急性呼吸窘迫综合征顽固性低氧的挽救治疗策略

doi:10.3969/j.issn.1674-490X.2023.04.005

摘要/Abstract

摘要： 急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)病因多样,以急性低氧、顺应性降低、非心源性肺水肿、双肺弥漫性渗出为特点。保护性通气策略已被临床广泛实施,然而仍有10%~15%患者死于顽固性低氧。目前对于这些患者多采取挽救性治疗,如俯卧位通气、早期应用肌肉松弛剂、各种肺复张、实施非常规通气模式、吸入肺血管活性药物、体外膜肺氧合等。这些挽救策略可改善患者氧合,但是否降低病死率、改善预后却备受争议。而且不同方法各有利弊,需根据患者个体情况采取相应治疗策略。

关键词: 急性呼吸窘迫综合征, 低氧血症, 机械通气, 呼吸机相关肺损伤

Abstract: Acute respiratory distress syndrome is a condition of varied etiology characterized by the acute onset of hypoxemia, reduced lung compliance, noncardiogenic pulmonary edema and diffuse exudative lesions of both lungs. Although protective ventilation strategy has been implemented in clinical practice, an estimated 10%-15% of the deaths in ARDS are caused due to refractory hypoxemia. In these cases, clinicians may resort to “salvage therapies”. These include prone position ventilation, application of early neuromuscular blockers, various recruitment maneuvers, unconventional ventilation modes, inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation. All the salvage therapies have been associated with improved oxygenation, but whether to reduce mortality and improve prognosis is controversial. Each of the salvage therapiesis associated with its own risks and benefits, specific treatment strategies should be adopted according to the individual situation of patients.

Key words: acute respiratory distress syndrome, hypoxemia, mechanical ventilation, ventilator induced lung injury

中图分类号:

张红强,张冰,瞿海龙. 急性呼吸窘迫综合征顽固性低氧的挽救治疗策略[J]. 医学研究与教育, 2023, 40(4): 31-36.

参考文献

[1] ASHBAUGH D, BIGELOW D, PETTY T, et al. Acute respiratory distress in adults[J]. Lancet, 1967, 2(7511): 319-323. DOI: 10.1016/S0140-6736(67)90168-7.
[2] 瞿海龙,张红强,张冰,等.血管外肺水的测量: 为急性呼吸窘迫综合征患者实施精准诊治[J].医学研究与教育, 2021, 38(1): 12-16. DOI: 10.3969/j.issn.1674-490X.2021.01.002.
[3] CHERIAN S V, KUMAR A, AKASAPU K, et al. Salvage therapies for refractory hypoxemia in ARDS[J]. Respir Med, 2018, 141: 150-158. DOI: 10.1016/j.rmed. 2018.06.030.
[4] NARENDRA D K, HESS D R, SESSLER C N, et al. Update in management of severe hypoxemic respiratory failure[J]. Chest, 2017, 152(4): 867-879. DOI: 10.1016/j.chest. 2017.06.039.
[5] 潘纯,孙骎,邱海波,等. 急性呼吸窘迫综合征及呼吸支持理念: 2019年的反思与进步[J]. 中华重症医学电子杂志, 2020, 6(2): 120-123.
[6] SCHOLTEN E L, BEITLER J R, PRISK G K, et al. Treatment of ARDS with prone positioning[J]. Chest, 2017, 151(1): 215-224. DOI: 10.1016/j.chest.2016.06.032.
[7] LANGER M, MASCHERONI D, MARCOLIN R, et al. The prone position in ARDS patients[J]. Chest, 1988, 94(1): 103-107. DOI: 10.1378/chest.94.1.103.
[8] TACCONE P, PESENTI A, LATINI R, et al. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial[J]. JAMA, 2009, 302(18): 1977-1984. DOI: 10.1001/jama.2009.1614.
[9] SUD S, FRIEDRICH J O, TACCONE P, et al. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis[J]. Intensive Care Med, 2010, 36(4): 585-599. DOI: 10.1007/s00134-009-1748-1.
[10] GUÉRIN C, REIGNIER J, RICHARD J C, et al. Prone positioning in severe acute respiratoy distress syndrome[J]. N Engl J Med, 2013, 368(23): 2159-2168. DOI: 10.1056/NEJMoa1214103.
[11] BEITLER J R, SHAEFI S, MONTESI S B, et al. Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis[J]. Intensive Care Med, 2014, 40(3): 332-341. DOI: 10.1007/s00134-013-3194-3.
[12] 中华医学会重症医学分会重症呼吸学组.急性呼吸窘迫综合征患者俯卧位通气治疗规范化流程[J].中华内科杂志, 2020, 59(10): 781-787. DOI: 10.3760/cma.j.cn112138-20200430-00439.
[13] 潘纯,张伟,杜斌,等.新型冠状病毒肺炎的挽救性治疗:实施俯卧位通气刻不容缓[J].中华内科杂志, 2020, 59(9): 670-672. DOI: 10.3760/cma.j.cn112138-20200304-00184.
[14] 高志伟,赵红梅,孙青松,等.神经肌肉阻滞剂对中重度急性呼吸窘迫综合征患者预后影响的系统评价[J].中华医学杂志, 2019, 99(48): 3819-3825. DOI: 10.3760/cma.j.issn.0376-2491.2019.48.012.
[15] HRAIECH S, YOSHIDA T, ANNANE D, et al. Myorelaxants in ARDS patients[J]. Intensive Care Med, 2020, 46(12): 2357-2372. DOI: 10.1007/s00134-020-06297-8.
[16] GAINNIER M, ROCH A, FOREL J M, et al. Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome[J]. Crit Care Med, 2004, 32(1): 113-119. DOI: 10.1097/01.CCM.0000104114.72614.BC.
[17] FOREL J M, ROCH A, MARIN V, et al. Neuromuscular blocking agents decrease inflammatory response in patients presenting with acute respiratory distress syndrome[J]. Crit Care Med, 2006, 34(11): 2749-2757. DOI: 10.1097/01.CCM.0000239435.87433.0D.
[18] PAPAZIAN L, FOREL J M, GACOUIN A, et al. Neuromuscular blockers in early acute respiratory distress syndrome[J]. N Engl J Med, 2010, 363(12): 1107-1116. DOI: 10.1056/NEJMoa1005372.
[19] MOSS M, HUANG D T, BROWER R G, et al. Early neuromuscular blockade in the acute respiratory distress syndrome[J]. N Engl J Med, 2019, 380(21): 1997-2008. DOI: 10.1056/NEJMoa1901686.
[20] 姜希,徐懋.心肺功能导向的保护性通气策略的应用进展[J].中国微创外科杂志, 2019, 19(12): 1117-1121.
[21] 郭俊,徐景龙.PEEP水平选择对俯卧位通气重度ARDS患者肺复张效果和炎性因子的影响[J]. 中华危重病急救医学, 2020, 32(6): 702-706. DOI: 10.3760/cma.j.cn121430-20200406-00290.
[22] CAVALCANTI A B, SUZUMURA É A, LARANJEIRA N, et al. Effect of lung recruitment and titrated positive end-expiratory pressure(PEEP)vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial[J]. JAMA, 2017, 318(14): 1335-1345. DOI: 10.1001/jama.2017.14171.
[23] MODRYKAMIEN A, CHATBURN R L, ASHTON R W. Airway pressure release ventilation: an alternative mode of mechanical ventilation in acute respiratory distress syndrome[J]. Cleve Clin J Med, 2011, 78(2): 101-110. DOI: 10.3949/ccjm.78a.10032.
[24] 李瑞,李琴,王玉珠,等.气道压力释放通气对急性呼吸窘迫综合征患者呼吸机相关性肺损伤的影响[J].中华灾害救援医学, 2022, 10(2): 61-66. DOI: 10.13919/j.issn.2095-6274.2022.02.001.
[25] 刘小毅,刘慧,冉慧,等.气道压力释放通气在治疗重度急性呼吸窘迫综合征患者中的应用观察[J].四川医学, 2019, 40(9): 947-951. DOI: 10.16252/j.cnki.issn1004-0501-2019.09.019.
[26] HUANG C T, LIN H H, RUAN S Y, et al. Efficacy and adverse events of high-frequency oscillatory ventilation in adult patients with acute respiratory distress syndrome: a meta-analysis[J]. Crit Care, 2014, 18(3): R102. DOI: 10.1186/cc13880.
[27] YOUNG D, LAMB S E, SHAH S, et al. High-frequency oscillation for acute respiratory distress syndrome[J]. N Engl J Med, 2013, 368(9): 806-813. DOI: 10.1056/NEJMoa1215716.
[28] FERGUSON N D, COOK D J, GUYATT G H, et al. High-frequency oscillation in early acute respiratory distress syndrome[J]. N Engl J Med, 2013, 368(9): 795-805. DOI: 10.1056/NEJMoa1215554.
[29] MEADE M O, YOUNG D, HANNA S, et al. Severity of hypoxemia and effect of high-frequency oscillatory ventilation in acute respiratory distress syndrome[J]. Am J Respir Crit Care Med, 2017, 196(6): 727-733. DOI: 10.1164/rccm.201609-1938OC.
[30] ALBERT M, CORSILLI D, WILLIAMSON D R, et al. Comparison of inhaled milrinone, nitric oxide and prostacyclin in acute respiratory distress syndrome[J]. World J Crit Care Med, 2017, 6(1): 74-78. DOI: 10.5492/wjccm.v6.i1.74.
[31] FULLER B M, MOHR N M, SKRUPKY L, et al. The use of inhaled prostaglandins in patients with ARDS: a systematic review and meta-analysis[J]. Chest, 2015, 147(6): 1510-1522. DOI: 10.1378/chest.14-3161.
[32] ATTAWAY A H, MYERS C, VELANI S, et al. Inhaled prostacyclin as salvage therapy for ARDS: can we find the right patient?[J]. Respir Care, 2017, 62(8): 1113-1115. DOI: 10.4187/respcare.05708.
[33] GRASSO S, TERRAGNI P, BIROCCO A, et al. ECMO criteria for influenza A(H1N1)-associated ARDS: role of transpulmonary pressure[J]. Intensive Care Med, 2012, 38(3): 395-403. DOI: 10.1007/s00134-012-2490-7.
[34] MA X C, LIANG M L, DING M, et al. Extracorporeal membrane oxygenation(ECMO)in critically ill patients with coronavirus disease 2019(COVID-19)pneumonia and acute respiratory distress syndrome(ARDS)[J]. Med Sci Monit, 2020, 26: e925364. DOI: 10.12659/MSM.925364.
[35] PEEK G J, MUGFORD M, TIRUVOIPATI R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure(CESAR): a multicentre randomised controlled trial[J]. Lancet, 2009, 374(9698): 1351-1363. DOI: 10.1016/S0140-6736(09)61069-2.
[36] IMAMURA T, NIKHIL N. Optimal therapeutic strategy using extracorporeal membrane oxygenation in patients with COVID-19[J]. J Card Surg, 2020, 35(10): 2872-2873. DOI: 10.1111/jocs.14831.
[37] COMBES A, HAJAGE D, CAPELLIER G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome[J]. N Engl J Med, 2018, 378(21): 1965-1975. DOI: 10.1056/NEJMoa1800385.