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中华重症医学电子杂志 ›› 2021, Vol. 07 ›› Issue (01): 66 -70. doi: 10.3877/cma.j.issn.2096-1537.2021.01.011

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ARDS患者自戕式肺损伤的机制和干预措施
李晗 1, 陈强 1, 韩旭东 1 , ( )   
  1. 1. 226000 江苏南通,南通大学附属南通第三医院重症医学科
  • 收稿日期:2020-04-29 出版日期:2021-02-28
  • 通信作者: 韩旭东
  • 基金资助:
    江苏省南通市卫健委市级重点学科支持项目(wx2017002); 江苏省南通市科技计划项目(MS12017004-2,MS12018040,XG202003-3)

Pathogenesis and Interventions of patient self-inflicted lung injury in ARDS

Han Li 1, Qiang Chen 1, Xudong Han 1 , ( )   

  1. 1. Department of Critical Care Medicine, Nantong Third Hospital Affiliated to Nantong University, Nantong 226000, China
  • Received:2020-04-29 Published:2021-02-28
  • Corresponding author: Xudong Han

自主呼吸可能对ARDS患者有多种生理益处,包括减少镇静需求,保持膈肌活动和改善心血管功能。然而,剧烈的自主呼吸努力可能会加重肺损伤,2017年起,用力呼吸导致的肺损伤被称为“患者自戕性肺损伤(P-SILI)”。如何减轻ARDS P-SILI,让患者保持“安全”的自主呼吸成为临床医疗的研究热点。本文就呼吸驱动力在ARDS P-SILI中的生理和临床意义做一综述,并探讨评估呼吸驱动力的方法和改善P-SILI的措施,旨在为减轻ARDS患者的肺损伤提供理论依据,并为最新暴发的新型冠状病毒肺炎的治疗提供新思路。

Spontaneous breathing may offer multiple physiologic benefits for patients with ARDS, including decreased need for sedation, preserved diaphragm activity and improving cardiovascular function. However, vigorous spontaneous breathing efforts may aggravate lung injury. The effort-dependent lung injury has been termed 'patient self-inflicted lung injury (P-SILI)' in 2017. How to prevent P-SILI in ARDS and keep 'safe' spontaneous breathing become the research focus in clinical treatment. This article reviews the physiological and clinical significance of respiratory driving force in ARDS patients with self-inflicted lung injury, and discusses methods to evaluate respiratory driving force and measures to improve P-SILI, in order to provide theoretical basis for reducing lung injury in ARDS patients, and provide a new idea for the treatment of the latest outbreak of COVID-19.

图1 大脑曲线和通气曲线的关系(大脑神经驱动的理论要求和肺部实际通气之间的关系)。图a为健康受试者的实际通气能达到理论要求的水平,其大脑曲线与通气曲线是重叠一致的。图b为ARDS患者的代谢曲线上移,在一定的分钟通气时,ARDS患者的PaCO2高于正常水平。由于呼吸负荷增加和肌无力,PaCO2升高,分钟通气量降低,通气曲线右移;而低氧血症、酸中毒和炎症水肿等引起神经呼吸驱动的刺激增加,大脑理论要求的分钟通气量更高,大脑曲线左移,导致ARDS患者大脑曲线与通气曲线的分离
表1 呼吸驱动力监测工具
1
Morais CCA, Koyama Y, Yoshida T, et al. High positive end-expiratory pressure renders spontaneous effort noninjurious [J]. Amer J Respir Crit Care Med, 2018, 197(10): 1285-1296.
2
Yoshida T, Uchiyama A, Matsuura N, et al. Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury [J]. Crit Care Med, 2012, 40(5): 1578-1585.
3
Yoshida T, Grieco DL, Brochard L, et al. Patient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing [J]. Curr Opin Crit Care, 2020, 26(1): 59-65.
4
Sasidhar M, Chatburn RL. Tidal volume variability during airway pressure release ventilation: case summary and theoretical analysis [J]. Respir Care, 2012, 57(8): 1325-1333.
5
Lalgudi Ganesan S, Jayashree M, Chandra Singhi S, et al. Airway pressure release ventilation in pediatric acute respiratory distress syndrome. a randomized controlled trial [J]. Amer J Respir Crit Care Med, 2018, 198(9): 1199-1207.
6
Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure [J]. Amer J Respir Crit Care Med, 2017, 195(4): 438-442.
7
Spinelli E, Mauri T, Beitler JR, et al. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions [J]. Intensive Care Med, 2020, 46(4): 606-618.
8
Vaporidi K, Akoumianaki E, Telias I, et al. Respiratory drive in critically ill patients. pathophysiology and clinical implications [J]. Amer J Respir Crit Care Med, 2020, 201(1): 20-32.
9
Bhattacharya M, Kallet RH, Ware LB, et al. Negative-pressure pulmonary edema [J]. Chest, 2016, 150(4): 927-933.
10
Yoshida T, Amato MBP, Kavanagh BP, et al. Impact of spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome [J]. Curr Opin Crit Care, 2019, 25(2): 192-198.
11
Kiss T, Bluth T, Braune A, et al. Effects of positive end-expiratory pressure and spontaneous breathing activity on regional lung inflammation in experimental acute respiratory distress syndrome [J]. Crit Care Med, 2019, 47(4): e358-e365.
12
Yoshida T, Nakahashi S, Nakamura MAM, et al. Volume-controlled ventilation does not prevent injurious inflation during spontaneous effort [J]. Amer J Respir Crit Care Med, 2017, 196(5): 590-601.
13
Piquilloud L, Beloncle F, Richard JM, et al. Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study [J]. Ann Intensive Care, 2019, 9(1): 89.
14
Shi ZH, Jonkman A, de Vries H, et al. Expiratory muscle dysfunction in critically ill patients: towards improved understanding [J]. Intens Care Med, 2019, 45(8): 1061-1071.
15
Pellegrini M, Hedenstierna G, Roneus A, et al. The diaphragm acts as a brake during expiration to prevent lung collapse [J]. Amer J Respir Crit Care Med, 2017, 195(12): 1608-1616.
16
Bertoni M, Telias I, Urner M, et al. A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation [J]. Crit Care (London, England), 2019, 23(1): 346.
17
Carteaux G, Millán-Guilarte T, De Prost N, et al. Failure of noninvasive ventilation for de novo acute hypoxemic respiratory failure: role of tidal volume [J]. Crit Care Med, 2016, 44(2): 282-290.
18
Doorduin J, Nollet JL, Roesthuis LH, et al. Partial neuromuscular blockade during partial ventilatory support in sedated patients with high tidal volumes [J]. Amer J Respir Crit Care Med, 2017, 195(8): 1033-1042.
19
Mauri T, Yoshida T, Bellani G, et al. Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives [J]. Intens Care Med, 2016, 42(9): 1360-1373.
20
Yoshida T, Uchiyama A, Matsuura N, et al. The comparison of spontaneous breathing and muscle paralysis in two different severities of experimental lung injury [J]. Crit Care Med, 2013, 41(2): 536-545.
21
Mauri T, Alban L, Turrini C, et al. Optimum support by high-flow nasal cannula in acute hypoxemic respiratory failure: effects of increasing flow rates [J]. Intens Care Med, 2017, 43(10): 1453-1463.
22
Grieco DL, Menga LS, Raggi V, et al. Physiological comparison of high-flow nasal cannula and helmet noninvasive ventilation in acute hypoxemic respiratory failure [J]. Amer J Respir Crit Care Med, 2020, 201(3): 303-312.
23
Reyher C, Muellenbach RM, Lepper PM, et al. Update extracorporeal lung support [J]. Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie: AINS, 2020, 55(3): 165-177.
24
Costa R, Navalesi P, Cammarota G, et al. Remifentanil effects on respiratory drive and timing during pressure support ventilation and neurally adjusted ventilatory assist [J]. Respir Physiol Neurobiol, 2017, 244: 10-16.
25
Dashti-Khavidaki S, Khalili H. Considerations for statin therapy in patients with COVID-19 [J]. Pharmacotherapy, 2020, 40(5): 484-486.
26
McGonagle D, Sharif K, O'Regan A, et al. The role of cytokines including interleukin-6 in COVID-19 induced pneumonia and macrophage activation syndrome-like disease [J]. Autoimmun Rev, 2020, 19(6): 102537.
27
Spadaro S, Park M, Turrini C, et al. Biomarkers for acute respiratory distress syndrome and prospects for personalised medicine [J]. J Inflamm (Lond), 2019, 16: 1.
28
Henderson LA, Canna SW, Schulert GS, et al. On the alert for cytokine storm: Immunopathology in COVID-19 [J]. Arthritis Rheumatol, 2020, 72(7): 1059-1063.
29
Liu B, Bao L, Wang L, et al. Anti-IFN-γ therapy alleviates acute lung injury induced by severe influenza A (H1N1) pdm09 infection in mice[J]. J Microbiol Immunol Infect, 2019:S1684-1182(18)30438-9.
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