Lung- and Diaphragm-Protective Ventilation
Lung- and Diaphragm-Protective Ventilation
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DOI：
10.1164/rccm.202003-0655cp
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发表时间：
2020-10-01
影响因子：
24.7
通讯作者：
Brochard, Laurent
中科院分区：
文献类型：
--
作者：
Goligher, Ewan C.;Dres, Martin;Brochard, Laurent
机械通气可导致急性膈肌萎缩和损伤，这与不良的临床结局相关。尽管肺保护性通气的重要性和影响已得到广泛认可和确立，但肺保护性通气的概念最近已成为一种潜在的补充治疗策略。这一观点是根据欧洲重症监护医学会PLUG（胸膜压力工作组）召集的国际专家会议上的讨论制定的，它概述了基于越来越多的损伤机制证据的机械通气综合肺和肺保护方法的概念框架。我们提出了基于呼吸努力和患者-呼吸机同步性的膈肌保护目标。在某些条件下，隔膜保护和肺保护之间的冲突的可能性进行了讨论，我们强调，当出现冲突时，肺保护必须优先于隔膜保护。在机械通气期间，监测呼吸努力对于同时保护横膈膜和肺至关重要。为了实施肺和肺保护性通气，需要新的监测、设置呼吸机和滴定镇静的方法。辅助干预，包括体外生命支持技术，膈神经刺激，和临床决策支持系统，也可能在选定的患者在未来发挥重要作用。由于干预的复杂性，评估这种新模式的临床影响将具有挑战性。肺和肺保护性通气的概念为潜在改善危重患者的临床结局提供了新的机会。
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.