急性呼吸窘迫综合征患者支气管镜肺活检

目的 评估急性呼吸窘迫综合征(ARDS)患者进行支气管镜肺活检(TBLB)的安全性和诊断价值.方法 回顾性分析2003年1月～2007年9月在广州呼吸疾病研究所ICU做TBLB检查的8例ARDS患者的临床资料.结果 4例(50%)患者经TBLB确诊.侵袭性肺曲霉茵感染1例(12.5%)、放射性肺炎1例(12.5%)、混合性结缔组织疾病肺间质纤维化表现1例(12.5%)、肺结核1例(12.5%).ARDS患者非特异性病理改变4例(50%).3例(37.5%)患者因此更改了治疗方案.TBLB的并发症包括:出血＜30 mL者5例(62.5%)、出血≥30 mL者3例(37.5%)、低氧血症7例(87.5%)、低血压3例(37.5%)、心跳过速1例(12.5%)、无气胸及患者死亡.结论 在ARDS患者进行支气管镜肺活检有一定风险和诊断价值,在严格掌握适应证的情况下,可以作为肺活检选择.     

机械通气联合肺表面活性物质治疗早产儿呼吸窘迫综合征的疗效

新生儿呼吸窘迫综合征(NRDS)是由于缺乏肺表面活性物质(PS),呼气末肺泡萎陷而引起,临床表现为进行性呼吸困难、发绀、呻吟等急性呼吸窘迫症状和呼吸衰竭。NRDS多见于早产儿,胎龄越小,发病率越高。NRDS是引起早产儿死亡的主要原因,占早产儿死亡的50%~70%[1]。研究[2-5]发现患儿发病早期应用肺表面活性物质能够改善患儿预后,提高早产儿存活率,并减少氧气吸入和机械通气的应用。本研究回顾性分析     

急性呼吸窘迫综合征4例临床分析

急性呼吸窘迫综合征(acute respiratary distress syndmms ARDS)是危重病急救医学中较为常见的临床综合征，是指心源性以外的各种肺内外致病因素引起肺泡-毛细血管炎症损伤为主的急性呼吸衰竭。属于急性肺损伤(acute lung injury ALI)的严重阶段，常并发多脏器功能衰竭，其病死率很高。现对4例急性呼吸窘迫综合征进行临床分析，目的是提高广大医务工作者的认识。     

早产儿呼吸窘迫综合征机械通气与血小板动态变化

近几年国外报道 ,机械通气造成肺损伤时引起血循环中血小板减少[1 ,2 ] ,而早产儿类似肺损伤报道较少见。为了观察早产儿呼吸窘迫综合征 (ＲＤＳ)机械通气后血小板动态变化 ,我们对在我院新生儿监护病房 (ＮＩＣＵ)经气管插管下机械通气的 5 1例ＲＤＳ早产儿 ,进行回顾性分析 ,     

机械通气治疗急性呼吸窘迫综合征中的肺开放通气策略

机械通气是治疗急性呼吸窘迫综合征的关键性措施，肺开放通气策略是肺保护通气策略的重要补充，其最终日的是为了实现肺保护。实施肺开放通气策略我们主要是围绕以下两方面来进行：一方面是采用何种方式及压力水平使更多萎陷肺泡开放（open up the lung）。另一方面是打开肺后如何设法使已开放的肺泡尽量维持于开放状态（keep the lung open）。肺开放性通气策略实施的方法有多种，最佳PEEP是维持肺开放的核心，多种因素影响肺开放通气实施效果和检测。     

机械通气联合肺表面活性物质治疗早产儿呼吸窘迫综合征的效果及预后

选择收治呼吸窘迫综合征早产儿110例,依据治疗方式的不同设为对照组(48例)与研究组(62例),对照组行机械通气治疗,研究组行机械通气联合肺表面活性物质治疗,比对两组治疗前后动脉血气指标、疗效及并发症。治疗后研究组p H值、Pa CO_2、Pa O_2及PO_2/Fi O_2均优于对照组(P0.05);且研究组氧疗时间、机械通气时间、住院时间及住院费用均优于对照组(P0.05);研究组感染、气道损伤、肺不张及动脉导管阻塞等并发症均少于对照组(P0.05)。NRDS患儿行机械通气联合肺表面活性物质治疗可改善动脉血气指标,减少住院费用与并发症,缩短氧疗、机械通气及住院时间,值得推广。     

急性呼吸窘迫综合征机械通气策略的转变

急性呼吸窘迫综合征机械通气策略的转变朱铁楠（综述）刘大为（审校）急性呼吸窘迫综合征（ＡＲＤＳ）是由休克、创伤误吸、肺外或肺内感染等多种原因引起的一类急性呼吸衰竭，为危重患者致死的重要原因之一。机械通气作为一项基本的治疗手段，它的目的在于改善通气与氧合...     

应用肺表面活性物质预防早产儿呼吸窘迫综合征临床观察

目的 探讨肺表面活性物质(PS)是否具有预防早产儿呼吸窘迫综合征(NRDS)的临床作用.方法 对2001年1月至2005年12月浙江省台州市第一人民医院新生儿科收治的114例高危早产儿分成两组,预防组52例,为家庭条件允许应用PS者;对照组62例为同期住院未应用PS者.预防组用药前及用药后6 h分别采动脉血进行血气分析.对照组在入院时及综合处理后6 h也分别采动脉血进行血气分析.两组患儿入院后24 h内均拍胸片了解肺部情况,对两组进行比较.结果 预防组可有效减少NRDS的发病率及减轻病情,两组pH、PaO2、PaCO2值比较差异有统计学意义(P《0.05).两组并发NRDS情况比较差异有统计学意义(P《0.05).结论 预防性应用肺表面活性物质可有效减少NRDS的发病率及减轻病情.     

重症急性胰腺炎并发急性呼吸窘迫综合征的肺保护通气

目的探讨重症急性胰腺炎(AP)并发急性呼吸窘迫综合征(ARDS)的肺保护通气策略的临床效果。方法AP并发ARDS行气管插管机械通气患者56例,保持平台压<35cmH2O,最高不超过40cmH2O,肺容积低于压力容积曲线的高拐点。当平台压<25cmH2O时,预设潮气量6~8ml/kg;平台压在25~30cmH2O时,预设潮气量5~6ml/kg;如平台压>30cmH2O或有增高趋势,则用压力控制通气,保持pH值7.30~7.45。使用最佳呼气末正压(PEEP),吸入氧浓度(FIO2)尽量保持≤60%,氧和目标是PaO255~80mmHg或SaO288%~95%。结果机械通气时间7~31d,平均(16±6.4)d,控制性低通气时间3~7d,与通气前比较,通气后8h和48hPaO2/FIO2明显改善(P<0.01),PaCO2在通气后48h显著增加(P<0.05),pH值变化不明显(P>0.05)。无气压伤发生。结论以平台压为靶压力管理目标,适时选用容量通气或压力控制通气,合理调整参数,真正实行个体化保护性通气策略,最大程度地避免了呼吸机相关性肺损伤的发生。     

急性呼吸窘迫综合征机械通气策略的再评价

196 7年Ａｓｈｂａｕｇｈ首先提出急性呼吸窘迫综合征 (ＡＲＤＳ)以来 ,无论是其发病机制 ,还是治疗手段均取得了长足的进步。但是直到今天 ,ＡＲＤＳ仍然是急诊和危重病患者最严重的致命并发症之一 ,病死率高达 3 0 %～ 6 0 %。机械通气是ＡＲＤＳ最重要的支持和治疗手段 ,应用合理的机械通气策略 ,有可能最终降低ＡＲＤＳ患者的病死率。传统ＡＲＤＳ通气策略是采用较大水平的潮气量 (1 0～ 1 5ｍｌ/ｋｇ)促进萎陷的肺泡复张 ,维持正常的动脉血气 ,以最小的呼气末正压 (ＰＥＥＰ)达到“足够”的动脉氧合。近年的研究显示传统的通气策略是片…     

肺超声诊断早产儿呼吸窘迫综合征的临床价值

目的 分析早产儿呼吸窘迫综合征(NRDS)的肺超声表现,探讨不同肺超声表现诊断NRDS的临床应用价值.方法 选取我院收治的疑诊NRDS早产儿109例,于使用外源性肺表面活性物质和持续气道正压通气或常规机械通气治疗前行肺超声检查,同时进行血气分析和胸部X线检查.以临床诊断结果为标准,根据不同肺超声表现制定A、B、C三种诊...     

Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients

Objective: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. Design: A prospective, multi-institutional, initial cohort study including 28-day follow-up. Settings: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). Patients: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO₂/FIO₂ ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray); group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F ≤ 300 mmHg and bilateral infiltrates) and group 3 to patients with P/F of 300 mmHg or less but having exclusion criteria from the previous groups. Results: Nine hundred seventy-six patients entered the ICUs during the study period, 43 % of them being mechanically ventilated and 213 (22 %) meeting the criteria for one of the three groups. Among all the ICU admissions, ARDS, ALI and group 3 patients amounted, respectively, to 6.9 % (67), 1.8 % (17) and 13.3 % (129) of the patients, and represented 31.5 %, 8.1 % and 60.2 % of the hypoxemic, ventilated patients. The overall mortality rate was 41 % and was significantly higher in ARDS patients than in the others (60 % vs 31 % p < 0.01). In group 3, 42 patients had P/F less than 200 mmHg associated with unilateral lung injury; mortality was significantly lower (40.5 %) than in the ARDS group. In the whole group of hypoxemic, ventilated patients, septic shock and severity indices but not oxygenation indices were significantly associated with mortality, while the association with immunosuppression revealed only a trend (p = 0.06). Conclusions: In this survey we found that very few patients fulfilled the ALI non-ARDS criteria and that the mortality of the group with ARDS was high. Received: 21 September 1998 Final revision received: 3 February 1999 Accepted: 3 May 1999     

俯卧位通气对急性肺损伤和急性呼吸窘迫综合征临床疗效影响的Meta分析

目的 系统评价俯卧位通气(PPV)对我国急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)患者的短期临床疗效.方法 利用Cochrane系统评价法,全面检索2000年至2009年国内公开发表的所有ALI与ARDS患者PPV的临床研究资料.对纳入研究独立进行质量评价、资料提取、交叉核对后行Meta分析.结果 纳入研究8项共184例患者,PPV时患者动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)、呼吸系统总顺应性(C)均显著升高;动脉血二氧化碳分压(PaCO2)、中心静脉压(CVP)、呼吸道峰压(PIP)和呼吸系统总阻力(Raw)无显著的变化;心率(HR)与平均动脉压(MAP)显著升高. 结论 ALI与ARDS患者行PPV可增加呼吸系统总顺应性,改善患者低氧血症,相关临床研究结果基本一致.但因Meta分析的自身局限性,我们仍急需开展设计严谨的高质量大样本临床研究,明确PPV临床疗效、作用机制、科学的操作流程及PPV对患者血流动力学的影响等临床实际问题,改善国内ALI与ARDS患者的临床护理水平.     

体外膜肺氧合治疗急性呼吸窘迫综合征的临床疗效观察

目的 探讨体外膜肺氧合(ECMO)治疗急性呼吸窘迫综合征(ARDS)患者的临床疗效和安全性.方法 6例ARDS患者在机械通气治疗无明显效果后,予以ECMO辅助治疗.比较ECMO治疗前后氧合、呼气末正压(PEEP)水平和吸入氧浓度(FiO2)的变化,观察ECMO的不良反应.结果 应用ECMO辅助治疗后,6例患者脉搏血氧饱和度(SpO2)升高(从0.45 ～ 0.92升至0.94～ 1.00),PEEP(cm H2O,1 cm H2O =0.098 kPa)和FiO2降低(PEEP从10.0～22.0降至4.0～15.0;FiO2从1.00降至0.30～0.60).2例危重症甲型H1N1流感肺炎患者死于休克,1例危重症甲型H1N1流感肺炎和1例肺炎克雷伯杆菌肺炎患者因病情恶化放弃治疗,1例巨细胞病毒肺炎、1例鲍曼不动杆菌肺炎患者顺利恢复出院.主要并发症为出血、溶血.结论 ECMO可增加气体交换,改善氧合,部分替代肺的功能.ARDS患者如果机械通气治疗无效,宜及早使用ECMO辅助.     

急性呼吸窘迫综合征患者机械通气和营养支持治疗37例分析

目的探讨急性呼吸窘迫综合征（ARDS）患者机械通气和营养支持治疗的临床特点及治疗效果。方法回顾性分析37例ARDS患者经机械通气和营养支持治疗的临床资料。结果37例ARDS机械通气患者1次脱机成功者30例,2次脱机成功者5例,3次脱机成功者2例。机械通气3—10d,无一例依赖呼吸机。全胃肠外营养（TPN）支持4-12d,TPN支持期间合并高血糖5例,消化道出血4例,肺感染、呼吸衰竭5例,无一例中心静脉置管并发症。结论机械通气和营养支持治疗ARDS临床效果较好。但应注意营养供给方式的选择。     

有创通气的急性呼吸窘迫患者发生急性肾损伤的危险因素分析

目的:探讨有创机械通气的急性呼吸窘迫综合征（acute respiratory distress syndrome, ARDS）患者发生急性肾损伤（acute kidney injury,AKI）的危险因素。方法:回顾性分析2019年01月至2019年12月泰州市人民医院重症医学科收治的有创机械通气的ARDS患者的临床资料,根据患者是否发生AKI,分为AKI组和非AKI组。比较两组患者的临床特征和实验室指标;分析影响有创机械通气的ARDS患者发生AKI的危险因素;绘制Kaplan-Meier生存曲线,比较两组患者的生存率。结果:共120名有创机械通气的ARDS患者,其中57名发生AKI,发生率为47.5%。降钙素原、基础肌酐增高,pH值降低和意识障碍是有创机械通气的ARDS患者发生AKI的独立危险因素。120例患者中57名死亡,总住院病死率38.3%。Kaplan-Meier生存曲线表明,AKI组生存率低于非AKI组,差异有统计学意义（ P<0.001）。 结论:有创机械通气的ARDS患者AKI发生率高,可明显增加患者住院病死率。降钙素原、基础肌酐增高,pH值降低和意识障碍是有创机械通气的ARDS患者发生AKI的独立危险因素。     

Alveolar recruitment maneuver in patients with subarachnoid hemorrhage and acute respiratory distress syndrome: A comparison of 2 approaches

Purpose

The purpose of the study was to compare 2 alveolar recruitment maneuvers (ARMs) approaches in patients with subarachnoid hemorrhage (SAH) and acute respiratory distress syndrome (ARDS).

Material and Methods

Sixteen SAH patients with ARDS were randomized in 2 similar groups. One received ARM with continuous positive airway pressure (CPAP) of 35 cm H₂O for 40 seconds (CPAP recruitment), whereas the other received pressure control ventilation with positive-end expiratory pressure of 15 cm H₂O and pressure control above positive end-expiratory pressure of 35 cm H₂O for 2 minutes (pressure control recruitment maneuver [PCRM]). Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured before and after ARM. The ratio of arterial oxygen tension to fraction of inspired oxygen was measured before and 1 hour after the ARM.

Results

After ARM, ICP was higher in CPAP recruitment (20.50 ± 4.75 vs 13.13 ± 3.56 mm Hg; P = .003); and CPP was lower in CPAP recruitment (62.38 ± 9.81 vs 79.60 ± 6.8 mm Hg; P = .001). One hour after the ARM, the ratio of arterial oxygen tension to fraction of inspired oxygen increased significantly only in PCRM (108.5 to 203.6; P = .0078).

Conclusion

In SAH patients with ARDS, PCRM did not affect ICP and decreased CPP in safe levels, besides improving oxygenation.     

Extended prone position ventilation in severe acute respiratory distress syndrome: A pilot feasibility study

Objectives

The aim of the study was to evaluate the safety of extended prone position ventilation (PPV) and its impact on respiratory function in patients with severe acute respiratory distress syndrome (ARDS).

Design

This was a prospective interventional study.

Setting

Patients were recruited from a mixed medical-surgical intensive care unit in a university hospital.

Patients

Fifteen consecutive patients with severe ARDS, previously unresponsive to positive end-expiratory pressure adjustment, were treated with PPV.

Intervention

Prone position ventilation for 48 hours or until the oxygenation index was 10 or less (extended PPV).

Results

The elapsed time from the initiation of mechanical ventilation to pronation was 35 ± 11 hours. Prone position ventilation was continuously maintained for 55 ± 7 hours. Two patients developed grade II pressure ulcers of small extent. None of the patients experienced life-threatening complications or hemodynamic instability during the procedure. The patients showed a statistically significant improvement in Pao₂/Fio₂ (92 ± 12 vs 227 ± 43, P < .0001) and oxygenation index (22 ± 5 vs 8 ± 2, P < .0001), reduction of PaCo₂ (54 ± 9 vs 39 ± 4, P < .0001) and plateau pressure (32 ± 2 vs 27 ± 3, P < .0001), and increment of the static compliance (21 ± 3 vs 37 ± 6, P < .0001) with extended PPV. All the parameters continued to improve significantly while they remained in prone position and did not change upon returning the patients to the supine position.

Conclusions

The results obtained suggest that extended PPV is safe and effective in patients with severe ARDS when it is carried out by a trained staff and within an established protocol. Extended PPV is emerging as an effective therapy in the rescue of patients from severe ARDS.     

Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review

Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the “sponge lung” - and the “shape matching” -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients’ response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.     

重症急性胰腺炎并发急性呼吸窘迫综合征的临床分析

目的探讨重症急性胰腺炎（SAP）并发急性呼吸窘迫综合征（ARDS）患者的临床特点及治疗方法。方法SAP患者67例，按是否发生ARDS分为ARDS组和非ARDS组，观察两组患者的呼吸频率、APACHEⅡ评分、Ranson评分、胰腺CT评分、肠蠕动抑制发生率、胰腺感染率及病死率并进行比较。结果ARDS组死亡11例，病死率47．8％。ARDS组入院时呼吸频率、入院时及入院24h APACHEⅡ评分、入院24h Ranson评分、入院时胰腺CT评分、入院24h内肠蠕动抑制发生率以及胰腺感染率和病死率均明显高于非ARDS组（P〈0．05或P〈0．01）。结论SAP患者如入ICU和／或治疗24h后APACHEⅡ评分、Ranson评分、胰腺CT评分仍明显增高，或肠蠕动抑制仍不缓解，同时呼吸频率进行性加快时，要警惕ARDS发生。