ards治疗与循证医学.pptVIP

ARDS的治疗与循证医学 复兴医院ICU ARDSEBM 1972 Cochran 提出 evidence-based medicine ( EBM ) 1 EBM 的中心思想是-科学知识优于个人经验 1986 Sackett 首次用于抗血栓药推荐意见的临床研究 2 1. Cochran AL (1972) Nuffield Provincial Hospital Trust, London 2. Sackett DL (1986) Chest 89:2s-3s ARDSEBM Sackett 将科学资料分为5级 Level 1: 大样本,随机研究课题,结果清晰; 假阳性或假阴性的错误很低 Level 2: 小样本,随机研究课题,结果不确定;假阳性和/或假阴性的错误较高 Level 3: 非随机,同期(contemporaneous)控制研究 Level 4: 非随机,历史控制和专家意见 Level 5: 病历,非控制研究和专家意见 ARDSEBM 1997 肺动脉导管共识会( The Pulmonary Artery Catheter Consensus Conference )提出将科研结果分为5级 A: Supported by at least two level 1 investigation B: Supported by only one level 1 investigation C: Supported by level 2 investigation only D: Supported by at least one level 3 investigation E: Supported by level 4 or level 5 evidence Crit Care Med 1997 25:910-925 ARDSEBM 1995 Marin HK 提出了ARDS的证据质量和分级标准( The Quality of the Evidence and the Grading of Recommendation in ARDS) Quality of the Evidence Level 1: randomized, prospective, controlled investigation Level 2: nonrandomized, concurrent-cohort investigation, historical-cohort investigation, and case series of ARDS Level 3: randomized, prospective, controlled investigation of sepsis or other relevant conditions with potential application to ARDS Level 4: case reports of ARDS ARDSEBM Grading of recommendation A: Supported by at least two level 1 investigation B: Supported by only one level 1 investigation C: Supported by level 2 investigation only D: Supported by at least one level 3 investigation Ungraded: No available clinical investigation Kollef MH 1995 N Engl J Med 332: 27-37 ARDSEBM 应用EBM的原则评价ARDS的诊断,发病和治疗发现了很多问题 主要是缺乏前瞻性,随机的,控制的带有清晰的转归结果的研究 病死率 住院或ICU天数 无机械通气天数(ventilator-free days) ARDS的病理生理 Pathophysiology process of ARDS ARDSEBM 机械通气相关性肺损伤 1 气压伤 2 容积伤 3 剪切力 4 生物学损伤 Mechanical Ventilation Mechanical Ventilation ARDSEBM 机械通气的循证医学 1 寻找更合理的PEEP 2 肺保护通气和允许性高碳酸血症 3 肺泡复张更加充分 4 保留自主呼吸的机械通气模式 5 单肺通气 6 高频通气 7 体位治疗 8 提外膜氧合 PEEP 动物实验和临床 增加PEEP使ARDS的FRC增加, 肺顺应性和动脉氧合改善 CT扫描,PEEP使不充气的肺组织复张