急性呼吸窘迫综合征右心改变的认识进展

尽管治疗方案经历了长足的发展,急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)的病死率仍居高不下。随着研究的深入,学者们逐渐发现ARDS患者不仅出现肺损伤,也会出现循环损伤,导致右心功能不全及急性肺源性心脏病。短暂的低氧血症并非ARDS患者预后的独立危险因素,而循环损伤可直接影响其预后。因此,ARDS治疗的核心逐渐从肺保护转向于右心保护。本文对ARDS右心改变的特点及右心保护的策略进行梳理和总结,同时针对循环保护的环节,提出“抢先保护”的理念,为ARDS的治疗提供新的思路。     

肺动脉顺应性在急性呼吸窘迫综合征中的价值

目的 检测急性呼吸窘迫综合征(ARDS)患者肺动脉顺应性及右心功能,探讨肺动脉顺应性与右心功能及ARDS短期预后的关系.方法 选取同期135例ARDS患者(观察组)及46例健康体检者(对照组)为研究对象,根据30 d预后情况分为死亡组89例、生存组46例.检测受试者肺动脉收缩压(PASP),计算房间隔缺损面积指数(ASD-AI)、肺动脉顺应性指数(PACI),并以PACI作为评价肺动脉顺应性的指标;检测受试者每搏输出量(RVSV)等右心功能指标;分析PACI与右心功能的相关性;比较不同预后情况患者的PASP、ASD-AI、PACI水平;分析PACI对ARDS患者近期预后的预测价值.结果 观察组患者PASP、ASD-AI、心室舒张末期容积(RVEDV)、动脉血二氧化碳分压[pa(CO2)]水平均高于对照组,PACI、右心室射血分数(RVEF)、心室收缩末期容积(RVESV)、平均动脉压(MAP)、动脉血氧分压[pa(O2)]、氧合指数[pa(O2)/FiO2]水平均低于对照组,差异有统计学意义(P＜0.05).ARDS患者PACI与RVEF、RVESV及pa(O2)/FiO2呈正相关(P＜0.05),与RVEDV呈负相关(P＜0.05).死亡组患者PASP、ASD-AI水平高于生存组,PACI、pa(O2)/FiO2水平低于生存组,差异有统计学意义(P＜0.05).受试者工作特征(ROC)曲线显示,PACI对ARDS短期预后诊断的曲线下面积(AUC)为0.844,敏感性为70.8％,特异性为80.4％.结论 ARDS患者肺动脉顺应性和右心功能下降,PACI与右心功能存在一定相关性,PACI在ARDS患者近期预后中能够起到较好的预测作用.     

肺源性与肺外源性急性呼吸窘迫综合征的再思考

急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)是由一系列疾病损伤导致的急性呼吸衰竭,重症患者具有较高的病死率。根据危险因素的不同,ARDS可分为肺源性ARDS和肺外源性ARDS两种亚型,前者由于损伤直接作用于肺泡上皮细胞,造成肺泡膜破坏,影响气血交换;而后者通过全身性因素导致血管内皮损伤,肺血管通透性增加、肺间质渗出,进而出现肺泡塌陷、水肿,呼吸衰竭。各种肺内外危险因素在重症ARDS患者中往往同时存在,影像和呼吸力学等临床特征也未能很好区分肺源性/肺外源性ARDS,生物标志物的诊断效应还需验证,甚至病死率在肺源性/肺外源性ARDS患者中也并无明显差异。本文对肺源性ARDS和肺外源性ARDS的危险因素、临床特征、病死率进行比较,并针对ARDS的发病机制、临床表现及治疗与预后需关注之处进行梳理,为临床医生更加全面了解ARDS的发病机制、规范系统地启动ARDS的精准化评估与治疗提供借鉴,从而降低ARDS患者的病死率。     

急性呼吸窘迫综合征的新进展

一、关于急性呼吸窘迫综合征 (ＡＲＤＳ)定义及诊断标准的进展成人呼吸窘迫综合征 (Ａｄｕｌｔｒｅｓｐｉｒａｔｏｙｄｉｓｔｒｅｓｓｓｙｎｄｒｏｍｅ ,ＡＲＤＳ)的命名起自 1971年 ,沿用了 2 0年。 1992年美国胸病学会 (ＡＴＳ)和欧洲危重病学会 (ＥＳＩＣＭ)联合召开讨论会 ,共同建议将ＡＲＤＳ中的Ａ改为Ａｃｕｔｅ (急性 ) ,并建议将该综合征划分为急性肺损伤(Ａｃｕｔｅｌｕｎｇｉｎｊｕｒｙ ,ＡＬＩ)和ＡＲＤＳ (ａｃｕｔｅｒｅｓｐｉｒａｔｏｒｙｄｉｓｔｒｅｓｓｓｙｎｄｒｏｍｅ,ＡＲＤＳ)两部分 ,前者反映该综合征的病生理过程 ,…     

急性呼吸窘迫综合征的治疗进展--保护性肺通气

随着急性呼吸窘迫综合征 (acute respiratory distresssyndrome,ARDS)发病机理的不断研究 ,机械通气治疗ARDS患者已逐渐被人们接受。在 1994年 [1 ] 美国 -欧洲ARDS学会就 ARDS简单定义如下 :1急性突发症状 ;2Pa O2 /Fi O2 <2 0 0 mm Hg;3胸片示 :双肺渗出改变 ;4肺毛细血管嵌楔压≤ 18mm Hg;5无左房压增高的体征。从临床角度观察对临床医生有用的是机械辅助通气领域。1　新的通气策略ARDS患者由于严重低氧 ,故需要机械通气以利于气体交换。由于更好的了解了疾病过程 ,现在主要考虑 ARDS患者如何进行机械通气。目前最主要的概念…     

急性呼吸窘迫综合征的动物模型

急性呼吸窘迫综合征（ＡＲＤＳ）系多种原发疾病如休克、创伤、严重感染、误吸等疾病过程中发生的急性进行性缺氧性呼吸衰竭。其主要病理生理改变为弥漫性肺损伤、肺微血管壁通透性增加和肺泡群萎陷，导致肺内血液分流增加和通气／血流比失衡，临床表现为严重的不易缓解的...     

肺保护策略在感染相关急性呼吸窘迫综合征的应用

目的　探讨感染相关急性呼吸窘迫综合征 (ARDS)的治疗方法。方法　应用肺保护策略 (包括机械通气和抗炎、改善微循环等药物 )治疗感染相关急性肺损伤 (ALI) ,5 0例 ,ARDS 35例 ,并观察治疗后即刻、3d、5d急性肺损伤评分 ,部分病例检测细胞因子TNF -α、IL - 6的变化。结果　显效 32例 ,有效 2 7例 ,无效 2 6例。总有效率 6 9 4 %。治疗后肺损伤评分明显下降 (P <0 0 5 )。TNF -α、IL - 6血清水平均明显下降 (P <0 0 1)。结论　应用肺保护策略早上机早治疗 ,能提高感染相关ARDS的疗效。     

关于急性呼吸窘迫综合征的诊断

通过对１７例急性感染患者资料分析，从急性呼吸窘迫综合征（ＡＲＤＳ）的发展过程探讨其诊断，特别是早期诊断。     

急性呼吸窘迫综合征

急性呼吸窘迫综合征(ARDS)是一组继发于内外科疾患的以急性肺损伤为特征的临床综合征，本文就ARDS的定义、临床特征、流行病学特点以及发病机制方面的进展作一综述。     

Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome

Objective  To analyse the incidence and the impact on outcome of right ventricular failure (RVF) in patients with acute respiratory distress syndrome (ARDS). Patients and methods  A total of 145 ARDS patients included in the previously published French Pulmonary Artery Catheter (PAC) study were randomly assigned to receive a PAC. All patients were ventilated according to a strategy aimed at limiting plateau pressure. The RVF was defined by the concomitant presence of: (1) a mean pulmonary artery pressure (MPAP) > 25 mmHg, (2) a central venous pressure (CVP) higher than pulmonary artery occlusion pressure (PAOP) and (3) a stroke volume index < 30 mL m⁻². Results  Right ventricular failure was present in 9.6% of patients. Mortality was 68% at day-90 with no difference between patients with RVF (RVF+) and without RVF (71 vs. 67%, respectively). SAPS II, PaO₂/FiO₂ and PaCO₂ were similar in both groups. Tidal volume and I/E ratio were significantly higher in RVF+ (9.7 ± 2.8 vs. 8.6 ± 1.8 ml m⁻² and 0.7 ± 0.5 vs. 0.5 ± 0.2). Plateau pressure tended to be higher in RVF+ (28 ± 6 vs. 25 ± 6 cmH₂O, NS). In multivariate analysis, PaO₂/FiO₂, mean arterial pressure, arterial pH, SvO₂, MPAP and presence of CVP > PAOP, but not RVF, were independently associated with day-90 mortality. Conclusion  In this group of patients investigated early in the course of ARDS and ventilated according to a strategy aimed at limiting plateau pressure, the presence of RVF was about 10%. Unlike MPAP and the presence of CVP > PAOP, RVF at this early stage did not appear as an independent factor of mortality. This article is discussed in the editorial available at: doi:.     

Improved prognosis of acute respiratory distress syndrome 15 years on

Objective: Evaluation of the impact of low-volume, pressure-limited ventilation on the recovery rate of acute respiratory distress syndrome (ARDS). Design: Prospective observational clinical study with historical control. Setting: University hospital intensive care unit (ICU). Patients: We studied two groups of, respectively, 33 and 37 ARDS patients separated by 15 years (“historical”, June 1978–April 1981, and “recent”, October 1993–June1996). Method: ARDS was defined as the presence of bilateral chest infiltrates and a PaO₂/FIO₂ ratio of less than 200 mmHg under controlled ventilation regardless of PEEP level. Any cardiac participation was excluded by right heart catheterization in the “historical” group and by echo-Doppler examination in the “recent” group. The origin of ARDS was principally pulmonary (ARDS_p) in both groups (26/33 and 29/37, respectively), and secondarily extrapulmonary (ARDS_exp) (7/33 and 8/37, respectively). In the “historical” group, normocapnia was the major goal for respiratory support and was achieved in all patients regardless of airway pressure levels. In contrast, end-inspiratory plateau pressure in the “recent” group was limited to 30 cmH₂O under respiratory support, regardless of PaCO₂ level. The “historical” and “recent” ARDS groups were compared with regard to therapeutic procedure and outcome. Results: Normalization of PaCO₂ (36 ± 6 mmHg) in the “historical” group required high airway pressure (end-inspiratory plateau pressure at 39 ± 4 cmH₂O) and high tidal volume (13 ml/kg). Respiratory support used in the “recent” group was less aggressive, with lower airway pressure (end-inspiratory plateau pressure 25 ± 4 cmH₂O) and tidal volume (9 ml/kg) resulting in “permissive” hypercapnia (51 ± 10 mmHg).Mortality rates significantly decreased from 64 % in the “historical” group to 32 % in the “recent” group (p < 0.01). This decrease concerned only ARDS_p, which was markedly predominant in both groups. Conclusion: Mortality due to ARDS of pulmonary origin has declined in our unit over the last 15 years. Low-volume, pressure-limited (protective) ventilation seems the most likely reason for improved survival, despite hypercapnia. Received: 29 December 1998 Final revision received: 28 March 1999 Accepted: 8 June 1999     

重组人脑利钠肽治疗急性呼吸窘迫综合征的初步临床观察

目的 评价静脉注射重组人脑利钠肽(rhBNP)对急性呼吸窘迫综合征(ARDS)患者肺通气功能、尿量及肺损伤评分的影响.方法 30例ARDS患者随机分为rhBNP治疗组(n=15)和对照组(n=15), rhBNP治疗组在肺保护性通气策略为主的ICU综合治疗基础上持续 24 h静脉注射rhBNP 0.01 μg·kg~(-1)·h~(-1);对照组采取肺保护性通气策略为主的综合ICU治疗.比较两组患者治疗前后氧合指数(PaO_2/FiO_2)、尿量、心率、中心静脉压(CVP)及肺损伤评分、急性生理和慢性健康评分Ⅱ(APACHEⅡ)变化.结果 rhBNP治疗组治疗前后心率、CVP无明显变化,PaO_2/FiO_2、尿量明显增加(P<0.05),肺损伤评分、APACHEⅡ评分明显降低(P<0.05).对照组治疗前后尿量并无增加,PaO_2/FiO_2、肺损伤评分降低(P<0.05),两组尿量、PaO_2/FiO_2、肺损伤评分及APACHEⅡ评分比较差异均有统计学意义(P<0.05).结论 静脉注射rhBNP能显著改善机械通气ARDS患者的肺通气功能,并有显著利尿作用.     

肺表面活性物质防治急性呼吸窘迫综合征的实验研究

目的：探讨肺表面活性物质（pulmonary surfactant,PS)对内毒素诱发大鼠急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS)的防治作用。方法：48只健康雄性SD大鼠，手术并给予机械通气后随机分为6组：健康对照组（H组），ARDS模型组（M组），其余动物根据动脉血氧分压（PaO2)/FiO2比值分2个时期（PaO2/FiO2≤300mmHg早期－E、PaO2/FiO2≤200mmHg晚期－L）和所给猪肺PS分2个剂量（50mg/kg,100mg/kg），两两组合成E50、E100、L50和L100 4组。用PS后共观察6h。结果：M组和L50组的PaO2和静态胸肺压力－容积（P－V）曲线肺容积均较H组明显降低（P＜0．01），L100组上述指标明显高于M组（P＜0．05），而E50组和E100组PaO2和P－V曲线肺容积均较L100组进一步升高（P＜0．05，P＜0．01），E50组和E100组间上述指标差别不明显。支气管肺泡灌洗液（BALF）分析示L50组和L100组饱和卵磷脂（DSP)/总蛋白（TP）、TP和最小表面张力（STmin)均较M组改善（P＜0．01），但STmin仍高于H组（P＜0．01），E50组和E100组的BALF测值均明显优于L100组（P＜0．01），且STmin接近H组。结论：早期应用PS疗效明显优于晚期，且所需剂量较小，可能是防治ARDS的有效手段之一。     

糖皮质激素治疗对急性呼吸窘迫综合征患者预后的影响

目的：探讨早期应用糖皮质激素（GC）治疗对急性呼吸窘迫综合征（ARDS）患者预后的影响。方法回顾性分析成都军区总医院2008年1月至2011年12月收治的所有ARDS病例的临床资料,选择符合2012年柏林ARDS诊断标准的成人患者,根据是否采用过GC治疗将患者分为GC组与非GC组。GC组患者均在ARDS发生48 h内开始静脉使用低剂量GC（＜5 mg·kg-1·d-1,均换算为氢化可的松的剂量）治疗,激素种类为甲泼尼松龙、地塞米松,疗程为7～21 d;而非GC组为ARDS发生后未使用GC治疗。比较两组患者机械通气时间、重症加强治疗病房（ICU）住院时间、总住院时间、医疗费用和28 d生存率的差异。结果共纳入ARDS患者117例,其中GC组56例（占47.86%）,非GC组61例（占52.14%）。与非GC组比较,GC组机械通气时间明显缩短〔d：0（0,2.50）比2.00（0,2.50）,Z＝2.015,P＝0.044〕,28 d生存率明显升高〔71.43%（40/56）比50.82%（31/61）,χ2＝5.198,P＝0.023〕,ICU住院时间〔d：7.50（2.00,11.00）比4.00（1.00,9.00）,Z＝1.879, P＝0.060〕和总住院时间〔d：16.00（10.00,27.75）比15.00（7.00,28.00）,Z＝0.592,P＝0.552〕差异无统计学意义,但非GC组患者的医疗费用显著低于GC组〔万元：3.15（1.51,5.78）比4.39（1.66,10.88）,Z＝2.204,P＝0.028〕。结论早期使用GC治疗ADRS患者可改善预后,特别是28 d生存率。     

允许性高碳酸血症对重度急性呼吸窘迫综合征肺力学特征的影响

目的 :探讨允许性高碳酸血症 (PHC)对重度急性呼吸窘迫综合征 (ARDS)患者肺力学特征的影响。方法 :观察不同潮气量 (VT)条件下 ,10例重度ARDS患者肺力学及动脉和混合静脉血气参数的改变。结果 :当VT 从常规 10～ 12ml/kg降至 6～ 8ml/kg时 ,患者均出现PHC ,动脉氧分压和氧饱和度无显著变化 ,肺内分流率显著升高 (P <0 0 5 ) ,气道平台压力和平均压力均显著降低 ,吸气顺应性曲线中最后 2 0 %的顺应性与总顺应性之比 (C2 0 /C)明显增大。结论 :采用较正常偏低VT 实施PHC ,可防止肺泡过度膨胀 ,是治疗重度ARDS的重要手段     

Formation and validation of a telephone battery to assess cognitive function in acute respiratory distress syndrome survivors

PURPOSE: Describe initial development and validation of a test battery composed of established instruments designed to detect, via telephone interview, cognitive abnormalities in survivors of acute respiratory distress syndrome. METHODS: Two cross-sectional studies were performed, including the following phases: (1) initial battery construction, (2) feasibility, (3) item reduction, (4) convergent and divergent validity, and (5) telephone administration compared with in-face interviews in a separate population. RESULTS: There was a broad range of cognitive function detected in the derivation population, and all subjects completed the interview. There was convergence of cognitive impairment with moderate/severe anxiety (P = .008), the Sickness Impact Profile Psychosocial Summary Score (mean difference, 15.3; 95% CI, 7.74-22.9; P = .0001), and the mental health domains of the Short Form 36. Subjects with cognitive impairment had no detectable difference in the physical function domains of the Short Form 36. When administered to the validation population, telephone tests of memory, attention, reasoning, and executive functions had good intraclass correlation with the in-face interviews (P < .01). CONCLUSIONS: Detection of cognitive abnormalities in acute respiratory distress syndrome survivors using a telephone-administered test battery derived from standard cognitive tests is feasible and has evidence of construct validity. This battery may be useful as a research tool when in-face interviews are not feasible.     

肺泡表面活性物质在急性呼吸窘迫综合征治疗中的应用

目的 观察肺泡表面活性物质对急性呼吸窘迫综合征（ARDS）患者通气、氧合功能的影响。方法 选择我院ICU2002-01-2005-01由各种病因导致的ARDS患者15例。均在人工呼吸机支持下，选用固尔苏（Curosurf）按100mg／kg剂量经纤维支气管镜行肺泡灌洗补充外源性肺泡表面活性物质，并于灌洗前及以后24h内连续观察患者心率、血压、经皮血氧饱和度（TcSaO2），每6h采动脉血进行血气分析调整并记录呼吸机相关参数。结果 肺泡灌洗补充肺泡表面活性物质后6h内PaO2／FiO2明显改善（P〈0．05），12h迭高峰（P〈0.01），以后逐渐下降。结论 肺泡灌洗补充肺泡表面活性物质能够明显缓解临床症状。改善氧合功能，但持续时间相时较短。     

N-terminal pro-brain natriuretic peptide as a marker of right ventricular dysfunction after open-lung approach in patients with acute lung injury/acute respiratory distress syndrome

Purpose

The purpose of the study was to evaluate the utility of N-terminal pro-brain natriuretic peptide (NT-proBNP) as a marker of right ventricular (RV) dysfunction after open-lung approach (OLA) in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS).

Materials and Methods

Twenty-seven patients with ALI/ARDS underwent OLA (2-minute steps of fixed pressure-controlled ventilation with progressive positive end-expiratory pressure levels up to 30 cm H₂O, followed by stepwise decrement of positive end-expiratory pressure level by 2 cm H₂O). Patients who showed a PaO₂/FiO₂ increase of more than 50% from baseline were defined as responders. Plasma NT-proBNP levels were taken immediately before OLA and 2 and 6 hours later. A minimum 30% increase in NT-proBNP level from baseline was considered significant.

Results

Right-over-left ventricular stroke work ratio and its percentage change did not differ between responders and nonresponders, whereas these values were higher in patients showing NT-proBNP increase (P < .05). The NT-proBNP percentage change correlated with right-over-left ventricular stroke work ratio percentage change (r = 0.83), pulmonary vascular resistance (r = 0.81), and RV ejection fraction (r = -0.79) and correlated with plateau pressure in nonresponders only (r = 0.82).

Conclusions

In patients with ALI/ARDS, intraindividual NT-proBNP changes correlated with RV afterload following OLA, thereby serving as a potential marker for RV dysfunction after OLA.     

糖皮质激素对成人急性呼吸窘迫综合征疗效的Meta分析

目的 评价糖皮质激素对成人急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的疗效.方法 利用计算机检索已公开发表的有关糖皮质激素治疗ARDS的中英文文献,按纳入、排除标准纳入合格文献并进行质量评价,采用Rev Man 5.0软件进行Meta分析.结果 共纳入8项独立研究,含ARDS患者679例(激素组366例,对照组313例),Meta分析结果显示激素组与对照组相比,总病死率、早期治疗患者病死率、小剂量治疗患者病死率、氧合指数(PaO_2/FiO_2)的差异有统计学意义(P<0.05),合并相对危险度(RR)或标准化均数差(SMD)及95%置信区间(CI)依次为0.55(0.34～0.87),0.49(0.28～0.86),0.46(0.24～0.88),2.99(0.63～5.34).而晚期治疗患者病死率、大剂量治疗患者病死率、新发感染率的差异均无统计学意义(P>0.05).结论 早期激素治疗或小剂量激素治疗能够降低ARDS患者的病死率;激素应用后氧合情况有显著改善;激素治疗没有显著增加或减少感染性并发症的发病率.