急性呼吸窘迫综合征44例综合治疗分析

目的探讨急性呼吸窘迫综合征（ARDS）的有效治疗方法。方法对44例ARDS患者采用气管插管或气管切开施行机械通气治疗,通气模式为同步间隙指令通气（SIMV）加呼气末正压（PEEP）。同时积极治疗原发病,采用控制炎症反应、尽快纠正休克、保护脏器功能等综合措施。结果本组44例经综合治疗后,痊愈31例,发生呼吸机相关性肺炎（VAP）3例,无气胸、纵隔气肿发生。结论选择正确的机械通气模式,积极治疗原发病,采用控制炎症反应、尽快纠正休克、保护脏器功能等综合措施是治疗ARDS的有效方法。     

持续无创正压通气治疗巨细胞病毒肺炎并急性呼吸窘迫综合征疗效分析

目的:探讨持续无创正压通气对肾移植术后巨细胞病毒(cytomegalovirus,CMV)肺炎合并ARDS患者的疗效。方法:34例肾移植术后CMV肺炎合并ARDS患者,在早期抗病毒治疗、调整免疫抑制方案等综合治疗措施的基础上,全部给予持续无创正压通气治疗,观察其疗效。结果:34例患者中,持续无创正压通气治疗有效23例,有效率为68%;无效11例,改行气管插管机械通气治疗,气管插管机械通气率为32%,其中3例治愈出院,8例死亡。有效的23例患者治疗后2小时、24小时、48小时及治疗结束时的动脉血氧分压、氧合指数及呼吸频率较治疗前均有改善(均为P<0.01)。26例出现较轻的不良反应,经对症处理后均可好转。结论:持续无创正压通气可改善肾移植术后CMV肺炎合并ARDS患者的低氧血症,缓解呼吸窘迫症状,降低气管插管机械通气率,从而避免机械通气的相关并发症,降低病死率,该法不良反应轻,值得在临床推广使用。     

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。     

氯氮平中毒继发急性肺损伤/急性呼吸窘迫综合征的抢救体会

目的:探讨氯氮平中毒继发急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)有效的治疗方法。方法:总结分析16例氯氮平中毒继发ALI/ARDS患者的临床表现和治疗方法。患者在中毒后6～144h出现ALI/ARDS表现,予气管插管、机械通气,抗胆碱药物治疗及血液灌流等综合治疗。结果:本组患者均治愈,平均住院时间(14±1.6)d;机械通气时间平均(134±12)h,中毒后(48～96)h意识转清。结论:氯氮平中毒继发的急性肺损伤/急性呼吸窘迫综合征主要与肺水肿、吸入性肺炎及氯氮平对肺组织的直接损伤作用有关。早期进行机械通气联合血液灌流和合理抗胆碱药物的,是治疗重度氯氮平重度并发急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)的有效方法。     

ARDS应用机械通气38例分析

我院ICU 2001-06~2006-06共收治急性呼吸窘迫综合征(ARDS)患者38例,应用机械通气治疗救治成功22例,现分析如下。1临床资料本组男25例,女13例,年龄22~75岁。均符合1992年欧美ARDS联席会议提出的诊断标准[1]。诱发疾病:严重感染16例,急性出血坏死性胰腺炎12例,多发性创伤8例,中毒2例。2结果本组进入ICU后均使用机械通气治疗,平均带机时间19d。无创面罩通气4例,经口、鼻气管插管25例,经气管切开9例。采用俯卧全通气治疗12例,有效8例。最终抢救成功22例,死亡16例。3讨论3.1参数的设置ARDS的病理生理改变决定了大量肺泡发生水肿和萎缩,使…     

特重度烧伤并发急性呼吸窘迫综合征的护理

我科2004-05~2006-10收治特重度烧伤并发急性呼吸窘迫综合征(ARDS)16例,护理体会如下。1临床资料1.1一般资料本组均为男性,年龄18~56(平均35.6)岁。烧伤面积:51%~60%9例,61%~90%7例;急诊气管切开12例;平均通气时间25.5 d。ARDS发生于患者就诊24~48 h,均符合中华医学会呼吸病学组ARDS诊断标准[1]。1.2方法本组均入住ICU严密监护并实施机械通气等护理干预。其中,实施无创持续正压通气(CPAP)治疗2例,设定呼气末气道内正压(PEEP)为8~10 cm H2O;气管插管/气管切开14例,有创机械通气模式采用间歇指令呼吸(S IM V)加PEEP或S IM V加…     

严重急性呼吸综合征治疗中机械通气新模式的探讨

2003年春天,在我国局部及世界其他国家和地区出现的严重急性呼吸综合征(SARS)疫情中,机械通气在治疗中发挥了重要作用。2002年12月～2003年9月,我们共收治10例,均应用机械通气治疗,体会报告如下。1临床资料我们急救中心急诊ICU收治达到成人呼吸窘迫综合征(ARDS)诊断标准并气管插管持续机械通气7天以上的患者9例;省胸科医院收治SARS临床诊断患者1例,持续气管插管机械通气5天以上,进行综合治疗后均安全出院。在机械通气治疗过程中,采取非传统的辅助治疗方法,取得了良好的效果。     

呼吸支持为重点抢救钩吻中毒的护理对策

目的:总结钩吻中毒的急救护理经验。方法:对钩吻中毒31例患者,立即给予呼吸、心电、血氧饱和度等监护。常规备气管插管及呼吸机,并设定机械通气初始参数,做好气管插管及机械通气的舒适护理,做好患者及其家属的全程心理护理。结果:预防性气管插管15例,抢救性气管插管6例,共计需要机械通气者21例。治愈出院29例,死亡2例。结论:确立呼吸支持第一的急救理念和做好气管插管及机械通气的舒适护理是钩吻中毒急救的关键护理措施。     

有创与无创双水平气道正压通气序贯治疗急性呼吸窘迫综合征

目的:探讨有创与无创双水平气道正压通气(bi-level positive airway pressure,BiPAP)序贯治疗急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的疗效。方法:将重症监护病房(intensive care unit,ICU)76例ARDS患者随机分为有创与无创BiPAP序贯治疗组(A组)38例和常规同步间歇指令通气(synchronized intermittent mandatory ventilation,SIMV)组(B组)38例。所有患者均按ARDS常规治疗,尽早气管插管行SIMV,当"ARDS控制窗"出现时,A组拔除气管插管,改用鼻面罩无创BiPAP序贯治疗,B组继续SIMV治疗,以SIMV+压力支持通气(pressure support ventilation,PSV)模式撤机。结果:2组患者"ARDS控制窗"出现时间、生命体征的指标和动脉血气分析的指标比较差异均无统计学意义(P0.05);与B组比较,A组有创通气时间及总机械通气时间均减少,入住ICU时间缩短,呼吸机相关性肺炎(ventilator associated pneumonia,VAP)发生率、病死率均降低(P0.05)。结论:有创与无创BiPAP序贯治疗ARDS的疗效显著,可明显缩短机械通气时间,降低VAP发生率及病死率。     

抢救SARS时气管插管方式与医务人员感染的分析

SARS是一种急性呼吸系统疾病 ,病情严重时发生急性呼吸窘迫综合征(ARDS) ,是导致患者死亡的主要原因。在治疗原则中重要措施之一就是尽早气管插管 ,采取正压机械通气 ,充分供氧 ,改善低氧血症 ,预防肺泡萎缩 ,治疗多器官衰竭 (MOF)。但由于 SARS发展到ARDS时有病情重、病原毒力强和呼吸道传染性强的特点 ,在行气管插管时 ,医务人员与患者近距离接触 ,极易造成医务人员的感染。现就几种气管插管的方式与医务人员感染的关系分析如下。1　常规清醒气管插管这种方法是在争取患者充分合作的基础上 ,在喉镜直视下经口或经鼻进行的明视气管…     

百草枯中毒致肺损害与急性肾功能衰竭治疗探讨

目的:观察百草枯中毒致肺损害和肾功能的变化,以探讨其抢救和治疗措施。方法:回顾性分析我院48例百草枯中毒并发肺损害和急性肾功能衰竭(ARF)患者的临床表现、X线胸片、血气分析和肾功能。结果:服毒后3天开始出现肺损害,7天达到高峰;肾功能衰竭和肺损害先后发生,严重者表现出急性呼吸窘迫综合征(ARDS)和ARF,死亡率达64.6%。所有患者均给予糖皮质激素治疗。ARDS病例接受对症治疗,部分使用呼吸机行机械通气治疗,效果不明显。肾功能损害者要接受对症治疗,个别行血液灌洗治疗,肾功能有所改善。结论:百草枯中毒致肺损害和肾损害的发生时间早、进展快、易引起ARDS和ARF,死亡率高,患者宜早期治疗。     

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。     

Treatment of postoperative respiratory distress syndrome

We have studied 45 patients with postoperative adult respiratory distress syndrome (ARDS) who were treated by mechanical ventilation during the last four years. This period was divided into two periods, and the mortality and progress after treatment were analysed. The overall mortality was 56%. In the first period this rate was as high as 76%, while in the second period this rate improved to 43%. This improvement in the second period was thought to have resulted from aggressive cardiorespiratory treatment and the diminution of infection.According to the course of ARDS after treatment, four types could be classified. Type 1 showed rapid improvement in respiratory function. Type 2 showed gradual improvement. Type 3 showed relapse of respiratory failure. Type 4 resisted mechanical ventilation. Patients of types 3 and 4 had extremely poor prognoses. Stricter management to avoid infection, specific treatment of multiple organ failure (which was seen frequently) seemed advantageous. High frequency positive pressure ventilation (HFPPV) may have some role in improving the respiratory function of the patients with ARDS.     

Effects of partial ventilatory support modalities on respiratory function in severe hypoxemic lung injury

OBJECTIVE: The early phase of acute respiratory distress syndrome (ARDS) is characterized by impaired respiratory mechanics, ventilation-perfusion mismatch, and severe hypoxemia. Partial ventilatory support can effectively unload the respiratory workload and improve pulmonary gas exchange with less hemodynamic compromise. The partial ventilatory support mode most indicated in early phases of ARDS has not been determined. This study compares the effects of assisted ventilatory techniques on breathing pattern, gas exchange, hemodynamic function, and respiratory effort with those of controlled mechanical ventilation in similarly sedated subjects. DESIGN: Prospectively randomized crossover animal study. SETTING: Animal research laboratory. SUBJECTS: Eleven anesthetized and mechanically ventilated pigs. INTERVENTIONS: Acute lung injury was induced by lung lavage. Pressure-controlled ventilation (PCV), pressure-controlled assisted ventilation (P-ACV), bilevel positive airway pressure (BIPAP), and pressure support ventilation (PSV) with equal airway pressures and sedation were applied in random order. MEASUREMENTS AND MAIN RESULTS: Gas exchange, respiratory effort, and hemodynamic function were measured, and ventilation-perfusion distributions were calculated by multiple inert-gas-elimination techniques. The results revealed that partial ventilatory support was superior to PCV in maintaining adequate oxygenation and hemodynamic function with reduced sedation. The effects of P-ACV, BIPAP, and PSV were comparable with respect to gas exchange and hemodynamic function, except for a more pronounced reduction in shunt during BIPAP. P-ACV and PSV were superior to BIPAP to reduce respiratory drive and work of breathing. PSV affected the pattern of breathing and deadspace to a greater degree than did P-ACV. CONCLUSIONS: In acute lung injury, P-ACV preserves oxygenation and hemodynamic function with less respiratory effort compared with BIPAP and reduces the need for sedation compared with PCV.     

Mechanical ventilation in children with acute respiratory failure

PURPOSE OF REVIEW: Acute respiratory failure requiring mechanical ventilation continues to contribute to mortality and affect long-term functional outcomes in patients admitted to the pediatric intensive care unit (ICU). Studies in adults with acute respiratory distress syndrome (ARDS) far outnumber those conducted in the pediatric age group, and pediatric intensivists are left with the task of carefully selecting and critically appraising relevant adult data and extrapolating results to their domain of practice. RECENT FINDINGS: The recent ARDSNet study reinforces the use of low tidal volumes. Administration of surfactant is safe, but once again its beneficial effect was not sustained in a randomized trial. Surfactant proteins A and D have been shown to be of prognostic value in cases of acute lung injury. The effect of inhaled nitric oxide (NO) in patients with ARDS can be enhanced by aggressive lung recruitment strategies such as can be achieved using high-frequency oscillatory ventilation (HFOV). A recent adult trial shows good response rates but no significant long-term outcome benefit from prone positioning in patients with ARDS. Routine scheduled assessments of readiness for weaning and extubation may be more important than specific weaning modes and weaning criteria for children. A recent meta-analysis suggests that prophylactic dexamethasone use may decrease postextubation stridor and possibly reduce the need for reintubation in selected patients. Outcome data in children requiring mechanical support is encouraging, especially for high-risk groups such as bone marrow transplant (BMT) recipients, and may guide ethically challenging decision-making for these patients. SUMMARY: Mechanical ventilation strategies aiming for optimal alveolar recruitment with the judicious use of positive end-expiratory pressure (PEEP) and low tidal volumes will remain the mainstay for managing respiratory failure in children. Dexamethasone may prevent postextubation stridor. Prone positioning, surfactant therapy, HFOV, and inhaled NO are used sporadically and need to be evaluated for their effect on mortality and duration of ventilation.     

Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis

CONTEXT: The incidence of acute cor pulmonale (ACP), a frequent and usually lethal complication of acute respiratory distress syndrome (ARDS) during traditional respiratory support, has never been re-evaluated since protective ventilation gained acceptance. OBJECTIVE: We performed a longitudinal transesophageal echocardiographic (TEE) study to determine whether this incidence, and its severe implications for prognosis, might have changed in our unit as we altered respiratory strategy. DESIGN: Prospective open clinical study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Seventy-five consecutive ARDS patients given respiratory support with airway pressure limitation (plateau pressure < or =30 cm H2O). INTERVENTIONS: ACP was defined as a ratio of right ventricular end-diastolic area to left ventricular end-diastolic area in the long axis >0.6 associated with septal dyskinesia in the short axis during TEE examination. RESULTS: Normal right ventricular function was present in 56 patients, whereas right ventricular dysfunction was observed in 19 patients after 2 days of respiratory support. ACP was associated with pulmonary artery hypertension, increased heart rate, and decreased stroke index. Significant impairment of left ventricular diastolic function was also seen. All echo-Doppler abnormalities were reversible in patients who recovered, and the mortality rate was the same in both groups (32%). However, ACP patients who recovered required a longer period of respiratory support. A multivariate analysis individualized Paco2 level as the sole factor independently associated with ACP, suggesting that ACP development in ARDS is influenced by the severity of lung damage and/or the respiratory strategy. CONCLUSION: Evaluation of right ventricular function by TEE in a group of 75 ARDS patients submitted to protective ventilation revealed the persistence of a 25% incidence of ACP, resulting in detrimental hemodynamic consequences associated with tachycardia. However, ACP was reversible in patients who recovered and did not increase mortality.     

Science review: mechanisms of ventilator-induced injury

Acute respiratory distress syndrome (ARDS) and acute lung injury are among the most frequent reasons for intensive care unit admission, accounting for approximately one-third of admissions. Mortality from ARDS has been estimated as high as 70% in some studies. Until recently, however, no targeted therapy had been found to improve patient outcome, including mortality. With the completion of the National Institutes of Health-sponsored Acute Respiratory Distress Syndrome Network low tidal volume study, clinicians now have convincing evidence that ventilation with tidal volumes lower than those conventionally used in this patient population reduces the relative risk of mortality by 21%. These data confirm the long-held suspicion that the role of mechanical ventilation for acute hypoxemic respiratory failure is more than supportive, in that mechanical ventilation can also actively contribute to lung injury. The mechanisms of the protective effects of low tidal volume ventilation in conjunction with positive end expiratory pressure are incompletely understood and are the focus of ongoing studies. The objective of the present article is to review the potential cellular mechanisms of lung injury attributable to mechanical ventilation in patients with ARDS and acute lung injury.     

动态通气参数对急性呼吸窘迫综合征犬肺外炎症反应和肺外脏器功能的影响

目的 观察机械通气动态通气参数对急性呼吸窘迫综合征(ARDS)犬肺外炎症介质水平及肺外脏器功能的影响.方法 36条健康杂种犬,按照随机数字表法分为正常对照组(N组)、ARDS模型组(M组)及机械通气A-D组6组.采用气管内盐酸吸入法建立ARDS模型,按下述方案行机械通气.A组(LVLYHR):小潮气量、低吸气流速、高通气频率;B组(HVHFHR):大潮气量、高吸气流速、高通气频率;C组(HVHFLR):大潮气量、高吸气流速、低通气频率;D组(HVIYLR):大潮气量、低吸气流速、低通气频率.分组机械通气后4 h后处死动物,留取血清用放射性免疫吸附法行IL-8和TNF-α检测;留取肝肾组织行病理学检查.数据处理运用方差分析,以P<0.05为差异具有统计学意义.结果 B组、C组血中IL-8和TNF-α含量显著高于M组、A组、D组(P<0.05),A组、D组和M组差异无统计学意义(P>0.05).N组与其他相比差异具有统计学意义(P<0.05).B组肝肾组织病理学改变最为严重,C组较B组稍有减轻.A组和D组的病理学改变较B、C组明显减轻,A组和M组改变接近.结论 大潮气量、高吸气流速、高通气频率机械通气可以使血清炎症介质水平升高,加重肺外器官的炎症反应;降低通气频率及吸气流速,对防治多器官功能衰竭有重要意义.     

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.     

胸及上腹部手术后肺不张与呼吸衰竭的治疗体会

目的　探讨胸及上腹部手术后肺不张与呼吸衰竭的治疗方法。方法　术后肺不张患者 2 8例 ,全部行纤维支气管镜检查 ,术后呼吸衰竭需机械通气 18例 ,包括成人呼吸窘迫综合征 (ARDS) 5例 ,对ARDS患者采取保护性通气策略。结果　 2 3例粘稠痰液阻塞一侧主支气管或叶支气管 ,5例气管腔内只有少许粘液。治疗后 2 7例肺完全复张 ,1例死亡。呼吸衰竭患者机械通气时间 2～ 4d ,17例治愈 ,1例死亡。结论　用纤维支气管镜诊治胸及上腹部术后肺不张是相对安全有效的方法 ,但应考虑到各种不利因素 ,做好抢救准备。对呼吸衰竭需机械通气的患者 ,应判明有否ARDS ,采用相应的通气模式及参数