Coronavirus Disease 2019 and Acute Respiratory Distress Syndrome: Why the Intensivist Is More Important Than Ever.
Coronavirus Disease 2019 and Acute Respiratory Distress Syndrome: Why the Intensivist Is More Important Than Ever.
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DOI：
10.1097/ccm.0000000000004663
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发表时间：
2020-12
影响因子：
8.8
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中科院分区：
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重症监护医学www. ccmjournal。org 1839低氧血症（18），所涉及的努力可能会增加医务人员的风险。对于将“标准”ARDS护理应用于COVID-19的治疗，存在额外的担忧。首先，研究表明，COVID-19患者容易出现肺血栓和微血管病（19）。此外，尸检结果显示肾脏（可能还有心脏）病理学与缺血再灌注损伤一致（20，21）。这两种异常都是血容量不足的潜在后果。虽然需要更大规模的研究来证实，但这些发现的影响是惊人的。太小的电视会增加死空间。高水平的PEEP可能会增加过度充气和肺泡死腔（7）。此外，液体限制可能导致过度凝血和灌注不足。总体而言，确定COVID-19患者与其他形式的急性呼吸衰竭之间存在明显差异的因素应引起对一刀切疗法应用的关注。因此，在我们等待深入研究（而不是意见论文和描述性病例系列）的同时，对肺部病理生理学与该疾病一致的COVID-19患者应用“标准”ARDS治疗似乎是合适的。然而，依赖于周到的床边观察和生理的理解，确定重症监护实践的本质要素，是必不可少的。这种个体化方法的一个例子是优化肺力学、通气分布和右心室功能以提高肥胖ARDS患者生存率的抢救策略（22）。我们还应该考虑一个更大的问题：重症监护医学是否已经发展到我们能够根据疾病的复杂性和个体患者的特征来调整护理的程度？在这方面，COVID-19可能是一个重要的考验。共识标准根据氧合损伤程度确定和分级ARDS严重程度（3）。临床标准已应用于重症患者的其他疾病，最值得注意的是脓毒症（脓毒症-3）（23）。然而，呼吸力学的特定模式（20）、对肺泡复张的反应（24）和生物标志物谱（25）可预测ARDS结局和治疗效果的差异。这些发现表明，“ARDS”不是一个单一的实体，而是一个涵盖了许多不同的综合征。加州大学旧金山分校弗朗西斯科的研究人员使用生物标志物来识别对PEEP/TV（16）、液体管理（15）和某些药物（17）有独特反应的ARDS患者亚组。COVID-19肺炎和ARDS之间的关键区别表明，COVID-19患者可能在“ARDS伞”下占据自己独特的空间。总之，护理标准不应扼杀一个善于观察和训练有素的从业人员修改和完善管理的能力。然而，COVID-19的出现凸显了在复杂患者中对疾病知之甚少的情况下尝试提供个性化护理时可能出现的困境。找到平衡点对于抗击COVID-19肺炎和推进重症医学学科至关重要。
Critical Care Medicine www. ccmjournal. org 1839 hypoxemia (18), and the effort involved may increase the risk to medical personnel. There are additional concerns regarding the application of “standard” ARDS care to the treatment of COVID-19. First, studies suggest that COVID-19 patients are prone to pulmonary blood clots and microangiopathy (19). Additionally, autopsy results reveal renal (and perhaps cardiac) pathology consistent with ischemia-reperfusion injury (20, 21). Both abnormalities are potential consequences of hypovolemia. Although confirmation in larger studies is required, the implications of this constellation of findings are striking. Overly small TVs can increase dead space. High levels of PEEP might enhance hyperinflation and alveolar dead space (7). Additionally, fluid restriction may lead to excessive coagulation and hypoperfusion. Overall, the factors that identify distinct differences between the COVID-19 patients and other forms of acute respiratory failure should raise concern about the application of one-size-fits-all therapy. Thus, while we await in-depth studies (as opposed to opinion papers and descriptive case series), it seems appropriate to apply “standard” ARDS care to those COVID-19 patients whose pulmonary pathophysiology is consistent with that disorder. However, reliance on thoughtful bedside observation and physiologic understanding, the elements that identify the essence of intensive care practice, is essential. An example of such individualized approach is a rescue strategy optimizing lung mechanics, ventilation distribution, and right ventricular function to improve the survival of obese ARDS patients (22). We should also consider a larger question: has critical care medicine evolved to the point where we are able to titrate care to the complexity of the disorder and the characteristics of individual patients? In this regard, COVID-19 may serve as an important test. Consensus criteria identify and grade ARDS severity based on the degree of oxygenation impairment (3). Clinical criteria have been applied to other disorders in the critically ill, most notably sepsis (Sepsis-3)(23). However, specific patterns of respiratory mechanics (20), the response to alveolar recruitment (24), and biomarker profiles (25) are predictive of differences in outcomes and treatment efficacy in ARDS. These findings suggest that “ARDS” is not a single entity but rather an umbrella term for a number of distinct syndromes. Investigators at the University of California, San Francisco have used biomarker profiles to identify subsets of patients with ARDS who have unique responses to PEEP/TV (16), fluid administration (15), and certain drugs (17). Key differences between COVID-19 pneumonia and ARDS suggest that COVID-19 patients may occupy their own unique space under the “ARDS umbrella.” In conclusion, standards of care should not suffocate the ability of an observant and well-trained practitioner to modify and refine management. However, the emergence of COVID-19 highlights the dilemma that may present when provision of individualized care is attempted in poorly understood disorders in complex patients. Finding a balance is essential to combat COVID-19 pneumonia and to advance the discipline of critical care medicine.