肖贞良严重ARDS的治疗策略ppt课件

严重ARDS的治疗策略 成都军区总医院肖贞良 什么是ARDS 中华医学会重症医学分会 急性肺损伤 急性呼吸窘迫综合征诊断和治疗指南 2006 ChinCritCareMed Dec2006 Vol 18 No112 ALI ARDS是在严重感染 休克 创伤及烧伤等非心源性疾病过程中 肺毛细血管内皮细胞和肺泡上皮细胞损伤造成弥漫性肺间质及肺泡水肿 导致的急性低氧性呼吸功能不全或衰竭 以肺容积减少 肺顺应性降低 严重的通气 血流比例失调为病理生理特征 临床表现为进行性低氧血症和呼吸窘迫 肺部影像学表现为非均一性的渗出性病变 ARDS的关注要点 不是一个病 而是一个综合征 可以由一个原发病或诱因导致 也可以是多个诱因共同或序贯作用的结果 ARDS的本质是SIRS 是SIRS的严重阶段 ARDS是MODS或MOF在肺部的表现 小肺 通气和严重的顽固性低氧血症是其最重要的特征 ARDS的预防远比治疗更有意义 辅助治疗 维持 维护肺脏功能 为原发病的治疗赢得时间 ARDS的诊断标准 目前仍广泛沿用1994年欧美联席会议提出的诊断标准 急性起病 氧合指数 PaO2 FiO2 200mmHg 1mmHg 0 133kPa 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 FiO2 300mmHg且满足上述其他标准 可诊断ALI ARDS的基本治疗策略 压力控制通气气道峰压 35cmH2O 平台压 30cmH2O小潮气量 4 6ml kgPEEP8 20cmH2O允许性高碳酸血症 Permissivehypercapnia 严重ARDS的定义 当ARDS患者保护性肺通气策略失败 出现顽固性低氧血症和严重酸中毒 肺损伤评分 3分时 可以认为患者存在严重ARDS 应考虑挽救性治疗措施 Rescuetherapies CritCareMed2010Vol 38 No 8 严重ARDS的定义 肺损伤评分为以上所有项目评分之和 CritCareMed2010Vol 38 No 8 严重ARDS的治疗策略 六步法 肺复张和高PEEP俯卧位通气 PPV 高频振荡通气 HFOV 一氧化氮吸入 inhaledNO 糖皮质激素glucocorticoid 体外生命支持 ECLS CritCareMed2010Vol 38 No 8 六步法之一 肺复张和高PEEP 原理 RecruitmentManeuvers 复张手法 和高PEEP可以使陷闭和实变的部分或全部肺泡恢复通气 从而改善氧合 减少反复开放和关闭肺泡导致的肺损伤 风险 肺泡液清除率下降 VALI和血流动力学障碍 临床实施 RM结合高PEEP或单纯高PEEP 应考虑仅应用于危及生命的严重ARDS早期 有低氧血症且平台压30 cmH2O者 休克 气胸或局限性病变的患者不建议使用使用RM 实施前需要充分容量复苏和镇静 最佳PEEP设置应高于RM前5 10cmH2O 以维持肺开放 实施6 12小时内应反复评价氧合和顺应性是否得到改善 以决定后续治疗措施 CritCareMed2010Vol 38 No 8 常用的RMs 控制性肺膨胀 SI 法PEEP递增法压力控制 PCV 法 控制性肺膨胀 SI 法 如何实施RM 设置FiO2 1 0 等待10分钟 适当镇静 可能需要多次RM RM必须终止的情况 MAP 60mmHg或下降幅度 20mmHg SaPO2 88 HR 130or 60perminute新的心律失常 PEEP递增法 PCV法 Pins 40cmH2O 40S 20cmH2OPEEP维持 方法一 方法二 AmJRespirCritCareMedVol178 pp1156 1163 2008 Rationale Thereareconflictingdataregardingthesafetyandefficacyofrecruitmentmaneuvers RMs inpatientswithacutelunginjury ALI Objectives TosummarizethephysiologiceffectsandadverseeventsinadultpatientswithALIreceivingRMs Methods Systematicreviewofcaseseries observationalstudies andRCTswithpoolingofstudy leveldata MeasurementsandMainResults Fortystudies 1 185patients metinclusioncriteria Oxygenation 31studies 636patients wassignificantlyincreasedafteranRM PaO2 106versus193mmHg P50 001 andPaO2 FIO2ratio 139versus251mmHg P 0 001 Therewerenopersistent clinicallysignificantchangesinhemodynamicparametersafteranRM Ventilatoryparameters 32studies 548patients werenotsignificantlyalteredbyanRM exceptforhigherPEEPpost RM 11versus16cmH2O P50 02 Hypotension 12 anddesaturation 9 werethemostcommonadverseevents 31studies 985patients Seriousadverseevents e g barotrauma 1 andarrhythmias 1 wereinfrequent Only10 1 patientshadtheirRMsterminatedprematurelyduetoadverseevents Conclusions AdultpatientswithALIreceivingRMsexperiencedasignificantincreaseinoxygenation withfewseriousadverseevents TransienthypotensionanddesaturationduringRMsiscommonbutisself limitedwithoutseriousshort termsequelae GiventheuncertainbenefitoftransientoxygenationimprovementsinpatientswithALIandthelackofinformationontheirinfluenceonclinicaloutcomes theroutineuseofRMscannotberecommendedordiscouragedatthistime RMsshouldbeconsideredforuseonanindividualizedbasisinpatientswithALIwhohavelife threateninghypoxemia 六步法之二 俯卧位通气 原理 促进肺膨胀不全区域复张 主要机制是通过减轻外部压力 改善肺通气 血流比例 风险 局部并发症 如面部水肿 结膜出血 压疮 翻身导致管道脱落 临床实施 俯卧位通气持续的时间 建议 20小时 Introduction InpatientswithALIand orARDS recentrandomisedcontrolledtrials RCTs showedaconsistenttrendofmortalityreductionwithproneventilation Weupdatedameta analysisonthistopic Methods RCTsthatcomparedventilationofadultpatientswithALI ARDSinproneversussupinepositionwereincludedinthisstudy levelmeta analysis Analysiswasmadebyarandom effectsmodel TheeffectsizeonICUmortalitywascomputedintheoverallincludedstudiesandintwosubgroupsofstudies thosethatincludedallALIorhypoxemicpatients andthosethatrestrictedinclusiontoonlyARDSpatients Arelationshipbetweenstudies effectsizeanddailypronedurationwassoughtwithmeta regression Wealsocomputedtheeffectsofpronepositioningonmajoradverseairwaycomplications Results SevenRCTs including1 675adultpts ofwhom862wereventilatedintheproneposition wereincluded ThefourmostrecenttrialsincludedonlyARDSpatients andalsoappliedthelongestproningdurationsandusedlung protectiveventilation Theeffectsofpronepositioningdifferedaccordingtothetypeofstudy Overall proneventilationdidnotreduceICUmortality oddsratio 0 91 95 confidenceinterval 0 75to1 2 P 0 39 butitsignificantlyreducedtheICUmortalityinthefourrecentstudiesthatenrolledonlypatientswithARDS oddsratio 0 71 95 confidenceinterval 0 5to0 99 P 0 048 numberneededtotreat 11 Metaregressiononallstudiesdisclosedonlyatrendtoexplaineffectvariationbyproneduration P 0 06 Pronepositioningwasnotassociatedwithastatisticalincreaseinmajorairwaycomplications Conclusions LongdurationofventilationinpronepositionsignificantlyreducesICUmortalitywhenonlyARDSpatientsareconsidered 六步法之三 高频振荡通气 HFOV 原理 使用高平均气道压 使肺泡复张并改善氧合 通气靠一个振荡活塞在平均气道压上下建立高频率 180 900次 分 压力循环 产生小潮气量 1 2 5ML KG 风险 高压 可导致血流动力学恶化和气压伤 深度镇静和肌松影响气道分泌物的清除 可引起痰栓堵塞 临床实施 在严重低氧血症和 或高气道平台压的ARDS患者早期应用 不建议用于休克 严重气道堵塞 颅内出血 难治疗性气压伤和严重酸中毒患者 CritCareMed2010Vol 38 No 8 BMJ2010 340 c2327 Objective TodetermineclinicalandphysiologicaleffectsofHFOVcomparedwithconventionalventilationinpatientswithALI ARDS Design Systematicreviewandmeta analysis DatasourcesElectronicdatabasestoMarch2010 conferenceproceedings bibliographies andprimaryinvestigators StudyselectionRandomisedcontrolledtrialsofhighfrequencyoscillationcomparedwithconventionalventilationinadultsorchildrenwithALI ARDS DataselectionThreeauthorsindependentlyextracteddataonclinical physiological andsafetyoutcomesaccordingtoapredefinedprotocol Wecontactedinvestigatorsofallincludedstudiestoclarifymethodsandobtainadditionaldata Analysesusedrandomeffectsmodels Characteristicsofpopulationsofpatientsandriskofbias40intrialsincludedinsystematicreview Detailsofhighfrequencyoscillation HFO andconventionalmechanicalventilation CMV intrialsincludedinsystematicreview Additionalinterventionsorrescuetreatmentsandfundingintrialsofhighfrequencyoscillationandconventionalmechanicalventilationincludedinsystematicreview Hospitalor30daymortalityinpatientswithacutelunginjury acuterespiratorydistresssyndromeallocatedtohighfrequencyoscillationorconventionalmechanicalventilation ClinicaloutcomesandadverseeventsintrialsofhighfrequencyoscillationNooftrialsNoofpatients Subgroupanalysesbasedonageofpatients riskofbias anduseoflungprotectiveventilationincontrolgroups Results 8RCTs n 419patients wereincluded almostallpatientshadARDS Methodologicalqualitywasgood Theratioofpartialpressureofoxygentoinspiredfractionofoxygenat24 48 and72hourswas16 24 higherinpatientsreceivinghighfrequencyoscillation Therewerenosignificantdifferencesinoxygenationindexbecausemeanairwaypressureroseby22 33 inpatientsreceivinghighfrequencyoscillation P 0 01 Inpatientsrandomisedtohighfrequencyoscillation mortalitywassignificantlyreduced riskratio0 77 95 confidenceinterval0 61to0 98 P 0 03 sixtrials 365patients 160deaths andtreatmentfailure refractoryhypoxaemia hypercapnoea hypotension orbarotrauma resultingindiscontinuationofassignedtherapywaslesslikely 0 67 0 46to0 99 P 0 04 fivetrials 337patients 73events Otherrisksweresimilar Therewassubstantialheterogeneitybetweentrialsforphysiological I2 21 95 butnotclinical I2 0 outcomes Pooledresultswerebasedonfeweventsformostclinicaloutcomes Conclusion HFOmightimprovesurvivalandisunlikelytocauseharm Asongoinglargemulticentretrialswillnotbecompletedforseveralyears thesedatahelpclinicianswhocurrentlyuseorareconsideringthistechniqueforpatientswithARDS 六步法之四 NO吸入 原理 吸入NO通气使部分肺组织血管舒张 血流重新分布 改善通气血流比例 从而改善氧合 临床实施 用于前述措施治疗失败的严重低氧血症患者 吸入NO从1PPM开始 观察氧合改善情况 每30分钟滴定式增加剂量 最高至10PPM 无反应 应停止 有反应 应减量至维持氧合目标的最低剂量 使用时间 4天 CritCareMed2010Vol 38 No 8 Background Acutehypoxaemicrespiratoryfailure AHRF definedasALIandARDS arecriticalconditions AHRFresultsfromanumberofsystemicconditionsandisassociatedwithhighmortalityandmorbidityinallages Inhalednitricoxide INO hasbeenusedtoimproveoxygenationbutitsroleremainscontroversial Objectives TosystematicallyassessthebenefitsandharmsofINOincriticallyillpatientswithAHRF Searchstrategy RCTswereidentifiedfromelectronicdatabases theCochraneCentralRegisterofControlledTrials CENTRAL TheCochraneLibrary2010 Issue1 MEDLINE EMBASE ScienceCitationIndexExpanded InternationalWebofScience CINAHL LILACS andtheChineseBiomedicalLiteratureDatabase upto31stJanuary2010 Wecontactedtrialauthors authorsofpreviousreviews andmanufacturersinthefield Selectioncriteria WeincludedallRCTs irrespectiveofblindingorlanguage thatcomparedINOwithnointerventionorplaceboinchildrenoradultswithAHRF Datacollectionandanalysis Twoauthorsindependentlyabstracteddataandresolvedanydisagreementsbydiscussion Wepresentedpooledestimatesoftheinterventioneffectsondichotomousoutcomesasrelativerisks RR with95 confidenceintervals CI Ourprimaryoutcomemeasurewasallcausemortality WeperformedsubgroupandsensitivityanalysestoassesstheeffectofINOinadultsandchildrenandonvariousclinicalandphysiologicaloutcomes Weassessedtheriskofbiasthroughassessmentoftrialmethodologicalcomponentsandtheriskofrandomerrorthroughtrialsequentialanalysis Mainresults Weincluded14RCTswithatotalof1303participants 10ofthesetrialshadahighriskofbias INOshowednostatisticallysignificanteffectonoverallmortality 40 2 versus38 6 RR1 06 95 CI0 93to1 22 I2 0 andinseveralsubgroupandsensitivityanalyses indicatingrobustresults LimiteddatademonstratedastatisticallyinsignificanteffectofINOondurationofventilation ventilatorfreedays andlengthofstayintheintensivecareunitandhospital Wefoundastatisticallysignificantbuttransientimprovementinoxygenationinthefirst24hours expressedastheratioofpartialpressureofoxygentofractionofinspiredoxygenandtheoxygenationindex MD15 91 95 CI8 25to23 56 I2 25 However INOappearstoincreasetheriskofrenalimpairmentamongadults RR1 59 95 CI1 17to2 16 I2 0 butnottheriskofbleedingormethaemoglobinornitrogendioxideformation Authors conclusions INOcannotberecommendedforpatientswithAHRF INOresultsinatransientimprovementinoxygenationbutdoesnotreducemortalityandmaybeharmful 六步法之五 糖皮质激素 原理 可以通过抑制中性粒细胞活化 成纤维细胞增殖和胶原沉淀 阻止病情发展为严重和持续的ALI ARDS 临床实施 用于前述干预措施均失败的严重低氧血症患者 使用低剂量 1mg kg d 的甲强龙 3天后氧合指数 顺应性和PaCO2较基线水平无改善 则停用 有效则续用 CritCareMed2010Vol 38 No 8 RespirCare2010 55 1 43 52 Probabilityofsurvivalandtheproportionofpatientswithpersistentacuterespiratorydistresssyndromewhobecameabletobreathewithoutassistanceduringthefirst180daysafterrandomization FromReference12 withpermission MajorFindingsandAssessmentofBenefitorHarmforKeyOutcomesandPhysiologicParametersinPatientsWithARDS RandomizedtoMethylprednisolone vsPlacebo intheCorticosteroidforLate StageARDSClinicalTrial ARDSNetwork Effectofsteroidsonmortalityinacuterespiratorydistresssyndrome ARDS MajorFindingsandAssessmentofBenefitorHarmforKeyOutcomeandPhysiologicParametersinPatientsWithARDSWhoReceivedLow to Moderate DoseCorticosteroids vsPlacebo inProspectiveCohortandRandomizedControlledTrials intheMeta analysisbyTangetal ARDS发生的前1 14天 低中剂量的糖皮质激素使用在降低病死率和其他方面对患者是有利的 ARDS发生 14天 糖皮质激素的作用不确定 不推荐使用 六步法之六 体外生命支持ECLS 原理 用V V生命支持回路 将患者血液导出并通过膜氧合替代肺进行气体交换 分两种类型 即高流量ECMO和低流量CO2清除回路 临床实施 两种类型均可用于前述治疗措施无效的严重ARDS患者 但不用于有抗凝禁忌或高压机械通气 1周患者 CritCareMed2010Vol 38 No 8 EC