ards高危因素课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2017/3/5,#,ARDS,预防：高危因素评估和干预,华东医院,宋晓华,ARDS,的柏林定义与诊断标准,急性呼吸窘迫综合征,发病时机,在已知诱因后，或新出现或原有呼吸系统症状加重后一周内发病,胸部影像学,a,双肺透光度减低，且不能完全用胸腔积液、肺叶不张或结节解释,肺水肿来源,无法用心功能衰竭或液体负荷过多解释的呼吸衰竭如果没有危险因素，则需要客观评估（如心脏超声检查）排除静水压升高的肺水肿,低氧血症,b,轻度：,PEEP/CPAP 5 cmH2O,时,200,mmHg PaO2/FiO2 300 mmHg,c,中度：,PEEP/CPAP 5 cmH2O,时,100,mmHg PaO2/FiO2 200 mmHg,重度：,PEEP/CPAP 5 cmH2O,时,PaO2/FiO2 100,mmHg,CPAP，,持续气道正压；,PEEP，,呼气末正压,胸片或,CT,扫描,如果海拔超过,1000m，,应根据如下公式进行校正：,PaO2/FiO2 x (,大气压,/760),轻度,ARDS,患者可能接受无创通气,ARDS/ALI,的危险因素,直接,间接,肺炎,误吸,吸入性损伤,肺挫伤,肺血管炎,溺水,脂肪栓塞,肺移植或肺动脉取栓术后再灌注肺水肿,非肺源性脓毒血症,创伤,胰腺炎,严重烧伤,非心源性休克,药物过量,多次输血（,24h,内大于,15u,）或输血相关性,ALI,神经源性肺水肿,羊水栓塞,骨髓移植后,Modrykamien, Ariel M., and Pooja Gupta. The acute respiratory distress syndrome.Proceedings (Baylor University. Medical Center)28.2 (2021): 163.,【,个体因素,】,ARDS,与酗酒,酗酒与,ARDS,相关性研究,Moazed F,Calfee CS .Environmentalrisk factorsforacute respiratory distress syndrome. Clin Chest Med.2021 Dec;35(4):625-37. doi: 10.1016/j.ccm.2021.08.003. Epub 2021 Sep 30.,酗酒引起,ARDS,的机制,Moazed F,Calfee CS .Environmentalrisk factorsforacute respiratory distress syndrome. Clin Chest Med.2021 Dec;35(4):625-37. doi: 10.1016/j.ccm.2021.08.003. Epub 2021 Sep 30.,ARDS,与吸烟,吸烟与,ARDS,相关性研究,Moazed F,Calfee CS .Environmentalrisk factorsforacute respiratory distress syndrome. Clin Chest Med.2021 Dec;35(4):625-37. doi: 10.1016/j.ccm.2021.08.003. Epub 2021 Sep 30.,吸烟引起,ARDS,的机制,Moazed F,Calfee CS .Environmentalrisk factorsforacute respiratory distress syndrome. Clin Chest Med.2021 Dec;35(4):625-37. doi: 10.1016/j.ccm.2021.08.003. Epub 2021 Sep 30.,【,疾病因素,】,SpO2/FiO2,Mayo Clinic的研究2021,5584,个患者，其中,4646,名有,SpO,2,/FiO,2,记录,Festic E, Bansal V, Kor D J, et al. SpO2/FiO2 Ratio on Hospital Admission Is an Indicator of Early Acute Respiratory Distress Syndrome Development Among Patients at RiskJ. Journal of intensive care medicine, 2021: 0885066613516411.,SpO,2,/FiO,2,优势比,(OR),P,值, 100,2.49 (1.69-3.64), .001,100 200,1.75 (1.16-2.58),= .007,200 30,）,1,低蛋白血症,1,化疗,1,FiO,2,0.35,（,4L/min,）,2,呼吸急促（,RR 30bpm,）,1.5,SpO,2,95%,1,酸中毒（,pH 6L/min记2分,呼吸频率30次/min记1分,存在免疫抑制存在记1分,评分2分发生ALI的敏感性为0.89,特异性为0.75分,缺点：单中心研究,Levitt JE, Calfee CS, Goldstein BA, et al. Early acute lung injury: criteria for identifying lung injury prior to the need for positive pressure ventilation. Crit Care Med 2021; 41:19291937.,改善临床策略,ARDS,的时间特点,ARDS,很少发生在疾病之初,1,。,ARDS,一般发生于患者出现高危因素后,2-5,天,2,。,Levitt JE, Calfee CS, Goldstein BA, et al. Early acute lung injury: criteria for identifying lung injury prior to the need for positive pressure ventilation. Crit Care Med 2021; 41:19291937.,Gajic O, Dabbagh O, Park PK, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2021; 183:462470.,呼吸治疗,早期治疗肺不张。,减少过度通气。,对于低氧饱和度患者改善供氧,2,。,机械通气患者争取早期拔管,4,。,预防误吸。,Kallet RH, Matthay MA. Hyperoxic acute lung injury. Respir Care 2021; 58:123141.,Albert RK. The role of ventilation-induced surfactant dysfunction and atelectasis in causing acute respiratory distress syndrome. Am J Respir Crit Care Med 2021; 185:702708.,全身治疗,减少卧床时间。,早期活动,3,。,减少神经肌肉阻断剂的使用。,严格输血指证,1,。,尽早治疗,sepsis,2,。,目标液体复苏,4,。,Gajic O, Rana R, Winters JL, et al. Transfusion-related acute lung injury in the critically ill: prospective nested casecontrol study. Am J Respir Crit Care Med 2007; 176:886891.,Iscimen R, Cartin-Ceba R, Yilmaz M, et al. Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study. Crit Care Med 2021; 36:15181522.,Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2021. Crit Care Med 2021; 41:580637.,Albert RK. The role of ventilation-induced surfactant dysfunction and atelectasis in causing acute respiratory distress syndrome. Am J Respir Crit Care Med 2021; 185:702708.,肺创伤预防CLIP的评估表,Festic E, Kor D J, Gajic O. Prevention of acute respiratory distress syndromeJ. Current opinion in critical care, 2021, 21(1): 82-90.,药物预防,药物预防,Festic E, Kor D J, Gajic O. Prevention of acute respiratory distress syndromeJ. Current opinion in critical care, 2021, 21(1): 82-90.,药物,机制,阿司匹林,Inhibition of platelet-mediated cyclooxygenase metabolism involved in bronchoconstriction and vasoconstriction and inhibits plateletneutrophilendothelial interactions,全身使用皮质类固醇,Multipotent; inhibit inflammatory cytokines; induced apoptosis of macrophages; maintain endothelial cellular barrier,吸入肝素,In addition to potentiating antithrombin III, inhibits adhesion of neutrophils to endothelium and degrades intravascular and bronchial fibrin,吸入,皮质类固醇,Same as systemic corticosteroids. In theory, may spare patients from hyperglycemia, myopathy, superinfection, etc.,药物预防,Festic E, Kor D J, Gajic O. Prevention of acute respiratory distress syndromeJ. Current opinion in critical care, 2021, 21(1): 82-90.,药物,机制,吸入,Beta,受体激动剂,Enhanced alveolar fluid clearance and inhibit neutrophil adhesion to the endothelium,他汀类,Decrease inflammatory cytokine levels, adhesion molecule expression and neutrophil proliferation,肾素,-,血管紧张素轴抑制剂,Angiotensin-2 positively modulates nuclear factor-B gene expression. ACE type 2 receptor with angiotensin as its ligand, prevents endothelial damage,过氧化物酶体增殖物受体激动剂,(PPAR),Nuclear receptor superfamily related to the retinoid, steroid and thyroid receptors with three subtypes. They decrease inflammatory cytokine expression, neutrophil and macrophage chemotaxis plus inhibit oxidative burst in neutrophils,姜黄素,Upregulation of PPAR-,in various inflammatory cells (neutrophils, monocytes, T lymphocytes, endothelial and epithelial cells). Downregulation of inflammatory transcription factors, enzymes and cytokines,谢谢！,