(精编)【体外膜肺ECMO精品课件】 ARDS Acute Respiratory Distress Syndrome.pptVIP

* * * Fluid management “Dry lungs are happy lungs” ARDSnet RCT of 1000 patients (FACTT), Conservative vs liberal fluid strategy using CVP or PAOP monitoring to guide, primary outcome: death. Conservative fluids Improved oxygenation More ventilator-free days More days outside ICU No increase in shock or dialysis No mortality effects ARDSnet Fluid Management NEJM 2006;354:2564-75. Keys to management Treat underlying illness Supportive care Low tidal volume ventilation Nutrition Prevent ICU complications Stress ulcers DVT Nosocomial infections Pneumothorax No routine use of PA catheter Diuresis/avoidance of volume overload Give lungs time to recover Survival and Long Term Sequelae Traditionally mortality 40-60% May be improving, as mortality in more recent studies in range 30-40% Nonetheless survivors report decreased functional status and perceived health 79% of patients remember adverse events in ICU 29.5% with evidence of PTSD 1 year after ARDS survival Lung Function: FEV1 and FVC were normal; DLCO minimally reduced Only 20% had mild abnormalities on CXR Functionally: Survivors’ perception of health was 70% of normals in: Physical Role: Extent to which health limits physical activity Physical Functioning: Extent to which health limits work Vitality: Degree of energy patients have 6 minutes walk remained low Only 49% had returned to work NEJM 2003: 348: 683-693 Summary ARDS is a clinical syndrome characterized by severe, acute lung injury, inflammation and scarring Significant cause of ICU admissions, mortality and morbidity Caused by either direct or indirect lung injury Mechanical ventilation with low tidal volumes and plateau pressures improves outcomes So far, no pharmacologic therapies have demonstrated mortality benefit Ongoing large, multi-center randomized controlled trials are helping us better understand optimal management References Rubenfeld GD, et al. Incidence and outcomes of acute lung injury N Engl J Med. 2005;353:1685-93. Luhr OR, et al. Incid