Mechanical ventilation in the management of acute respiratory distress syndrome
Mechanical ventilation in the management of acute respiratory distress syndrome
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DOI：
10.1111/j.1525-139x.2006.00215.x
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发表时间：
2006-11-01
影响因子：
1.6
通讯作者：
Cook, Christopher K.
中科院分区：
文献类型：
--
作者：
Delong, Peter;Murray, James A.;Cook, Christopher K.
急性呼吸窘迫综合征（ARDS）的发生现在在世界各地的重症监护病房中很常见。 ARDS 的诊断基于的定义包括胸片上的双侧肺部浸润、氧合受损以及缺乏左心房压力升高的临床证据。 ARDS 是一组不同过程的临床结果，这些过程的范围从物理或化学损伤到先天炎症反应的广泛激活。所有这些过程都会损害肺泡毛细血管屏障的完整性，导致肺泡毛细血管通透性增加以及富含蛋白质的液体流入肺泡空间。这种肺泡充盈会导致低氧血症、表面活性剂失活、肺内分流和肺泡通气受损。急性呼吸窘迫综合征的治疗本质上主要是支持性的，在保证患者生命的同时让肺部愈合，并最大限度地减少进一步的肺部损伤。 1994 年，国家心肺血液研究所 (NHLBI) 建立了 ARDS 网络来开展临床试验。这是一个由美国国立卫生研究院支持的网络，为精心设计的、多中心的、随机的 ARDS 治疗试验提供基础设施。该小组于 2001 年进行的第一项研究产生了具有里程碑意义的数据，表明采用特定的机械通气策略可改善 ARDS 的死亡率。具体而言，低潮气量机械通气已被证明可将死亡率降低 22%。其他策略，例如高呼气末正压和俯卧位，尚未被证明可以降低死亡率。参与 ARDS 患者护理的临床医生应对机械通气和指导这些患者机械通气策略的证据有基本的了解。在发表进一步的证据之前，提供者应采用容量和压力限制的方法进行机械通气。
The occurrence of acute respiratory distress syndrome (ARDS), is now common in intensive care units throughout the world. The diagnosis of ARDS is based on a definition that includes bilateral pulmonary infiltrates on chest radiographs, impaired oxygenation, and the absence of clinical evidence of elevated left atrial pressure. ARDS is the clinical result of a group of diverse processes, which range from physical or chemical injury, to extensive activation of innate inflammatory response. All these processes damage the integrity of the alveolar-capillary barrier causing increased alveolar-capillary permeability and an influx of protein-rich fluid into the alveolar space. This alveolar flooding results in hypoxemia, inactivated surfactant, intrapulmonary shunt, and impaired alveolar ventilation. The treatment of acute respiratory distress syndrome is largely supportive in nature, keeping patients alive while allowing their lungs to heal, and minimizing further pulmonary insult. In 1994 the National Heart, Lung, and Blood Institute (NHLBI) established the ARDS Network for the conduct of clinical trials. This is a network, supported by the National Institutes of Health, that provided the infrastructure for well-designed, multicenter, randomized trials of therapies for ARDS. The first study from this group in 2001 produced landmark data demonstrating mortality improvements in ARDS with particular mechanical ventilation strategies. Specifically, low tidal volume mechanical ventilation was demonstrated to reduce mortality by 22%. Other strategies such as high positive end expiratory pressure and prone positioning have not been shown to reduce mortality. Clinicians who are involved in the care of patients with ARDS should have a basic understanding of mechanical ventilation and the evidence guiding the mechanical ventilation strategies of these patients. Until further evidence is published, providers should adopt the use of a volume and pressure limited approach to mechanical ventilation.