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Rescure therapies for refractory hypoxemia in srvere ARDS

急性呼吸窘迫综合征( ARDS) 本身即为呼吸系统的急危重症, 80% 以上ARDS 患者需要气管插管和机械通气 。 凡属严重ARDS 的患者, 均有应用挽救性治疗( rescue therapies) 的适应证。

The application of extracorporeal membrane oxygenation in patients with COVID-19: a systematic review and meta-analyses of cohort studies

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.

Research progress of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in the treatment of adult severe respiratory failure

As an extracorporeal life support technology, veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been demonstrated its role in the treatment of patients with severe respiratory failure. Its main advantages include the ability to maintain adequate oxygenation and remove excess CO2, increase oxygen delivery, improve tissue perfusion and metabolism, and implement lung protection strategies. Clinicians should accurately assess and identify the patient's condition, timely and accurately carry out VV-ECMO operation and management. This article will review the patient selection, cannulation strategy, anticoagulation, clinical management and weaning involved in the application of VV-ECMO.

Bone Marrow Mesenchymal Stem Cells for Treatment of Seawater Drowning Induced Acute Lung Injury

With the growth of offshore activities, the incidence rates of seawater drowning (SWD) induced acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) increase significantly higher than before. Pulmonary interstitial edema, alveolar septum fracture, red blood cells, and inflammatory cells infiltration can be seen under light microscope in the pathologic changes of lungs. The major clinical manifestations are continual hyoxemia and acidosis, which lead to a severe condition, a high death rate, and a poor treatment effect. Bone marrow mesenchymal stem cells are capable of self-renewal, multilineage differentiation and injured lung-homing, which are induced to differentiate into alveolar epithelial cells and pulmonary vascular endothelial cells for tissues repairing. This may be a new way to treat SWD-ALI and SW-ARDS.

Efficacy of prone positioning ventilation in acute respiratory distress syndrome after acute Stanford type A aortic dissection surgery

Objective To explore the efficacy of prone positioning ventilation in patients with acute respiratory distress syndrome (ARDS) after acute Stanford type A aortic dissection (STAAD) surgery. Methods From November 2019 to September 2021, patients with ARDS who was placed prone position after STAAD surgery in the Xiamen Cardiovascular Hospital of Xiamen University were collected. Data such as the changes of blood gas, respiratory mechanics and hemodynamic indexes before and after prone positioning, complications and prognosis were collected for statistical analysis. ResultsA total of 264 STAAD patients had surgical treatment, of whom 40 patients with postoperative ARDS were placed prone position. There were 37 males and 3 females with an average age of 49.88±11.46 years. The oxygen partial pressure, oxygenation index and peripheral blood oxygen saturation 4 hours and 12 hours after the prone positioning, and 2 hours and 6 hours after the end of the prone positioning were significantly improved compared with those before prone positioning ventilation (P<0.05). The oxygenation index 2 hours after the end of prone positioning which was less than 131.42 mm Hg, indicated that the patient might need ventilation two or more times of prone position. Conclusion Prone position ventilation for patients with moderate to severe ARDS after STAAD surgery is a safe and effective way to improve the oxygenation.

俯卧位通气治疗人感染 H7N9 禽流感致重度急性呼吸窘迫综合征二例报道

目的初步探索俯卧位通气（PPV）在人感染 H7N9 禽流感致重度急性呼吸窘迫综合征（ARDS）的疗效和安全性。方法收集福州肺科医院 RICU 2017 年 2 月至 4 月确诊人感染 H7N9 禽流感 2 例患者的 PPV 前 2 h（Pre-PPV），PPV 后 2 h、4 h、6 h、8 h、10 h、12 h（PPV-2 h、PPV-4 h、PPV-6 h、PPV-8 h、PPV-10 h、PPV-12 h），改为仰卧位通气（SPV）后 2 h、4 h（SPV-2 h、SPV-4 h）相关呼吸力学和血流动力学数据，利用 SPSS 19.0 软件进行分析。结果2 例均行有创机械通气；1 例 PPV 前纵隔气肿；症状出现至首次 PPV 分别为 5 d、8 d。共行 12 次 PPV，PPV 13（12～15）h/次，PPV 过程中（PPVmean）氧合指数（OI）较 Pre-PPV 改善［（186.20±71.34）mm Hg 比（131.36±45.43）mm Hg，P=0.020］；PPV 过程中（PPVmean）平均动脉压（MAP）较 Pre-PPV 有所下降［（86.84±10.17）mm Hg 比（97.58±20.51）mm Hg，P=0.009］。SPV 后（SPVmean）每小时尿量较 PPV 增多［（100.19±96.73）mL/h 比（52.96±21.64）mL/h，P=0.002］。与 Pre-PPV 对比，OI 以 PPV 10 h 和 12 h 改善为著（P 值分别为 0.009、0.040）。2 例均存活。PPV 过程中未发生深静脉置管滑脱、气管插管意外脱管、气管插管滑入一侧气管、气管插管阻塞。结论PPV 可改善人感染 H7N9 禽流感所致的重度 ARDS 患者的氧合功能，并发症少。

Noninvasive Positive Pressure Ventilation in Acute Lung Injury and Acute Respiratory Distress Syndrome:A Randomized Controlled Study

Objective To evaluate the efficiency and associated factors of noninvasive positive pressure ventilation( NPPV) in the treatment of acute lung injury( ALI) and acute respiratory distress syndrome( ARDS) .Methods Twenty-eight patients who fulfilled the criteria for ALI/ARDS were enrolled in the study. The patients were randomized to receive either noninvasive positive pressure ventilation( NPPV group) or oxygen therapy through a Venturi mask( control group) . All patients were closely observed and evaluated during observation period in order to determine if the patients meet the preset intubation criteria and the associated risk factors. Results The success rate in avoiding intubation in the NPPV group was 66. 7%( 10/15) , which was significantly lower than that in the control group ( 33. 3% vs. 86. 4% , P = 0. 009) . However, there was no significant difference in the mortality between two groups( 7. 7% vs.27. 3% , P =0. 300) . The incidence rates of pulmonary bacteria infection and multiple organ damage were significantly lower in the NPPV success subgroup as compared with the NPPV failure group( 2 /10 vs. 4/5, P =0. 01;1 /10 vs. 3/5, P = 0. 03) . Correlation analysis showed that failure of NPPV was significantly associated with pulmonary bacterial infection and multiple organ damage( r=0. 58, P lt;0. 05; r =0. 53, P lt;0. 05) . Logistic stepwise regression analysis showed that pulmonary bacterial infection was an independent risk factor associated with failure of NPPV( r2 =0. 33, P =0. 024) . In the success subgroup, respiratory rate significantly decreased( 29 ±4 breaths /min vs. 33 ±5 breaths /min, P lt; 0. 05) and PaO2 /FiO2 significantly increased ( 191 ±63 mmHg vs. 147 ±55 mmHg, P lt;0. 05) at the time of 24 hours after NPPV treatment as compared with baseline. There were no significant change after NPPV treatment in heart rate, APACHEⅡ score, pH and PaCO2 ( all P gt;0. 05) . On the other hand in the failure subgroup, after 24 hours NPPV treatment, respiratory rate significantly increased( 40 ±3 breaths /min vs. 33 ±3 breaths /min, P lt;0. 05) and PaO2 /FiO2 showed a tendency to decline( 98 ±16 mmHg vs. 123 ±34 mmHg, P gt; 0. 05) . Conclusions In selected patients, NPPV is an effective and safe intervention for ALI/ARDS with improvement of pulmonary oxygenation and decrease of intubation rate. The results of current study support the use of NPPV in ALI/ARDS as the firstline choice of early intervention with mechanical ventilation.

糖皮质激素在急性呼吸窘迫综合征晚期患者中的应用

急性呼吸窘迫综合征（ARDS）是由多种病因引起的急性呼吸衰竭综合征，其特点为非心源性肺水肿、低氧血症和弥漫性肺实质病变。ARDS前期以急性炎症和肺泡毛细血管的损伤为主要特点，后期缓慢恢复或发展为持续性的感染和紊乱的纤维增生，伴发持续性酸血症、高热、白细胞增多症。自1967年Ashbaugh等描述了12例ARDS病例之后的40多年，ARDS一直是临床医生面临的巨大挑战。目前在美国重症加强治疗病房（ICU）中，约有9%的患者患有ARDS，病死率高达40%~60%。在ARDS晚期各种抗炎药物与免疫抑制剂中，皮质激素无疑是研究最多的。现就皮质激素在ARDS晚期患者中的应用及发展前景综述如下。

17例重症胰腺炎并发成人呼吸窘迫综合征诊治体会

Effects of Lateral Position Ventilation on Lung Volume and Oxygenation in Patients with Acute Respiratory Distress Syndrome

Objective To explore the effects of lateral position ventilation on lung volume and oxygenation in patients with acute respiratory distress syndrome ( ARDS) . Methods Fourteen patients with ARDS were enrolled. Supine position, lateral position and supine position were successively adopted and continued for one hour respectively. End-expiratory lung volume ( EELV) was measured at the end of each epoch. Effects of different position on gas exchange, lung mechanics and hemodynamics were monitored.Results EELV was increased from ( 1109 ±321) mL to ( 1376 ±381) mL after lateral ventilation ( P lt;0. 05) , and decreased to ( 1143 ±376) mL after the second supine ventilation ( P lt;0. 05) . Compared with initial supine ventilation, there was no significant difference in EELV after the second supine ventilation( P gt;0. 05) . PaO2 /FiO2 was increased from ( 154. 3 ±35. 0) mm Hg to ( 189. 9 ±60. 1) mm Hg after lateral ventilation ( P lt;0. 05) , and increased to ( 209. 2 ±75. 4) mm Hg after the second supine ventilation ( P lt; 0. 05) . Compared with initial supine ventilation, PaO2 /FiO2 was increased greatly after the secondsupine ventilation ( P lt; 0. 01) . There was no significant difference in PaCO2 , lung mechanics and hemodynamics after changing different position. Conclusion Lateral position ventilation can increase EELV and improve oxygenation in patients with ARDS.