急性呼吸窘迫综合征机械通气中的自主呼吸:兴利除弊
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摘要
急性呼吸窘迫综合征(ARDS)是重症医学科(ICU)常见危重症。尽管人们不断地探索其诊疗方法,但病死率仍高达40%。肺保护性通气策略指导的机械通气仍是ARDS治疗的基石。ARDS患者接受机械通气时保留适度的自主呼吸有助于塌陷肺泡的复张、改善氧合、预防膈肌功能障碍等。联合有效的监测技术,设置恰当的机械通气模式及参数等措施使患者保持耐受性良好的自主呼吸状态,预防患者自身诱发性肺损伤(P-SILI),可能是肺保护性通气策略的又一重要组成部分。
Acute respiratory distress syndrome(ARDS) is a common critical illness in the intensive care unit(ICU). Although many studies have been performed to explore the diagnostic and therapeutic methods for ARDS, its mortality rate is still as high as 40%. Mechanical ventilation guided by the lung protective strategy is still the cornerstone of ARDS treatment. Maintaining moderate spontaneous breathing during mechanical ventilation in ARDS patients is helpful to lung recruitment, oxygenation improvement,diaphragm dysfunction prevention and so on. By combining with effective monitoring techniques, setting appropriate mechanical ventilation modes and parameters to assist patients in maintaining well-tolerated spontaneous effort and prevent patient-self inflicted lung injury(P-SILI) may be important for the lung protective strategy.
Acute respiratory distress syndrome(ARDS) is a common critical illness in the intensive care unit(ICU). Although many studies have been performed to explore the diagnostic and therapeutic methods for ARDS, its mortality rate is still as high as 40%. Mechanical ventilation guided by the lung protective strategy is still the cornerstone of ARDS treatment. Maintaining moderate spontaneous breathing during mechanical ventilation in ARDS patients is helpful to lung recruitment, oxygenation improvement,diaphragm dysfunction prevention and so on. By combining with effective monitoring techniques, setting appropriate mechanical ventilation modes and parameters to assist patients in maintaining well-tolerated spontaneous effort and prevent patient-self inflicted lung injury(P-SILI) may be important for the lung protective strategy.
引文
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2 ARDS Definition Task Force,Ranieri VM,Rubenfeld GD,et al.Acute respiratory distress syndrome:the Berlin Definition[J].JAMA,2012,307(23):2526-2533.
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4 Fan E,Brodie D,Slutsky AS.Acute Respiratory Distress Syndrome:Advances in Diagnosis and Treatment[J].JAMA,2018,319(7):698-710.
5 Fan E,Villar J,Slutsky AS.Novel approaches to minimize ventilatorinduced lung injury[J].BMC Med,2013,11:85.
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12 Goligher EC,Dres M,Fan E,et al.Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes[J].Am J Respir Crit Care Med,2018,197(2):204-213.
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14 Goligher EC,Fan E,Herridge MS,et al.Evolution of Diaphragm Thickness during Mechanical Ventilation.Impact of Inspiratory Effort[J].Am J Respir Crit Care Med,2015,192(9):1080-1088.
15 Pellegrini M,Hedenstierna G,Roneus A,et al.The Diaphragm Acts as a Brake during Expiration to Prevent Lung Collapse[J].Am J Respir Crit Care Med,2017,195(12):1608-1616.
16 Curley GF,Laffey JG,Zhang H,et al.Biotrauma and VentilatorInduced Lung Injury:Clinical Implications[J].Chest,2016,150(5):1109-1117.
17 Yoshida T,Nakahashi S,Nakamura MAM,et al.Volume-controlled Ventilation Does Not Prevent Injurious Inflation during Spontaneous Effort[J].Am J Respir Crit Care Med,2017,196(5):590-601.
18 Yoshida T,Uchiyama A,Matsuura N,et al.Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model:high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury[J].Crit Care Med,2012,40(5):1578-1585.
19 Yoshida T,Fujino Y,Amato MB,et al.Fifty Years of Research in ARDS.Spontaneous Breathing during Mechanical Ventilation.Risks,Mechanisms,and Management[J].Am J Respir Crit Care Med,2017,195(8):985-992.
20 Holanda MA,Vasconcelos RDS,Ferreira JC,et al.Patient-ventilator asynchrony[J].J Bras Pneumol,2018,44(4):321-333.
21 SubiràC,de Haro C,Magrans R,et al.Minimizing Asynchronies in Mechanical Ventilation:Current and Future Trends[J].Respir Care,2018,63(4):464-478.
22 Yoshida T,Amato MBP,Kavanagh BP,et al.Impact of spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome[J].Curr Opin Crit Care,2019,25(2):192-198.
23 Papazian L,Forel JM,Gacouin A,et al.Neuromuscular blockers in early acute respiratory distress syndrome[J].N Engl J Med,2010,363(12):1107-1116.
24 Langer T,Vecchi V,Belenkiy SM,et al.Extracorporeal gas exchange and spontaneous breathing for the treatment of acute respiratory distress syndrome:an alternative to mechanical ventilation?[J].Crit Care Med,2014,42(3):e211-e220.
25 Mauri T,Grasselli G,Suriano G,et al.Control of Respiratory Drive and Effort in Extracorporeal Membrane Oxygenation Patients Recovering from Severe Acute Respiratory Distress Syndrome[J].Anesthesiology,2016,125(1):159-167.
26 van Haren F,Pham T,Brochard L,et al.Spontaneous Breathing in Early Acute Respiratory Distress Syndrome:Insights From the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure Study[J].Crit Care Med,2019,47(2):229-238.
27 Henderson WR,Chen L,Amato MBP,et al.Fifty Years of Research in ARDS.Respiratory Mechanics in Acute Respiratory Distress Syndrome[J].Am J Respir Crit Care Med,2017,196(7):822-833.
28 Yoshida T,Roldan R,Beraldo MA,et al.Spontaneous Effort During Mechanical Ventilation[J].Crit Care Med,2016,44(8):e678-e688.
29 Doorduin J,Nollet JL,Roesthuis LH,et al.Partial Neuromuscular Blockade during Partial Ventilatory Support in Sedated Patients with High Tidal Volumes[J].Am J Respir Crit Care Med,2017,195(8):1033-1042.
30 Heider J,Bansbach J,Kaufmann K,et al.Does volatile sedation with sevoflurane allow spontaneous breathing during prolonged prone positioning in intubated ARDS patients?A retrospective observational feasibility trial[J].Ann Intensive Care,2019,9(1):41.
2 ARDS Definition Task Force,Ranieri VM,Rubenfeld GD,et al.Acute respiratory distress syndrome:the Berlin Definition[J].JAMA,2012,307(23):2526-2533.
3 Bellani G,Laffey JG,Pham T,et al.Epidemiology,Patterns of Care,and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries[J].JAMA,2016,315(8):788-800.
4 Fan E,Brodie D,Slutsky AS.Acute Respiratory Distress Syndrome:Advances in Diagnosis and Treatment[J].JAMA,2018,319(7):698-710.
5 Fan E,Villar J,Slutsky AS.Novel approaches to minimize ventilatorinduced lung injury[J].BMC Med,2013,11:85.
6 Putensen C,Hering R,Wrigge H.Controlled versus assisted mechanical ventilation[J].Curr Opin Crit Care,2002,8(1):51-57.
7 Levine S,Nguyen T,Taylor N,et al.Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans[J].N Engl J Med,2008,358(13):1327-1335.
8 Putensen C,Zech S,Wrigge H,et al.Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury[J].Am J Respir Crit Care Med,2001,164(1):43-49.
9 Magalhaes PAF,Padilha GA,Moraes L,et al.Effects of pressure support ventilation on ventilator-induced lung injury in mild acute respiratory distress syndrome depend on level of positive endexpiratory pressure:A randomised animal study[J].Eur J Anaesthesiol,2018,35(4):298-306.
10 Gattinoni L,Marini JJ,Pesenti A,et al.The″baby lung″became an adult[J].Intensive Care Med,2016,42(5):663-673.
11 Gattinoni L,Marini JJ,Collino F,et al.The future of mechanical ventilation:lessons from the present and the past[J].Crit Care,2017,21(1):183.
12 Goligher EC,Dres M,Fan E,et al.Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes[J].Am J Respir Crit Care Med,2018,197(2):204-213.
13 Petrof BJ,Hussain SN.Ventilator-induced diaphragmatic dysfunction:what have we learned?[J].Curr Opin Crit Care,2016,22(1):67-72.
14 Goligher EC,Fan E,Herridge MS,et al.Evolution of Diaphragm Thickness during Mechanical Ventilation.Impact of Inspiratory Effort[J].Am J Respir Crit Care Med,2015,192(9):1080-1088.
15 Pellegrini M,Hedenstierna G,Roneus A,et al.The Diaphragm Acts as a Brake during Expiration to Prevent Lung Collapse[J].Am J Respir Crit Care Med,2017,195(12):1608-1616.
16 Curley GF,Laffey JG,Zhang H,et al.Biotrauma and VentilatorInduced Lung Injury:Clinical Implications[J].Chest,2016,150(5):1109-1117.
17 Yoshida T,Nakahashi S,Nakamura MAM,et al.Volume-controlled Ventilation Does Not Prevent Injurious Inflation during Spontaneous Effort[J].Am J Respir Crit Care Med,2017,196(5):590-601.
18 Yoshida T,Uchiyama A,Matsuura N,et al.Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model:high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury[J].Crit Care Med,2012,40(5):1578-1585.
19 Yoshida T,Fujino Y,Amato MB,et al.Fifty Years of Research in ARDS.Spontaneous Breathing during Mechanical Ventilation.Risks,Mechanisms,and Management[J].Am J Respir Crit Care Med,2017,195(8):985-992.
20 Holanda MA,Vasconcelos RDS,Ferreira JC,et al.Patient-ventilator asynchrony[J].J Bras Pneumol,2018,44(4):321-333.
21 SubiràC,de Haro C,Magrans R,et al.Minimizing Asynchronies in Mechanical Ventilation:Current and Future Trends[J].Respir Care,2018,63(4):464-478.
22 Yoshida T,Amato MBP,Kavanagh BP,et al.Impact of spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome[J].Curr Opin Crit Care,2019,25(2):192-198.
23 Papazian L,Forel JM,Gacouin A,et al.Neuromuscular blockers in early acute respiratory distress syndrome[J].N Engl J Med,2010,363(12):1107-1116.
24 Langer T,Vecchi V,Belenkiy SM,et al.Extracorporeal gas exchange and spontaneous breathing for the treatment of acute respiratory distress syndrome:an alternative to mechanical ventilation?[J].Crit Care Med,2014,42(3):e211-e220.
25 Mauri T,Grasselli G,Suriano G,et al.Control of Respiratory Drive and Effort in Extracorporeal Membrane Oxygenation Patients Recovering from Severe Acute Respiratory Distress Syndrome[J].Anesthesiology,2016,125(1):159-167.
26 van Haren F,Pham T,Brochard L,et al.Spontaneous Breathing in Early Acute Respiratory Distress Syndrome:Insights From the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure Study[J].Crit Care Med,2019,47(2):229-238.
27 Henderson WR,Chen L,Amato MBP,et al.Fifty Years of Research in ARDS.Respiratory Mechanics in Acute Respiratory Distress Syndrome[J].Am J Respir Crit Care Med,2017,196(7):822-833.
28 Yoshida T,Roldan R,Beraldo MA,et al.Spontaneous Effort During Mechanical Ventilation[J].Crit Care Med,2016,44(8):e678-e688.
29 Doorduin J,Nollet JL,Roesthuis LH,et al.Partial Neuromuscular Blockade during Partial Ventilatory Support in Sedated Patients with High Tidal Volumes[J].Am J Respir Crit Care Med,2017,195(8):1033-1042.
30 Heider J,Bansbach J,Kaufmann K,et al.Does volatile sedation with sevoflurane allow spontaneous breathing during prolonged prone positioning in intubated ARDS patients?A retrospective observational feasibility trial[J].Ann Intensive Care,2019,9(1):41.