急性呼吸窘迫综合征机械通气策略的新进展

Mechanical ventilation in acute respiratory distress syndrome

摘要:

急性呼吸窘迫综合征（ARDS）机械通气的目标是保证足够的氧合和最小的呼吸机相关肺损伤。无创机械通气应慎用于ARDS。小潮气量通气的肺保护性通气策略能降低ARDS死亡率,以驱动压为导向设置潮气量更合理。建议根据静态压力-容积曲线采用低位转折点法来确定理想的呼气末正压（PEEP），不支持常规使用高水平PEEP。俯卧位通气、高频振荡通气和体外膜氧合技术可用于拯救重症ARDS。机械通气中保持ARDS患者自主呼吸很重要，可采用双相气道正压通气、压力支持通气和神经电活动辅助通气等辅助通气模式。不推荐补充外源性肺泡表面活性物质、吸入一氧化氮或支气管扩张剂、气道压力释放通气和部分液体通气。

Abstract:

The goal of mechanically ventilating patients with acute respiratory distress syndrome (ARDS) is to ensure adequate oxygenation and minimal ventilator-associated lung injury. Non-invasive ventilation should be cautiously used in patients with ARDS. Protective ARDS mechanical ventilation strategies with low tidal volumes can reduce mortality. Driving pressure is the most reasonable parameter to optimize tidal volume. Available evidence does not support the routine use of higher positive end expiratory pressure (PEEP) in patients with ARDS. The optimal level of PEEP may be titrated by the inflection point obtained from static pressure-volume curve. Promising therapies include prone position ventilation, high frequency oscillatory ventilation and extracorporeal membrane oxygenation as salvage treatment. While mechanically ventilating, it is also important for ARDS patients to maintain spontaneous breathing via assisted ventilation mode such as bilevel positive airway pressure, pressure support ventilation and neurally adjusted ventilation assist. Exogenous surfactant, inhaled nitric oxide, bronchodilators, airway pressure release ventilation and partial liquid ventilation are not recommended therapies.