ARDS诊治进展.ppt

,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,城阳区人民医院重症医学科,Pulmonary Protective Ventilation In ARDS,ARDS,诊治进展,ARDS,的病理生理,定义,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,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？,1,肺间质,2,肺泡,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,血流动力性肺水肿,(,hemodynamic pulmonary edema,),毛细血管静水压升高，流入肺间质液体增多所形成的肺水肿，但蛋白质分子的渗透性，或液体的传递方面均无任何变化,通透性肺水肿,(,permeability,pulmonary edema,),不仅肺水通过肺毛细血管内皮细胞剧增，且蛋白质渗透过内皮细胞也增加,“,肺水肿,”,分类,(,按照病因及发生机制,),ARDS,！,1.,感染性肺水肿,(pulmonary edema due to infection),2.,毒素吸入性肺水肿,(pulmonary edema due to poison,),3.,淹溺性肺水肿,(pulmonary edema due to drowning),4.,尿毒症性肺水肿,(pulmonary edema in uremia),5.,氧中毒肺水肿,(pulmonary edema due to oxygen toxicity),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,.,参与反应的细胞,中性粒细胞,巨噬细胞,上皮细胞,内皮细胞,参与反应的介质,氧自由基,蛋白溶解酶,花生四烯酸代谢物,补体系统,凝血和纤溶系统,PAF,TNF,IL,.,A,R,D,S,发,病,的炎症机,制,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-European Consensus,Conference,AECC,）,急性呼吸窘迫综合征（,Acute Respiratory Disease Syndrome,，,ARDS,）,首次提出,ALI,提出,AECC,标准,AECC,标准,局限性,病程,急性起病,无具体时间,ALI,PaO2/FiO2300mmHg,误解,201-300mmHg,为,ALI,ARDS,PaO2/FiO2200mmHg,，未考虑,PEEP,水平,不同的,PEEP,及,FiO2,，,PaO2/FiO2,也不同,胸片,双肺弥漫性浸润,缺乏客观评价指标,PAWP,PAWP18mmHg,，无左心房高压,ARDS,及高水平,PAWP,可同时存在，,PAWP,有不确定性,AECC,诊断标准的局限,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.,例：,ARDS,患者在不同通气条件下的变化,在（,day1,）时间点,FiO20.5+PEEP 10,，,30min,条件下,重新分类为,ARDS,ALI,ARF,29%ARDS,患者,PAWP,18mmHg,（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-artery versus central venous catheter to guide treatment of acute lung injury.N Engl J Med.2006 May 25;354(21):2213-24.,CVP,PAWP,例：,ARDS,与,PAWP,、,CVP,8,18,Berlin Definition 2012,柏林定义,ARDS,的诊断及病情分级,发病时间,1,周以内起病、或新发、或恶化的呼吸症状,2.,胸部影像学,双肺模糊影,不能完全由渗出、肺塌陷或结节来解释,3.,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,，,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,轻度,200 mmHg PaO2/FiO2300mmHg with PEEP 5cmH2O,中度,100 mmHg PaO2/FiO2200mmHg with PEEP 5cmH2O,重度,PaO2/FiO2100mmHg with PEEP 5cmH2O,Berlin Definition of ARDS,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,Kumar et al Crit Care Med 2006;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，,PaO,2,60-80mmHg,；,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？,Ventilator Induced Lung,Injury,，,VILI,Overdistention,过度扩张,Barotrauma,压力伤,Volutrauma,容量伤,Recruitment/Derecruitment Injury,（,Atlectrauma,）剪切伤,/,萎陷伤,Translocation of Cells,细胞形态移位,Biotrauma,生物伤,Oxidant Injury,氧中毒,Overdistention,Barotrauma,&Volutrauma,“,Shear,”,Recruitment/Derecruitment Injury,跨肺压,若用,30cmH,2,O,的正压通气，则跨肺压约,35cmH,2,O,。,两个肺单位之间产生高达,140cmH,2,O,的切变力。,Biotruama,Inciting Event,PMNs/Macs,Endothelium,Epithelium,Adhesion,Proteases,O,2,radicals,Coagulation,Proteins,Cytokines,IL-6,IL-8,IL-10,IL-8-RA,TNF-,a,ENA-78,MIP-1,a,Transferrin,PAF,Complement,LPB,LTB4,LTC4,Biophysical,Injury,shear,overdistention,cyclic stretch,D intrathoracic,pressure,alveolar-capillary,permeability,cardiac output,organ perfusion,Biochemical Injury,(Biotrauma),mf,cytokines,complement,PGs,LTs,ROS,proteases,bacteria,Epithelium/,interstitium,neutrophils,Distal Organ Dysfunction,Mechanical Ventilation,Slutsky,Tremblay,Am J,Resp,Crit,Care Med,.1998;157:1721-5,DEATH,ARDS,的保护性通气策略？,Oxidant injury-,keep FiO2 60,Barotrauma,-keep alveolar inflation pressures 35 cm H2O,Volutrauma,-Baby lung concept or stretch injury,Atelectrauma,-repeated opening and closing,Biotrauma,-release of inflammatory mediators and bacterial translocation,OPEN GENTLY AND KEEP THEM OPEN,温柔的打开肺泡，并保持开放,Principle,原则,Whitehead T,Slutsky AS.Thorax.2002;57:636,传统的肺保护性通气策略,小潮气量（,6 ml,kg,理想体重）,允许性高碳酸血症（,PHC,）,控制气道平台压,30,cmH,2O,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。,LUNG PROTECTIVE VENTILATION WITH LOW TIDAL VOLUME,N Engl J Med 2000;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,300 250 200 150 100 50,提纲：临床探讨的通气模式与参数,Tidal volume,Plateau pressures,pH,PEEP,VC vs PCV,Recruitment maneuvers,High-frequency oscillatory,Prone positioning,ECMO,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,肺通气保护策略在儿童,ARDS,中的应用,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,Low Tidal Volume,ARDS Net.2000,36,平台压的调整策略（跨肺压、驱动压）,787 patients from ARDS Network study,平台压,死,亡,率,PEEP,：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.,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,Ventilation Using the Best PEEPPrevention of Atelectrauma,（最佳,PEEP,）,VCV,vs,PCV,定容与定压,没有定论，各有优劣！,RECRUITMENT,肺复张,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,45%,：,CPAP of 3550 cm H,2,O for 2040 seconds,23%,：,high pressure control,20%,：,incremental PEEP,10%,：,high VT/sigh,Fan E,Wilcox ME,Brower RG,et al.Recruitment maneuvers for acute lung injury.Am J Respir Crit Care Med 2008;178(11):115663.,RECRUITMENT MANEUVER,Driving pressure:,15 cm H,2,O,Best V/P,Best pO,2,/FIO,2,Umbrello M,et al.Int J Mol Sci 2017;18:64,A ventilation strategy that included recruitment manoeuvres in participants with ARDS reduced intensive care unit mortality without increasing the risk of barotrauma but had no effect on 28-day and hospital mortality.We downgraded the quality of the evidence to low.Cochrane Database Syst Rev 2016;11:CD006667,Variations in Patients:Some Need Higher PEEP Than Others,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：,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,Fan E,Wilcox ME,Brower RG,et al.Recruitment maneuvers for acute lung injury.Am J Respir Crit Care Med 2008;178(11):115663.,PRONE POSITIONING,俯卧位通气,Computed tomography scan of the lungs showing ARDS when the patient is lying,supine(left)and prone(right).,Gattinoni L,Protti A.Ventilation in the prone position:for some but not for all?CMAJ 2008;178(9):11746),Prone Positioning,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 Spain,20 hours/day,Similar 28-day mortality-31.0%vs 32.8%;RR 0.97;(95%CI 0.841.13;,P,=0.72),Mortality 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.,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-frequency oscillatory ventilation,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,。,Sud 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,体外膜氧合,ECMO is supportive care and is not intended as a primary ARDS treatment,CESAR 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 ECMO,The trial was stopped for efficacy after 180 patients,Survival without severe disability at 6 months was 47%vs 63%at 6 months,Peek 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.,小结：常规通气方式选择与设定,无创通气,有创通气,定压、自主通气及允许性高碳酸血症，肺开放策略,PEEP,：经验设置为,8,12cmH2O,，或,10,15cmH2O,平台压：,30cmH2O,潮气量：,4,6mL/Kg,（,PHC,）,吸气流量：递减波，,60,90L/min,频率：,20,25,次,/,分,吸呼比：,1,：,1.5,触发灵敏度：,-2,-4cmH2O,FiO2,：,40%in 10 days,Multiple ICU issues as expected,CRRT/HD for months,Rehabilitation,2 Years Later full recovery,谢谢,