急性呼吸窘迫综合症指南解读及治疗进展.pptVIP

Pplat 30cmH2O Vt 4-8ml/Kg 但是(but)……? 反复RM + 高PEEP 适宜PEEP 氧合仍难维持？？ 俯卧位通气 吸入ON HOFV 糖皮质激素 2008.8.13 9 am ECMO 中毒性肺损伤治疗 机械通气 液体管理 液体管理是一个复杂的问题，到目前为止，我们 尚不清楚多一点或少一点液体对机体更有益！ Fluid management is a complex issue, and, until now, it was not clear whether providing more or less fluids was more beneficial ”--- Gordon Bernard More fruid less fruid 20 academic centers were involved across North America 1000 例ALI / ARDS 纳入 ARDS net --fluid and catheter therapy trial , FACTT 目的之一： 限制性液体与开放液体输入谁更优势 ？ NEJM 2006，354:2564-2575 在保证组织灌注的基础上 限制性液体策略 2004年的一项荟萃分析显示,在不包括慢性阻塞性肺疾病和心源性肺水肿的急性低氧性呼吸衰竭病人中,与标准氧疗相比,N IV可明显降低气管插管率,并有减少ICU住院时间及降低住院病死率的趋势。但分层分析显示NIV对ALI/ARDS的疗效并不明确。最近N IV 治疗54 例AL I/ARDS病人的临床研究显示, 70%病人应用N IV治疗无效。逐步回归分析显示,休克、严重低氧血症和代谢性酸中毒是 ARDS病人N IV治疗失败的预测指标。一项RCT研究显示,与标准氧疗比较, N IV虽然在应用第1小时明显改善AL I/ARDS病人的氧合,但不能降低气管插管率,也不改善病人预后。可见,AL I/ARDS病人应慎用N IV。当ARDS病人神志清楚、血流动力学稳定,并能够得到严密监测和随时可行气管插管时, 可以尝试NIV 治疗。Sevransky等建议, 在治疗全身性感染引起的ALI/ARDS时,如果预计病人的病情能够在48～72小时内缓解,可以考虑应用NIV。 * Patients with acute lung injury ARDS were Enrolled in a multicenter, randomized trial. Two Group: traditional CMV treatment(contral group), which involved an initial tidal volume of 12 ml/Kg and plateau pressure of 50 cm of water or less. ventilation with a lower tidal volume, which involved an initial tidal volume of 6 ml /kg and Pplat 30 cm of water or less. .10 center trial of 861 patients with ALI/ARDS prospectively randomized to 6 vs 12 ml/kg IBW Current recommend the use of 30 cmH2O CPAP for 30-40 sec during the first RM followed by careful assessment of the results. If the response is inadequate but patient tolerance is good, the RM should be repeated in 15-20 minutes at a higher CPAP level (35-40 cmH2O). If the response to the second RM is inadequate, a third RM at 40 cmH2O CPAP should be performed. (40×40) LOVS(Canada): CPAP 40×40 Some with PCV ＋PEEP , some with more high CPAP * * 建立体外循环后可减轻肺负担、有利于肺功能恢复。非对照临床研究提示，严重的ARDS患者应用ECMO后存活率为46%-66%。但RCT研究显示，ECMO并不改善ARDS患者预后。随着ECMO技术的