再议俯卧位通气的时机

doi:10.3877/cma.j.issn.2096-1537.2023.01.002

患者在俯卧位状态下进行呼吸支持的技术称为俯卧位通气（PPV），PPV具有促进塌陷肺泡复张、改善通气血流比、改善呼吸系统顺应性、利于分泌物引流，以及减少呼吸机相关性肺损伤（VILI）的优点，但PPV启动时机缺少统一指征。目前急性呼吸窘迫综合征（ARDS）机械通气指南推荐对中重度ARDS患者实施PPV，鉴于VILI使ARDS复杂化，对于传统ARDS，PPV应尽早实施；对于体外膜肺氧合（ECMO）支持的ARDS患者，建议在有条件的中心，在ECMO支持早期开始实施PPV。对于气管插管的低顺应性型新冠肺炎患者实施PPV的时机可参考传统ARDS患者。关于新冠肺炎患者清醒PPV的时机逐渐前移，只要新冠肺炎患者无清醒PPV的禁忌证，且患者可耐受，即使氧合无明显降低，亦可开始PPV。

关键词: 俯卧位通气, 时机, 急性呼吸窘迫综合征, 新冠肺炎, 体外膜肺氧合

Prone position ventilation (PPV) is a technique of respiratory support for patients under a prone position. PPV has the advantages of promoting collapsed alveolar recruitment, enhancing ventilation/perfusion ratio, improving respiratory system compliance, facilitating secretion drainage, and reducing ventilator-associated lung injury. However, there is no unified recommendations for the timing of PPV initiation. For patients with moderate and severe ARDS, PPV is now recommended by guidelines for mechanical ventilation of acute respiratory distress syndrome (ARDS). Considering that ventilator-associated lung injury complicates ARDS, PPV should be implemented as soon as possible for patients with traditional ARDS. For those receiving extracorporeal membrane oxygenation (ECMO), it is recommended to start PPV at the early stage of ECMO support in ECMO centers. The timing of PPV for intubated COVID-19 patients with poor respiratory compliance can refer to patients with traditional ARDS. The timing for awake PPV in COVID-19 gradually moves forward. Even if oxygenation does not dramatically drop, PPV can be started in COVID-19 patients as long as they are tolerable and have no contraindications.

Key words: Prone position ventilation, Timing, Acute respiratory distress syndrome, COVID-19, Extracorporeal membrane oxygenation

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