肺保护性通气策略在非ARDS患者的临床应用

doi:10.3969/j.issn.1674-490X.2019.05.002

摘要/Abstract

摘要： 随着机械通气治疗的发展,有创通气在危重患者的抢救及全麻患者手术中得到广泛应用,然而其亦有双面性。机械通气作为一种侵入性治疗,可直接导致肺组织损伤,即呼吸机相关肺损伤(ventilator-induced lung injury,VILI)。在急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者的治疗过程中,为预防VILI的发生,肺保护性通气策略被提出并应用于临床。近年研究显示保护性通气对非ARDS患者也具有明显效应,从小潮气量通气中亦可获益。低水平驱动压通气正受到大家推荐,而对高水平呼气末正压(positive end-expiratory pressure,PEEP)是否获益尚不能确定。

关键词: 肺保护通气, 呼吸机相关肺损伤, 急性呼吸窘迫综合征

Abstract: With the development of mechanical ventilation,invasive ventilation is a life-saving strategy in critically ill patients and an indispensable tool in patients under general anesthesia for surgery,it also acts as a double-edged sword.Ventilation as a potentially dangerous intrusion that has the potential to harm lungs,in a condition known as ‘ventilator-induced lung injury'(VILI).In order to prevent the occurrence of VILI,so-called ‘lung-protective' ventilator settings were used to improve outcomes in patients with ARDS.Since the last few years,there has been increasing interest in possible benefit of lung-protective ventilation in patients under ventilation for reasons other than ARDS.Patients without ARDS could benefit from tidal volume reduction during mechanical ventilation.Low driving pressures during ventilation is recommended,however,it is uncertain whether higher levels of positive end-expiratory pressure could benefit these patients as well.

Key words: lung-protective ventilator, ventilator-induced lung injury, acute respiratory distress syndrome

中图分类号:

瞿海龙,周英莲,张红强,彭广军. 肺保护性通气策略在非ARDS患者的临床应用[J]. 医学研究与教育, 2019, 36(5): 7-11.

参考文献

[1] NIEMAN G F,SATALIN J,KOLLISCH-SINGULE M,et al.Physiology in Medicine:Understanding dynamic alveolar physiology to minimize ventilator-induced lung injury[J].J Appl Physiol(1985),2017,122(6):1516-1522.DOI: 10.1152/japplphysiol.00123.2017.
[2] 谢沙,栾永.肺保护性通气策略在房颤射频消融术中的应用[J].实用医学杂志,2018,34(3):424-426.DOI: 10.3969/j.issn.1006-5725.2018.03.020.
[3] FAN E,DEL SORBO L,GOLIGHER E C,et al.An official american thoracic society/european society of intensive care medicine/society of critical care medicine clinical practice guideline:mechanical ventilation in adult patients with acute respiratory distress syndrome[J].Am J Respir Crit Care Med,2017,195(9):1253-1263.DOI: 10.1164/rccm.201703-0548ST.
[4] 瞿海龙,周英莲,刘鹏,等.脓毒症致急性呼吸窘迫综合征的研究进展[J].医学研究与教育,2016,33(5):30-34.DOI: 10.3969/j.issn.1674-490X.2016.05.007.
[5] BEIN T,WEBER-CARSTENS S,GOLDMANN A,et al. Lower tidal volume strategy(≈3 ml/kg)combined with extracorporeal CO₂ removal versus ‘conventional’ protective ventilation(6 ml/kg)in severe ARDS:the prospective randomized Xtravent-study[J]. Intensive Care Med,2013,39(5):847-856. DOI: 10.1007/s00134-012-2787-6.
[6] 黄琳娜,夏金根,李正东,等. 急性呼吸窘迫综合征呼吸支持策略与方式选择[J]. 中华结核和呼吸杂志,2016,39(1):51-54.DOI: 10.3760/cma.j.issn.1001-0939.2016.01.014.
[7] BRIEL M,MEADE M,MERCAT A,et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome:systematic review and meta-analysis[J]. JAMA,2010,303(9):865-873. DOI: 10.1001 /jama.2010.218.
[8] Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial(ART)Investigators,CAVALCANTI A B,SUZUMURA É A,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.
[9] AMATO M B,MEADE M O,SLUTSKY A S,et al. Driving pressure and survival in the acute respiratory distress syndrome[J]. N Engl J Med,2015,372(8):747-755. DOI: 10.1056/NEJMsa1410639.
[10] SERPA NETO A,SCHMIDT M,AZEVEDO L C,et al. Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome:a pooled individual patient data analysis:Mechanical ventilation during ECMO[J]. Intensive Care Med,2016,42(11):1672-1684. DOI: 10.1007/s00134-016-4507-0.
[11] SERPA NETO A,SIMONIS F D,BARBAS C S,et al. Association between tidal volume size,duration of ventilation,and sedation needs in patients without acute respiratory distress syndrome:an individual patient data meta-analysis[J]. Intensive Care Med,2014,40(7):950-957. DOI: 10.1007/s00134-014-3318-4.
[12] NETO A S,SIMONIS F D,BARBAS C S,et al. Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome:a systematic review and individual patient data analysis[J]. Crit Care Med,2015,43(10):2155-2163. DOI: 10.1097/CCM.0000000000001189.
[13] NETO A S,BARBAS C S V,SIMONIS F D,et al. Epidemiological characteristics,practice of ventilation,and clinical outcome in patients at risk of acute respiratory distress syndrome in intensive care units from 16 countries(PRoVENT):an international,multicentre,prospective study[J]. Lancet Respir Med,2016,4(11):882-893. DOI: 10.1016/S2213-2600(16)30305-8.
[14] BEITLER J R,GHAFOURI T B,JINADASA S P,et al. Favorable neurocognitive outcome with low tidal volume ventilation after cardiac arrest[J]. Am J Respir Crit Care Med,2017,195(9):1198-1206. DOI: 10.1164/rccm.201609-1771OC.
[15] FULLER B M,FERGUSON I T,MOHR N M,et al. Lung-protective ventilation initiated in the emergency department(LOV-ED):a quasi-experimental,before-after Trial[J]. Ann Emerg Med,2017,70(3):406-418. DOI: 10.1016/j.annemergmed 2017.01.013.
[16] LAS VEGAS investigators. Epidemiology,practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications:LAS VEGAS—an observational study in 29 countries[J]. Eur J Anaesthesiol,2017,34(8):492-507. DOI: 10.1097/EJA.0000000000000646.
[17] 瞿海龙,周英莲,张新欣,等. 间充质干细胞治疗ARDS的新观点[J]. 医学研究与教育,2018,35(5):7-11. DOI: 10.3969/j.issn.1674-490X.2018.05.002.
[18] SERPA NETO A,FILHO R R,CHERPANATH T,et al. Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation:a systematic review and meta-analysis of randomized controlled trials[J]. Ann Intensive Care,2016,6(1):109. DOI: 10.1186/s13613-016-0208-7.
[19] COSTA LEME A,HAJJAR L A,VOLPE M S,et al. Effect of intensive vs moderate alveolar recruitment strategies added to lung-protective ventilation on postoperative pulmonary complications:a randomized clinical trial[J]. JAMA,2017,317(14): 1422-1432. DOI: 10.1001/jama.2017.2297.
[20] ALGERA A G,PISANI L,BERGMANS D C J,et al. RELAx—REstricted versus liberal positive end-expiratory pressure in patients without ARDS:protocol for a randomized controlled trial[J]. Trials,2018,19(1):272. DOI: 10.1186/s13063-018 -2640-5.
[21] PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology,HEMMES S N,GAMA DE ABREU M,et al. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery(PROVHILO trial):a multicentre randomised controlled trial[J]. Lancet,2014,384(9942):495-503. DOI: 10.1016/S0140-6736(14)60416-5.
[22] TEJERINA E,PELOSI P,MURIEL A,et al. Association between ventilatory settings and development of acute respiratory distress syndrome in mechanically ventilated patients due to brain injury[J]. J Crit Care,2017,38:341-345. DOI: 10.1016/j.jcrc. 2016. 11.010.
[23] NETO A S,HEMMES S N,BARBAS C S,et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia:a meta-analysis of individual patient data[J]. Lancet Respir Med,2016,4(4):272-280. DOI: 10.1016/S2213-2600(16)00057-6.