气道压力释放通气治疗急性肺损伤和急性呼吸窘迫综合征的研究进展

气道压力释放通气是以持续气道正压为工作基础的压力控制机械通气模式,其从高气道压向低气道压释放压力产生通气量进行气体交换.它能在肺保护通气策略基础上维持肺复张、开放及减少呼吸机相关肺损伤.它对急性肺损伤/急性呼吸窘迫综合征患者在降低气道峰压及平均压、提高氧合、改善血流动力学和胃肠灌注、减少镇静和麻醉药物使用等方面产生广泛有利影响;而且,自主呼吸对重力依赖区塌陷肺组织的重新开放在其中发挥重要作用,其应用受到研究者和临床医师越来越多的关注.     

适应性支持通气在老年急性呼吸窘迫综合征中的应用

目的探讨适应性支持通气(adaptive support ventilation,ASV)在老年急性呼吸窘迫综合征病人中的临床应用价值。方法入组2013年1月至2016年6月入住江苏省省级机关医院重症监护病房的年龄≥65岁的急性呼吸窘迫综合征行有创机械通气的病人32例,将ASV模式与同步间歇指令通气模式(SIMV)进行前后自身比较,探讨ASV模式对呼吸力学、血流动力学、血气指标及舒适度的影响。结果两种模式下病人动脉血氧合指数、二氧化碳分压、乳酸水平比较差异无统计学意义(P0.05),分钟通气量、胸肺动态顺应性、潮气量差异亦无统计学意义(P0.05),但在ASV模式下病人气道峰压、平均气道压力、吸气阻力及呼吸频率明显低于SIMV模式(P0.05),重症监护室疼痛观察工具法(CPOT)评分、躁动镇静评估表(RASS)评分、丙泊酚使用剂量亦降低(P0.05),ASV通气模式下地佐辛及咪达唑仑使用剂量较SIMV模式有下降趋势,但差异无统计学意义(P0.05)。结论 ASV模式可改善老年急性呼吸窘迫综合征病人呼吸力学指标,增加舒适度,安全有效。     

气道压力释放通气治疗急性肺损伤和急性呼吸窘迫综合征的临床研究进展

气道压力释放通气作为一种新的通气模式不同于常规通气模式。它通过从高气道压向低气道压释放完成机械通气,而常规通气是通过吸气相升高气道压力来完成机械通气的,同时由于它具有低气道压、低分钟通气量、对心血管的损害小等诸多的优点越来越受到临床医生和研究者的关注。     

适应性支持通气加肺复张在颅脑损伤合并急性呼吸窘迫综合征患者中的应用价值

目的探讨适应性支持通气加肺复张在颅脑损伤合并急性呼吸窘迫综合征患者中的应用价值。方法选择我院2011年4月-2015年6月重症监护室收治的70例颅脑损伤合并急性呼吸窘迫综合征患者为研究对象。随机分为对照组和观察组,对照组行同步间隙性指令通气(SIMV),观察组行适应性支持通气(ASV)和肺复张治疗,记录两组患者的呼吸力学、血气、氧代谢指标和颅内压。结果治疗后观察组患者的气道峰值压、平台压、平均气道压均低于对照组,肺动态顺应性高于对照组,差异均有统计学意义(P0.05)。治疗后两组患者的p H值、Pa O2和Pa CO2比较,差异无统计学意义(P0.05),但对照组和观察组在治疗前后组内比较,差异有统计学意义(P0.05)。治疗后两组患者的颅内压降低,动脉血氧分压、机体氧供、氧耗增加,且观察组优于对照组,差异有统计学意义(P0.05)。结论适应性支持通气加肺复张可有效降低呼吸力学参数和颅内压,增加氧代谢指标,有利于在颅脑损伤合并急性呼吸窘迫综合征的治疗。     

经鼻不同正压通气模式在治疗早产新生儿呼吸窘迫综合征的临床比较

目的探讨经鼻不同正压通气模式在治疗早产新生儿呼吸窘迫综合征的临床疗效。方法回顾性分析呼吸窘迫综合征早产新生儿65例。按照通气模式的不同,分为经鼻持续气道正压通气(n CPAP)模式(对照组)以及经鼻气道压力释放通气APRV模式(观察组),比较两组患儿通气治疗后1h、6h、12h、24h、48h的二氧化碳分压(PaCO_2),氧分压(PaO_2)以及氧合指数(PaO_2/FiO_2),两组患儿观察时间内总有创通气情况以及支气管肺发育不良情况。结果观察组PaCO_2水平在治疗后6小时、12小时、24小时均较对照组显著降低,PaO_2水平在治疗后6h以及治疗后12小时均显著高于对照组,氧合指数在治疗后12小时以及治疗后24小时显著高于对照组,总有创通气例数显著低于对照组(P均0.05)。结论经鼻气道压力释放通气APRV模式在早期能有效的降低患呼吸窘迫综合征的早产新生儿二氧化碳分压,提高氧分压以及氧合指数,减少患儿实施有创通气。     

机械通气治疗ARDS过程中气压伤发生的相关因素分析

将入住ICU或其他监护病房的68例无气胸发生和9例发生气压伤的急性呼吸窘迫综合征（ARDS）患者就通气模式、潮气量、吸气峰压、平台压、呼气末正压等指标进行回顾性分析。结果9例气压伤患者中6例机械通气的平台压大于35cmH2O，另3例有胸部外伤。认为平台压过高是ARDS机械通气中致气压伤的关键因素，合理的调控平台压是防止气压伤发生的关键。     

高频程序通气在多发伤后急性呼吸窘迫综合征中的应用

目的探讨高频程序通气治疗多发伤后急性呼吸窘迫综合征的效果。方法对60例多发伤引起的急性呼吸窘迫综合征患者进行高频程序通气,观察通气前后动脉血气、血流动力学指标变化。结果治疗24h后氧分压、二氧化碳分压、血氧饱和度较治疗前均明显改善,差异有统计学意义（P〈0．05）;平均动脉压、心率、中心静脉压与通气前相比差异无统计学意义。结论应用高频程序通气能改善多发伤者急性呼吸窘迫综合征氧合状况。     

液体通气治疗急性呼吸窘迫综合征的研究进展

液体通气是一种新的通气模式，近年来发展很快。本阐述液体通气在治疗急性呼吸窘迫综合征中的研究进展及存在的问题。     

有创-无创序贯性机械通气治疗急性呼吸窘迫综合征的研究

急性呼吸窘迫综合征(acute respiratory dis-tress syndrome,ARDS)是发生于休克、创伤、严重感染、误吸及急性重症胰腺炎等疾病过程中出现肺泡-毛细血管膜损伤导致的以进行性低氧血症、呼吸窘迫为特征的临床综合征。机械通气可明显降低ARDS患者的病死率,但易并发气道损伤、呼吸     

肺表面活性物质联合气道正压通气治疗新生儿呼吸窘迫综合症的临床观察

目的 探讨鼻塞式气道正压通气联合肺表面活性物质治疗新生儿呼吸窘迫综合征的临床疗效.方法 给42例患有呼吸窘迫综合征的新生儿行气管插管,经气管内滴入肺表面活性物质,给予持续性气道正压通气呼吸支持治疗.结果 患儿治疗前与治疗后相比较,血气分析各项指标（PaO2 、氧和指数PaO2/FiO2、pH值、PaCO2变化情况）及机械通气各项指标（吸入氧浓度FiO2、通气频率RR、峰压PIP、呼气末正压PEEP的变化情况）有显著好转（P＜0.01）.结论 对早产儿呼吸窘迫综合症而言,持续性气道正压通气联合肺表面活性物质能迅速有效地改善患儿临床症状,提高了患儿的抢救成活率.     

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??Abstract??Mechanical ventilation is still one of the main treatment measures of acute respiratory distress syndrome (ARDS).From the traditional high tidal volume ventilation (10 ~ 15 mL/kg) to the current use of lung protective ventilation strategies??low tidal volume ventilation (VT)??positive end-expiratory pressure (PEEP)??airway pressure release ventilation (APRV)??bilevel positive airway pressure(BIPAP)??considerable progress has been made.In addition to the well-known conventional mechanical ventilation modes and methods??there are many non-standard mechanical ventilation modes and methods??such as prone position ventilation??neurally adjusted ventilatory assist (NAVA)??extracorporeal membrane oxygenation (ECMO)??high-frequency ventilation and etc.All these measures produce unique effects on the treatment of ARDS.     

气道压力释放通气应用于急性肺损伤/急性呼吸窘迫综合征患者的研究

目的评价气道压力释放通气(airway pressure release ventilation,APRV)对急性肺损伤(acute lung injury,ALI)/急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者的疗效,评估其对患者呼吸机相关性肺损伤(Ventilator-Induced Lung Injury,VILI)程度,并探讨可能的机制。方法采用前瞻性研究方法,入组患者随机分为APRV组、小潮气量肺保护通气组。描记肺准静态压力-容积曲线(pressure-volume curve,P-V曲线),并据此设置呼吸机参数,通气24h、48h观察效果。结果两组患者氧合明显改善,血流动力学指标无明显变化,APRV组Pmean明显高于SIMV+PEEP组,准静态P-V曲线三角区Pflex容积(Vdelta)增加明显,血清SP-D浓度呈升高趋势。结论 APRV应用于急性肺损伤/急性呼吸窘迫综合征患者,相对于小潮气量肺保护性通气策略,氧合改善、呼吸力学类似;较高的平均气道压,能更有效地肺复张,未对血流动力学产生影响,但加重了肺损伤,导致呼吸机相关性肺损伤。     

New modalities of mechanical ventilation: high-frequency oscillatory ventilation and airway pressure release ventilation

Management of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) is largely supportive, with the use of mechanical ventilation being a central feature. Recent advances in the understanding of ALI/ARDS and mechanical ventilation have revealed that lung-protective ventilation strategies may attenuate ventilator-associated lung injury and improve patient morbidity/mortality. High-frequency oscillatory ventilation and airway pressure release ventilation are two novel alternative modes of ventilation that theoretically fulfill the principles of lung protection and may offer an advantage over conventional ventilation for ALI/ARDS.     

Current role of high frequency oscillatory ventilation and airway pressure release ventilation in acute lung injury and acute respiratory distress syndrome

Lung protective ventilatory strategies using conventional ventilators have resulted in decreased mortality in adult patients who have acute lung injury and acute respiratory distress syndrome. Conceptually, high frequency oscillatory ventilation and airway pressure release ventilation appear not only able to fulfill the goals of lung protection, but also to offer some additional advantages over conventional ventilation. Although early data for each of these modes in adults have been encouraging, their widespread use--particularly outside of a rescue situation--cannot be recommended without further evidence.     

食道压测定对急性呼吸窘迫综合征患者机械通气设置的指导意义

在急性肺损伤/急性呼吸窘迫综合征患者的机械通气中,如何在减少肺泡塌陷和防止肺过度膨胀之间实现利益平衡依然充满挑战.通过测定食道压来估算跨肺压可能允许个体化设置呼吸机参数以适应不同患者在肺和胸壁力学特征上的差异,并有可能减少急性肺损伤/急性呼吸窘迫综合征患者进一步的肺损伤.     

High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized,controlled trial

Observational studies of high-frequency oscillatory ventilation in adults with the acute respiratory distress syndrome have demonstrated improvements in oxygenation. We designed a multicenter, randomized, controlled trial comparing the safety and effectiveness of high-frequency oscillatory ventilation with conventional ventilation in adults with acute respiratory distress syndrome; 148 adults with acute respiratory distress syndrome (Pa(O2)/fraction of inspired oxygen 相似文献   

Significance of the changes in the respiratory system pressure-volume curve during acute lung injury in rats

The hypothesis that the changes in the respiratory system pressure- volume (PV) curve during pulmonary edema mainly reflect distal airway obstruction was investigated in rats. Normal rats had a well-defined upper inflection point (UIP) at low airway pressure. Airway occlusion by liquid instillation decreased compliance (Crs) and the volume (Vuip) of the UIP, and increased end-inspiratory pressure. The same changes were observed during the progression of edema produced by high volume ventilation (HV). Changes in Vuip and in Crs produced by HV were correlated with edema severity in normal rats or rats with lungs preinjured with alpha-naphthylthiourea. Vuip and Crs changes were proportional, reflecting compression of the PV curve on the volume axis and suggesting reduction of the amount of ventilatable lung at low airway pressure. In keeping with this explanation, the lower Vuip and Crs were before HV, the more severe HV-induced edema was in alpha-naphthylthiourea-injected rats. When edema was profuse, PV curves displayed a marked lower inflection point (LIP), the UIP at low pressure disappeared but another was seen at high volume above the LIP, and the correlation between Vuip changes and edema severity was lost. These observations may have clinical relevance in the context of the "open lung" strategy. Keywords: ventilator-induced lung injury; respiratory mechanics; acute respiratory distress syndrome     

不同呼吸频率机械通气对ARDS病人二氧化碳清除的影响

目的比较常规呼吸频率和高呼吸频率持续正压机械通气对急性呼吸窘迫综合征(ARDS)病人二氧化碳清除的影响。方法对16例ARDS病人入科后第一天给予有创机械通气,设置呼吸机模式为压力控制(PCV)。前后两次的控制压力及PEEPe设置相同(≤30cmH2O)且吸呼比(I∶E)不变。比较不同呼吸频率机械通气后的分钟通气量(MV);二氧化碳分压(PaCO2)、氧分压(PaO2);PEEPi;心脏指数(CI)、平均动脉血压(MBP)、中心静脉压(CVP)。结果与使用常规呼吸频率时比较,高呼吸频率通气时的分钟通气量虽然明显上升(P<0.05),但二氧化碳分压和氧分压无明显变化;内源性呼气末正压及中心静脉压有显著增高(P<0.05);在心脏指数、平均动脉血压方面有显著下降(P<0.05)。结论ARDS机械通气病人应用高呼吸频率并不能增加机体二氧化碳的清除,但导致内源性呼气末正压升高;同时降低心脏射血指数,影响血液动力学。     

High-frequency oscillatory ventilation in pediatric patients

HFOV is a mode of ventilation that can achieve oxygenation and ventilation while maintaining maximal lung recruitment on the deflation limb of its pressure-volume curve. The primary theoretical advantages of HFOV over CMV in the management of acute lung injury are that HFOV allows adequate alveolar ventilation with minimal peak-trough pressure changes, provides lung recruitment, and avoids end-inspiratory overdistension of the relatively compliant nondependent lung. Taken together, the results of studies in animals, preterm and term neonates, and older pediatric patients reveal that an "open-lung" strategy, with the goal of a high end-expiratory lung volume, is safe and superior to CMV in both the short-term (rapidly improved oxygenation and/or ventilation) and longer-term (lower incidence of chronic lung disease). The improved longer-term clinical outcomes on HFOV are presumably because of less ventilator-induced lung injury. As experience with HFOV in older patients grows, ventilator technology matures, and understanding of the pathophysiology of acute respiratory distress syndrome (RDS) deepens, it is likely that HFOV will find widespread use for the management of respiratory failure caused by acute lung injury in patients from preterm neonates to adults.