ARDS诊治进展ppt课件

.,城阳区人民医院重症医学科,PulmonaryProtectiveVentilationInARDS,ARDS诊治进展,.,ARDS的病理生理定义,急性呼吸窘迫综合征（AcuteRespiratoryDistressSyndrome，ARDS）心源性以外的各种肺内外致病因素急性、进行性缺氧性呼吸衰竭,导致,.,ARDS的病因,直接肺损伤间接肺损伤挫伤脓毒症（非肺炎引起）肺炎重度胰腺炎误吸烧伤吸入性损伤非心源性休克溺水药物过量肺栓塞大量输血氧中毒,ARDS的发生机制？,.,ARDS是一种水循环障碍的“肺水肿”,.,失活表面活性物质,正常肺泡,急性期受损肺泡,完整II型细胞,坏死或凋亡的II型细胞,表面活性物质层,II型细胞,肺泡腔,迁移的白细胞,透明膜,肺泡巨噬细胞,激活的白细胞,富含蛋白的水肿液,氧化剂,.,“肺水肿”分类(按照病因及发生机制),ARDS！,.,1.感染性肺水肿(pulmonaryedemaduetoinfection),2.毒素吸入性肺水肿(pulmonaryedemaduetopoison),3.淹溺性肺水肿(pulmonaryedemaduetodrowning),4.尿毒症性肺水肿(pulmonaryedemainuremia),5.氧中毒肺水肿(pulmonaryedemaduetooxygentoxicity),通透性肺水肿病因及分类,.,ARDS肺水肿的成分：富含蛋白细胞碎片未激活的PS中性粒细胞巨噬细胞炎症介质.,.,ARDS的病理生理,肺容积明显降低-“小肺”（不均一性）肺泡水肿肺间质水肿压迫远端细支气管肺泡表面活性物质的消耗或不足：肺泡萎陷肺顺应性明显降低-“硬肺”通气/血流比例失调肺内分流和死腔样通气最终致顽固性低氧血症,ARDS的临床诊断？,.,临床诊断标准的变迁AECC定义,1967年，Ashbaugh等首先描述“成人中的急性呼吸窘迫”1971年，Petty等正式命名“成人呼吸窘迫综合征（ARDS）”1992年，美欧共识会（American-EuropeanConsensusConference,AECC）,急性呼吸窘迫综合征（AcuteRespiratoryDiseaseSyndrome，ARDS）首次提出ALI提出AECC标准,.,AECC诊断标准的局限,.,AnearlyPEEP/FIO2trialidentifiesdifferentdegreesoflunginjuryinpatientswithacuterespiratorydistresssyndrome.AmJRespirCritCareMed.2007；15;176(8):795-804.,例：ARDS患者在不同通气条件下的变化,在（day1）时间点FiO20.5+PEEP10，30min条件下重新分类为ARDS,ALI,ARF,.,29%ARDS患者PAWP18mmHg（或CVP升高）,而其中97%PAWP升高的ARDS患者中有正常的心脏功能。结论：PAWP或CVP升高不能作为ARDS的排除标准。,Pulmonary-arteryversuscentralvenouscathetertoguidetreatmentofacutelunginjury.NEnglJMed.2006May25;354(21):2213-24.,CVP,PAWP,例：ARDS与PAWP、CVP,8,18,.,BerlinDefinition2012柏林定义,.,BerlinDefinitionofARDS,.,ARDS的治疗策略？,.,ARDS的治疗原则,（一）原发病治疗：积极治疗原发病是遏制ARDS发展的必要措施。全身性感染、创伤、休克、烧伤、SAP等是导致ARDS的常见原因。全身性感染患者有25-50%发生ARDS，而且在感染、创伤等导致的MODS中肺是最早发生衰竭的器官。控制原发病，遏制其诱导的全身失控性炎症反应，是预防和治疗ARDS的必要措施。,急性呼吸窘迫综合征诊断和治疗指南(2015）,.,延误使用有效抗生素增加重症肺炎死亡率,KumaretalCritCareMed2006;34:1589-1596,延误使用有效抗生素1小时，死亡率增加12%,.,ARDS的治疗原则,呼吸支持治疗：包括氧疗、机械通气。1.氧疗：治疗目的是改善低氧血症，PaO260-80mmHg；根据低氧血症改善的程度和治疗反应调整氧疗方式，首先使用鼻导管，当需要较高吸氧浓度时，可采用可调节氧浓度的文丘里面罩或带贮氧袋的非重吸收式氧气面罩；ARDS患者往往低氧血症严重，常规的氧疗难以奏效，机械通气是最主要的呼吸支持手段！,急性呼吸窘迫综合征诊断和治疗指南(2015）,.,ARDS的治疗原则,2.无创机械通气预计病情能够在短期缓解的早期ARDS患者可考虑应用无创机械通气。合并免疫功能低下的ARDS患者早期可首先试用无创机械通气。应用无创机械通气治疗ARDS应严密监测患者的生命体征及治疗反应。神志不清、休克、气道自洁能力障碍者不宜应用无创机械通气。,急性呼吸窘迫综合征诊断和治疗指南(2015）,.,ARDS的治疗原则,3.有创机械通气,传统机械通气的肺损伤？,.,VentilatorInducedLungInjury，VILI,Overdistention过度扩张Barotrauma压力伤Volutrauma容量伤Recruitment/DerecruitmentInjury（Atlectrauma）剪切伤/萎陷伤TranslocationofCells细胞形态移位Biotrauma生物伤OxidantInjury氧中毒,.,OverdistentionBarotrauma157:1721-5,.,ARDS的保护性通气策略？,.,Oxidantinjury-keepFiO260Barotrauma-keepalveolarinflationpressures35cmH2OVolutrauma-BabylungconceptorstretchinjuryAtelectrauma-repeatedopeningandclosingBiotrauma-releaseofinflammatorymediatorsandbacterialtranslocationOPENGENTLYANDKEEPTHEMOPEN温柔的打开肺泡，并保持开放,Principle原则,WhiteheadT,SlutskyAS.Thorax.2002;57:636,.,传统的肺保护性通气策略,小潮气量（6mlkg理想体重）允许性高碳酸血症（PHC）控制气道平台压30cmH2O使用合适的PEEP,是迄今为止少有的被大规模随机对照研究证实，能降低ARDS患者死亡率的治疗措施。,.,LUNGPROTECTIVEVENTILATIONWITHLOWTIDALVOLUME,NEnglJMed2000;342:1301-1308,.,提高治疗干预强度,轻度ARDS,中度ARDS,严重ARDS,小潮气量通气,更高水平PEEP,无创通气,低-中水平PEEP,俯卧位通气,神经肌肉阻滞剂,高频振荡通气,ECCO2-R,ECMO,30025020015010050,.,提纲：临床探讨的通气模式与参数,TidalvolumePlateaupressurespHPEEPVCvsPCVRecruitmentmaneuversHigh-frequencyoscillatoryPronepositioningECMO,潮气量平台压允许性高碳酸血症呼气末正压定容与定压手法复张高频振荡通气俯卧位通气体外膜氧合,.,2000年NEJM，861名成人ARDS患者治疗组：小潮气量（4-6ml/kg）,限制压力（平台压30cmH2O），允许性高碳酸血症但保持pH大于7.3显著改善预后病死率39.8%31%自主呼吸天数10天12天首次为小潮气量通气模式提供可靠的循证医学证据,小潮气量LowTidalVolume,ARDSNet.2000,.,36,平台压的调整策略（跨肺压、驱动压）,.,787patientsfromARDSNetworkstudy,平台压,死亡率,.,PEEP：较高的呼气末正压(Meta),BrielM,MeadeM,MercatA,etal.Highervslowerpositiveend-expiratorypressureinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome.JAMA2010;303(9):86573.,医院死亡率ICU死亡率气胸气胸后死亡脱机时间,.,39,pH值的调整策略,.,VentilationUsingtheBestPEEPPreventionofAtelectrauma（最佳PEEP）,.,VCVvsPCV定容与定压,没有定论，各有优劣！,.,RECRUITMENT肺复张,Arecentsystematicreviewanalyzed40studiesthatevaluatedRMs;（4wereRCTs,32prospectivestudies,and4retrospectivecohortstudies）Thesustainedinflationmethod45%：CPAPof3550cmH2Ofor2040seconds23%：highpressurecontrol20%：incrementalPEEP10%：highVT/sigh,FanE,WilcoxME,BrowerRG,etal.Recruitmentmaneuversforacutelunginjury.AmJRespirCritCareMed2008;178(11):115663.,.,RECRUITMENTMANEUVER,Drivingpressure:15cmH2O,BestV/PBestpO2/FIO2,UmbrelloM,etal.IntJMolSci2017;18:64,AventilationstrategythatincludedrecruitmentmanoeuvresinparticipantswithARDSreducedintensivecareunitmortalitywithoutincreasingtheriskofbarotraumabuthadnoeffecton28-dayandhospitalmortality.Wedowngradedthequalityoftheevidencetolow.CochraneDatabaseSystRev2016;11:CD006667,.,VariationsinPatients:SomeNeedHigherPEEPThanOthers,.,CurrentevidencesuggeststhatthatRMsshouldnotberoutinelyusedonallARDSpatientsunlessseverehypoxemiapersistsorasarescuemaneuvertoovercomeseverehypoxemia,toopenthelungwhensettingPEEP,orfollowingevidenceofacutelungderecruitmentsuchasaventilatorcircuitdisconnect结论：RM不常规用在所有的ARDS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（设置PEEP），或者由于管路断开出现急性肺陷闭,FanE,WilcoxME,BrowerRG,etal.Recruitmentmaneuversforacutelunginjury.AmJRespirCritCareMed2008;178(11):115663.,.,PRONEPOSITIONING俯卧位通气,.,ComputedtomographyscanofthelungsshowingARDSwhenthepatientislyingsupine(left)andprone(right).,GattinoniL,ProttiA.Ventilationintheproneposition:forsomebutnotforall?CMAJ2008;178(9):11746),.,PronePositioning,.,TheProne-SupineIIStudyisthelargestclinicaltrial(N5342)inadultARDSpatients,conductedin23centersinItalyand2inSpain20hours/daySimilar28-daymortality-31.0%vs32.8%;RR0.97;(95%CI0.841.13;P=0.72)Mortalityinseverehypoxemiawasdecreasedinthepronegroup-37.8%inthepronegroupand46.1%inthesupinegroup(RR,0.87;95%CI,0.661.14P=0.31),TacconeP,PesentiA,LatiniR,etal.Pronepositioninginpatientswithmoderateandsevereacuterespiratorydistresssyndrome:arandomizedcontrolledtrial.JAMA2009;302:197784.,.,Complications,镇静肌松气道阻塞短暂SpO2下降呕吐低血压心律失常深静脉脱落气管插管移位气管切开移位,.,High-frequencyoscillatoryventilation,HFOV高频振荡通气,.,52,Meta分析结论维持高平均气道压以保持肺复张，避免肺泡周期性开放、闭合。均为小样本研究。2010BMJmeta-analysis：系统分析多项随机对照临床研究，HFOV提高氧合指数、显著降低死亡率。,SudS,SudM,FriedrichJO,etal.Highfrequencyoscillationinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome(ARDS):systematicreviewandmeta-analysis.BMJ2010;340:c2327.,.,ECMO体外膜氧合,.,ECMOissupportivecareandisnotintendedasaprimaryARDStreatmentCESARtrial-Patientswererandomizedtoeitherconventionalcareat1o