特重烧伤后急性肺损伤/急性呼吸窘迫综合征12例分析

目的:探讨特重烧伤后急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)的临床特点及治疗方法。方法:回顾分析12例入院时不伴明显呼吸功能障碍的特重烧伤病例发生ALI/ARDS的原因及其治疗效果,分别给予氧疗或机械通气、抗炎、补充胶体、抗感染、手术等治疗。结果:5例经吸氧、药物治疗后痊愈,未行机械通气;7例行机械通气,其中6例痊愈,1例并发肺部感染后死于MODS。结论:特重烧伤可致ALI/ARDS,积极的抗休克、抗感染、手术、抗炎、机械通气等治疗可较有效救治ALI/ARDS。     

急性肺损伤/急性呼吸窘迫综合征患者机械通气管理策略

急性肺损伤(acute lung injury,ALI)/急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)是临床常见的肺部综合征[1],临床以进行性呼吸困难、低氧血症、肺顺应性下降为特征,病死率为40%~50%。机械通气作为支持呼吸的重要手段,能够缓解呼吸窘迫、改善肺压力-容量关系,为ALI/ARDS患者的病因治疗争取时间、创造条件。本文将重点讨论ALI/ARDS患者的机械通气管理策略。保护性机械通气策略ALI/ARDS患者的临床监护往往面临努力确保足够氧合与减小氧中毒潜在危险两方面的困难选择[2]。20世纪70年代,ALI/ARDS患者机械通气…     

抗凝治疗——急性肺损伤/急性呼吸窘迫综合征治疗的新思路

急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)是指由心源性以外的各种肺内外致病因素导致的急性、进行性呼吸衰竭,以呼吸窘迫和低氧血症为特点,常需要机械通气治疗[1].     

乌司他丁对急性肺损伤机械通气患者肺保护的临床研究

近年来,随着以机械通气为主的综合治疗,急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)的病死率有所下降,但仍高达30%～50%[1].本研究拟观察在机械通气为主的综合治疗基础上加用乌司他丁治疗ALI/ARDS患者的呼吸力学、血流动力学及动脉血气的变化,以评价乌司他丁在ALI/ARDS机械通气的肺保护及防治多器官功能障碍综合征(MODs)、降低病死率中的作用.     

急性肺损伤的药物治疗研究进展

在过去的十几年中,机械通气治疗,特别是小潮气量机械通气和压力限制通气的应用,已经使急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)患者的病死率有所下降,但仍然在一个较高水平,探索药物治疗是今后努力的方向,现就最新进展进行综述.     

急性肺损伤／急性呼吸窘迫综合征患者机械通气管理策略

急性肺损伤（acute lung injury，ALI）急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS）是临床常见的肺部综合征，临床以进行性呼吸困难、低氧血症、肺顺应性下降为特征，病死率为40％-50％。机械通气作为支持呼吸的重要手段，能够缓解呼吸窘迫、改善肺压力-容量关系，为ALI／ARDS患者的病因治疗争取时间、创造条件。本文将重点讨论ALI／ARDS患者的机械通气管理策略。     

无创正压通气治疗36例溺水后并急性肺损伤/急性呼吸窘迫综合征的临床观察

目的 探讨无创正压通气(NIPPV)在溺水后并急性肺损伤/急性呼吸窘迫综合征患者中应用的可行性研究.方法 收集溺水后并急性肺损伤/急性呼吸窘迫综合征病人36例,采用无创正压通气治疗,记录治疗前后的血气分析结果和心率、呼吸频率、血压的改变,观察其疗效,并作统计学分析.结果 NIPPV能明显改善溺水后并ALI/ARDS患者的临床监测指标.结论 溺水后出现急性肺损伤、早期急性呼吸窘迫综合征时可考虑尝试无创正压通气治疗.     

急性呼吸窘迫综合征机械通气治疗进展

1 引 言 自1967年Ashbaugh应用呼气末正压通气PEEP后，机械通气已成为急性呼吸窘迫综合征ARDS的主要治疗手段，尤对非感染性所致的急性肺损伤ALI和ARDS的治疗取得较好的疗效。近十年来，随着对ARDS的病理生理以及机械通气生理学效应对ARDS的影响的深入研究，如何防治机械通气所致的肺损伤、氧中毒、反复肺部感染等并发症的发生，尤对肺损伤发生机制的认识深化，改变了机械通气治疗ARDS的策略，其目的是以最适宜、即最低压力的吸入氧浓度达到有效的气体交换。2 机械通气相关性肺损伤 通气机引起的肺损伤 ventilato…     

蛋白酶激活受体在急性肺纤维化中的作用机制研究进展

急性肺纤维化是继发于多种原因(如创伤、感染、中毒、MODS等)导致的急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)期间及其后以过度纤维修复为主的病理过程,常常导致呼吸衰竭而死亡。     

血液灌流联合高容量血液滤过治疗急性呼吸窘迫综合征的临床研究

急性呼吸窘迫综合征(ARDS)是一种以进行性呼吸困难和顽固性低氧血症为特征的急性呼吸衰竭,细胞因子和炎症介质在ARDS局部炎症的发生发展及全身炎症反应中起着重要的作用[1].虽然目前使用机械通气和保护性肺通气策略能提高ARDS患者的抢救成功率,但尚无有效方法中止ARDS的炎症性肺损伤,致使ARDS的病死率居高不下.本研究中通过小样本随机对照试验探讨血液灌流(HP)联合高容量血液滤过(HVHF)对ARDS患者呼吸功能和预后的影响.     

肺复张和保护性肺通气在急性肺损伤救治中的护理

目的探讨肺复张联合保护性肺通气策略治疗急性肺损伤患者的疗效及护理。方法对42例急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)患者均采用保护性机械通气,并联合肺复张手法,给予35 cmH2O的气道压力,持续30 s后,恢复原通气模式及条件。结果 31例患者成功撤机,临床症状明显好转,治愈出院,成功率73.8%。死亡11例,病死率26.2%。结论肺复张和保护性肺通气策略是治疗急性肺损伤的主要手段。做好保护性机械通气期间的护理及严密监测是治疗成功的关键。     

压力和容量控制通气在ARDS肺保护通气策略中的比较

目的　比较急性呼吸窘迫综合征 (ARDS)时实行肺保护通气策略中 ,压力控制通气 (PCV)和容量控制通气 (VCV)模式对患者呼吸力学、血气及血流动力学的影响 ,并探讨其临床意义。方法　 5 0例 ARDS患者按随机表法分为 PCV组和 VCV组进行机械通气治疗 ,均实行允许高碳酸血症策略和肺开放策略 ,比较两组患者呼吸力学、血气及血流动力学各指标的变化。结果　 PCV组通气 2 4 h气道峰压低于 VCV组 ,而平均气道压高于 VCV组 ;两组通气 2 4 h后中心静脉压明显升高 ,而 VCV组上升更明显 ;两组治疗后心率显著减慢 ,PCV组改善更明显 ;两组同时间点平均动脉压比较均无显著性差异 ;两组均未发生气压伤 ;两组治疗2 4 h后 Pa O2 比治疗前均明显升高 ,PCV组改善更明显。结论　对于 ARDS患者在实行肺保护通气策略时 ,PCV和 VCV通气模式均可改善氧合 ,防止气压伤的发生 ,对患者血流动力学影响小 ,PCV模式控制气道峰压更有效 ;主张对于 ARDS患者尽量采用 PCV模式实行肺保护通气策略     

早产儿湿肺伴急性呼吸窘迫综合征的临床分析

目的 探讨早产儿湿肺伴急性呼吸窘迫综合征的临床特点和机械通气治疗的效果。方法 分析我科1998年1月至2002年8月收治的30例早产儿湿肺伴急性呼吸窘迫综合征的临床表现、动脉血气变化及机械通气疗效结果早产儿湿肺伴急性呼吸窘迫综合征者占同期新生儿湿肺总数的20％(30／150)。30例均为削宫产临床表现以气促、呼吸闲难、青紫为主。24h后明显加重。胸片显示急性呼吸窘迫综合征。30例均需机械通气治疗,5、6d临床症状明显好转,全部治愈。结论 早产儿湿肺可继发急性呼吸窘迫综合征,动态观察胸片变化和及时行机械通气治疗有助于治疗。     

Pharmacotherapy of acute lung injury and the acute respiratory distress syndrome

Acute lung injury and the acute respiratory distress syndrome are common syndromes with a high mortality rate that affect both medical and surgical patients. Better understanding of the pathophysiology of acute lung injury and the acute respiratory distress syndrome and advances in supportive care and mechanical ventilation have led to improved clinical outcomes since the syndrome was first described in 1967. Although several promising pharmacological therapies, including surfactant, nitric oxide, glucocorticoids and lysofylline, have been studied in patients with acute lung injury and the acute respiratory distress syndrome, none of these pharmacological treatments reduced mortality. This article provides an overview of pharmacological therapies of acute lung injury and the acute respiratory distress syndrome tested in clinical trials and current recommendations for their use as well as a discussion of potential future pharmacological therapies including beta(2)-adrenergic agonist therapy, keratinocyte growth factor, and activated protein C.     

Uneven distribution of ventilation in acute respiratory distress syndrome

As in the adult with acute lung injury and acute respiratory distress syndrome, the use of lung-protective ventilation has improved outcomes for neonatal lung diseases. Animal models of neonatal respiratory distress syndrome and congenital diaphragmatic hernia have provided evidence that 'gentle ventilation' with low tidal volumes and 'open-lung' strategies of using positive end-expiratory pressure or high-frequency oscillatory ventilation result in less lung injury than do the traditional modes of mechanical ventilation with high inflating pressures and volumes. Although findings of retrospective studies in infants with respiratory distress syndrome, congenital diaphragmatic hernia, and persistent pulmonary hypertension of the newborn have been similar to those of the animal studies, prospective, randomized, controlled trials have yielded conflicting results. Successful clinical trial design in these infants and in children with acute lung injury/acute respiratory distress syndrome will require an appreciation of the data supporting the modern ventilator management strategies for infants with lung disease.     

清肺汤对ALVARDS患者呼出气冷凝液及血清中NO的影响

目的：研究急性肺损伤（ALI）／急性呼吸窘迫综合征（ARDS）患者使用清肺汤治疗后呼出气冷凝液（EBC）和血清中一氧化氮（NO）改变的临床意义。方法：ICu行机械通气的Au／ARDs患者54例,随机分为常规治疗组（给予机械通气、液体管理、抗炎、综合营养支持等）和清肺汤治疗组（在常规治疗基础上联用中药清肺汤）。ALI／ARDS患者在第1天及第5天采用改进的德国JAEGER公司Ecoscreen呼出气冷凝液收集器收集EBC标本。54例患者均同步抽取静脉血5ml,在室温下离心留取血清。以ELISA法测定EBC和血清中的NO浓度。同时进行APACHEⅡ评分,记录氧合指数及机械通气时间。结果：①清肺汤治疗组第5天,EBC和血清中NOE（26．71±9．32）μmol／L,（31．28±8．73）μmol／L]均低于常规治疗组[（34．27±9．96）／μmol／L,（39．34±9．15）tlmol／L],均P〈0．05。②清肺汤治疗组治疗前后氧合指数差值（94．74±42．19）mmHg高于常规治疗组（68．41±35．21）mmHg,P〈0．05;③清肺汤治疗组机械通气时间（225．06±74．79）h少于常规治疗组（296．42±96．25）h,P〈0．05;④清肺汤治疗组APACHEⅡ评分（9．75±4．52）低于常规治疗组（13．02±5．31）,P〈0．05。结论：ALI／ARDs患者联用中药清肺汤有助于控制炎症反应,减轻肺损伤,可提高临床疗效。     

Surfactant therapy in adults with acute lung injury/acute respiratory distress syndrome

PURPOSE OF REVIEW: Several phase II and phase III studies have been performed to investigate safety, efficacy and the improvement of survival due to exogenous surfactant instillation in patients with acute lung injury or acute respiratory distress syndrome. In this review we will discuss the most recent of these studies, paying particular attention to differences in the composition of the exogenous surfactant used, the diverse modes of delivery and dose of therapy and the influence of mechanical ventilation. RECENT FINDINGS: Several phase II studies performed on patients with acute lung injury or acute respiratory distress syndrome and a phase III study performed on a pediatric population have shown beneficial effects of surfactant on oxygenation and survival. No effect of exogenous surfactant has been shown on survival in phase III studies in adult patients. SUMMARY: The changes in the surfactant system of patients with acute lung injury and acute respiratory distress syndrome form the rationale for the instillation of exogenous surfactant. There is enough evidence to use surfactant instillation for pediatric patients with acute lung injury. Due to the results of the randomized controlled trials performed so far, however, exogenous surfactant is not recommended for routine use in patients with acute lung injury or acute respiratory distress syndrome. In the future, other surfactants with different compositions may show beneficial effects.     

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.     

肺保护性机械通气和传统机械通气治疗新生儿急性呼吸衰竭临床观察

目的观察传统机械通气和肺保护性机械通气治疗新生儿急性呼吸衰竭的临床情况。方法选择40例急性呼吸衰竭新生儿患儿，随机分为两组，A组用传统机械通气，B组用肺保护性机械通气。A组潮气量（VT）10～12ml／kg，气道峰压（PIP）〈25cmH2O，呼气末正气（PEEP）（5．0±1．5）cmH2O，呼吸频率（RR）60次／min；B组VT为5～8ml／kg，PEEP为（7．6±1．5）cmH2O，RR为40～60次／分。结果转归比较：两组所有病人均治愈。呼吸机参数比较：两组在维持SaO2在90％以上且PaCO2〈8．0kPa的呼吸机各项参数，A组的VT（10．11±1．20）ml／kg、PIP（24．01±2．10）cmH2O、PEEP（7．50±1．50）cmH2O，两组VT、PIP差异有非常显著性（P〈0．01），两组PEEP的差异无显著性（P〉0．05）。血气比较：pH值A组7．35±0．10，B组7．25±0．15；PaCO2为A组（6．90±0．72）kPa，B组（93．0±2.8）kPa；两组pH、PaCO2、SaCO2（％）值比较差异均无显著性（P均〉0．05）。两组并发症比较：A组肺损伤4例，循环系统并发症3例，B组无。结论传统策略和肺保护性策略通气均能治愈新生儿急性呼吸衰竭，但后者并发症较少。在维持PH、PaCO2、PaO2、SaO2基本相同的情况下，肺保护性通气的呼吸机参数VT和PIP较传统通气明显降低。     

The chest wall in acute lung injury/acute respiratory distress syndrome

PURPOSE OF REVIEW: There has recently been renewed interest in the chest wall during mechanical ventilation, related to lung-protective ventilation strategies, as well as in the role of abdominal pressure in many facets of critical illness. The purpose of this review is to address relevant issues related to the chest wall and mechanical ventilation, particularly in patients with acute lung injury/acute respiratory distress syndrome. RECENT FINDINGS: In mechanically ventilated patients with acute lung injury, intra-abdominal pressure is an important determinant of chest wall compliance. With elevated intra-abdominal pressure, the compliance of the chest wall and total respiratory system is decreased, with a relatively normal compliance of the lungs. The lung compression effects of increased intra-abdominal pressure may lead to a loss of lung volume with atelectasis. An appropriate level of positive end-expiratory pressure is necessary to counterbalance this collapsing effect on the lungs. Also, the stiff chest wall results in a lower transpulmonary pressure during positive-pressure ventilation. SUMMARY: As chest wall compliance may have important clinical implications during positive-pressure ventilation, the physiology of this effect should be considered, particularly in patients with acute lung injury and increased abdominal pressure.