ARDS诊断治疗指南-讲义PPT幻灯片

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,ARDS,诊断和治疗指南,(2006,中华医学会重症医学分会,),杨 毅 邱海波,东南大学医学院附属中大医院,ICU,东南大学急诊与危重病医学研究所,1,内容提要,ALI/ARDS,的概念与流行病学,病理生理和发病机制,临床特征和诊断,ARDS,治疗,2,概 念,严重感染、休克、创伤及烧伤等疾病,肺实质细胞损伤,(,肺毛细血管内皮细胞和肺泡上皮细胞损伤,),临床特征：进行性低氧血症、呼吸窘迫,影像学特征：,X,线胸片呈斑片状阴影,(,非均一性的渗出性改变,),病理生理特征：,FRC,、肺顺应性降低,肺内分流增加，肺毛细血管静水压不高,临床综合征,3,ARDS in 1967,1967 Ashbaugh,N=12 (7,例创伤，,1,例胰腺炎，,4,例肺炎,),呼吸衰竭,呼吸频速：,2064 bpm,低氧血症：,SaO2 41%85%,肺顺应性降低：,919ml/cmH,2,O,胸片：早期斑片状影，后期浸润扩大,吸氧不能低氧，,PEEP,部分纠正,预后：,9,例死亡,(Mortality 75%),尸检：,7,例,大体：肺重量增加，变硬，肺切面与肝类似,光镜：,肺毛细血管充血、扩张,广泛肺泡萎陷,大量中性粒细胞浸润,肺泡内有透明膜形成,部分有明显间质纤维化,4,ALI/ARDS,发病率,根据,1994,年欧美联席会议,ALI/ARDS,诊断标准,1994:,ALI,发病率：每年,18/10,万,ARDS,发病率： 每年,13,23/10,万,2005,年,ALI,发病率：每年,79/10,万,ARDS,发病率：每年,59/10,万,Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med, 2005, 353 : 1685-1693.,5,ARDS Mortality: ALI vs ARDS,78 European ICU,patients meeting ARDS/ALI criteria,2/1/99 to 3/31/99,Mortality,ARDS 57.9%,ALI 32.7%,ICM 2004;30:51-61,6,ARDS,的病死率,临床研究进行荟萃分析,1967,1994,年国际正式发表的,ARDS,3264,例,ARDS,患者的病死率：,50,中国上海市,15,家成人,ICU,2001,年,3,月至,2002,年,3,月,ARDS,病死率：,68.5%,7,Risk factors,Direct lung injuryIndirect lung injury,Common causes,PneumoniaSepsis,Aspiration of GI contentsSevere trauma with shock and multiple transfusions,Less common causes,Pulmonary contusion Cardiopulmonary bypass,Fat emboliDrug overdose,Near-drowningAcute pancreatitis,toxic inhalation Transfutions of blood products,Inhalational injury,Reperfusion pulmonary edema,8,病因与患病率,ALI/ARDS,患病率,严重感染：,25%,50%,大量输血：,40%,多发性创伤：,11%,25%,严重误吸时：,9%,26%,同时存在两个或三个危险因素时，,ALI/ARDS,患病率进一步升高,危险因素持续作用时间越长，,ALI/ARDS,的患病率越高，危险因素持续,24,、,48,及,72h,时，,ARDS,患病率分别为,76%,、,85%,和,93%,9,肺容积明显降低,(a),肺泡水肿,(b),肺泡表面活性物质的消耗或不足,(c),肺间质水肿压迫远端细支气管,肺顺应性明显降低,通气,/,血流比例失调,肺内分流和死腔样通气,ARDS,的病理生理,10,临床特征,急性起病，在直接或间接肺损伤后,12-48h,内发病,常规吸氧后低氧血症难以纠正,肺部体征无特异性，急性期双肺可闻及湿啰音，或呼吸音减低,早期病变以间质性为主，胸部,X,线片常无明显改变。,病情进展后，可出现肺内实变，,表现为双肺野普遍密度增高，透亮度减低，肺纹理增多、增粗，可见散在斑片状密度增高阴影，即弥漫性肺浸润影,无心功能不全证据,11,诊断标准,目前,ALI/ARDS,诊断仍广泛沿用,1994,年欧美联席会议提出的：,急性起病,氧合指数,(PaO2/FiO2)200mmHg,不管呼气末正压,(PEEP),水平,正位,X,线胸片显示双肺均有,斑,片状阴影,肺动脉嵌顿压,18mmHg,，或无左心房压力增高的临床证据,如,PaO2/FiO2300mmHg,且满足上述其它标准，则诊断为,ALI,12,治 疗,原发病治疗,非药物治疗（呼吸支持治疗）,药物治疗,13,原发病的治疗,推荐意见,1,：积极控制原发病是遏制,ALI/ARDS,发展的必要措施,(,推荐级别：,E,级,),14,氧 疗,吸氧治疗的目的,:,改善低氧血症，,PaO2 6080 mmHg,氧疗方式,:,鼻导管,文丘里面罩,带贮氧袋的氧气面罩,推荐意见,2,：,氧疗是纠正,ALI/ARDS,病人低氧血症的基本手段,(,推荐级别：,E,级,),15,无创通气,推荐意见,3,：预计病情能够短期缓解的早期,ALI/ARDS,病人可考虑应用,NPPV (,推荐级别：,C,级,),推荐意见,4,： 合并免疫功能低下的,ALI/ARDS,病人早期可首先试用,NPPV (,推荐级别：,C,级,),推荐意见,5,：应用,NPPV,治疗,ALI/ARDS,应严密监测病人的生命体征及治疗反应。神志不清、休克、气道自洁能力障碍的,ALI/ARDS,病人不宜应用,NPPV(,推荐级别：,C,级,),16,机械通气,经高浓度吸氧仍不能改善低氧血症时，应气管插管进行有创机械通气,ARDS,病人呼吸功明显增加,有创机械通气有效性,:,改善低氧血症，降低呼吸功，缓解呼吸窘迫，并改善全身缺氧,推荐意见,6,：,ARDS,病人应积极进行机械通气治疗,(,推荐级别：,E,级,),17,小潮气量通气,PHC,避免肺泡过度膨胀,最佳,PEEP,避免剪切力(,Shear force),性损害,Volume,Pressure,肺保护性通气策略的基本内容,18,Meta-analysis of ALI and ARDS trials testing low tidal volumes,Meta analysis: 2002,Author,No. Pats,VT (ml/kg),Mortality (%),P,Low VT,Control,Low VT,Control,Low VT,Control,Amato et al,29,24,6.10.2,11.90.5,38,71,0.001,Stewart et al,60,60,7.20.8,10.60.2,50,47,0.72,Brochard et al,58,58,7.20.2,10.40.2,47,38,0.38,Brower et al,26,26,7.30.1,10.20.1,50,46,0.60,ARDSNet(4),432,429,6.30.1,11.70.1,31,40,0.007,Eichacker PQ,et,al.,Am J Respir Crit Care Med. 2002 Dec 1;166(11):1510-4.,19,control groups (high VT),low VT groups,recommended Pplat limit 35,Meta analysis: Eichhacker et al. 2002,20,最佳,PEEP,的选择方法,优点 缺点,氧输送法金标准临床持续监测困难,动脉氧分压法简单易行PEEP水平过高，,可能降低CO,和,DO,2,静态肺顺应性曲线法准确可靠曲线低位转折点,不,易获得,21,推荐意见,7,：,对,ARDS,病人实施机械通气时应采用肺保护性通气策略，气道平台压不应超过,30,35cmH2O (,推荐级别：,B,级,),推荐意见,9,：应使用能防止肺泡塌陷的最低,PEEP,，有条件情况下，应根据静态,P-V,曲线低位转折点压力,+2cmH2O,来确定,PEEP (,推荐级别：,C,级,),22,ARDS,肺保护性通气存在局限性,1,.,小,V,t,不能复张塌陷肺泡，加重低氧血症,实施肺保护性通气策略,至少1525%患者需提高,FiO2,23,2.PEEP,不足，大量肺泡难以复张,Collapsed,airway,V1,V2,Pressure,Volume,V1,V1 + V2,Opening,pressure,Normal,ARDS,PEEP,adjustment,LIP：,塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力,ARDS,肺保护性通气存的局限性,24,30,kg,猪,肺灌洗复制,ARDS,模型,压力控制通气,PCV,Paw 13 cmH,2,O,PEEP 5 cmH,2,O,肺复张策略,25,1.,控制性肺膨胀,(SI),法,2. PEEP,递增法,3.,压力控制,(PCV),法,肺开放的实施方法,26,RM,中止的临床指标,动脉收缩压降低到,90 mm Hg,或下降,30 mm Hg,HR,增加到,140/min，,或增加,20/min,SpO2,降低到,90%，,或降低,5%,以上,发生心律失常,27,肺开放后的,PEEP,选择,-PaO,2,/FiO,2,1. RM,后,PEEP: 20cmH,2,O,2. PEEP,递减,: 2cmH,2,O/5min,3. PEEP,阈值,:,PaO,2,/FiO,2,5%,4. PEEP:,PEEP,阈值,+2cmH,2,O,28,肺开放后的,PEEP,选择,- Stress index,29,BASELINE VENTILATION,Tidal volume=6ml/kg,PEEP=5cmH,2,O,Modify PEEP to get a,1.1,0.9,recruiting maneuver,Measure,1.1,0.9,Leave PEEP unchanged,stress index,0.9,1.1,Decrease PEEP until 1.1,stress index,0.9,Crit Care Med, 2004, 32: 1018-1027,肺开放后的,PEEP,选择,- Stress index,推荐意见,8,：,可采取肺复张手法促进,ARDS,病人塌陷肺泡复张，改善氧合,(,推荐级别：,E,级,),30,Effect of spontaneous breathing on ventilation-perfusion distribution in ARDS,Putensen et al.: AJRCCM; 150: 101-8 (1994),BIPAP,推荐意见,10,ARDS,患者机械通气时应尽可能保留自主呼吸,(,推荐级别,:C,级,),31,推荐意见,11,若无禁忌症，机械通气的,ARDS,病人应采用,30,45,度半卧位,(,推荐级别：,B,级,),体位与误吸,32,俯卧位通气,推荐意见,12,常规机械通气治疗无效的重度,ARDS,病人，若无禁忌症，可考虑采用俯卧位通气,(,推荐级别：,D,级,),33,镇静与肌松,降低,MV,时间,vs ICU,住院时间,推荐意见,13,14,推荐意见,13,：应对机械通气的,ARDS,病人制定镇静方案,(,镇静目标和评估,) (,推荐级别：,B,级,),推荐意见,14,：机械通气的,ARDS,病人不推荐常规使用肌松剂,(,推荐级别：,E,级,),34,液体通气,液体通气：只有一个,RCT,研究,改善氧合和肺顺应性,但并不明显改善预后,各研究中病死率仍在,50,左右,Hirschl R.,JAMA, 1996, 275: 383-389.,Hirschl R.,Ann Surg, 1998, 228: 692-700.,Hirschl DB. Am J Respir Crit Care Med, 2002, 165: 781-787.,常规治疗无效的严重,ARDS,患者可考虑试用液体通气,35,治 疗,药物治疗,液体治疗,Steroid,Other,36,肺水含量与病死率正相关,Sakka SG,et al,. Chest, 2002, 122: 2080-2086,肺水含量是,ARDS,的预后指标,*,P=0.002,*,P12 mmHg：,病死率明显增高,根据治疗后,PAWP,改变,ARDS,分为两组：,降低25%为反应组,Chest 1990, 97: 1176,38,ARDS,的液体管理策略,问题：是否应该限制液体，限制性的液体管理是否影响其他器官功能,Randomized study n=1000 pats with ALI,Conservative vs liberal strategy of fluid management,N Engl J Med 2006;354,39,限制性液体管理不改善预后，但改善呼吸功能,40,ARDS,的液体管理,推荐意见,16,在保证组织器官灌注前提下，应实施限制性的液体管理，有助于改善,ALI/ARDS,病人的氧合和肺损伤,(,推荐级别：,B,级,),41,低蛋白血症,-Higher mortality,Am J Respir Crit Care Med, 1997, 155: A504,42,SAFE,研究,(saline vs albumin fluid evaluation study),2004,年 澳大利亚与新西兰学者,16,家,ICU 6997,名患者,相等入选条件 随机分组,以,4%,白蛋白液与,0.9% NaCl,液对比评价,两组,28,天病死率无差别,输注白蛋白液无害,纠正了,1998,年,Cochrane,荟萃分析错误判断,N Engl J Med,2004, 350;2247,可以补充白蛋白,?,肺水肿,/ARDS,43,Alb,防治,ARDS/MODS,Objective: To test the hypothesis that albumin iv to correct hypoalbuminemia might have beneficial effects on organ function in a mixed population of critically ill patients.,Prospective, controlled, randomized study,Critical ill pats with serum Alb 30g/L, n=100,Intervention:,Albumin group: 300 mL of 20% alb on D1, then 200 mL/day if serum alb30 g/L,Control group: To receive no albumin solution,血清白蛋白浓度的改变,Crit Care Med 2006. 34(10),44,ARDS,白蛋白的应用,推荐意见,16,存在低蛋白血症的,ARDS,患者，可通过补充白蛋白等胶体溶液和应用利尿剂，有助于实现液体负平衡，并改善氧合,(,推荐级别：,C,级,),45,Persistent ARDS: excessive fibroproliferation, ongoing,inflammation - prolonged MV, and a substantial risk of death.,multicenter, randomized controlled trial,Pats with persistent ARDS (,day,7,-,28 after the onset of ARDS,), n=180,Methylprednisolone 2mg/kg, 0.5 mg/kg q6h for14d, 0.5 mg/kg q12h for 7 days, and then tapering of the dose.,Groups:,Randomization within 7,13 Days after ARDS Onset,Randomization within 14,28 Days after ARDS Onset,180-Day mortality according to baseline BAL procollagen peptide type III level(PCPIII),Median,N Engl J Med 2006;354:1671-84,46,糖皮质激素明显改善呼吸和循环功能,P=0.04,P=0.02,P=0.02,47,Effect of steroid on outcome of ARDS,48,Outcome vs Steroid at ARDS onset 7-13d vs 14d,49,糖皮质激素在,ARDS,的应用,推荐意见,17,不推荐应用糖皮质激素预防治疗,ARDS,(,推荐级别：,B,级,),50,一氧化氮,(NO),NO,在短时间内可使约,60%ARDS,患者氧合改善,NO,吸入不能改善,ARDS,患者病死率,(2 RCT trials),Prospective, multicenter, randomized, double-blind, placebo-controlled, phase II trial,177 ARDS patients (placebo VS inhaled NO),acute response to treatment gas, defined as PaO,2,Increase,20%,Crit Care Med, 1998, 26: 15-23.,Figure 3. The percentage of patients in each dose group with an acute (or=to20% increase in PaO,2,) response to treatment gas over the first 4 hrs of treatment gas.,推荐意见,18,不推荐吸入,NO,作为,ARDS,病人常规治疗,(,推荐级别：,A,级,),51,Effect of Omega-3 fatty acids on outcome in ARDS,To explore the effects of an enteral diet enriched with EPA, GLA and antioxidants on pats with ALI,Single-center, prospective, randomized, controlled, unblinded study.,N=,100 pat with acute lung injury,Group: standard isonitrogenous, isocaloric enteral diet OR the standard diet + EPA and GLA for 14 ds,Singer P. Crit Care Med. 2006, 34:1033,EPA+GLA,显著改善氧合,明显改善肺顺应性,明显缩短机械通气时间,Mortality:,35%,vs 37% (P0.05),52,Omega-3 fatty acids,在,ARDS,的应用,推荐意见,19,可通过肠内或静脉途径给予,ALI/ARDS,病人补充,EPA,和,-,亚油酸以改善氧合，缩短机械通气时间,(,推荐级别：,C,级,),53,中华医学会重症医学分会,编写工作小组成员,(,按姓氏笔画排序,),马晓春，王辰，方强，刘大为，邱海波，秦英智，席修明，黎毅敏,54,Thanks for your attention,55,