Clinical skills in acute care: a role for simulation training.
Clinical skills in acute care: a role for simulation training.
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急症护理中的临床技能：模拟培训的作用。
DOI：
10.1097/01.ccm.0000191129.02958.82
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发表时间：
2006
影响因子：
8.8
通讯作者：
Murray,David
中科院分区：
文献类型：
--
作者：
Murray,David
机械通气可诱发或加重肺损伤(1)。限制肺泡过度扩张的低潮气量策略已被证明可以改善急性呼吸窘迫综合征(ARDS)患者的预后(2，3)。尚未得到临床证实的实验数据表明，通过限制潮汐漂移和/或周期性的开放和崩溃，正呼吸末压也有助于减少呼吸机诱导的肺损伤(VILI)(4，5)。这种入路固有的低潮气量和有限的潮气压力漂移可能导致肺泡通气量不足和呼吸性酸中毒(RA)，特别是在具有最大生理死腔和死亡风险的患者中。高碳酸血症和呼吸性酸中毒通常被认为是肺保护策略的后果，这些策略将被容忍(允许性高碳酸血症)、有限(增加呼吸频率或气管注气)或部分治疗(注入缓冲液)。最近，吸入二氧化碳(治疗性高碳酸血症)在实验模型中被发现可以限制包括VILI(7，8)在内的各种类型的肺损伤。最佳的床边治疗方法仍然存在争议。从理论上讲，平衡RA的副作用和与特定呼吸机设置(潮气量或最大肺泡压、呼气末正压和通气率)相关的风险，以实现给定的肺泡通气量和PaCO2是至关重要的。还需要考虑以下几点：a)影响对RA耐受性的合并症的存在(例如，心肌功能、冠脉情况)。
Mechanical ventilation can induce or exacerbate lung injury (1). A low tidal volume strategy limiting alveolar overdistention has been shown to improve outcome in patients with acute respiratory distress syndrome (ARDS)(2, 3). Experimental data not yet clinically confirmed suggest that positive endexpiratory pressure may also help reduce ventilator-induced lung injury (VILI) by limiting tidal excursion and/or cyclic opening and collapse (4, 5). The low tidal volume and limited tidal pressure excursion inherent to such approach may result in alveolar hypoventilation and respiratory acidosis (RA), especially in patients with the largest physiologic deadspace and risk of death (6). Hypercapnia and respiratory acidosis are generally viewed as the consequences of lung-protective strategies that are to be tolerated (permissive hypercapnia), limited (increased respiratory rate or tracheal gas insufflation), or partially treated (infusion of buffer). More recently, inhaled carbon dioxide (therapeutic hypercapnia) was found in experimental models to limit various types of lung injury including VILI (7, 8).The optimal bedside approach is still debated. In theory, balancing the side effects of RA with the risks associated with the specific ventilatory settings (tidal volume or peak alveolar pressure, positive end-expiratory pressure, and ventilatory rate) used to achieve a given alveolar ventilation and PaCO2 is of paramount importance. One also needs to consider the following: a) the presence of comorbidity affecting the tolerance to RA (eg, the myocardial function, the coronary circu-