2022年ARDS通气策略宋立强资料

西京医院呼吸与危重医学科西京医院呼吸与危重医学科 宋立强宋立强急性呼吸窘迫综合征急性呼吸窘迫综合征 （Acute Respiratory Distress Syndrome，ARDS）心源性以外的各种肺内外致病因素心源性以外的各种肺内外致病因素 急性、进行性急性、进行性 缺氧性呼吸衰竭缺氧性呼吸衰竭导致导致1 肺间质肺间质2 肺泡肺泡(pulmonary edema due to infection)(pulmonary edema due to poison)(pulmonary edema due to drowning)(pulmonary edema in uremia)(pulmonary edema due to oxygen toxicity)ARDS肺水肿的肺水肿的成分：成分：l富含蛋白富含蛋白l细胞碎片细胞碎片l未激活的未激活的PSl中性粒细胞中性粒细胞l巨噬细胞巨噬细胞l炎症介质炎症介质l.参与反应的细胞 l中性粒细胞中性粒细胞l巨噬细胞巨噬细胞l上皮细胞上皮细胞l内皮细胞内皮细胞参与反应的介质 l氧自由基氧自由基l蛋白溶解酶蛋白溶解酶l花生四烯酸代谢物花生四烯酸代谢物l补体系统补体系统l凝血和纤溶系统凝血和纤溶系统lPAFlTNFlILl.ARDS发发病病的的炎炎症症机机制制ApexHilumBase病变分布有重力依赖性，病变分布有重力依赖性，从肺前部到背部从肺前部到背部 1.正常区正常区30%2.陷闭区陷闭区2030%3.实变区实变区4050%病理生理变化病理生理变化 1.间歇性分流间歇性分流2.切变力损伤切变力损伤3.肺循环阻力增加肺循环阻力增加病理生理变化病理生理变化 1.持续性分流持续性分流2.肺循环阻力增加肺循环阻力增加力学曲线变化力学曲线变化 1967年，年，Ashbaugh等首先描述等首先描述“成人中的急性呼吸窘迫成人中的急性呼吸窘迫”1971年，年，Petty等正式命名等正式命名“成人呼吸窘迫综合征（成人呼吸窘迫综合征（ARDS）”1992年，美欧共识会（年，美欧共识会（American-European Consensus Conference,AECC）l 急性呼吸窘迫综合征（急性呼吸窘迫综合征（Acute Respiratory Disease Syndrome，ARDS）l 首次提出首次提出ALIl 提出提出AECC标准标准AECC标准标准局限性局限性l病程病程急性起病急性起病无具体时间无具体时间lALIPaO2/FiO2300mmHg误解误解201-300mmHg为为ALIl氧合指数氧合指数PaO2/FiO2200mmHg，未考虑未考虑PEEP水平水平不同的不同的PEEP及及FiO2，PaO2/FiO2也不同也不同l胸片胸片双肺弥漫性浸润双肺弥漫性浸润缺乏客观评价指标缺乏客观评价指标lPAWPPAWP18mmHg，无左心，无左心房高压房高压ARDS及高水平及高水平PAWP可同时存可同时存在，在，PAWP有不确定性有不确定性An early PEEP/FIO2 trial identifies different degrees of lung injury in patients with acute respiratory distress syndrome.Am J Respir Crit Care Med.2007；15;176(8):795-804.l在（在（day1）时间点）时间点 FiO20.5+PEEP 10，30min条件下条件下l重新分类为重新分类为ARDS,ALI,ARFl 29%ARDS患者患者PAWP18mmHg（或（或CVP升高）升高）,而其中而其中97%PAWP升高的升高的ARDS患者中有正常的心脏功能。患者中有正常的心脏功能。结论：结论：PAWP或或CVP升高不能作为升高不能作为ARDS的排除标准的排除标准。Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.N Engl J Med.2006 May 25;354(21):2213-24.CVPPAWP818ARDS的诊断及病情分级的诊断及病情分级1.发病时间发病时间1周以内起病、或新发、或恶化的呼吸症状周以内起病、或新发、或恶化的呼吸症状2.胸部影像学胸部影像学双肺模糊影双肺模糊影 不能完全由渗出、肺塌陷或结节来解释不能完全由渗出、肺塌陷或结节来解释3.肺水肿起因肺水肿起因不能完全由心力衰竭或容量过负荷解释的呼吸衰竭不能完全由心力衰竭或容量过负荷解释的呼吸衰竭，没有发现危险因素时可行超声心动图等检查排除血流源性肺水肿没有发现危险因素时可行超声心动图等检查排除血流源性肺水肿4.氧合指数氧合指数轻度轻度200 mmHg PaO2/FiO2300mmHg with PEEP 5cmH2O中度中度100 mmHg PaO2/FiO2200mmHg with PEEP 5cmH2O重度重度 PaO2/FiO2100mmHg with PEEP 5cmH2O Overdistention 过度扩张过度扩张 l Barotrauma压力伤压力伤l Volutrauma容量伤容量伤 Recruitment/Derecruitment Injury （Atlectrauma）剪切伤剪切伤/萎陷伤萎陷伤 Translocation of Cells 细胞形态移位细胞形态移位 Biotrauma 生物伤生物伤 Oxidant Injury 氧中毒氧中毒“Shear”Recruitment/Derecruitment Injury 跨肺压跨肺压l若用若用30cmH2O的正的正压通气，则压通气，则跨肺压跨肺压约约35cmH2O。l两个肺单位之间产两个肺单位之间产生高达生高达140cmH2O的的切变力切变力。Bilek,A.M.D.P.Gaver IIIJ Appl Physiol 94:770-783,2003 Disrupting the alveolar epithelium Tearing in capillary endothelium Inciting EventPMNs/MacsEndotheliumEpitheliumAdhesionProteasesO2 radicalsCoagulationProteinsCytokinesIL-6IL-8IL-10IL-8-RATNF-aENA-78MIP-1aTransferrinPAFComplementLPBLTB4LTC4 BiophysicalInjury shear overdistention cyclic stretch D intrathoracicpressure alveolar-capillarypermeability cardiac output organ perfusionBiochemical Injury (Biotrauma)cytokines,complement,PGs,LTs,ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistal Organ DysfunctionMechanical VentilationSlutsky,Tremblay Am J Resp Crit Care Med.1998;157:1721-5DEATHOxidant injury-keep FiO2 60 Barotrauma-keep alveolar inflation pressures 35 cm H2OVolutrauma-Baby lung concept or stretch injuryAtelectrauma-repeated opening and closingBiotrauma-release of inflammatory mediators and bacterial translocationOPEN GENTLY AND KEEP THEM OPEN温柔的打开肺泡，并保持开放温柔的打开肺泡，并保持开放Whitehead T,Slutsky AS.Thorax.2002;57:636 小潮气量小潮气量（6 mlkg理想体重）理想体重）允许性高碳酸血症允许性高碳酸血症 控制气道平台压控制气道平台压30 cmH 2O 使用合适的使用合适的PEEPl 是迄今为止少有的被大规模随机对照研究证实，是迄今为止少有的被大规模随机对照研究证实，能降低能降低ARDSARDS患者死亡率的治疗措施。患者死亡率的治疗措施。提提高高治治疗疗干干预预强强度度轻度轻度ARDS中度中度ARDS严重严重ARDS小潮气量通气小潮气量通气更高水平更高水平PEEP无创通气无创通气低低-中水平中水平PEEP俯卧位通气俯卧位通气神经肌肉阻滞剂神经肌肉阻滞剂高频振荡通气高频振荡通气ECCO2-RECMO300 250 200 150 100 50Tidal volume Plateau pressurespHPEEPVC vs PCVRecruitment maneuversHigh-frequency oscillatoryProne positioningECMO潮气量潮气量平台平台压压允许允许性高碳酸血症性高碳酸血症呼气末正压呼气末正压定容与定压定容与定压手法复张手法复张高频振荡通气高频振荡通气俯卧位通气俯卧位通气体外膜氧合体外膜氧合肺通气保护策略在儿童ARDS中的应用2000年年 NEJM，861名成人名成人ARDS患者患者治疗组：小潮气量（治疗组：小潮气量（4-6ml/kg）,限制压力（平台限制压力（平台压压30cmH2O），允许性高碳酸血症但保持），允许性高碳酸血症但保持pH大大于于7.3 显著改善预后显著改善预后l病死率病死率 39.8%31%l自主呼吸天数自主呼吸天数 10天天12天天l首次为小潮气量通气模式提供可靠的循证医学首次为小潮气量通气模式提供可靠的循证医学证据证据 ARDS Net.2000Hager DN et al.Tidal Volume Reduction in Patients with Acute Lung Injury When Plateau Pressures Are Not High.AJRCCM 2005.Vol 172 1241-1245多个研究比较多个研究比较*死亡率死亡率787 patients from ARDS Network study平台压平台压死死亡亡率率30PEEP：较高的呼气末正压(Meta)Briel M,Meade M,Mercat A,et al.Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome.JAMA 2010;303(9):86573.l 医院死亡率医院死亡率l ICU死亡率死亡率l 气胸气胸l 气胸后死亡气胸后死亡l 脱机时间脱机时间允许性高碳酸血症的通气策略33流程图起始选择与设置起始选择与设置l 潮气量：潮气量：VT of 8mL/kg vs VT of 1015 mL/kgl PEEP：titrating PEEP as high as possible without increasing the maximal PEI to greater than 30 cm H2OPurpose:To determine whether ventilation with low tidal volume(VT)and limited airway pressure or higher positive end-expiratory pressure(PEEP)improves outcomes for patients with ARDS or acute lung injuryl住院死亡率住院死亡率l随访死亡率随访死亡率l气压伤气压伤l因严重低氧所致因严重低氧所致抢救性治疗的应用率抢救性治疗的应用率l抢救性治疗的死亡率抢救性治疗的死亡率l第第1 1天的天的PaOPaO2 2lroutine use of low VT tends to be beneficial in all patients with acute lung injury or ARDS because this ventilation strategy improved hospital mortality.l Higher PEEP strategies during lower VT ventilation did not improve hospital mortality and cannot be recommended in unselected patients with acute lung injury or ARDS.lHigher PEEP strategies during lower VT ventilation may prevent life-threatening hypoxemia.PCV的优点的优点:variable flow so more comfortable if dys-synchrony,prolong i time for oxygenation,control peak pressuresRCT multicenter,79 patients with ARDSPCV(n-37)versus VCV(n=42).P plat 35 cm H2OlNo difference in mortalityltrend to more renal failure in VCV grouplBUT patients in VCV group had a higher in-house mortality related to higher number of extra-pulmonary organ failures(78%vs 51%)（TV 8cc/kg of weight）A recent systematic review analyzed 40 studies that evaluated RMs;（4 were RCTs,32 prospective studies,and 4 retrospective cohort studies）The sustained inflation method l45%：CPAP of 3550 cm H2O for 2040 seconds l23%：high pressure controll20%：incremental PEEPl10%：high VT/sighFan E,Wilcox ME,Brower RG,et al.Recruitment maneuvers for acute lung injury.Am J Respir Crit Care Med 2008;178(11):115663.Current evidence suggests that that RMs should not be routinely used on all ARDS patients unless severe hypoxemia persists or as a rescue maneuver to overcome severe hypoxemia,to open the lung when setting PEEP,or following evidence of acute lung derecruitment such as a ventilator circuit disconnect结论：结论：RM不常规用在所有的不常规用在所有的ARDS患者，除非持续的严患者，除非持续的严重低氧血症，或者做为严重低氧血症的一种肺开放手段重低氧血症，或者做为严重低氧血症的一种肺开放手段（设置（设置PEEP），或者由于管路断开出现急性肺陷闭），或者由于管路断开出现急性肺陷闭Fan E,Wilcox ME,Brower RG,et al.Recruitment maneuvers for acute lung injury.Am J Respir Crit Care Med 2008;178(11):115663.Computed tomography scan of the lungs showing ARDS when the patient is lyingsupine(left)and prone(right).Gattinoni L,Protti A.Ventilation in the prone position:for some but not for all?CMAJ 2008;178(9):11746)The Prone-Supine II Study is the largest clinical trial(N 5342)in adult ARDS patients,conducted in 23 centers in Italy and 2 in Spainl20 hours/daylSimilar 28-day mortality-31.0%vs 32.8%;RR 0.97;(95%CI 0.841.13;P=0.72)lMortality in severe hypoxemia was decreased in the prone group-37.8%in the prone group and 46.1%in the supine group(RR,0.87;95%CI,0.661.14 P=0.31)Taccone P,Pesenti A,Latini R,et al.Prone positioning in patients with moderate and severe acute respiratory distress syndrome:a randomized controlled trial.JAMA 2009;302:197784.Effect of mechanical ventilation in the prone position on clinical outcomes in patientswith acute hypoxemic respiratory failure:a systematic review and meta-analysis.CMAJ2008;178(8):115361短时间短时间长时间长时间P=0.32P=0.68Sud S,Sud M,Friedrich JO,et al.Effect of mechanical ventilation in the prone position on clinicaloutcomes in patients with acute hypoxemic respiratory failure:a systematic review andmeta-analysis.CMAJ 2008;178(8):115361第第1天天第第2天天第第3天天P0.001P0.001P0.001l镇静肌松镇静肌松l气道阻塞气道阻塞l短暂短暂SpO2下降下降l呕吐呕吐l低血压低血压l心律失常心律失常l深静脉脱落深静脉脱落l气管插管移位气管插管移位l气管切开移位气管切开移位54Sud S,Sud M,Friedrich JO,et al.High frequency oscillation in patients with acute lung injury and acute respiratory distress syndrome(ARDS):systematic review and meta-analysis.BMJ 2010;340:c2327.ECMO is supportive care and is not intended as a primary ARDS treatmentCESAR trial-Patients were randomized to either conventional care at 1 of 68 tertiary care centers or to a single center using a treatment protocol that included ECMOlThe trial was stopped for efficacy after 180 patientslSurvival without severe disability at 6 months was 47%vs 63%at 6 monthsPeek GJ,Mugford M,Tiruvoipati R,et al.Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure(CESAR):a multicentre randomised controlled trial.Lancet 2009;374(9698):135163.58中国危重病急救医学中国危重病急救医学.2006;18(12):706-710预计病情能够短期缓解的早期预计病情能够短期缓解的早期ALI/ARDS患者可考虑应用患者可考虑应用NIV。(B级级)合并免疫功能低下的合并免疫功能低下的ALI/ARDS 患者早期可首先试用患者早期可首先试用NIV。(B级级)应用应用NIV 治疗治疗ALI/ARDS 应严密监测患者的生命体征及治应严密监测患者的生命体征及治疗反应。意识不清、休克、气道自洁能力障碍的疗反应。意识不清、休克、气道自洁能力障碍的ALI/ARDS 患者不宜应用患者不宜应用NIV。(C 级级)NPPV被推荐的适应症及强度高高中中低低lAECOPDAECOPDl急性心源性肺水肿急性心源性肺水肿l免疫力低下呼衰免疫力低下呼衰lCOPDCOPD脱机脱机l术后呼衰术后呼衰l拔管失败的预防拔管失败的预防l拒绝插管拒绝插管lARDSARDSl创伤创伤l肺间质纤维化肺间质纤维化(pulmonary edema due to infection)(pulmonary edema due to poison)(pulmonary edema due to drowning)(pulmonary edema in uremia)(pulmonary edema due to oxygen toxicity)1.1.经验性抗感染治疗的原则：经验性抗感染治疗的原则：早期、广谱、联合、强效、足量早期、广谱、联合、强效、足量 2.48-722.48-72小时做出评价，有效的表现：小时做出评价，有效的表现：体温下降体温下降 症状改善症状改善 临床状态稳定临床状态稳定 白细胞趋于正常、下降或升高（降低者）白细胞趋于正常、下降或升高（降低者）胸片吸收常较晚些胸片吸收常较晚些 Kumar et al Crit Care Med 2006;34:1589-1596延误使用有延误使用有效抗生素效抗生素1小时，死亡小时，死亡率增加率增加 12%Am J Respir Crit Care.2005,17I(4)：388-416.美平美平?无创通气无创通气有创通气有创通气定压、自主通气及允许性高碳酸血症，肺开放策略定压、自主通气及允许性高碳酸血症，肺开放策略lPEEP：经验设置为：经验设置为812cmH2O，或，或1015cmH2Ol平台压：平台压：30cmH2Ol潮气量：潮气量：812mL/Kg，或，或68mL/Kg（PHC）l吸气流量：递减波，吸气流量：递减波，6090L/minl频率：频率：2025次次/分分l吸呼比：吸呼比：1：1.5l触发灵敏度：触发灵敏度：-2-4cmH2OlFiO2：0.6（二）肺开放策略（二）肺开放策略提提高高治治疗疗干干预预强强度度轻度轻度ARDS中度中度ARDS严重严重ARDS小潮气量通气小潮气量通气更高水平更高水平PEEP无创通气无创通气低低-中水平中水平PEEP俯卧位通气俯卧位通气神经肌肉阻滞剂神经肌肉阻滞剂高频振荡通气高频振荡通气ECCO 2-RECMO300 250 200 150 100 50感谢专家的批评指正！感谢专家的批评指正！感谢专家的批评指正！感谢专家的批评指正！