現已認識到免疫反應、轉錄因子核因子κB( NF-κB) 的激活、細胞因子、中性粒細胞的激活和肺泡滲入、凝血級聯反應、腎素-血管緊張素系統等多種因素構成的復雜網絡參與急性肺損傷/急性呼吸窘迫綜合征( ALI/ARDS) 的發病過程[ 1-5] 。雖然膿毒癥、創傷、肺炎等ALI/ARDS誘發因素很常見, 但僅有部分病人發生ALI/ARDS, 并且具有相似臨床特征的ALI/ARDS病人可有截然不同的結果, 這種異質性引起研究者對影響ALI/ARDS 易感性和預后的遺傳因子進行鑒別的濃厚興趣[ 6] 。由于數量龐大的表現型變異, 不完全的基因外顯率、復雜的基因-環境相互作用及高度可能的基因座不均一性而使ALI 遺傳學的研究受到挑戰[ 7] 。近年來基因組學技術被應用于ALI/ARDS 發病機制的研究, 加深了人們對ALI/ARDS的認識并有可能發展出新的治療策略以降低其發病率和病死率。
Objectives About 12.9-50% patients of SARS (Severe Acute Respiratory Syndrome), require brief mechanical ventilation (MV) to save life. All the reported principles and guidelines for therapy SARS were based on experiences from clinical treatments and facts of inadequacy. Neither prospective randomized controlled trials (RCT) nor other high quality evidences were in dealing with SARS. Our objective is to seek safe and rational non-drugs interventions for patients with severe SARS by retrospectively reviewing clinical studies about MV all over the world, which include clinical guidelines, systematic reviews (SR), Meta-analysis, economic researches and adverse events. Methods To search MEDLINE and Cochrane Library with computer. According to the standards of inclucion or exclusion, the quality of the article which as assessed, and relevant data which were extracted double checked. The Meta-analysis was conducted if the studies had no heterogeneity. Results 14 papers were eligible. Due to the significant heterogeneity between these studies, further Meta-analysis could not be conducted, and the authors’ conclusions were described only. Conclusions The outcome of PPV is better than that of VPV. Patients who underwent PPV had a significantly lower mortality than that of VPV. Of course, the volutrauma should be watched. With low tidal volume and proper PEEP, or decreased FiO2, even permissive hypercapnia, the mortality and length of stay were cut down. Non-invasive mechanical ventilation (NIMV) was effective in treating haemodynamical stable patients, minimizing complications and reducing medical staff infection. Patients with serious dyspnea with PaO2/FiO2lt;200, no profit of NIMV, or couldn’t tolerance hypoxaemia were unlikely to benefit from this technique and needed ventilation with endotracheal intubation. Prone position could improve PaO2/FiO2, NO maybe increased pulmonary perfusion, improved V/Q, and raised oxygenation. Furthermore, Inhaled NO sequentially (SQA) was better than Inhaled NO continuouly (CTA). Some studies implied that practice of protocol-directed weaning from mechanical ventilation implemented by nurses excelled that of traditional physician-directed weaning.
急性呼吸窘迫綜合征( ARDS) 本身即為呼吸系統的急危重癥, 80% 以上ARDS 患者需要氣管插管和機械通氣 。 凡屬嚴重ARDS 的患者, 均有應用挽救性治療( rescue therapies) 的適應證。
Objective To investigate the effects of high dose ulinastatin with lung protective ventilatory strategies on respiratory function and prognosis in critical disease patients combined with acute lung injury/acute respiratory distress syndrome. Methods Using retrospective analysis, we involved the critical disease patients combined with ALI/ARDS in ICU of The Second Affiliated Hospital of Anhui Medical University. According to whether they were treated with high dose ulinastatin with lung protective ventilatory strategies or not, the patients were divided into the treatment group and the control group. Then pulmonary vascular permeability index (PVPI), extravascular lung water index (EVLWI), oxygenation index, length of SIRS, length of stay in ICU and APACHE Ⅱ score were observed. Statistic analysis was conducted using SPSS 19.0 software. Results A total of 24 patients were included, 13 cases in the treatment group and 11 cases in the control group. After 72 h, PVPI (P=0.016), EVLWI (P=0.045), length of SIRS (P=0.002), length of stay in ICU (P=0.024) and APACHE Ⅱ score (P=0.002) decreased significantly, while oxygenation index (P=0.004) increased significantly in the treatment group compared with the control group. Conclusion High dose ulinastatin with lung protective ventilatory strategies decreased lung capillary permeability, reduced lung blood capillary leakage and extravascular lung water, resulted in the improvement of lung oxygenation function, decreased of length of stay in ICU and the improvement of prognosis in critical disease patients combined with acute lung injury/acute respiratory distress syndrome.
ObjectiveTo systematically review the application of extracorporeal membrane oxygenation (ECMO) in patients with coronavirus disease 2019 (COVID-19).MethodsPubMed, The Cochrane Library, EMbase, CBM, WanFang Data and CNKI databases were searched for studies on ECMO for COVID-19 from December 1st, 2019 to December 31st, 2020. Two researchers independently screened literature, extracted data, and evaluated the risk of bias of included studies. Meta-analysis was then performed using RevMan 5.3 software.ResultsA total of 24 studies were included, involving 1 576 acute respiratory distress syndrome (ARDS) patients with COVID-19. The overall mortality of patients was 27.3% (430/1 576). The rate of ECMO treatment was 4.68% (379/1576), and the survival rate was 69.4% (263/379). The mean duration of mechanical ventilation prior to ECMO treatment for ARDS patients ranged from 2.07±0.40 to 15.89±13.0 days, compared with 1.64±0.78 days and 29.9±3.60 days for ECMO treatment. Of the 11 studies included in the meta-analysis, 84.0% (405/482) patients with ARDS received conventional treatment with COVID-19, and 16.0% (77/482) received ECMO treatment on the basis of conventional treatment with ARDS. Results of meta-analysis showed that there was statistically significant difference in the survival rate of ARDS patients with COVID-19 treated with conventional therapy combined with ECMO or with conventional therapy alone (RR=1.27, 95%CI 1.00 to 1.62, P=0.05).ConclusionsThis study suggests that the survival rate of COVID-19 patients after ECMO treatment has a tendency to improve. Due to the limitation of quantity and quality of included studies, the above conclusions are needed to be verified by more high-quality studies.
急性肺損傷( ALI) 及急性呼吸窘迫綜合征( ARDS) 是各種肺內外致病因素導致的急性呼吸衰竭, 以進行性呼吸困難和頑固性低氧血癥為特征, 常繼發于休克、創傷、嚴重感染以及大面積燒傷等疾病。病理以雙肺彌漫性的滲出為特點。病情進展迅速, 預后極差, 具有很高死亡率。治療時需要糾正缺氧, 以保證組織氧供。傳統的常規機械通氣( CMV) 在改善氧合、呼吸力學參數以及肺內炎癥反應的同時, 導致肺損傷, 即呼吸機相關性肺損傷( VALI) 。近年認為, 采用高頻振蕩通氣( HFOV) 代替CMV 能明顯避免產生VALI, 并能改善ALI/ARDS的呼吸系統順應性和氧合作用, 減輕肺內炎癥反應和VALI, 利于急性損傷肺內塌陷和閉塞的小氣道和肺泡重新開放。并且有人提出HFOV 與部分液體通氣( PLV)聯用( HFOV-PLV) 可進一步改善氣體交換, 抑制肺組織的炎性反應, 減少肺損傷及氟碳化合物( PFCs) 用量, 穩定全身血液循環, 減少中樞神經系統( CNS) 并發癥[ 1] 。
ObjectiveTo evaluate the effect of prone position ventilation on mortality in ARDS patients by cumulative meta-analysis.MethodsDatabases including PubMed, EMbase, Web of Science, The Cochrane Library, CBM, CNKI, VIP, WanFang Data were searched from inception to September 30th, 2016 to collect randomized controlled trials (RCTs) about prone position ventilation in ARDS patients. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies. In accordance with the published literature or published in chronological order, cumulative meta-analysis was performed using Stata12.0 software, and the trial sequencing analysis (TSA) method was used to assess the reliability and authenticity of the results.ResultsA total of 9 RCTs involving 2 359 patients were included. The cumulative meta-analysis results showed that the prone position ventilation could reduce the mortality in ARDS patients (OR=0.60, 95%CI 0.40 to 0.90). The TSA results showed that the definite conclusion had been obtained before the desired amount of information had been reached.ConclusionThe current evidence shows that prone position ventilation is associated with decreased mortality in ARDS patients. Due to limited quality and quantity of included studies, the above results are needed to validate by more studies.
ARDS 是引起重癥患者呼吸衰竭的主要原因, 盡管醫療技術有了很大的進步, 但對ARDS 的治療只局限在器官支持層面, 其病死率仍高達40% [ 1] 。ARDS的主要病理改變為肺泡上皮細胞和毛細血管內皮細胞受損, 通透性增加, 富含蛋白質的液體滲出積聚于肺間質和肺泡。因此促進損傷肺毛細血管內皮細胞和肺泡上皮細胞的有效修復可能是ARDS治療的關鍵所在。隨著干細胞工程學的發展, 間充質干細胞( MSC) 作為一種理想的組織修復來源, 在ARDS 治療中的應用受到越來越多的關注, 這可能為ARDS 的治療開辟一條新的途徑。
Objective To formulate an evidence-based position program for a ventilation patient with acute respiratory distress syndrome (ARDS). Methods Based on fully assessing the patient’s conditions, the clinical problems were put forward according to PICO principles. Such database as The Cochrane Library (2005 to January 2011), DARE (March 2011), CCTR (March 2011), MEDLINE (1996 to January 2011) and CNKI (1979 to January 2011) were retrieved to collect high quality clinical evidence, and then the optimum nursing program was designed in line with patient’s conditions and relatives’ willingness. Results Three meta-analyses, three randomized controlled trials, one systematic review and one anterior-posterior self-control study were included. The available clinical evidence displayed that: a) the prone position adopting earlier, especially for patients with bilateral lungs or left lung functional disorder, was propitious to effectively improve the oxygenation condition and reduce the incidence of ventilator induced lung injury (VILI); b) The long-term prone position could increase the risk of pressure sore; c) The prone position could prolong the survival time, but there was no enough evidence to prove that it could obviously decrease the mortality rate of ARDS. So finally a nursing plan was made in combination with literature evidence and patient’s condition: adopting the prone position after onset within 24 to 36 hours, and enhancing the skin nursing to prevent pressure sore at the same time. After 4-week comprehensive therapy and prone position ventilation, the patient got obvious alleviated in oxygenation, with SpO 2 up to 90% to 100%, stable vital signs, and no more VILI and pressure sore. And then the patient was stopped applying ventilator, and transferred to a general ward for further treatment. Conclusion The earlier adoption of prone position ventilation for severe ARDS can improve oxygenation and reduce ventilator associated pneumonia (VAP) and VILI, but whether it can prolong survival time and reduce mortality for mild ARDS or not still has to be proved with more high quality evidence in the future.