1例危重型新型冠状病毒肺炎合并ARDS患者的成功救护

目的 总结1例重症新型冠状病毒肺炎继发ARDS患者在ICU期间的治疗和护理。方法 回顾其临床资料、治疗及护理方案,包括消毒与隔离、抗病毒用药不良反应观察、序贯性呼吸治疗支持、俯卧位通气治疗、雾化联合机械辅助排痰、标本采集、营养支持、早期功能锻炼等8个方面内容,进行案例经验总结。结果 通过对症支持治疗及护理,患者入科后第20天新型冠状病毒核酸检测转为阴性,入科第38天时彻底脱机,入科第55天时拔除气管切开导管,病情日益好转,转出ICU,科室医务人员零感染。结论 新型冠状病毒肺炎为突发的公共卫生事件,临床缺乏经验,本案例的成功救治经验,可为临床提供借鉴。     

侧卧位通气治疗新型冠状病毒肺炎重症患者的临床研究

目的探讨侧卧位通气对重症新型冠状病毒肺炎（COVID-19）患者的临床价值。 方法采用回顾性研究,收集2020年1月20日至3月7日在重庆三峡中心医院重症应急病区住院的41例COVID-19并中、重度急性呼吸窘迫综合征（ARDS）患者的临床资料。在经鼻高流量湿化氧疗（HFNC）或无创通气（NIV）的基础上,按是否进行侧卧位通气将患者分为侧卧位组（24例）和仰卧位组（17例）。统计2组患者的性别、年龄、急性生理与慢性健康状况（APACHEⅡ）评分和合并基础疾病情况,比较治疗前及治疗后第1、3、5天的心率（HR）、呼吸频率（RR）、氧合指数（PaO₂/FiO₂）、二氧化碳分压（PaCO₂）、平均动脉压（MAP）,以及轻症化率、HFNC或NPPV时间、气管插管发生率、住院时间、压疮发生情况等预后指标。 结果41例患者中,男性21例,女性20例;年龄43~79岁,平均（60.9±11.1）岁。2组患者年龄、性别、APACHEⅡ评分、合并基础疾病,以及治疗前RR、PaO₂/FiO₂、PaCO₂和MAP等比较,差异均无统计学意义（P均＞0.05）。2组患者治疗后HR、RR、MAP较治疗前下降,而PaCO₂、PaO₂/FiO₂上升,其中PaO₂/FiO₂在第5天较治疗前明显改善［侧卧位组：（166.4±45.4）mmHg vs（253.0±66.0）mmHg,仰卧位组：（183.8±54.4）mmHg vs（227.4±62.8）mmHg,P均＜0.05,1 mmHg=0.133 kPa］。2组间比较,侧卧位组在治疗后第1天RR较仰卧位组降低（P=0.006）;侧卧位组的中、重度ARDS患者PaO₂/FiO₂在治疗后第5天较仰卧位组改善,差异有统计学意义［（260.8±58.5）mmHg vs （221.6±64.9）mmHg,P=0.043］。2组HFNC或NIV时间和气管插管发生率比较,差异无统计学意义（P均＞0.05）,而侧卧位组总住院时间明显短于仰卧位组,差异有统计学意义［（15.5±7.2）d vs （21.5±9.8）d,P=0.028］,ICU住院时间也短于仰卧位组,差异有统计学意义［（10.3±6.3）d vs （16.9±11.0）d,P=0.021］,侧卧位组病死率低于仰卧位组,差异有统计学意义（8.3 % vs 23.5 %,P = 0.047）。 结论侧卧位通气能改善COVID-19并中、重度ARDS患者的氧合,缩短住院时间,降低病死率,提高疗效,促进患者康复。     

新型冠状病毒肺炎急性呼吸窘迫综合征的血流动力学治疗

由于新型冠状病毒肺炎的特殊性,新型冠状病毒肺炎急性呼吸窘迫综合征患者既有传统急性呼吸窘迫综合征的血流动力学特点,又有其特别之处。血流动力学治疗是新型冠状病毒肺炎急性呼吸窘迫综合征患者的核心治疗手段,肺内血流分布状态和右心-肺循环单元的血流改变其是核心环节。重症超声为基础的多元监测有助于精细地描述新型冠状病毒肺炎急性呼吸窘迫综合征的血流动力学特点,导向肺血流分布调节-右心-左心一体化精准治疗。由于治疗与伤害并存,贯彻保护与预警理念对患者的早期救治及预后改善尤为重要。     

重度ARDS患者应用ECMO治疗的气道护理

正体外膜肺氧合(ECMO)是指将患者静脉血引出,经人工肺(氧合器)氧合后重新回输入患者动脉或静脉内,代替部分心肺功能的支持手段,为治疗原发病争取时间[1]。2019年2月15日～3月26日,我们收治4例重度急性呼吸窘迫综合征(ARDS)使用ECMO治疗的患者,经过积极治疗和精心护理后     

重症新型冠状病毒肺炎呼吸治疗流程专家建议

新型冠状病毒肺炎以发热、干咳、乏力为主要表现,多数患者在1周后出现呼吸困难,严重者快速发展为急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)。国家卫生健康委发布的《新型冠状病毒感染的肺炎重症、危重症病例诊疗方案(试行)》[1]中关于重症和危重症的主要临床诊断标准即为存在不同严重程度ARDS需要呼吸支持治疗。     

1例ECMO联合双重滤过血浆置换治疗危重型新型冠状病毒肺炎并发成人呼吸窘迫综合征的护理

对1例危重型新型冠状病毒肺炎病人应用体外膜肺氧合(ECMO)联合双重滤过血浆置换治疗(DFPP)的护理经验进行总结,认为ECMO联合DFPP治疗操作复杂且并发症较多,需要严密监测病人生命体征及做好ECMO及DFPP参数观察及管路护理,预见性地采取有效护理措施,以预防并发症。     

一例成人腺病毒肺炎合并ARDS患者的护理

成人腺病毒肺炎近些年的发病率和致死率逐渐升高。本文通过对一例成人腺病毒肺炎合并急性呼吸窘迫综合症（ARDS）的患者,进行积极的治疗配合科学的护理措施,包括：消毒隔离、俯卧位通气治疗、镇静护理、高热护理,并发症观察与预防、心理护理,能够有效的控制病情的进一步发展,使患者得到好转,趋于稳定后转入病房予继续治疗。     

中西医结合治疗肾移植术后肺炎合并急性呼吸窘迫综合征4例

肾移植术后并发肺炎患者的病死率约为50％，合并急性呼吸窘迫综合征(ARDS)则病死率更高。肾移植术后主要死因中肺部感染占第一位。因此，肾移植术后肺炎的治疗对于提高肾移植患者生存率有重要意义。我们于2002年7-10月连续救治4例肾移植术后肺炎合并ARDS患者，均获得成功，报告如下。     

重症新型冠状病毒肺炎:是急性呼吸窘迫综合征吗？

新型冠状病毒肺炎(coronavirus disease 2019,COVID-19)在全球暴发流行,危害严重。虽然目前临床研究和尸检结果提高了人们对COVID-19的认识,但仍存在诸多争议,最大的争议之一即为重症COVID-19是否可诊断为急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)。重症COVID-19符合ARDS柏林标准,但与其他原因导致的ARDS存在诸多不同之处,包括发病晚、部分患者肺顺应性相对正常、高碳酸血症出现较早、肺CT表现和肺凝血活化明显。目前对COVID-19相关ARDS的分型多基于观察性研究,偏倚较大。至今其病理生理过程尚未明确,过早分型可能误导机械通气策略,期待大样本临床研究结果带来更多证据。     

体外膜肺氧合对重度急性呼吸窘迫综合征患者远期预后的影响

体外膜肺氧合(ECMO)治疗改善重度急性呼吸窘迫综合征(ARDS)患者的生存,但存活的患者仍面临远期存活率低、生存质量不佳等问题,主要表现为身体功能下降、精神障碍、社会特征改变等。深入了解ECMO患者远期预后及其相关影响因素,有助于指导优化ECMO治疗及改善ECMO患者的远期预后。     

无泵体外膜肺氧合治疗急性呼吸窘迫综合征的实验研究

目的观察无泵型体外膜肺氧合(ECMO)对ARDS的治疗效果。方法用已知方法建立ARDS动物模型,分别进行单纯呼吸机辅助及无泵ECMO 呼吸机辅助的治疗。结果组Ⅰ在治疗后8h内均发生严重呼衰,很快死亡。组Ⅱ可保持SaO2在90%以上,PEEP水平较低,且治疗后肺动脉压(PAP)显著降低(P<0.05)。而当单用ECMO时SaO2降至(84.1±2.1)%。结论对于心功能正常的急性肺损伤,无泵ECMO是一种有效、简便、易行的呼吸辅助方法。     

Efficacy of convalescent plasma therapy in severe COVID-19 patients

IntroductionThe use of convalescent plasma (CP) transfusions is very valuable in the current COVID-19 outbreak, given that there are no specific preventive and therapeutic options.Materials and methods50 patients with severe COVID-19 disease treated with convalescent plasma transfusion were included in the study. The efficacy of CP and in which situations it was effective were investigated.Conclusion80 % of the patients recovered, and 20 % died in our study. The mean age of the patients who died was found to be higher than the patients who recovered. CRP, ferritin, D-dimer, neutrophil, MPV, and NLR counts were found to be higher, and lymphocyte and platelet counts were lower in the deceased group after CP. It was determined that patients who received CP within the first five days were hospitalized for a shorter period.DiscussionAdministration of CP transfusion within the first five days in severe COVID-19 patients has been shown to reduce hospital stay length.     

Quantitative-analysis of computed tomography in COVID-19 and non COVID-19 ARDS patients: A case-control study

PurposeThe aim of this study was to assess whether the computed tomography (CT) features of COVID-19 (COVID+) ARDS differ from those of non-COVID-19 (COVID−) ARDS patients.Materials and methodsThe study is a single-center prospective observational study performed on adults with ARDS onset ≤72 h and a PaO₂/FiO₂ ≤ 200 mmHg. CT scans were acquired at PEEP set using a PEEP-FiO₂ table with VT adjusted to 6 ml/kg predicted body weight.Results22 patients were included, of whom 13 presented with COVID-19 ARDS. Lung weight was significantly higher in COVID− patients, but all COVID+ patients presented supranormal lung weight values. Noninflated lung tissue was significantly higher in COVID− patients (36 ± 14% vs. 26 ± 15% of total lung weight at end-expiration, p < 0.01). Tidal recruitment was significantly higher in COVID− patients (20 ± 12 vs. 9 ± 11% of VT, p < 0.05). Lung density histograms of 5 COVID+ patients with high elastance (type H) were similar to those of COVID− patients, while those of the 8 COVID+ patients with normal elastance (type L) displayed higher aerated lung fraction.     

Long-term physical impairments in survivors of COVID-19-associated ARDS compared with classic ARDS: A two-center study

PurposeThis work aimed to compare physical impairment in survivors of classic ARDS compared with COVID-19–associated ARDS (CARDS) survivors.Material and methodsThis is a prospective observational cohort study on 248 patients with CARDS and compared them with a historical cohort of 48 patients with classic ARDS. Physical performance was evaluated at 6 and 12 months after ICU discharge, using the Medical Research Council Scale (MRCss), 6-min walk test (6MWT), handgrip dynamometry (HGD), and fatigue severity score (FSS). We also assessed activities of daily living (ADLs) using the Barthel index.ResultsAt 6 months, patients with classic ARDS had lower HGD (estimated difference [ED]: 11.71 kg, p < 0.001; ED 31.9% of predicted value, p < 0.001), 6MWT distance (ED: 89.11 m, p < 0.001; ED 12.96% of predicted value, p = 0.032), and more frequent significant fatigue (OR 0.35, p = 0.046). At 12 months, patients with classic ARDS had lower HGD (ED: 9.08 kg, p = 0.0014; ED 25.9% of predicted value, p < 0.001) and no difference in terms of 6MWT and fatigue. At 12 months, patients with classic ARDS improved their MRCss (ED 2.50, p = 0.006) and HGD (ED: 4.13 kg, p = 0.002; ED 9.45% of predicted value, p = 0.005), while those with CARDS did not. Most patients in both groups regained independence in ADLs at 6 months.COVID-19 diagnosis was a significant independent predictor of better HGD (p < 0.0001) and 6MWT performance (p = 0.001), and lower prevalence of fatigue (p = 0.018).ConclusionsBoth classic ARDS and CARDS survivors experienced long-term impairments in physical functioning, confirming that post-intensive care syndrome remains a major legacy of critical illness. Surprisingly, however, persisting disability was more common in survivors of classic ARDS than in CARDS survivors. In fact, muscle strength measured with HGD was reduced in survivors of classic ARDS compared to CARDS patients at both 6 and 12 months. The 6MWT was reduced and fatigue was more common in classic ARDS compared to CARDS at 6 months but differences were no longer significant at 12 months. Most patients in both groups regained independent function in ADLs at 6 months.     

新型冠状病毒肺炎重症患者的管理

自2019年12月以来,新型冠状病毒肺炎(简称:新冠肺炎,2019-nCoV)疫情已波及全国各省、直辖市和地区。截至到2020年2月7日24时,31个省(自治区、直辖市)和新疆生产建设兵团累计报告确诊病例31774例,其中重症病例6101例,累计死亡722例,治愈出院2050例。同时发现疑似病例27657例,并且尚在医学观察的密切接触者189660人[1]。更令人担心的是,近几日重症病例持续增多,新增死亡病例数仍持续增加,这一现象对重症医学的干预和管理提出了严峻挑战。