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邵逸夫醫(yī)院3F-ICU高建平2013.12邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ARDS的綜合治療邵逸夫醫(yī)院3F-ICU高建平邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F(ww1邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()2邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()3邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()FirstreportedbyAshbaughetalin1967.Characteristicsdescribed:tachypnoea,hypoxaemia,lossoflungcompliance,bilateralinfiltrate,healthyyoungindividuals.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()First4邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ARDStodaystillwithhighincidenceandmortality邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ARDSt5邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()6邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()7邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Pathophysiology:1.Diffusealveolardamage(cytokines,proteases,reactiveoxygenspecies,matrixmetalloproteinases,IL-1,6,8,TNF)2.Alveolarcapillaryleakage(typeIepithelialcells,barrierbreakdown)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Pathop8邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()3.Proteinrichpulmonaryoedema4.Ventilationperfusionmismatch(typeIIepithelialcells,impairedsurfactantsysnthesis)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()3.Pro9邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()10邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ClinicalmanifestationSeverehypoxaemia
ImpairedCO2excretionPoorlungcomplianceBilateralinfiltrates邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Clinic11邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Diagnosis邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Diagno12邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()13邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()14邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()15邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Therapyimprovements邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Therap16邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Mechanicalventilation邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Mechan17邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心,隨機(jī)對照12ml/PBW,Pplat45-50cmH2Ovs
6ml/PBW,Pplat25-30cmH2O入組:861人,提早結(jié)束邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心,隨機(jī)18邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()19邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()20邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()21邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()MVfornon-ARDS,howtoset?Lowtidalvolume?ReduceBarotraumaVolutraumaBiotrauma邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()MVfor22邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()NetoAS,CardosoSO,ManettaJA,etal.JAMA,2012,308(16):1651-1659.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()NetoA23邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Vt6-8ml/kgPBWPplat<20cmH2OPEEP4-8cmH2O邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Vt6-24邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Restrictivefluidmanagement邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Restri25邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()WiedemannHP,WheelerAP,BernardGR,etal.NEnglJMed,2006,354(24):2564-2575.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Wiedem26邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()27邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()28邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()29邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()30邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Corticosteroidstherapy激素邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Cortic31邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,對照納入人數(shù):180人.開始使用時間:7天后方案:2mg/kg(理想體重)bolus+0.5mg/kgq6h*14d+0.5mg/kgq12h*7d+2-4d逐步停用邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,32邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()33邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()34邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()35邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,對照5家醫(yī)院的ICU納入人數(shù):91人,2:1匹配.開始使用時間:診斷ARDS后3天內(nèi).使用方案:1mg/kgbolus+1mg/kg/d*14d+0.5mg/kg/d*7d+0.25mg/kg/d*4d+0.125mg/kg/d*3d邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,36邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()37邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()38邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()39邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肌松藥(NMBA)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肌松藥(N40邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國20家ICU)雙盲對照入組人數(shù):340人開始使用時間:明確重癥ARDS48h內(nèi)
P/F<150,PEEP>5cmH2O,Vt6-8ml/kg使用方案:苯碳酸順阿曲庫銨,15mgivbolus+37.5mg/h*48h邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國41邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()42邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()43邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()44邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()PronePositioning俯臥位通氣PaoloTaccone,AntonioPesenti,RobertoLatini,etal.
JAMA,2009,302(18):1977-1984.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Prone45邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(意大利23個,西班牙2個),隨機(jī)非盲對照納入人數(shù):342人,研究組168人,對照組174人
中度ARDS192人(P/F100-200mmHg)
重度150人(<100mmHg)俯臥位通氣:至少20h/d.治療時間:診斷ARDS72h內(nèi)開始
至病情恢復(fù)或28d邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(意大46邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()47邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()48邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()49邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()50邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國26家ICU,西班牙1家)隨機(jī)對照納入人數(shù):466人重癥:P/F<150mmHg,F(xiàn)iO2>0.6,PEEP>5cmH2O,Vt6ml/PBW俯臥位通氣:至少16h/d時間:ARDS36h內(nèi)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國51邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()52邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()53邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肺復(fù)張RMPCV法
1.鎮(zhèn)靜2.降低FiO2至維持SpO290%,通過SpO2的變化判斷肺復(fù)張操作的效果3.PCV模式:
基礎(chǔ)壓力:維持潮氣量8ml/kg的PplatPIP:
35cmH2O開始,每個壓力重復(fù)3-5次,每次3-5個呼吸周期,然后回到基礎(chǔ)壓力。如無效,調(diào)整PIP每次5cmH2O。每次氣道吸引或環(huán)路脫開后,重復(fù)肺復(fù)張。Ti:延長直至吸氣末有停頓時間Rr:可增加呼吸頻率至20bpmPEEP:從20cmH2O(重度ARDS)逐步下調(diào);或10cmH2O逐步上調(diào)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肺復(fù)張54邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()CPAP法:CPAP35-40cmH2O
維持40秒,最大壓力40cmH2O,15分鐘重復(fù)。邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()CPAP法:55邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ECMOLungreststrategyExtracorporealLifeSupportOrganization(ELSO)ECMOconsidered:P/F<150mmHgonFiO2>90%;andMurrayScore2-3;mortalityrisk>50%.ECMOstarted:P/F<80mmHgonFiO2>90%andMurrayScore3-4;PaCO2>80mmHg,Pplat>30cmH2O;mortalityrisk>80%.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ECMOLu56邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()?邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()?57邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()58邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()59邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Independentlungventilation
獨立肺通氣single(mostly)ordoubleventilatorssingleordouble-lumen(mostly)tubeasynchronousorsynchronous(mostly)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Indepe60邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()61邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()HighfrequencyoscillatoryventilationPartialliquidventilation
(perfluorocarbon)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Highf62邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()HighfrequencyoscillatoryventilationPartialliquidventilation(perfluorocarbon)NitricoxideProstacyclins(PGE)Exogenoussurfactants邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Highf63邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Antioxidantsβ2agonistω-3fattyacidCellularbasedtherapy(MSC)Othersupportivemeasuresappropriateantimicrobialtherapyearlyenteralnutrition
prophylaxisofDVTandGI
ulceration
邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Antiox64邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Thanks
邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Thanks65邵逸夫醫(yī)院3F-ICU高建平2013.12邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ARDS的綜合治療邵逸夫醫(yī)院3F-ICU高建平邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F(ww66邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()67邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()68邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()FirstreportedbyAshbaughetalin1967.Characteristicsdescribed:tachypnoea,hypoxaemia,lossoflungcompliance,bilateralinfiltrate,healthyyoungindividuals.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()First69邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ARDStodaystillwithhighincidenceandmortality邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ARDSt70邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()71邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()72邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Pathophysiology:1.Diffusealveolardamage(cytokines,proteases,reactiveoxygenspecies,matrixmetalloproteinases,IL-1,6,8,TNF)2.Alveolarcapillaryleakage(typeIepithelialcells,barrierbreakdown)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Pathop73邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()3.Proteinrichpulmonaryoedema4.Ventilationperfusionmismatch(typeIIepithelialcells,impairedsurfactantsysnthesis)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()3.Pro74邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()75邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ClinicalmanifestationSeverehypoxaemia
ImpairedCO2excretionPoorlungcomplianceBilateralinfiltrates邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Clinic76邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Diagnosis邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Diagno77邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()78邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()79邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()80邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Therapyimprovements邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Therap81邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Mechanicalventilation邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Mechan82邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心,隨機(jī)對照12ml/PBW,Pplat45-50cmH2Ovs
6ml/PBW,Pplat25-30cmH2O入組:861人,提早結(jié)束邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心,隨機(jī)83邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()84邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()85邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()86邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()MVfornon-ARDS,howtoset?Lowtidalvolume?ReduceBarotraumaVolutraumaBiotrauma邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()MVfor87邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()NetoAS,CardosoSO,ManettaJA,etal.JAMA,2012,308(16):1651-1659.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()NetoA88邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Vt6-8ml/kgPBWPplat<20cmH2OPEEP4-8cmH2O邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Vt6-89邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Restrictivefluidmanagement邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Restri90邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()WiedemannHP,WheelerAP,BernardGR,etal.NEnglJMed,2006,354(24):2564-2575.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Wiedem91邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()92邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()93邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()94邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()95邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Corticosteroidstherapy激素邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Cortic96邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,對照納入人數(shù):180人.開始使用時間:7天后方案:2mg/kg(理想體重)bolus+0.5mg/kgq6h*14d+0.5mg/kgq12h*7d+2-4d逐步停用邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,97邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()98邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()99邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()100邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,對照5家醫(yī)院的ICU納入人數(shù):91人,2:1匹配.開始使用時間:診斷ARDS后3天內(nèi).使用方案:1mg/kgbolus+1mg/kg/d*14d+0.5mg/kg/d*7d+0.25mg/kg/d*4d+0.125mg/kg/d*3d邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()隨機(jī),雙盲,101邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()102邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()103邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()104邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肌松藥(NMBA)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肌松藥(N105邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國20家ICU)雙盲對照入組人數(shù):340人開始使用時間:明確重癥ARDS48h內(nèi)
P/F<150,PEEP>5cmH2O,Vt6-8ml/kg使用方案:苯碳酸順阿曲庫銨,15mgivbolus+37.5mg/h*48h邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國106邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()107邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()108邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()109邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()PronePositioning俯臥位通氣PaoloTaccone,AntonioPesenti,RobertoLatini,etal.
JAMA,2009,302(18):1977-1984.邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()Prone110邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(意大利23個,西班牙2個),隨機(jī)非盲對照納入人數(shù):342人,研究組168人,對照組174人
中度ARDS192人(P/F100-200mmHg)
重度150人(<100mmHg)俯臥位通氣:至少20h/d.治療時間:診斷ARDS72h內(nèi)開始
至病情恢復(fù)或28d邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(意大111邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()112邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()113邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()114邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()115邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國26家ICU,西班牙1家)隨機(jī)對照納入人數(shù):466人重癥:P/F<150mmHg,F(xiàn)iO2>0.6,PEEP>5cmH2O,Vt6ml/PBW俯臥位通氣:至少16h/d時間:ARDS36h內(nèi)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()多中心(法國116邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()117邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()118邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肺復(fù)張RMPCV法
1.鎮(zhèn)靜2.降低FiO2至維持SpO290%,通過SpO2的變化判斷肺復(fù)張操作的效果3.PCV模式:
基礎(chǔ)壓力:維持潮氣量8ml/kg的PplatPIP:
35cmH2O開始,每個壓力重復(fù)3-5次,每次3-5個呼吸周期,然后回到基礎(chǔ)壓力。如無效,調(diào)整PIP每次5cmH2O。每次氣道吸引或環(huán)路脫開后,重復(fù)肺復(fù)張。Ti:延長直至吸氣末有停頓時間Rr:可增加呼吸頻率至20bpmPEEP:從20cmH2O(重度ARDS)逐步下調(diào);或10cmH2O逐步上調(diào)邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()肺復(fù)張119邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()CPAP法:CPAP35-40cmH2O
維持40秒,最大壓力40cmH2O,15分鐘重復(fù)。邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()CPAP法:120邵逸夫醫(yī)院重癥醫(yī)學(xué)科3F()ECMOLungreststrategyExtracorporealLifeSupportOrganization(ELSO)ECMOconsidered:P/F<150mmHgonFiO
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