165例急性呼吸窘迫综合征患者的病因分析及治疗

目的总结急性呼吸窘迫综合征(ARDS)的诊断治疗经验.方法收集1994年1月至2003年12月十年间急救科GICU收治的165例ARDS患者临床资料,进行回顾性分析,其中男性患者91例,女性74例;年龄11～90岁,平均年龄57岁.将1994年1月至1998年12月49例患者归入A组,1999年1月2003年12月116例患者归入B组.比较两组患者发病率、氧合指数、APACHEⅡ评分、带管时间、住院天数、发生与呼吸机相关性肺损伤(VALI)、病死率.结果A组患者发病率、氧合指数、APACHEⅡ评分、带管时间、住院天数、VALI、病死率分别为1.5%、(163±35)、(26.5±3.3)分、(28.6±2.3)d、(36.4±3.7)d、12.2%和63.2%;B组分别为4.7%,除氧气指数和APACHE Ⅱ评分两指标外,其余指标差异均有显著性.结论随着对发病原因及发病机制的不断认识,综合救治方法的不断改进,ARDS患者临床救治时间明显缩短,病死率显著下降.     

糖皮质激素在急性呼吸窘迫综合征综合救治中的价值探讨

目的：探讨糖皮质激素(GC)在急性呼吸窘迫综合征(ARDS)综合救治中的价值。方法：前瞻性收集2000年5月-2002年8月收入ICU所有ARDS患者的临床资料，依据是否应用GC，将患者分为GC与非GC组，统计分析两组年龄、性别、原发病、急性生理与慢性健康状况评分(APACHE Ⅱ)、氧合指数(PaO2／FiO2)、肺内分流(Qs／Qt)、机械通气、呼气末正压(PEEP)水平、病死率与直接死亡原因；同时还分析了GC组应用GC时机、剂量、疗程等对预后的影响。结果：77例患者中，GC组60例，非GC组17例，两组性别、年龄、APACHE Ⅱ评分、PaO2／FiO2与Qs／Qt、机械通气时间、PEEP水平、缺氧改善情况等均无显著差异(P均＞0．05)；消化道出血发生率与血浆肿瘤坏死因子—α(TNF—α)水平两组无显著差异(P均＞0．05)；GC组病死率(71．7％)高于非GC组(52．9％)，但无统计学差异(P＞0．05)；两组因ARDS所致病死率均低(7．0％和11．1％)；GC组死亡患者的年龄、APACHE Ⅱ评分、基础疾病等方面与存活患者差异显著(P＜0．001或P＜0．005)，住院时间也短(P＜0．05)；确诊前与确诊后24h内应用GC患者的病死率(66．7％和68．2％)低于确诊24h后应用GC的患者(90．0％)。结论：GC是ARDS综合救治的措施之一，一旦出现顽固性缺氧与休克时，应及时应用GC。     

Antioxidant status in patients with acute respiratory distress syndrome

Objectives: Reactive oxygen species (ROS) have been implicated in the pathophysiology of ARDS. We investigated the pattern of antioxidants in plasma and ROS production by neutrophils in patients with ARDS over 6 days. Design: Observational study. Blood samples were taken when the diagnosis was made (D0) and after 3 (D3) and 6 days (D6) during therapy. Setting: Intensive care units at a University Hospital. Patients: Eight patients with ARDS were investigated, 17 healthy volunteers served as controls. Measurements and results: Plasma levels of ascorbate, α-tocopherol, retinol, β-carotene, selenium and lipid peroxidation products (MDA) were determined and the activities of the antioxidative enzymes catalase (CAT), superoxide dismutase (SOD) and glutathione-peroxidase (GSH-PX) in erythrocytes were measured. In addition, ROS production (superoxide anion and hydrogen peroxide) in activated neutrophils was assessed. Plasma levels of α-tocopherol, ascorbate, β-carotene and selenium were reduced from the onset of illness. MDA plasma levels were increased throughout the illness. ROS generation from neutrophils was normal on D0 and decreased to D6 in ARDS patients. Conclusion: The antioxidative system is severely compromised in patients with ARDS. Plasma levels of α-tocopherol, ascorbate, β-carotene and selenium are decreased. Elevated MDA levels provide further evidence of massive oxidative stress. The routine replacement of micronutrients according to recommended daily allowances was inadequate to compensate for the increased requirements. Received: 8 April 1998 Final revision received: 22 September 1998 Accepted: 5 October 1998     

Prone positioning in patients with acute respiratory distress syndrome

Prone positioning is a technique used to treat patients with acute respiratory distress syndrome (ARDS). Nurses are ideally placed to initiate and manage prone positioning. This article examines the aetiology of ARDS and how nurses can identify this condition. Patient groups that benefit most from prone positioning are considered as well as the research evidence on the use of prone positioning in the treatment of ARDS. This article addresses nurse involvement in delivering therapy and suggests that nurses alert members of the multidisciplinary team to the possible use of this therapy.     

急性呼吸窘迫综合征预后的影响因素分析

目的急性呼吸窘迫综合征（ARDS）预后的影响因素分析。方法纳入2009年1月至2012年2月在温州医学院附属第二医院重症医学科就诊的ARDS患者151例,其中死亡49例。对患者年龄、性别、血压、血糖、人体质量指数（BMI）、ARDS分级、急性病生理学和长期健康评价（APACHE）11评分、序贯器官衰竭估计（SOFA）评分、前降钙素原（PCT）、血管活性药物使用等相关因素进行单因素Logistic回归分析,选择有统计学意义的变量进行多因素Logistic回归分析。结果单因素Logistic分析发现,性别、血压、血糖对ARDS患者预后无统计学意义,而年龄、BMI、ARDS分级、APACHEII评分、SOFA评分、PCT、血管活性药物7个指标均影响ARDS患者的预后（P均〈0．05）。多因素logistic回归分析发现,影响ARDS患者预后的危险因素为ARDS分级（OR=6．895,95％CI=1．447～32．860）、年龄（OR=3．633,95％C1=1．333～9．906）APACHEU评分（OR=1．210,95％CI：1．033～1．417）及SOFA评分（O尺=1．676,95％CI=1．253～2．242）,而BMI是保护因素（OR=0．379,95％CI：0．168～0．856）。结论ARDS分级、APACHEII评分、SOFA评分及年龄是ARDS患者预后的不利因素,而BMI是保护因素。     

Protective ventilation of patients with acute respiratory distress syndrome

In a recent issue of the British Journal of Anaesthesia, Moloney and Griffiths reviewed clinically pertinent issues surrounding the management of the acute respiratory distress syndrome (ARDS) patient, particularly as it pertains to the treatment of ventilator induced/associated lung injury (VILI). In addition to highlighting the important observations that have contributed to further our understanding of the relationship between the mechanical ventilator and inflammatory lung injury, the authors also offer a concise reappraisal of the clinical strategies used to minimize VILI in ARDS. Special emphasis is placed on the theory of biotrauma, which attempts to explain how multi-organ failure may develop in patients who ultimately succumb to this syndrome.     

糖皮质激素在重症医学科急性呼吸窘迫综合征中的应用

目的评价糖皮质激素(glucocorticoids,GCs)在重症监护室(intensive care unit,ICU)治疗急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)中的作用。方法回顾性分析本院入住ICU的ARDS患者的临床资料,并根据致病因素在肺损伤中的作用,将所入选患者分为肺内源性ARDS(primarily from pulmonary diseases,ARDSp)和肺外源性ARDS(primarily from extra-pulmonary diseases,ARDSexp);ARDSp患者62例,ARDSexp患者101例。根据GCs的使用量各分为3组,分析ARDSp及ARDSexp应用GCs和未应用GCs患者的病情改善和病死率。结果 ARDSp及ARDSexp患者各组急性生理与慢性健康评分(Acute Physiology and Chronic Health EvaluationⅡ,APACHE-Ⅱ)相当(P0.05)。GCs治疗30mg/d组与≥30mg/d组比较,病情改善时间和呼吸机治疗时间明显缩短(P0.01),病死率也略低(P0.05);GCs治疗30mg/d组与非GCs治疗组比较差异有统计学意义(P0.01);≥30mg/d组与非GCs治疗组比较差异无统计学意义(P0.05)。ARDS患者总体病死率23.3%(38/163),其中使用GCs治疗组病死率22.8%(34/149),未使用GCs治疗组病死率28.6%(4/14)(P0.05)。结论低剂量(30mg/d)、早期应用(24h内)、长期疗程(7d)的GCs,可及时遏制炎性介质的"瀑布样效应",在一定程度上缩短病程,降低病死率。     

Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome

Purpose

Cytomegalovirus (CMV) reactivation occurs frequently in patients with the acute respiratory distress syndrome (ARDS) and has been associated with increased mortality. However, it remains unknown whether this association represents an independent risk for poor outcome. We aimed to estimate the attributable effect of CMV reactivation on mortality in immunocompetent ARDS patients.

Methods

We prospectively studied immunocompetent ARDS patients who tested seropositive for CMV and remained mechanically ventilated beyond day 4 in two tertiary intensive care units in the Netherlands from 2011 to 2013. CMV loads were determined in plasma weekly. Competing risks Cox regression was used with CMV reactivation status as a time-dependent exposure variable. Subsequently, in sensitivity analyses we adjusted for the evolution of disease severity until onset of reactivation using marginal structural modeling.

Results

Of 399 ARDS patients, 271 (68 %) were CMV seropositive and reactivation occurred in 74 (27 %) of them. After adjustment for confounding and competing risks, CMV reactivation was associated with overall increased ICU mortality (adjusted subdistribution hazard ratio (SHR) 2.74, 95 % CI 1.51–4.97), which resulted from the joint action of trends toward an increased mortality rate (direct effect; cause specific hazard ratio (HR) 1.58, 95 % CI 0.86–2.90) and a reduced successful weaning rate (indirect effect; cause specific HR 0.83, 95 % CI 0.58–1.18). These associations remained in sensitivity analyses. The population-attributable fraction of ICU mortality was 23 % (95 % CI 6–41) by day 30 (risk difference 4.4, 95 % CI 1.1–7.9).

Conclusion

CMV reactivation is independently associated with increased case fatality in immunocompetent ARDS patients who are CMV seropositive.

     

Protective ventilation of patients with acute respiratory distress syndrome

In a recent issue of the British Journal of Anaesthesia, Moloney and Griffiths reviewed clinically pertinent issues surrounding the management of the acute respiratory distress syndrome (ARDS) patient, particularly as it pertains to the treatment of ventilator induced/associated lung injury (VILI). In addition to highlighting the important observations that have contributed to further our understanding of the relationship between the mechanical ventilator and inflammatory lung injury, the authors also offer a concise reappraisal of the clinical strategies used to minimize VILI in ARDS. Special emphasis is placed on the theory of biotrauma, which attempts to explain how multi-organ failure may develop in patients who ultimately succumb to this syndrome.     

Translaryngeal tracheostomy in acute respiratory distress syndrome patients

OBJECTIVE: To prevent gas exchange deterioration during translaryngeal tracheostomy (TLT) in patients with acute respiratory distress syndrome (ARDS) ventilation is maintained through a small diameter endotracheal tube (ETT; 4.0 mm i.d.) advanced beyond the tracheostoma. We report on the feasibility of uninterrupted ventilation delivered through a high-resistance ETT in ARDS patients, and relevant ventilatory adjustments and monitoring. DESIGN AND SETTING: Prospective, observational clinical study in an eight-bed intensive care unit of a university hospital. Patients: Eight consecutive ARDS patients scheduled for tracheostomy. INTERVENTIONS: During TLT volume control ventilation was maintained through the 4.0-mm i.d. ETT. Tidal volume, respiratory rate, and inspiratory to expiratory ratio were kept constant. Fractional inspiratory oxygen was 1. Positive end expiratory pressure (PEEP) set on the ventilator (PEEP(vent)) was reduced to maintain total PEEP (PEEP(tot)) at baseline level according to the measured intrinsic PEEP (auto-PEEP). MEASUREMENTS AND MAIN RESULTS: Data were collected before tracheostomy and while on mechanical ventilation with the 4.0-mm i.d. ETT. Neither PaCO(2) nor PaO(2) changed significantly (54.5+/-10.0 vs. 56.4+/-7.0 and 137+/-69 vs. 140+/-59 mmHg, respectively). Auto-PEEP increased from 0.6+/-1.1 to 9.8+/-6.5 cmH(2)O during ventilation with the 4.0-mm i.d. ETT. By decreasing PEEP(vent) we obtained a stable PEEP(tot) (11.4+/-4.3 vs. 11.8+/-4.3 cmH(2)O), and end-inspiratory occlusion pressure (26.7+/-7.4 vs. 28.0+/-6.6 cmH(2)O). Peak inspiratory pressure rose from 33.8+/-8.1 to 77.8+/-12.7 cmH(2)O. CONCLUSIONS: The high-resistance ETT allows ventilatory assistance during the whole TLT procedure. Assessment of stability in plateau pressure and PEEP(tot) by end-inspiratory and end-expiratory occlusions prevent hyperinflation and possibly barotrauma.     

Glucocorticoids in the treatment of acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is characterized by local inflammation and an intense systemic inflammatory reaction. Glucocorticoid administration has been suggested due to their anti-inflammatory properties. However, results from the initial studies of glucocorticoids in ARDS, which evaluated high-dose and short-term treatments, were negative. More recent studies have evaluated the effect of lower doses of glucocorticoids administered over longer periods, but the results thus far have been inconclusive.     

Incidence,clinical course,and outcome in 217 patients with acute respiratory distress syndrome

OBJECTIVE: To assess prospectively acute respiratory distress syndrome incidence, etiologies, physiologic and clinical features, and mortality and its predictors in four intensive care units in Argentina. DESIGN: Prospective inception cohort. SETTING: Four general intensive care units in teaching hospitals. PATIENTS: All consecutive adult patients admitted between January 3, 1999, and January 6, 2000, that met the criteria of the American-European Consensus Conference for acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 235 patients developed acute respiratory distress syndrome, and 217 survived for >24 hrs; these were further analyzed. Main risk factors were: sepsis (44%, including 65 pneumonia cases), shock (15%), trauma (11%), gastric aspiration (10%), and other (34%). At admission, nonsurvivors had significantly higher Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment and McCabe scores, and lower oxygenation and pH. During the first week, Pao2/Fio2, Sequential Organ Failure Assessment, pH, base excess, and driving pressure consistently discriminated between survivors and nonsurvivors. Hospital mortality was 58%. One third of patients died early. Main causes of death were multiple organ dysfunction syndrome, sepsis, and septic shock; refractory hypoxemia was uncommon. Factors independently associated with mortality were organ dysfunctions on day 3, Pao2/Fio2 on day 3, and McCabe score. CONCLUSIONS: Acute respiratory distress syndrome was a frequent syndrome in this cohort. Sepsis was its leading cause, and pneumonia was the most common single diagnosis. Mortality was high but similar to most recent series that included serious comorbidities. Independent predictors of death 72 hrs after admission emphasize the importance of both extrapulmonary and pulmonary factors together with preexisting severe illnesses.     

急性呼吸窘迫综合征生物标志物与生物治疗研究

自1967年Ashbaug等提出成人呼吸窘迫综合征到今天的急性呼吸窘迫综合征(ARDS)经历了近49年的研究发展,不仅对定义进行了修订,并且完善了诊断标准,尤其是柏林诊断标准强调了发病的高危因素、发病时间、严重程度的分级及影像学量化分级等;在临床治疗上也取得了较好的进展,包括小潮气量等肺保护性通气策略、俯卧位通气及体外膜肺氧合,且都已经成为ARDS的常规治疗手段.但是,以上研究仍以临床诊断及支持治疗为主,针对高危因素导致ARDS的炎症反应,以及发病机制,尚缺乏足够的认识及有效的控制措施,无论如何优化通气策略,均不能治愈ARDS.近10余年来ARDS病死率并无明显降低,仍维持在40％ ～ 50％之间[1].因此,只有尽早确定并祛除导致ARDS的危险因素,中断其发病途径,才是逆转ARDS的关键.近年来对于ARDS发病的炎症反应及其生物标志物与生物治疗的研究也取得了一些进展.     

危重病患者并发急性呼吸窘迫综合征173例分析

目的提高对危重病患者发生急性呼吸窘迫综合征(ARDS)的认识.方法分析了137例ARDS患者的临床资料,病人至少符合PaO2＜8.0kPa(60mmHg)或氧合指数PaO2/FiO2＜40kPa(300mmHg).结果173例危重病患者中并发全身炎症反应综合征(SIRS)126例(72.8%),并发多器官功能障碍综合征(MODS)79例(45.7%),全组中死亡94例(54.3%).以呼吸衰竭作为第一位死因者30例(31.9%),以MODS作为第一位死因者52例(55.3%),其它原因死亡者12例(12.8%).结论在治疗中应积极救治原发疾病,动态监测动脉血气,计算PaO2/FiO2,同时注意保护和监测其它重要脏器的功能,以免发生MODS,提高ARDS的救治水平.     

右美托咪定在急性呼吸窘迫综合征机械通气患者中的应用

目的 观察右美托咪定对急性呼吸窘迫综合征(ARDS)机械通气患者镇静镇痛效果及呼吸和血流动力学的影响.方法 将70例需镇静镇痛的ARDS机械通气患者按照随机原则分为右美托咪定组(D组,35例)和咪达唑仑组(M组,35例).用微量泵静脉注射给药,D组给予右美托咪定负荷量1 μg/kg,10 min后继以0.2～0.7 μg·kg-1·h-1维持;M组给予咪达唑仑负荷量0.06 mg/kg 后以0.04～0.20 mg·kg-1·h-1维持.比较两组患者疼痛评分、唤醒时间、机械通气时间、顺行性遗忘以及心率(HR)、收缩压(SBP)、舒张压(DBP)、呼吸频率(RR)和动脉血氧饱和度(SaO2)的变化.结果 两组患者性别、年龄及急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分比较差异均无统计学意义(均P＞0.05),有可比性.Ramsay评分在2～4分时,D组视觉模拟评分(VAS,分)明显低于M组(2.68±0.47比5.87±0.62,P＜0.01),唤醒时间(h)明显短于M组(0.18±0.04比1.78±0.62,P＜0.01),顺行性遗忘例数明显少于M组(8比33,P＜0.01);而D组和M组机械通气时间(d)相似(3.65±1.73比3.76±1.61,P＞0.05).两组用药30 min后HR、SBP、DBP、RR均较用药前下降,其中D组HR、SBP、DBP、RR较M组下降明显[HR,次/min:69.4±7.5比80.6±9.3;SBP,mm Hg(1 mm Hg=0.133 kPa):90.8±4.8比98.2±4.3;DBP,mm Hg:51.4±6.8比60.2±7.6;RR,次/min:20.5±4.1比22.6±3.2,均P＜0.05];两组SaO2下降不明显(P＞0.05).结论 右美托咪定是ARDS机械通气患者较理想的镇静镇痛药物.