患者的无创通气治疗

目的评价双水平气道正压(BiPAP)无创通气对肾移植术后合并ARDS患者的临床应用价值。方法对20例肾移植术后合并ARDS患者采用BiPAP呼吸机经鼻面罩双水平正压通气治疗,监测通气前后患者生命体征(呼吸、心率、血压)及动脉血气(pH、PaO2、PaCO2、SaO2)的变化,并观察其临床疗效。结果18例患者经无创通气治疗后生命体征及动脉血气指标改善,无创通气治疗降低患者的血压、呼吸、心率及血PaCO2水平,提高了血pH、PaO2、SaO2水平,治疗前后组间有显著差异(P<0.05)。结论肾移植术后合并ARDS患者病情重,进展快,BiPAP无创通气能迅速改善患者临床症状和低氧血症,是一种安全有效的治疗方法。     

无创正压机械通气在治疗急性胰腺炎所致急性呼吸窘迫综合征中的应用

目的 探讨无创正压机械通气( NPPV)治疗急性胰腺炎并发急性呼吸窘迫综合征(ARDS)的临床价值。方法 回顾性分析2007年1月至2010年5月收治的27例急性胰腺炎并发ARDS患者行NPPV治疗的病例资料,对比治疗前后患者心率、呼吸频率、动脉血氧分压(PaO2)、氧合指数(OI)及动脉血二氧化碳分压(PaCO2)的变化情况。结果 27例患者中,25例(92.6％)经NPPV治疗后,心率、呼吸频率从上机前的(118.4±13.4)次/min、(32.1±1.7)次/min降低到上机后48 h的(81.9±8.5)次/min、(19.9±2.1)次/min,PaO2、OI及PaCO2从上机前的(74.1±5.0)mmHg(1 mmHg=0.133 kPa)、(148.2±10.0) mmHg、(28.7±1.6) mmHg增加到上机后48 h的(110.4±20.8) mmHg、(204.5±71.1) mmHg、(38.4±3.6) mmHg,最终顺利脱机并过渡为文丘里面罩给氧;2例(7.4％)患者呼吸情况恶化,最终改为经口气管插管接有创呼吸机辅助呼吸。结论 急性胰腺炎并发ARDS患者使用NPPV治疗的疗效满意。NPPV操作相对简单,容易学习和掌握,并发症少,值得在临床上推广应用。     

无创正压通气在非COPD急性呼吸衰竭治疗中的应用

无创正压通气 (NPPV)治疗急性呼吸衰竭 (ARF)成为急救医学领域中一项重要进展 ,本文重点对非COPD肺部疾病引起的ARF临床应用NPPV治疗进行综述。     

无创正压通气治疗糖尿病高脂血症重症急性胰腺炎并发呼吸窘迫综合症的临床研究

目的探讨2型糖尿病患者在高脂血症重症急性胰腺炎（HL—SAP）并发急性呼吸窘迫综合征（ARDS）时早期应用无创正压通气治疗的临床疗效。方法对2004年5月～2007年5月枣矿集团中心医院收治的32例患者早期应用呼吸机SIMV＋PSV模式辅助呼吸治疗,以心率变化、血气分析、氧合指数等为观察指标,与2004年5月以前30例同种疾病患者做对比。结果32例患者早期应用无创正压通气后血气分析中尤其PO2、SaO2、PaO2／FiO2改善明显,心率恢复时间较常规组缩短;平均住院时间及住院费用减少,具有统计学差异。结论治疗2型糖尿病高脂血症重症胰腺炎患者并发急性呼吸窘迫综合征时早期应用无创正压通气（NPISV）对于改善肺功能、控制病情、节约住院时间及费用具有积极的临床意义。     

无创机械通气治疗急性呼吸窘迫综合征61例临床体会

目的 探讨无创机械通气治疗急性呼吸窘迫综合征（ARDS）的临床疗效.方法 在综合治疗的基础上,采用面罩连接无创机械通气治疗早期急性呼吸窘迫综合征61例,观察患者的呼吸、pH、PaO2、SaO2、PaCO2、氧合指数（PaO2/FiO2）.结果 经无创机械通气治疗后,45例患者效果明显,原有的呼吸困难、紫绀等症状明显改善,APACHE Ⅱ、pH、SaO2、氧合指数（PaO2/FiO2）均较治疗前明显上升 （P＜0.05）,R、PaCO2明显改善（P＜0.05）,16例患者效果不佳,改为有创机械通气.结论 在综合治疗原发病的基础上,对急性呼吸窘迫综合征采取积极早期的无创机械通气治疗,可迅速改善患者的呼吸困难、紫绀等症状,使PaO2、SaO2升高,PaCO2降低,对于效果不佳的患者,采取有创机械通气.     

治疗急性呼吸衰竭的又一重要手段--无创正压通气

目的评价无创正压通气(NIPPV)治疗不同病因导致急性呼吸衰竭的价值.方法 43例急性呼吸衰竭患者,分全程无创组(30例)和无创-有创组(13例),比较全程无创组患者治疗前与治疗后2～8小时的PaO 2;比较全程无创组中COPD患者治疗前与治疗后2～8小时的PaCO 2;比较两组的APACHEⅡ分值;比较全程无创组中脱机成功与失败的APACHEⅡ分值.结果全程无创组治疗前与治疗后2～8小时的PaO 2有显著差异;COPD患者治疗前与治疗后2～8小时的PaCO 2有显著差异;两组间APACHEⅡ分值有显著差异,全程无创组中脱机成功与失败患者的APACHEⅡ分值有显著差异.结论 NIPPV是治疗不同病因急性呼吸衰竭安全而有效的手段.     

慢性阻塞性肺疾病合并昏迷并非无创正压通气的禁忌症

目的 评价无创正压通气(NIPPV)治疗慢性阻塞性肺疾病(COPD)急性加重期合并昏迷的价值.方法 48例COPD急性加重期患者,按照格拉斯哥昏迷评分(GCS)分为两组,GCS≤8为昏迷组,GCS＞8为对照组.比较两组间NIPPV治疗后的转归和治疗前后动脉血PH值、氧合指数(PaO2/FiO2)、PaCO2.结果 昏迷组与对照组的NiPPV有显著差异(P＜0.01),两组间的APACHEⅡ分值无显著差异,两组治疗前与治疗后2、24 h的动脉血PH值、PaO2/FiO2、PaCO2均有显著差异(P＜0.05);治疗成功组与失败组的APACHEⅡ分值有显著差异(P＜0.05),两组间的GCS无显著差异.结论 NIPPV对COPD急性加重期合并昏迷患者疗效确切,值得临床推广.     

经鼻间歇正压通气治疗新生儿呼吸窘迫综合征的临床研究

目的探讨经鼻间歇正压通气(NIPPV)治疗新生儿呼吸窘迫综合征(NRDS)的临床疗效价值及安全性,以期更好的为临床决策与发展提供相关依据。方法通过运用前瞻性研究方法,对我院自2014年1月-2016年1月期间收治患有呼吸窘迫综合征的120例新生儿随机分组,分别采用经鼻间歇正压通气或经鼻持续气道正压通气(NCPAP)联合肺表面活性物质进行治疗,对两组患儿治疗后的临床疗效加以评价。比较指标包括:氧合指数(OI)、pH值、PaO_2、PaCO_2、治疗成功率、病死率、辅助通气时间及肺漏气率等。结果两组治疗后PaO_2、pH值、OI值均显著升高,PaCO_2显著降低(P0.05)。治疗1 h时:间歇组PaO_2、pH值、OI值均显著高于持续组(P0.05),两组PaCO_2差异无统计学意义(P0.05)。治疗12 h:两组PaO_2、PaCO_2、pH值、OI值差异无统计学意义(P0.05)。另外,NIPPV组的治疗成功率明显高于NCPAP组(P0.05),而NCPAP组的辅助通气时间明显高于NIPPV组(P0.05),病死率、肺气漏比较无明显统计学差异(P0.05)。结论 NIPPV作为一种新型的无创呼吸机械通气技术,治疗效果更优,起效时间更快,治疗成功率更高,在NRDS的治疗中将有着广阔的前景,值得进行推广。     

Personalizing mechanical ventilation for acute respiratory distress syndrome

Lung-protective ventilation with low tidal volumes remains the cornerstone for treating patient with acute respiratory distress syndrome (ARDS). Personalizing such an approach to each patient’s unique physiology may improve outcomes further. Many factors should be considered when mechanically ventilating a critically ill patient with ARDS. Estimations of transpulmonary pressures as well as individual’s hemodynamics and respiratory mechanics should influence PEEP decisions as well as response to therapy (recruitability). This summary will emphasize the potential role of personalized therapy in mechanical ventilation.     

Awake extracorporeal membrane oxygenation in patients with severe postoperative acute respiratory distress syndrome

Background

A clinical trial of extracorporeal membrane oxygenation (ECMO) as an alternative ventilator tool is being performed as a new indication for ECMO. The purpose of this study was to evaluate the feasibility of awake ECMO to increase the success rate of weaning patients from ECMO and ventilator care during treatment of postoperative severe acute respiratory distress syndrome (ARDS).

Methods

We retrospectively analyzed the clinical reports of 10 patients who underwent awake ECMO due to postoperative ARDS between August 2012 and May 2015. We analyzed patient history, the partial arterial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio, and patient outcome.

Results

Seven patients (70%) were weaned from ECMO without difficulty; one patient failed to maintain awake ECMO, was re-intubated after 2 days of awake ECMO, and was re-tried on awake ECMO after 4 days of ventilator care. We weaned that patient from ECMO 2 days later. We weaned a total of eight patients (80%) from awake ECMO. The ECMO duration of surviving patients was 9.13±2.2 days (range, 6–12 days), and mean ventilator use duration was 6.8±4.7 days (range, 2–16 days). Two cases failed awake ECMO and died due to disease aggravation.

Conclusions

Awake ECMO was a useful weaning strategy after severe postoperative ARDS, as it avoids long-duration use of mechanical ventilation. Additionally, it is possible for patients to breathe spontaneously, which might prevents respiratory muscle dystrophy.     

Dynamic evaluation of the pulmonary protective effects of prone position ventilation via respiratory mechanics for patients with moderate to severe acute respiratory distress syndrome

BackgroundPatients with moderate to severe acute respiratory distress syndrome (ARDS) have been recommended to receive prone position ventilation (PPV). However, the dynamic changes in respiratory mechanics during PPV and their relationship with the prognosis have not been sufficiently evaluated. In addition, the impact of using neuromuscular blocking agents (NMBAs) during PPV on respiratory mechanics is not clear enough. Thus, the study aims to investigate the above-mentioned issues.MethodsA prospective cohort study was conducted on 22 patients with moderate to severe ARDS who received PPV in the intensive care unit (ICU) of the First Affiliated Hospital of Guangzhou Medical University. A multifunctional gastric tube was used to measure the patients’ respiratory mechanics during supine position ventilation (SPV), early PPV (PPV within 4 h of initiation), and middle/late PPV (more than 6 h after the initiation of PPV). Longitudinal data were analyzed with generalized estimating equations (GEE).ResultsCompared with SPV, the esophageal pressure swings (ΔPes) measured during the PPV was significantly higher (SPV 7.46 vs. early PPV 8.00 vs. middle/late PPV 8.30 cmH₂O respectively; P_{SPV vs. middle/late PPV} =0.025<0.05). A stratified analysis by patients’ outcome showed that the peak airway pressure (Ppeak), ΔPes and respiration rate (RR) in the death group were significantly higher than survival group. On the contrary, the tidal volume (Vt), diaphragmatic electromyogram (EMGdi) and PaO₂/FiO₂ ratio (PFR) in the death group were significantly lower than survival group. Notably, the ΔPes and transpulmonary driving pressure (DPL) were significantly lower in the patients treated with NMBAs (7.08 vs. 8.76 cmH₂O ΔPes; P<0.01), (14.82 vs. 18.08 cmH₂O DPL; P<0.001).ConclusionsDuring the transition from SPV to early PPV and then to middle/late PPV, the ΔPes in the PPV were greater than SPV and it fluctuated within a normal range while oxygenation improved significantly in all patients. The Ppeak, ΔPes and RR in the death group were significantly higher than survival group. When NMBAs were used, the ΔPes, inspiratory transpulmonary pressure (PLei), driving pressure (DP) and DPL were significantly decreased, suggesting that the rational combination of NMBAs and PPV may exert a synergistic protective effect on the lungs.     

BIPAP通气模式在ARDS中的应用价值

目的探讨BIPAP通气模式在ARDS患者中的临床价值。方法观察组与对照组每组40例,观察组予BIPAP通气,对照组予SIMV通气,观察两组血气分析、肺顺应性、血流动力学变化、带机时间、不良反应及死亡率。结果两组患者治疗48 h后,PaO2/FiO2、MAP、CVP及Cst均增高,PaCO2下降,观察组PaCO2显著低于对照组,pH值高于对照组,带机时间及死亡率均低于对照组,气胸发生率与照组无统计学差异。结论 BIPAP通气模式应用于ARDS患者,可改善通气/血流比、肺顺应性及循环功能,提高氧合指数,降低并发症及患者病死率。     

Reducing acute respiratory distress syndrome occurrence using mechanical ventilation

The standard treatment for acute respiratory distress syndrome (ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality remains unacceptably high (> 40%). Indeed, once ARDS is established it becomes refractory to treatment, and therefore avoidance is key. However, preventive techniques and therapeutics to reduce the incidence of ARDS in patients at high-risk have not been validated clinically. This review discusses the current data suggesting that preemptive application of the properly adjusted mechanical breath can block progressive acute lung injury and significantly reduce the occurrence of ARDS.