Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support
Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support
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DOI：
10.23736/s0375-9393.19.13418-9
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发表时间：
2019-09-01
影响因子：
3.2
通讯作者：
Antonelli, Massimo
中科院分区：
文献类型：
--
作者：
Grieco, Domenico L.;Menga, Luca S.;Antonelli, Massimo
自主呼吸在急性低氧性呼吸衰竭和ARDS患者中的作用存在争议：虽然避免无创通气（NIV）或高流量鼻插管插管可改善临床结局，但治疗失败会增加死亡率。最近的数据表明，患者自身造成的肺损伤（P-SILT）是加重这些患者肺损伤的可能机制。P-SILI是由强烈的吸气努力产生的：（A）跨肺压（即肺应力）波动，导致通气室中的大体积充气因疾病引起的通气损失而显著减少;（B）跨血管压异常增加，有利于负压肺水肿;（C）不同肺区之间的气体潮气内转移。由肌肉力量的不同传递（即pendelluft）产生;（D）膈肌损伤。实验数据表明，并非所有受试者都会发生P-SILI：PaO 2/FiO（2）比值低于200 mmHg的患者可能代表风险最高的人群。对于他们来说，目前的证据表明，单独使用高流量鼻插管可能上级通过面罩输送的间歇性低PEEP NIV，而持续高PEEP头盔NIV可能促进治疗成功并可能减轻肺损伤。然而，低氧性呼吸衰竭/ARDS的最佳初始无创治疗仍不确定;高流量鼻插管和高PEEP头盔NIV是提高该方法成功率的有希望的工具，但这些技术之间的最佳平衡尚未确定。在无创支持期间，仍必须进行仔细的临床监测，以便及时发现治疗失败，以免延误插管和保护性通气。
The role of spontaneous breathing among patients with acute hypoxemic respiratory failure and ARDS is debated: while avoidance of intubation with noninvasive ventilation (NIV) or high-flow nasal cannula improves clinical outcome, treatment failure worsens mortality. Recent data suggest patient self-inflicted lung injury (P-SILT) as a possible mechanism aggravating lung damage in these patients. P-SILI is generated by intense inspiratory effort yielding: (A) swings in transpulmonary pressure (i.e. lung stress) causing the inflation of big volumes in an aerated compartment markedly reduced by the disease-induced aeration loss; (B) abnormal increases in transvascular pressure, favouring negative-pressure pulmonary edema; (C) an intra-tidal shift of gas between different lung zones. generated by different transmission of muscular force (i.e. pendelluft); (D) diaphragm injury. Experimental data suggest that not all subjects are exposed to the development of P-SILI: patients with a PaO2/FiO(2) ratio below 200 mmHg may represent the most at risk population. For them, current evidence indicates that high-flow nasal cannula alone may be superior to intermittent sessions of low-PEEP NIV delivered through face mask, while continuous high-PEEP helmet NIV likely promotes treatment success and may mitigate lung injury. The optimal initial noninvasive treatment of hypoxemic respiratory failure/ARDS remains however uncertain; high-flow nasal cannula and high-PEEP helmet NIV are promising tools to enhance success of the approach, but the best balance between these techniques has yet to be identified. During noninvasive support, careful clinical monitoring remains mandatory for prompt detection of treatment failure, in order not to delay intubation and protective ventilation.