ARDS诊治进展-PPT.ppt

ARDS的病理生理定义ARDS的病因ARDS的发生机制？1肺间质

2肺泡失活表面活性物质1.感染性肺水肿(pulmonaryedemaduetoinfection)ARDS肺水肿的
成分：

富含蛋白
细胞碎片
未激活的PS
中性粒细胞
巨噬细胞
炎症介质
......ARDS的病理生理ARDS的临床诊断？AnearlyPEEP/FIO2trialidentifiesdifferentdegreesoflunginjuryinpatientswithacuterespiratorydistresssyndrome.AmJRespirCritCareMed.2007；15;176(8):795-804.29%ARDS患者PAWP≥18mmHg（或CVP升高）,而其中97%PAWP升高的ARDS患者中有正常的心脏功能。结论：PAWP或CVP升高不能作为ARDS的排除标准。BerlinDefinition2012柏林定义BerlinDefinitionofARDSARDS的治疗策略？ARDS的治疗原则延误使用有效抗生素增加重症肺炎死亡率ARDS的治疗原则ARDS的治疗原则ARDS的治疗原则VentilatorInducedLungInjury，VILIOverdistentionBarotrauma&VolutraumaARDS的保护性通气策略？Oxidantinjury-keepFiO2<60
Barotrauma-keepalveolarinflationpressures<35cmH2O
Volutrauma-Babylungconceptorstretchinjury
Atelectrauma-repeatedopeningandclosing
Biotrauma-releaseofinflammatorymediatorsandbacterialtranslocation

OPENGENTLYANDKEEPTHEMOPEN
温柔的打开肺泡，并保持开放传统的肺保护性通气策略LUNGPROTECTIVEVENTILATIONWITHLOWTIDALVOLUME提纲：临床探讨的通气模式与参数肺通气保护策略在儿童ARDS中的应用36787patientsfromARDSNetworkstudy39VentilationUsingtheBestPEEPPreventionofAtelectrauma（最佳PEEP）VCVvsPCV定容与定压RECRUITMENT肺复张RECRUITMENTMANEUVERVariationsinPatients:SomeNeedHigherPEEPThanOthersCurrentevidencesuggeststhatthatRMsshouldnotberoutinelyusedonallARDSpatientsunlessseverehypoxemiapersistsorasarescuemaneuvertoovercomeseverehypoxemia,toopenthelungwhensettingPEEP,orfollowingevidenceofacutelungderecruitmentsuchasaventilatorcircuitdisconnect
结论：RM不常规用在所有的ARDS患者，除非持续的严重低氧血症，或者做为严重低氧血症的一种肺开放手段（设置PEEP），或者由于管路断开出现急性肺陷闭ComputedtomographyscanofthelungsshowingARDSwhenthepatientislying
supine(left)andprone(right).PronePositioningTheProne-SupineIIStudyisthelargestclinicaltrial(N5342)inadultARDSpatients,conductedin23centersinItalyand2inSpain
20hours/day
Similar28-daymortality-31.0%vs32.8%;RR0.97;(95%CI0.84–1.13;P=0.72)
Mortalityinseverehypoxemiawasdecreasedinthepronegroup-37.8%inthepronegroupand46.1%inthesupinegroup(RR,0.87;95%CI,0.66–1.14P=0.31)Complications52ECMO体外膜氧合ECMOissupportivecareandisnotintendedasaprimaryARDStreatment
CESARtrial-
Patientswererandomizedtoe