医学常见的小儿急性呼吸窘迫综合征ards2017讲课.pptVIP

ECMO improves survival in neonates with PPHN (UK study) iNO decreases need for ECMO in neonates with PPHN: 64% vs 38% ECMO and NO in Neonates Clark et al, NEJM, 2000 液体（高氟碳化合物）为携氧介质 开放肺泡 肺泡灌洗，降低表面张力 血流重新分布 抗炎作用 部分液体通气的机制 柏林2012-ARDS的治疗流程 300 250 200 150 100 50 重度 ARDS 中度 ARDS 轻度 ARDS 低潮气量通气 无创通气 低-中等水平 PEEP 损伤程度逐渐增加 高水平等水平 PEEP 神经肌肉阻滞剂 高频通气 腑卧位通气 体外清除CO2 体外膜肺 治疗措施逐步加强 PaO2/FiO2 氧合指数 查体：T 38℃; P 160, RR 60 , BP100/56mmHg. 神志清，端坐呼吸，鼻扇，三凹征（+）面罩吸氧（FL8L/min）SPO2 80%.双肺未闻及罗音。心音有力。腹软，肝脾不大。四肢末梢暖。 血常规：WBC12.5G/L,N70%,LY 30%,HGB,PLT正常 BG:PH7.35,PaO2 45mmHg,PaCO2 50mmHg,BE-3mmol/L 病例：男，10岁，发热、咳嗽2天，气促半天。 床边胸正位片 * 如果海拔超过1000m，应根据如下公式进行校正：[PaO2/FiO2 x (大气压/760)] * 根据我们的检索，目前尚未发现儿科界进行过以地域为单位计算发病率，多以PICU为单位计算发病率 * 我们从已有的研究中（不一定是流行病学调查），选取一些样本量相对较大的研究，来观察小儿ARDS的死亡率 *其中有43%的ARDS患者其病因为毛细支气管炎患儿 * * * * * * * 40% vs. 31% mortality Vent-free days in the first 28 days was significantly higher in the low tidal volume group (12 +/- 11 vs. 10 +/-11;p=0.007 * In Stewart’s study, If peak pressure is 30 and tidal volume is 8 mL/kg, then there was no difference in mortality. * Hickling, Intensive Care Med 1990 * When hypercapnia is produced through the limitation of tidal volumes and inspiratory airway pressures without adequate PEEP, the Qs/Qt ratio increases secondary to progressive derecruitment of alveolar units. Under such conditions, oxygenation will be further impaired by the hypercapnia-induced increase in cardiac output. This increase in cardiac output induces a worsening Qs/Qt ratio as blood flow increases preferentially to the gravitationally dependent, poorly ventilated lung regions and results in additional intrapulmonary shunting The increase in Qs/Qt can frequently be counteracted through the optimization of lung volume by means of recruitment maneuvers and application of suitable levels of PEEP. Hypercapnic acidosis enhances hypoxic pulmonary vasoconstriction,