严重ARDS的治疗策略.pptxVIP

严重ARDS的治疗策略;什么是ARDS?;第3页/共73页;ARDS 的关注要点;ARDS的诊断标准;ARDS的基本治疗策略;严重ARDS的定义;Crit Care Med 2010 Vol. 38, No. 8;严重ARDS的定义;严重ARDS的治疗策略-六步法;六步法之一:肺复张和高PEEP;原理：Recruitment Maneuvers(复张手法）和高PEEP可以使陷闭和实变的部分或全部肺泡恢复通气,从而改善氧合,减少反复开放和关闭肺泡导致的肺损伤. 风险：肺泡液清除率下降、VALI和血流动力学障碍。 临床实施：RM结合高PEEP或单纯高PEEP，应考虑仅应用于危及生命的严重ARDS早期、有低氧血症且平台压30＜cmH2O者。休克、气胸或局限性病变的患者不建议使用使用RM。实施前需要充分容量复苏和镇静。最佳PEEP设置应高于RM前5-10 cmH2O，以维持肺开放。实施6-12小时内应反复评价氧合和顺应性是否得到改善，以决定后续治疗措施。 ;常用的RMs;控制性肺膨胀(SI)法;第15页/共73页;如何实施RM?;RM必须终止的情况;第18页/共73页;PEEP递增法;PCV法;Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008;Rationale: There are conflicting data regarding the safety and efficacy of recruitment maneuvers (RMs) in patients with acute lung injury (ALI). Objectives: To summarize the physiologic effects and adverse events in adult patients with ALI receiving RMs. Methods: Systematic review of case series, observational studies, and RCTs with pooling of study-level data. Measurements and Main Results: Forty studies (1,185 patients) met inclusion criteria. Oxygenation (31 studies; 636 patients) was significantly increased after an RM(PaO2: 106versus193mmHg, P50.001;and PaO2/FIO2 ratio: 139 versus 251mmHg, P,0.001). There were no persistent, clinically significant changes in hemodynamic parameters after an RM. Ventilatory parameters (32 studies; 548 patients)were not significantly altered by an RM, except for higher PEEP post-RM (11 versus 16 cm H2O; P 5 0.02). Hypotension (12%) and desaturation (9%) were the most common adverse events (31 studies; 985 patients). Serious adverse events (e.g., barotrauma [1%] and arrhythmias [1%]) were infrequent. Only 10 (1%) patients had their RMs terminated prematurely due to adverse events.;第23页/共73页;第24页/共73页;第25页/共73页;第26页/共73页;第27页/共73页;第28页/共73页;第29页/共73页;Conclusions: Adult patients with ALI receiving RMs experienced a significant increase in oxygenation, with few serious adverse events. Transient hypotension and desaturation during RMs is common but is self-limited without serious short-term