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…     

急性呼吸窘迫综合征病人的机械通气

机械通气是重症护理中最常用的技术之一。尽管呼吸机很普及，但护理计划对临床情况仍有深远影响。选择最好的通气模式，重症监护护士的知识和对机械通气的理解对保证病人安全度过机械通气的急性期到撤离呼吸机是非常重要的。最重要的是使用改善病人结果的证据。本文重点讨论急性呼吸窘迫综合征（ARDS）病人机械通气和撤机的有关问题。     

俯卧位机械通气在急性呼吸窘迫综合症患者中的应用状况

急性呼吸窘迫综合征（acuterespiratorydistresssyndrome,ARDS）是指肺内、外严重疾病导致以肺毛细血管弥漫性损伤、通透性增强为基础,以肺水肿、透明膜形成和肺不张为主要病理变化,以进行性呼吸窘迫和难治性低氧血症为临床特征的急性呼吸衰竭综合征。ARDS是急性肺损伤（acutelunginjury,ALI）发展到后期的典型表现。该病起病急骤,发展迅猛,预后极差,     

机械通气治疗急性呼吸窘迫综合征48例

目的 观察机械通气在急性呼吸窘迫综合征的应用。方法 选取入住本院监护室的成人急性呼吸窘迫综合征(ARDS)患者48例。根据病情需要给予有创与无创机械通气，将患者随机分为序贯治疗组和常规治疗组，每组为24例。观察两组患者基本情况、ARDS控制窗、及撤机后主要指标变化。结果 序贯治疗组有创通气时间、总机械通气时间均比常规治疗组短，呼吸机相关肺炎(VAP)及多器官功能不全综合征(MODS)发生率、院内死亡、撤机失败均低于常规治疗组。讨论机械通气是目前治疗ARDS最重要、最具肯定疗效的方法。但在病情允许的情况下，尽可能的缩短气管插管的时间。     

机械通气治疗急性呼吸窘迫综合征的护理进展

①　多年来 ,急性呼吸窘迫综合征 (ＡＲＤＳ)的死亡率居高不下 ,随着呼吸机和各类通气模式的研究、改进 ,近几年中有所改善 ,但也相应地对护理提出了更高的要求。现就机械通气治疗ＡＲＤＳ的护理进展作一综述。1　机械通气的进展ＡＲＤＳ的定论已有 30年 ,但直到 1990年人们才认识到 :ＡＲＤＳ患者残存的有通气功能的肺泡已大为减少 ,与婴儿相当[1] 。应用机械通气治疗ＡＲＤＳ近十余年来 ,人们越来越认识到 ,根据正常肺设置的潮气量 (10～ 12ｍｌ/ｋｇ)和通气效能 (ＰａＣＯ2 )势必导致气道峰压 (ＰＩＰ)过度升高和残存的有通气功能的肺区…     

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...     

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…     

急性呼吸窘迫综合征保护性机械通气策略的研究

急性呼吸窘迫综合征 (ARDS)是多种病因或疾病引起的肺泡上皮和内皮屏障破坏的急性炎性反应 ,肺泡内含蛋白丰富的渗出液增加而导致的急性呼吸衰竭 ,表现为非心源性肺水肿和顽固性低氧血症 ,是炎症反应综合征在肺部的表现。其病理表现为肺泡塌陷、肺顺应性下降、肺内分流增加和低氧血症。机械通气治疗ARDS已有三十多年历史 ,其在一定程度上改善氧合 ,降低了ARDS的死亡率 ,但其死亡率目前仍达 5 0 % [1] 。随着对ARDS病理生理和机械通气机制的研究 ,发现机械通气在治疗ARDS的同时会加重原有肺损伤。因此 ,目前主张对ARDS实施保护性通…     

机械通气治疗单肺急性呼吸窘迫综合征疗效观察

全肺切除术后并发急性呼吸窘迫综合征(ARDS)虽不常见,但因涉及通气和循环两方面的问题,却是病死率较高的围手术期并发症[1-2].机械通气是治疗ARDS最重要的措施,只剩单肺的患者实施机械通气治疗有一定的特殊性,总结本科近3年收治的全肺切除术后出现ARDS病例资料,谈谈体会.     

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.     

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.     

早期应用机械通气对急性重症胰腺炎伴急性呼吸窘迫综合征的防治作用

急性重症胰腺炎常因伴发急性呼吸窘迫综合征（ARDS）而死亡。机械通气被认为是治疗ARDS的最重要手段之一。以往对急性重症胰腺炎早期使用呼吸机防治ARDS的报道较少,国内尚无统一方案。我们对1995～2004年在我院住院的34例急性重症胰腺炎患者,早期使用呼吸机后的疗效进行了观察,报告如下。     

Controlling mechanical ventilation in acute respiratory distress syndrome with fuzzy logic

Purpose

The current ventilatory care goal for acute respiratory distress syndrome (ARDS) and the only evidence-based approach for managing ARDS is to ventilate with a tidal volume (V_T) of 6 mL/kg predicted body weight (PBW). However, it is not uncommon for some caregivers to feel inclined to deviate from this strategy for one reason or another. To accommodate this inclination in a rationalized manner, we previously developed an algorithm that allows for V_T to depart from 6 mL/kg PBW based on physiological criteria. The goal of the present study was to test the feasibility of this algorithm in a small retrospective study.

Materials and Methods

Current values of peak airway pressure, positive end-expiratory pressure (PEEP), and arterial oxygen saturation are used in a fuzzy logic algorithm to decide how much V_T should differ from 6 mL/kg PBW and how much PEEP should change from its current setting. We retrospectively tested the predictions of the algorithm against 26 cases of decision making in 17 patients with ARDS.

Results

Differences between algorithm and physician V_T decisions were within 2.5 mL/kg PBW, except in 1 of 26 cases, and differences between PEEP decisions were within 2.5 cm H₂O, except in 3 of 26 cases. The algorithm was consistently more conservative than physicians in changing V_T but was slightly less conservative when changing PEEP.

Conclusions

Within the limits imposed by a small retrospective study, we conclude that our fuzzy logic algorithm makes sensible decisions while at the same time keeping practice close to the current ventilatory care goal.     

Noninvasive ventilation for patients with acute lung injury or acute respiratory distress syndrome

Few studies have been performed on noninvasive ventilation (NIV) to treat hypoxic acute respiratory failure in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The outcomes of these patients, for whom endotracheal intubation is not mandatory, depend on the degree of hypoxia, the presence of comorbidities and complications, and their illness severity. The use of NIV as an alternative to invasive ventilation in severely hypoxemic patients with ARDS (ie, P(aO(2))/F(IO(2)) < 200) is not generally advisable and should be limited to hemodynamically stable patients who can be closely monitored in an intensive care unit by highly skilled staff. Early NIV application may be extremely helpful in immunocompromised patients with pulmonary infiltrates, in whom intubation dramatically increases the risk of infection, pneumonia, and death. The use of NIV in patients with severe acute respiratory syndrome and other airborne diseases has generated debate, despite encouraging clinical results, mainly because of safety issues. Overall, the high rate of NIV failure suggests a cautious approach to NIV use in patients with ALI/ARDS, including early initiation, intensive monitoring, and prompt intubation if signs of NIV failure emerge.     

不同体位对 ARDS 患者机械通气效果的影响

目的：比较不同体位对ARDS患者机械通气效果的影响。方法选择2010年1月-2012年12月行机械通气治疗且无俯卧位机械通气禁忌证的ARDS患者40例,采用随机数字表法随机分为俯卧位通气组和仰卧位通气组,每组各20例。比较两组患者机械通气前后生命体征和动脉血气变化,治疗3d后平均气道压、平台压、气道阻力,机械通气时间和急诊科住院时间。结果组内比较,两组患者治疗后T、P、MAP、PaCO2均降低,差异均有统计学意义（P＜0．01）;PETCO2、pH值、PaO2、PaO2/FiO2均升高,差异均有统计学意义（P＜0．01）。组间比较,T、P、PETCO2、MAP、pH值、PaO2、PaCO2差异均无统计学意义（P＞0．05）;俯卧位通气组患者在俯卧位治疗3 d后PaO2/FiO2为（282±177;22）,高于仰卧位通气组治疗3 d后的（245±177;21）,差异有统计学意义（t＝6．18,P＜0．01）。治疗3 d后,俯卧位通气组患者平均气道压、平台压、气道阻力分别为（6．8±177;0．5）cmH2O,（17．1±177;2．0）cmH2O,（14．9±177;1．2）cmH2O/（L±183; s）,仰卧位通气组分别为（8．5±177;0．9）cmH2O,（20．6±177;2．3）cmH2O,（21．1±177;0．8）cmH2O/（L±183; s）,差异均有统计学意义（t值分别为7．38,5．13,18．83;P＜0．01）。俯卧位通气组患者机械通气时间和急诊科住院时间均短于仰卧位通气组,差异均有统计学意义（ t值分别为9．007,6．379;P＜0．01）。结论俯卧位通气可以更有效地改善氧合指数,纠正低氧血症,同时对患者气道影响较小,是较为理想的通气体位。     

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。