1、ARDS诊断困惑与治疗策略空军总医院呼吸科张波ARDS诊断难以判断之处 急性起病 脓毒症者约一半以上患者在24小时内出新浸润 肺外创伤患者可以在数天到1周内出现浸润 80%以上的患者1周内发生肺部浸润 双肺浸润影 肺梗塞 肺不张 肺水肿 胸腔积液 肺泡出血等 无左心功能受累的证据难以掌握ARDS诊断的困惑 现行诊断标准的敏感性和特异性？ 382例外科ICU中死亡的患者进行了尸体解剖 127例达到ARDS的临床诊断标准 临床标准诊断ARDS中度敏感(75%)和特异(84%) 重症患者ARDS的临床标准和病理诊断存在差异 Esteban A,etal. Ann Intern Med2004,141
2、:440-445 临床、影像和病理学诊断的差异 ARDS病因的异质性决定诊断的困难性 感染性（细菌、病毒、真菌） 非感染（药物中毒、免疫损伤等） 肺外与肺内因素The Role of Open-Lung Biopsy in ARDS? Sanjay R. Patel, Chest. 2004;125:197-20257例ARDS开胸肺活检患者资料Age, yr 53 Age, yr 53 18 18PaOPaO2 2/FIO/FIO2 2, mm Hg 145 , mm Hg 145 61 61Positive end-expiratory pressure, cm HPositive end
3、-expiratory pressure, cm H2 2O 10.3 O 10.3 4.1 4.1Male gender 36 (63.2)Male gender 36 (63.2)Immunosuppressed 17 (29.8)Immunosuppressed 17 (29.8)BAL prior to biopsy 44 (77.2)BAL prior to biopsy 44 (77.2)Days from admission to biopsy 7 (148)Days from admission to biopsy 7 (148)Days from intubation to
4、biopsy 3 (025)Days from intubation to biopsy 3 (025)病理诊断DAD 23DAD 23Acute phase 5Acute phase 5Fibroproliferative phase 18Fibroproliferative phase 18Specific infection 8Specific infection 8Diffuse alveolar hemorrhage 5Diffuse alveolar hemorrhage 5BOOP 5BOOP 5Bronchiolitis 3Bronchiolitis 3Culture-nega
5、tive purulent pneumonia 2Culture-negative purulent pneumonia 2Drug reaction 2Drug reaction 2Pulmonary lymphoma 2Pulmonary lymphoma 2Lymphangitic tumor 1Lymphangitic tumor 1Organizing pneumonia 1Organizing pneumonia 1Desquamative interstitial pneumonia 1Desquamative interstitial pneumonia 1Hypersensi
6、tivity pneumonitis 1Hypersensitivity pneumonitis 1Chronic eosinophilic pneumonia 1Chronic eosinophilic pneumonia 1Allergic bronchopulmonary aspergillosis 1Allergic bronchopulmonary aspergillosis 1Pulmonary edema 1Pulmonary edema 1主要并发症Complications N（%）Major 4 (7.0)Death 1 (1.8)Hemothora 2 (3.5)New
7、dialysis 1 (1.8)Minor 18 (31.6)Acute renal failure 6 (10.5) Persistent air leak 12 (21.1)Any 22(38.6)41例开胸肺活检ARDS患者特征主要提示 ARDS的临床诊断标准无法准确反映导致疾病的诱因 ARDS是一组异质性疾病的统称 没有病理诊断往往导致错误治疗或不必要的过度治疗 对ARDS患者选择性进行开胸肺活检是可以接受的一项检查关于诊断的总结 现有的诊断标准有缺陷但尚在沿用 病因的复杂性决定了临床表现的多样性 ARDS的病因诊断水平有限 病因的异质性决定了对治疗反应的不同 早期病因诊断决定治疗成败
8、一、ARDS病理生理PEEP15cmH2O A:over stretched B:excessive stress C:repeated opened and closedARDS机械通气目标 Maintain adequate O2 delivery Maintain normal CO2 Avoid Atelectasis Avoid ventilator-induced lung injury barotrauma MODS Atelectasis Hemodynamic impairment Patient-ventilator asynchrony Support ventilati
9、on Reduce mortality、hospital day、ventliator free day and cost肺保护性通气策略的应用PEEP in ARDS-how much is enough? Brower RG,et al.N Engl J Med2004,351:389 549 ARDS patients Keep VT6ml/kg, Pplat30cmh2O High PEEP group 13.2+/-3.5cmH2O Low PEEP group8.3+/-3.2cmH2O Mortality before discharge High PEEP group 27.5
10、% Low PEEP group 24.9% 1-28days MV free time High PEEP group 14.5 +/-10.4d Low PEEP group 13.8 +/-10.6d合适PEEP水平的确定方法 气流阻断法 静态顺应性法HEARTSPPulmonary Parenchymal Injury1. Overdistention Injury - Pplat 15 cmH20)3. Prolonged Collapse Injury- Recruitment, Prone, Liquid实变区延迟开放需要实施肺开放策略需要实施肺开放策略RM的应用现状对多种新的通
11、气模式的评价 VAPSVVAPSV PRVCVPRVCV VSVVSV Permissive Hypercapnia IRV High frequency ventilation Inhaled nitric oxide Prone positioning PLV TGI ARPV 理论上具有先进性 患者临床情况的复杂性、多变性，决定了监测指标的多变性 目前尚没有比传统模式优越的客观证据 需进一步进行深入临床研究 对多种新的通气模式目前尚不能作为常规推荐应用Synchronized TransitionsSpontaneous BreathPTPEEPHPEEPLCMV BIPAPARCMVD
12、S, 24 hours on each mode. P. Neumann (Gttingen) Putensen C et al.: AJRCCM2001 Jul 1;164(1):43-9PCVAPRV 权衡利弊、个体化、紧急优先原则 氧合状态（SpO210个有意义) 预防治疗策略预防治疗策略 IV Ig-CMV Advantages:Few side effects Disadvantages:Low efficacy High-dose acyclovir Advantages: Few side effectsDisadvantages: High cost Ganciclovir Advantages: Highly effective Disadvantages: High risk of neutropenia (especially in BMT*); late CMV disease possible
