ALI/ARDS患者俯卧位通气的研究进展

阐述了急性肺损伤（ALI）及急性呼吸窘迫综合征（ARDS）患者俯卧位通气的理论基础、俯卧位通气的优越性和改善ALI/ARDS患者氧合状况的机制,分析了俯卧位通气治疗的适应证、应用时机、禁忌证、并发症及治疗时间,提出俯卧位通气治疗的实施方法和护理,以期为临床俯卧位通气治疗提供参考。     

ALI/ARDS患者俯卧位通气的研究进展

阐述了急性肺损伤(ALI)及急性呼吸窘迫综合征(ARDS)患者俯卧位通气的理论基础、俯卧位通气的优越性和改善ALI/ARDS患者氧合状况的机制,分析了俯卧位通气治疗的适应证、应用时机、禁忌证、并发症及治疗时间,提出俯卧位通气治疗的实施方法和护理,以期为临床俯卧位通气治疗提供参考。     

ALI/ARDS病人侧卧位通气的疗效观察

目的探讨急性肺损伤 /急性呼吸窘迫综合征 (ALI/ARDS)病人实施侧卧位通气的效果。方法对 18例ALI/ARDS病人实施侧卧位通气 ,分别于通气前、侧卧位通气 1h后及恢复仰卧位通气 1h做血气分析 ,观察变动体位通气对呼吸循环指标的影响。结果 12例侧卧位通气有效 ,有效率 6 6 .7% ;其氧分压 (PaO2 )、氧分压 /吸氧浓度 (PaO2 /FiO2 )明显高于通气前 (均P <0 .0 1) ;恢复仰卧位 1h后上述指标有所下降 ,但仍高于通气前 (P <0 .0 5 ) ;体位变动通气时病人呼吸循环指标变化比较 ,差异无显著性意义 (均P >0 .0 5 )。结论侧卧位通气对ALI/ARDS特别是对ALI病人治疗有效 ,与俯卧位通气比较 ,实施更方便、安全。     

ARDS与俯卧位通气

俯卧位通气能有效改善大部分病人的氧合状况,对呼吸力学、血流动力学无明显影响,且实施比较方便,不会造成严重的副作用,因而可用于ARDS的辅助治疗。本文就俯卧位通气对ARDS病人的作用、机制及临床应用情况作一综述。     

重症急性胰腺炎并发ALI/ARDS24例临床分析

目的：探讨重症急性胰腺炎并发急性肺损伤（ALI）／急性呼吸窘迫综合征（APDS）的证断与治疗。方法：回顾性分析本院1997年1月至2000年12月收治的28例重症急性胰腺炎中并发的24例ALI／ARDS患者。结果：重症急性胰腺并发ALI／ARDS的发病率高达85．7％,20例为ALI,4例为ARDS,均治愈。结论：在重症急性胰腺炎的急性反应期,应反复测定血气分析,不应拘泥于动脉氧分压数值,当氧合指数（PaO2/FiO2）≤300mmHg,可早期证断出ALI,经积极处理,可避免向ARDS转化。     

基于肠内营养耐受性评分的俯卧位通气患者早期肠内营养实施

目的 探讨肠内营养耐受评估表在急性呼吸窘迫综合征（ARDS）行俯卧位通气患者早期肠内营养（EN）中的应用效果。方法 将2014年12月至2019年12月收治的ARDS行俯卧位通气患者30例,按入科时间分为对照组（n=12）和观察组（n=18）。对照组按常规护理方法实施早期肠内营养,观察组在常规护理基础上应用肠内营养耐受评估表指导早期肠内营养的实施。比较两组俯卧位通气治疗期间EN耐受情况、72 h内70%目标热量达标率、达70%目标热量时间,机械通气时间、俯卧位通气时间、俯卧位通气前后前白蛋白指标及ICU住院时间等。结果 观察组达70%目标热量的时间显著短于对照组（P<0.05）,且观察组喂养量及72 h内70%目标热量达标率显著高于对照组（P<0.05,P<0.01）。两组胃肠道并发症发生率及预后指标方面比较,差异无统计学意义（均P＞0.05）。结论 肠内营养耐受性评估表在指导行俯卧位通气治疗患者早期肠内营养的护理中具有重要的价值,能规范早期肠内营养方案,及早发现并积极防治肠内营养不耐受情况,对提高俯卧位通气患者早期肠内营养支持成功率有重要的意义。     

俯卧位通气在急性Stanford A型主动脉夹层术后急性呼吸窘迫综合征中的疗效

目的 探讨俯卧位通气在急性Stanford A型主动脉夹层（acute Stanford type A aortic dissection,STAAD）术后急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）中的疗效。方法 收集2019年11月—2021年9月厦门大学附属心血管病医院STAAD术后并发ARDS且行俯卧位通气患者的临床资料,整理俯卧位前后血气分析、呼吸力学和血流动力学指标,对预后和不良事件等数据进行统计学分析。结果 共264例STAAD患者行外科手术治疗,术后并发ARDS并行俯卧位通气患者40例,其中男37例、女3岁,平均年龄（49.88±11.46）岁。与俯卧位通气前相比,俯卧位通气开始后4 h、12 h,俯卧位通气结束后2 h、6 h氧分压、氧合指数及末梢血氧饱和度均明显改善（P<0.05）。俯卧位通气结束后2 h,氧合指数<131.42 mm Hg提示患者可能需要二次或多次俯卧位通气。结论 STAAD术后中重度ARDS患者采用俯卧位通气是一种安全有效的改善患者氧合的方法。     

急性胰腺炎并发ALI及ARDS的机制

急性胰腺炎发病急骤,病情变化迅速,可并发急性肺损伤(ALI)及急性呼吸窘迫综合征(ARDS),甚至发生多器官功能障碍综合征,病死率一直居高不下.急性胰腺炎并发ALI及ARDS的机制错综复杂,涉及炎症反应失控、细胞的损伤与凋亡、胰酶的作用、凝血与纤溶失衡等多个层面,而这些层面彼此相互关联形成复杂的网络.深入探讨急性胰腺炎并发ALI及ARDS的机制,将为临床诊治提供更多新的作用靶点.     

俯卧体位在ARDS治疗中的作用

俯卧位作为一种治疗ARDS病人的辅助方法，已有20多年历史。本文重点介绍了这种辅助方法的治疗机制：主要是俯卧位时肺内气体重新分布的结果。还详详细地介绍了其临床应用及存在的问题。     

The use of prone ventilation in acute lung injury and acute respiratory distress syndrome

Prone positioning has been suggested since 1974 as a ventilatory strategy to improve oxygenation and pulmonary mechanics in patients with acute lung injury and acute respiratory distress syndrome. Although this mode of ventilation can improve gas exchange, the optimal role of the prone position is uncertain. The aim of this article is to examine the evidence in support of this mode of ventilation in adult patients with acute lung injury and acute respiratory distress syndrome. Limitations of the currently available evidence upon which the recommendations are made must be recognized. With these limitations in mind, however, the available evidence has been considered and conclusions presented. Considerable clinical experience confirms that prone ventilation can improve oxygenation in the majority of patients. It is difficult to predict which patients will respond. There are few contraindications and with experienced staff it can be achieved safely. Most patients should therefore be considered for a trial of prone positioning. Prolonged and repeated prone ventilation may be more effective. Whether the improvement in physiological parameters translates into improved clinical outcomes is less certain and well-designed randomized controlled trials will be required to address this issue.     

Airway pressure release ventilation and prone positioning in severe acute respiratory distress syndrome

BACKGROUND: Implementation of lung protective strategy in the treatment of severe Acute Respiratory Distress Syndrome (ARDS) has been reported to be associated with improved outcome. To fulfil this approach, sedation, neuromuscular blocking agents and full mechanical ventilatory support are often used in critical failure of gas exchange. CASE REPORT: We present a patient who developed multiple organ failure, including severe ARDS, after severe skin injuries and septic shock. Ventilatory strategy consisted of lung protective approach, permissive hypercapnia and prone positioning. Airway pressure release ventilation (APRV) with the patient's superimposed spontaneous breathing was implemented and maintained, also during prone episodes. Improvement of gas exhange occurred after application of combined use of APRV and prone positioning. CONCLUSION: APRV and maintenance of patients' spontaneous ventilation is feasible during prone positioning, and this approach may have beneficial synergistic effects on gas exhange in patients with severe acute lung injury.     

Protective ventilation of patients with acute respiratory distress syndrome

The majority of patients with acute respiratory distress syndrome(ARDS) require mechanical ventilation. This support providestime for the lungs to heal, but the adverse effects of mechanicalventilation significantly influence patient outcome. Traditionally,these were ascribed to mechanical effects, such as haemodynamiccompromise from decreased venous return or gross air leaks inducedby large transpulmonary pressures. More recently, however, theARDS Network study has established the clinical importance oflowering the tidal volume to limit overdistension of the lungwhen ventilating patients with ARDS. This study suggests thatventilator-associated lung injury (VALI) caused by overdistensionof the lung contributes to the mortality of patients with ARDS.Moreover, the results from clinical and basic research haverevealed more subtle types of VALI, including upregulation ofthe inflammatory response in the injured and overdistended lung.This not only damages the lung, but the overflow of inflammatorymediators into the systemic circulation may explain why mostpatients who die with ARDS succumb to multi-organ failure ratherthan respiratory failure. The results of these studies, thepresent understanding of the pathophysiology of VALI, and protectiveventilatory strategies are reviewed. Br J Anaesth 2004; 92: 261–70     

急性肺损伤/急性呼吸窘迫综合征液体治疗策略

背景 高通透性肺水肿是急性肺损伤/急性呼吸窘迫综合征(acute lung injury/acute respiratory distress syndrome,ALI/ARDS)的基本病理生理特征,其程度与ALI/ARDS的预后密切相关.目的 对ALI/ARDS患者合理的液体管理,有助于改善ALI/ARDS患者的肺水肿,降低该病病死率.内容 回顾了ALI/ARDS液体治疗策略探索过程中存在争议的问题(如限制性或开放性的液体治疗策略及治疗液体种类的选择),总结了该领域近年来的研究进展(如ALI/ARDS病程不同阶段的差异化治疗及液体治疗的监测指标).趋向 今后将进一步探索该病在不同的病理生理状态下特异性的液体治疗方法,寻求高效敏感的监测指标,指导液体治疗策略的选择和调整.     

严重急性呼吸窘迫综合征孕妇俯卧位通气的护理进展

俯卧位通气是一种改善严重急性呼吸窘迫综合征患者氧合的体位治疗方式。对于发生严重急性呼吸窘迫综合征的孕妇,俯卧位通气在一定程度上可以缓解肺部区域塌陷,降低妊娠子宫的压力,改善患者氧合。本文对已有的严重急性呼吸窘迫综合征孕妇俯卧位通气成功案例进行综述,以期从临床差异、作用机制、临床应用、病情观察和应用效果对严重急性呼吸窘迫综合征孕妇俯卧位通气的护理进行总结,为临床干预提供参考。     

Prone positioning ventilation for treatment of acute lung injury and acute respiratory distress syndrome

Patients who are diagnosed with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) usually have ventilation-perfusion mismatch, severe decrease in lung capacity, and gas exchange abnormalities. Health care work-ers have implemented various strategies in an attempt to compensate for these pathological alterations. By rotating patients with ALI/ARDS between the supine and prone position, it is possible to achieve a significant improvement in PaO2/FiO2, decrease shunting and therefore improve oxy-genation without use of expensive, invasive and experimen-tal procedures.     

Perioperative risk analysis for acute respiratory distress syndrome after elective oesophagectomy

Background: Acute respiratory distress syndrome (ARDS) is a major contributor to respiratory morbidity and mortality after oesophagectomy. Several pre‐, intra‐ and post‐operative factors are thought to predispose to its development in the post‐oesophagectomy period. The aim of this study was to determine factors predisposing to ARDS in the post‐oesophagectomy period. Methods: A total of 112 patients who underwent elective oesophagectomy for oesophageal cancer (gastro‐oesophageal adenocarcinoma and high‐grade dysplasia, 93; oesophageal squamous cell carcinoma, 16; oesophageal oat cell tumour, 1; oesophageal anaplastic carcinoma, 1; oesophageal colloid carcinoma, 1) between 1 January 2003 and 31 December 2006 formed the study group in this retrospective study. The pre‐, intra and post‐operative data for these patients (male : female = 89:23, mean age 60.8 years) were collected from an oesophagectomy database and hospital medical records. Results: The incidence of ARDS was 13%. The in‐hospital mortality among ARDS cases was 20% and 1‐year mortality was 40%. Various factors such as preoperative chronic respiratory disease (P‐value = 0.000, odds ratio = 17.76), smoking pack‐years (P‐value = 0.045, odds ratio = 1.02), abnormal preoperative forced expiratory volume in 1 s (P‐value = 0.009, odds ratio = 7.97), high percentage of oxygen in inspired air (P‐value = 0.041, odds ratio = 1.24) and use of perioperative inotropes (P‐value = 0.021, odds ratio = 4.26) were associated with ARDS. Conclusions: Preoperative physiological status as indicated by a preoperative history of chronic respiratory disease and preoperative pulmonary function influenced the post‐operative outcome in our patients. The use of perioperative inotropes suggests perioperative cardiorespiratory instability, and could also predispose to the development of ARDS in the post‐operative period.     

肝移植术后急性肺损伤/急性呼吸窘迫综合征的研究进展

急性肺损伤/急性呼吸窘迫综合症（ALI/ARDS）是肝移植术后常见的并发症,可延长受者术后重症监护室入住时间,影响肝移植手术疗效,病情严重可致受者死亡,临床中引起了肝移植外科医师的高度重视。肝移植术后ALI/ARDS可由肺源性因素（例如机械通气相关肺损伤、肺部感染、误吸等）直接导致,也可由非肺源性因素（例如肺部以外的严重感染、输血、缺血-再灌注损伤等）间接导致。本文对肝移植术后ALI/ARDS的诊断标准及发生情况、发生机制、危险因素、实验室及临床诊断方法以及治疗方法等进行综述,加深对肝移植围手术期ALI/ARDS的理解与认知,以期为肝移植术后ALI/ARDS的诊治提供借鉴。     

Effects of prone and supine posture on cardiopulmonary function after experimental chlorine gas lung injury

BACKGROUND: Chlorine gas may induce severe acute lung injury. Improvement of pulmonary gas exchange in patients and animals with acute lung injury nursed in the prone position was observed in recent years. The purpose of this study was to evaluate the effects of prone and supine positions on pulmonary and cardiovascular functions following experimental chlorine gas lung injury. METHODS: Twenty anesthetized and mechanically ventilated pigs were exposed to chlorine gas (400 p.p.m. in air) for 20 min in the supine position, then assigned randomly to ventilation in the supine or prone positions (n=10 in each group). Hemodynamics, gas exchange, lung mechanics and oxygen transport were evaluated for 5 h. RESULTS: All animals showed severe pulmonary dysfunction immediately after chlorine gassing with a threefold increase in pulmonary vascular resistance index, a drop in arterial oxygenation (12.3+/-1.3 kPa to 5.4+/-0.7 kPa) and a fall in lung-thorax compliance (22+/-1 ml cmH2O-1 to 8+/-2 ml cmH2O-1). Venous admixture (Qs/Qt) improved in animals in the prone position while there was no change in the supine position (prone 32+/-11% vs. supine 42+/-9% at 5 h,P<0.05). Lung-thorax compliance improved significantly with time in the prone group only (P<0.01). Oxygen delivery increased significantly in prone animals compared with animals nursed in the supine posture (P<0.001). CONCLUSION: Immediate prone positioning after chlorine gas injury not only inhibited deterioration of gas exchange but was also associated with improved pulmonary function and oxygen transport.