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.
现已认识到免疫反应、转录因子核因子κB( NF-κB) 的激活、细胞因子、中性粒细胞的激活和肺泡渗入、凝血级联反应、肾素-血管紧张素系统等多种因素构成的复杂网络参与急性肺损伤/急性呼吸窘迫综合征( ALI/ARDS) 的发病过程[ 1-5] 。虽然脓毒症、创伤、肺炎等ALI/ARDS诱发因素很常见, 但仅有部分病人发生ALI/ARDS, 并且具有相似临床特征的ALI/ARDS病人可有截然不同的结果, 这种异质性引起研究者对影响ALI/ARDS 易感性和预后的遗传因子进行鉴别的浓厚兴趣[ 6] 。由于数量庞大的表现型变异, 不完全的基因外显率、复杂的基因-环境相互作用及高度可能的基因座不均一性而使ALI 遗传学的研究受到挑战[ 7] 。近年来基因组学技术被应用于ALI/ARDS 发病机制的研究, 加深了人们对ALI/ARDS的认识并有可能发展出新的治疗策略以降低其发病率和病死率。
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。
急性肺损伤( ALI) 及急性呼吸窘迫综合征( ARDS) 是各种肺内外致病因素导致的急性呼吸衰竭, 以进行性呼吸困难和顽固性低氧血症为特征, 常继发于休克、创伤、严重感染以及大面积烧伤等疾病。病理以双肺弥漫性的渗出为特点。病情进展迅速, 预后极差, 具有很高死亡率。治疗时需要纠正缺氧, 以保证组织氧供。传统的常规机械通气( CMV) 在改善氧合、呼吸力学参数以及肺内炎症反应的同时, 导致肺损伤, 即呼吸机相关性肺损伤( VALI) 。近年认为, 采用高频振荡通气( HFOV) 代替CMV 能明显避免产生VALI, 并能改善ALI/ARDS的呼吸系统顺应性和氧合作用, 减轻肺内炎症反应和VALI, 利于急性损伤肺内塌陷和闭塞的小气道和肺泡重新开放。并且有人提出HFOV 与部分液体通气( PLV)联用( HFOV-PLV) 可进一步改善气体交换, 抑制肺组织的炎性反应, 减少肺损伤及氟碳化合物( PFCs) 用量, 稳定全身血液循环, 减少中枢神经系统( CNS) 并发症[ 1] 。
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.
Background: Poor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists' chest radiograph interpretations for ARDS diagnosis. Methods: We conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force ("the panel") before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs. Results: Overall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 +/- 14.8% before training vs. 55.3 +/- 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 +/- 0.406 vs. 0.461 +/- 0.575, p = 0.792), Fleiss's kappa (0.133 +/- 0.575 vs. 0.178 +/- 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470). Conclusions: The radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force.
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.
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.
Objective To investigate the titration of best positive end-expiratory pressure (Best PEEP) based on mechanical power (MP) and transpulmonary pressure monitoring during lung reexpansion in patients with acute respiratory distress syndrome (ARDS), and to analyze the value of both in evaluating the prognosis of ARDS patients.Methods ARDS patients treated in the intensive care Unit of the First Affiliated Hospital of Jinzhou Medical University from September 2021 to March 2023 were selected and divided into survival group and death group according to the 28-day mortality rate. After full sedation, esophageal pressure tube was inserted through the nasal passage, and lung recruitment maneuvers (RM) was performed by incremental PEEP method. The Best PEEP method was titrated based on MP and transpulmonary pressure. Pearson correlation analysis was used to analyze the correlation between MP at RM 30 min and 2 h and transpulmonary pressure. The changes of clinical indicators at 30 minutes and 2 hours after RM were compared between the two groups with different outcomes. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of 2 h MP and transpulmonary pressure for 28-day mortality in ARDS patients. Results MP and transpulmonary pressure in the survival group decreased significantly at 30 min and 2 h, while MP and transpulmonary pressure in the death group showed a significant upward trend (P < 0.05). The Best PEEP and RR at 30 min and 2 h of the RM in the survival group were lower than those in the death group (P < 0.05). Pearson correlation analysis showed that MP at RM 30 min and 2 h was significantly correlated with transpulmonary pressure (r = 0.710 and 0.804, P < 0.05). The area under the ROC curve of MP and transpulmonary pressure were 0.812 and 0.795, respectively. 95% confidencial interval: 0.704 - 0.920 and 0.687 - 0.903 (P < 0.05); The sensitivity was 86.95% and 82.50%, respectively. The specificity were 76.67% and 59.40%; The positive predictive values were 0.851 and 0.688; The negative predictive values were 0.793 and 0.759; The optimal cut-off values were 15.5 and 17.5, respectively. RM 2 h MP and transpulmonary pressure have good predictive value for 28-day mortality in ARDS patients. Conclusion Monitoring MP and transpulmonary pressure during lung recruitment maneuver can effectively guide the titration of Best PEEP in ARDS patients, and both have good evaluation value for the prognosis of ARDS patients.