机械通气抢救胸外伤并发急性呼吸窘迫综合征

呼吸窘迫综合征 (ＡＲＤＳ)是胸外伤合并严重肺挫伤的患者致死的主要原因。我中心 1998～ 2 0 0 0年内收治该类病人17例 ,均及时有效地应用机械通气 ,抢救成功 16例 ,死于并发急性肾功能衰竭 1例 ,现介绍如下。1　资料与方法1 1　资料　 17例病人中 ,男 16例 ,女 1例 ,平均年龄 35岁。其中双侧多发肋骨骨折合并血气胸 8例 ;单侧多发肋骨骨折合并血气胸 4例 ;肋骨骨折合并血胸 5例 ,均伴有严重肺挫裂伤。其中开胸手术治疗 10例 ,保守治疗 3例 ,单纯闭式引流 5例 ,均经胸ＣＴ扫描 ,Ｘ线平片诊断 ,均并发ＡＲＤＳ。ＡＲＤＳ的诊断标准参照中华…     

机械通气治疗重症胸外伤并发急性呼吸窘迫综合征的护理

急性呼吸窘迫综合征（ARDS）是以呼吸窘迫、顽固性低氧血症和非心源性肺水肿为临床特征的严重急性缺氧性呼吸衰竭,其发病主要是由非心源性的各种肺内外致病因素共同作用的结果。重症胸外伤患者易并发ARDS,病死率较高。文献[1]报道,重症胸外伤并发ARDS的发生率为3%-18%,病死率为40%-70%。     

严重肝损伤合并胸外伤致急性呼吸窘迫综合征24例治疗分析

目的 探讨严重肝损伤合并胸外伤致急性呼吸窘迫综合征（ARDS）的有效急救治疗方法。方法 回顾分析24例严重肝损伤合并胸外伤致ARDS的急救治疗方法及治疗效果。结果 24例肝损伤均属Ⅲ级以上重度损伤，均合并肋骨骨折或肺挫伤而致ARDS，行抗休克、合理补充血容量、合理的机械通气及急诊外科手术抢救治疗，临床治愈20例，死亡4例（死亡率16.66％）。结论 早期诊断、及时抗休克和处理肝损伤及胸外伤，尽早正确采用机械通气是治疗严重肝损伤合并胸外伤致ARDS的关键，是降低死亡率的有效措施。     

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患者机械通气策略新进展

机械通气是治疗急性呼吸窘迫综合症(ARDS)的重要措施之一。随着近年来对ARDS病理的进一步研究,机械通气策略也由过去的大潮气量逐渐发展为肺保护性通气策略。本文通过阐述ARDS患者机械通气策略的新发展,为临床通气治疗ARDS患者提供参考。ARDS机械通气治疗近期有望实现突破。     

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…     

胸外伤后急性呼吸窘迫综合征呼吸机肺保护性通气治疗

目的:探讨严重胸外伤后发生急性呼吸窘迫综合征早期诊断和呼吸机肺保护性通气治疗.方法:回顾性分析31例胸外伤后急性呼吸窘迫综合征的诊治过程.结果:31例患者分为2组,传统机械呼吸+终末正压通气组20例,带机时间平均(7.3±1.6)d,死亡9例,病死率50%;呼吸机肺保护性通气组11例,带机时间平均(4.5±1.8)d,死亡3例,病死率27.27%.2组比较差异有统计学意义(P<0.05).结论:呼吸机肺保护性通气治疗急性呼吸窘迫综合征效果优于传统机械呼吸+终末正压通气治疗.     

胸外伤并急性呼吸窘迫综合征的护理

目的：探讨胸外伤并急性呼吸窘迫综合征(ARDS)的护理。方法：回顾性分析1996年12月至2003年2月36例严重胸外伤并发ARDS的护理。结果：通过采取严密观察病情、保持气道通畅、正确运用机械通气、保持胸腔闭式引流管通畅及做好患者心理护理等措施，本组患者治愈31例，治愈率86．1％，死亡5例，死亡率13．9％。结论：机械通气仍是治疗ARDS的主要手段，而护理上严密观察病情、保持气道通畅、做好机械通气及胸腔闭式引流管护理等也是决定胸外伤并ARDS治疗成功与否的关键。     

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。     

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.     

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     

Preemptive mechanical ventilation can block progressive acute lung injury

Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.     

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。     

两种俯卧位角度对急性呼吸窘迫综合征机械通气患者临床指标的影响

目的比较10°和25°头高足低俯卧位通气角度对急性呼吸窘迫综合征(ARDS)患者氧合指标、血流动力学、压力性损伤发生率、VAP发生率的影响。方法将2020年4月—2021年4月医院收治的ARDS患者,按组间特征具有可比性的原则分为观察组25例和对照组26例。对照组患者给予10°头高足低俯卧位,观察组患者给予25°头高足低俯卧位,观察比较两组俯卧位动脉血氧分压(PaO₂)、二氧化碳分压(PaCO₂)、氧合指数(PaO₂/FiO₂)、血流动力学指标、压力性损伤发生率、VAP的发生情况。结果俯卧位后两组氧合指标、心率等较俯卧位前均有改善,但两指标组间比较差异无统计学意义(P>0.05)。观察组患者压力性损伤发生率及VAP发生率低于对照组,差异有统计学意义(P<0.05)。结论ARDS患者取25°头高足低俯卧位通气既可以有效改善氧合,也可以降低患者压力性损伤及VAP发生率,是ARDS患者行机械通气时较合适的体位。     

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.     

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,     

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.     

急性呼吸窘迫综合征患者侧卧位通气与俯卧位通气的临床疗效观察

目的 评价侧卧位通气和俯卧位通气对急性呼吸窘迫综合征（ARDS）患者的临床疗效。并对两种体位通气方法进行对比观察。方法 将ICU2005年收治的23例ARDS患者随机分为两组，分别施行侧卧位通气（15例）和俯卧住通气（8例），监测仰卧位时，体位改变后1、2、4h及转复为仰卧位后1h的呼吸循环指标，并分别进行比较。结果 体位改变后1、2、4h及转复为仰卧住后1h，两组患者动脉血氧分压、氧舍指数均较仰卧位时升高（P〈0．05），心率、平均动脉压、气道峰压及动脉血二氧化碳分压与仰卧位时比较差异无统计学意义（P〉0．05）。以氧分压升高10mmHg为有效标准。治疗有效率侧卧位组73．3％，俯卧位组66．7％，两组比较差异无统计学意义（P〉0．05）。结论 作为ARDS机械通气治疗手段，侧卧位通气与俯卧位通气治疗的有效率接近。但侧卧位实施更容易，护理更方便。并发症少，值得临床进一步探讨。