ARDS诊断治疗指南-讲义推荐.ppt

* * * * * * In the case of Acute Respiratory Distress Syndrome patients or patient with Acute Lung Injury, one can observe on a “Lower Inflexion Point”. The main reason for this can be explained as follow: - on the above picture, when the insufflation starts,only the alveoli “V1” are inflated. There total volume is V1. The alveoli “V2” are not recruited because of the collapsed airway; - but after a given level of pressure, this airway is opened and the alveoli “V2” can be inflated. Above this opening pressure, the total volume is “V1+V2”, and so, it is easy to understand that the compliance is greater. The PEEP level should be adjusted just above this LIP to recruit the maximum number of alveoli. * But the lung protective ventilation strategies is not enough for ARDS ARDS animal and clinical study show that there are a lot of consolidation in dependent zone when lung protective ventilation strategies was used * * * * * * * * * * * * * * * * * * * * * * * * * 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) * 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 * 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) * 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) * 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 * 治 疗 药物治疗 液体治疗 Steroid Other * 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 *P0.001 * 降低PCWP---改善ARDS预后 ARDS pas n=40 PAWP与ARDS病死率正相关 PAWP12 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 * 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 manag