切换至 "中华医学电子期刊资源库"

第五届中国出版政府奖音像电子网络出版物奖提名奖

中国科技核心期刊

中国科学引文数据库(CSCD)来源期刊

中华重症医学电子杂志 ›› 2024, Vol. 10 ›› Issue (04) : 325 -328. doi: 10.3877/cma.j.issn.2096-1537.2024.04.002

述评

肺保护性镇静:应重视呼吸驱动和吸气努力的床旁评估
苗明月1, 周建新1,()   
  1. 1.100038 北京,首都医科大学附属北京世纪坛医院急危重症医学中心 急性肺损伤临床诊疗与研究中心
  • 收稿日期:2024-02-08 出版日期:2024-11-28
  • 通信作者: 周建新
  • 基金资助:
    首都医科大学临床诊疗与研究中心项目(CMU-2023-45)

Lung protective sedation: emphasize bedside assessment of respiratory drive and inspiratory effort

Mingyue Miao1, Jianxin Zhou1,()   

  1. 1.Clinical and Research Center on Acute Lung Injury, Emergency and Critical Care Medical Center, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
  • Received:2024-02-08 Published:2024-11-28
  • Corresponding author: Jianxin Zhou
引用本文:

苗明月, 周建新. 肺保护性镇静:应重视呼吸驱动和吸气努力的床旁评估[J/OL]. 中华重症医学电子杂志, 2024, 10(04): 325-328.

Mingyue Miao, Jianxin Zhou. Lung protective sedation: emphasize bedside assessment of respiratory drive and inspiratory effort[J/OL]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2024, 10(04): 325-328.

镇痛镇静是重症患者治疗的重要环节,其治疗目的已经从改善患者舒适度进展到器官功能保护。对于机械通气患者,新近提出的肺保护性镇静概念,是对优化机械通气、镇静策略和呼吸机相关肺-膈肌损伤三者内在关联的进一步认识。也提示临床医师对机械通气患者的镇痛镇静管理,应在唤醒量表评估的基础上,有针对性地对呼吸驱动和吸气努力进行评估和调控,以达到肺-膈肌保护性通气的目的。

Analgesia and sedation play important roles in critically ill patients, with the target shifting from improving patient comfort to organ function protection.For mechanically ventilated patients,the newly proposed concept of lung-protective sedation represents a further understanding of the inherent interconnection between optimizing mechanical ventilation, sedation strategies, and respiratory-related lungdiaphragm injuries.It also reminds clinicians that in the analgesic and sedation management of mechanically ventilated patients, they should evaluate and regulate respiratory drive and inspiratory effort in a targeted manner based on the arousal scale assessments to achieve the purpose of lung-diaphragm protective ventilation.

表1 气道压指标用于评估吸气努力的优点、局限性和参考界值
图1 气道压指标测量示意图。图a 为P0.1 和ΔPOCC 的测量方法,其中红色短双向箭头表示吸气末气道阻断最初的100 ms 内的压力变化,所测量数值即为P0.1;红色长双向箭头表示吸气末气道阻断后的最大气道压力降低幅度,所测量数值即为ΔPOCC。图b 为PMI 的测量方法,其中红色双向箭头表示吸气末气道阻断后气道峰压与气道平台压之间的差值,所测量数值即为PMI;1 cmH2O=0.098 kPa 注:P0.1 为气道阻断压;ΔPOCC 为最大气道压力降幅;PMI 为肌肉压力指数
1
Devlin JW, Skrobik Y, Gélinas C, et al.Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium,immobility, and sleep disruption in adult patients in the ICU [J].Crit Care Med, 2018, 46(9): e825-e873.
2
中华医学会重症医学分会.中国成人ICU 镇痛和镇静治疗指南 [J/OL].中华重症医学电子杂志, 2018, 4(2): 90-113.
3
杨毅, 邱海波.镇痛和镇静治疗的进步: 从改善患者舒适度到器官功能保护 [J].中华内科杂志, 2011, 50(10): 809-811.
4
Brochard L, Slutsky A, Pesenti A.Mechanical ventilation to minimize progression of lung injury in acute respiratory failure [J].Am J Respir Crit Care Med, 2017, 195(4): 438-442.
5
Schepens T, Dres M, Heunks L, et al.Diaphragm-protective mechanical ventilation [J].Curr Opin Crit Care, 2019, 25(1): 77-85.
6
Miao MY, Chen W, Zhou YM, et al.Validation of the flow index to detect low inspiratory effort during pressure support ventilation [J].Ann Intensive Care, 2022, 12(1): 89.
7
Goligher EC, Dres M, Patel BK, et al.Lung- and diaphragm-protective ventilation [J].Am J Respir Crit Care Med, 2020, 202(7): 950-961.
8
Chanques G, Constantin JM, Devlin JW, et al.Analgesia and sedation in patients with ARDS [J].Intensive Care Med, 2020, 46(12): 2342-2356.
9
Kassis EB, Beitler JR, Talmor D.Lung-protective sedation: moving toward a new paradigm of precision sedation [J].Intensive Care Med,2023, 49(1): 91-94.
10
安友仲.无监测 勿镇静——浅谈重症医学镇痛和镇静治疗的评估与监测 [J].中华内科杂志, 2011, 50(10): 814-816.
11
Dzierba AL, Khalil AM, Derry KL, et al.Discordance between respiratory drive and sedation depth in critically ill patients receiving mechanical ventilation [J].Crit Care Med, 2021, 49(12): 2090-2101.
12
Mauri T, Foti G, Fornari C, et al.Sigh in patients with acute hypoxemic respiratory failure and ARDS: the PROTECTION pilot randomized clinical trial [J].Chest, 2021, 159: 1426-1436.
13
Spinelli E, Pesenti A, Slobod D, et al.Clinical risk factors for increased respiratory drive in intubated hypoxemic patients [J].Crit Care, 2023,27(1):138.
14
Mauri T, Yoshida T, Bellani G, et al.Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives[J].Intensive Care Med, 2016, 42(9): 1360-1373.
15
Barwing J, Pedroni C, Olgemöller U, et al.Electrical activity of the diaphragm (EAdi) as a monitoring parameter in difficult weaning from respirator: a pilot study [J].Crit Care, 2013, 17(4): R182.
16
常炜, 刘玲.呼吸驱动及呼吸努力床旁评估的研究进展 [J/OL].中华重症医学电子杂志, 2023, 9(1): 25-29.
17
Pavez N, Damiani LF.Inspiratory and expiratory pause during pressure support ventilation: maneuvers that we should incorporate into clinical practice [J].Med Intensiva (Engl Ed), 2022, 46(4): 213-216.
18
Whitelaw WA, Derenne JP, Milic-Emili J.Occlusion pressure as a measure of respiratory center output in conscious man [J].Respir Physiol, 1975, 23(2): 181-199.
19
Telias I, Junhasavasdikul D, Rittayamai N, et al.Airway occlusion pressure as an estimate of respiratory drive and inspiratory effort during assisted ventilation [J].Am J Respir Crit Care Med, 2020,201(9): 1086-1098.
20
Beloncle F, Piquilloud L, Olivier PY, et al.Accuracy of P0.1 measurements performed by ICU ventilators: a bench study [J].Ann Intensive Care, 2019, 9(1): 104.
21
张琳琳, 田野, 苗明月, 等.呼吸机自动测量气道阻断压与标准测量方法的一致性 [J].首都医科大学学报, 2022, 43(5): 728-733.
22
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, 2019,23(1): 346.
23
de Vries HJ, Tuinman PR, Jonkman AH, et al.Performance of noninvasive airway occlusion maneuvers to assess lung stress and diaphragm effort in mechanically ventilated critically ill patients [J].Anesthesiology, 2023, 138(3): 274-288.
24
Foti G, Cereda M, Banfi G, et al.End-inspiratory airway occlusion:a method to assess the pressure developed by inspiratory muscles in patients with acute lung injury undergoing pressure support [J].Am J Respir Crit Care Med, 1997,156(4 Pt 1): 1210-1216.
25
Yang YL, Liu Y, Gao R, et al.Use of airway pressure-based indices to detect high and low inspiratory effort during pressure support ventilation: a diagnostic accuracy study [J].Ann Intensive Care, 2023,13(1): 111.
26
Bianchi I, Grassi A, Pham T, et al.Reliability of plateau pressure during patient-triggered assisted ventilation.Analysis of a multicentre database [J].J Crit Care, 2022, 68: 96-103.
27
Docci M, Rezoagli E, Teggia-Droghi M, et al.Individual response in patient’s effort and driving pressure to variations in assistance during pressure support ventilation [J].Ann Intensive Care, 2023, 13(1): 132.
[1] 徐婷婷, 詹泳池, 王晓东, 刘兴会. 电子胎心监测结果出现正弦波形的胎母输血综合征围生期结局分析[J/OL]. 中华妇幼临床医学杂志(电子版), 2024, 20(04): 382-389.
[2] 周冠宇, 谭鲁平, 杨亚晶, 李晓光. 1 916例肠道门诊食源性疾病患者病原学监测和临床特征[J/OL]. 中华实验和临床感染病杂志(电子版), 2024, 18(04): 200-206.
[3] 高一飞, 刘根祥, 孙长华, 周广军. 喉返神经监测在无充气腋窝入路腔镜单侧甲状腺切除+中央区淋巴结清扫术中的应用效果[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(05): 483-486.
[4] 韦雅丽, 范利杰. 术前右美托咪定滴鼻在腹股沟斜疝患儿腹腔镜下疝囊高位结扎术中的应用[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(04): 446-450.
[5] 王莹莹. 神经导航联合术中神经电生理监测在脑干胶质瘤手术切除中的应用[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(05): 293-298.
[6] 潘冬生, 梁国标. 颅脑创伤治疗的最新进展与未来趋势[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(04): 193-197.
[7] 韦小霞, 陈管洁, 李雪珠, 李晓青, 钱淑媛. 机械通气患者抗菌药物雾化吸入的临床实施[J/OL]. 中华重症医学电子杂志, 2024, 10(04): 334-337.
[8] 唐韵, 杨小博, 余愿, 舒化青, 尚游. 苯磺酸瑞马唑仑的临床研究进展[J/OL]. 中华重症医学电子杂志, 2024, 10(04): 389-393.
[9] 潘清, 葛慧青. 基于机械通气波形大数据的人机不同步自动监测方法[J/OL]. 中华重症医学电子杂志, 2024, 10(04): 399-403.
[10] 刘春峰, 徐朝晖, 施红伟, 陈瑢, 马腾飞, 李鹏飞, 袁蓉, 陈建荣, 徐爱明. 机械通气患者肌肉减少症的诊断及其对预后的影响[J/OL]. 中华临床医师杂志(电子版), 2024, 18(09): 820-825.
[11] 张平骥, 徐钰, 李天水, 庞文翼, 符师宁, 张梦圆. 重症患者镇静治疗现状及期望的调查研究[J/OL]. 中华临床医师杂志(电子版), 2024, 18(06): 562-567.
[12] 王立辉, 杜海涛, 万军, 陈倩倩. 动态反流监测在食管-咽喉反流性疾病诊断中的临床应用[J/OL]. 中华胃肠内镜电子杂志, 2024, 11(04): 268-272.
[13] 刘晓鹏, 柳聪艳, 杨宁, 蔡琛, 李晓兵, 王红宇, 张思森. 三穴五针联合腹部提压法在机械通气患者肺康复中的疗效[J/OL]. 中华卫生应急电子杂志, 2024, 10(04): 193-198.
[14] 刘晴雯, 韩勇, 陈丽丹, 邓哲. 早期机械通气对成人院内心脏骤停病死率的影响:一项回顾性队列研究[J/OL]. 中华卫生应急电子杂志, 2024, 10(04): 203-206.
[15] 孙志军, 梁立丰, 柳晓娜, 杨汪洋, 邸北冰, 张妮潇, 彭晖. 接受ICM 的不明原因晕厥患者需行起搏治疗的临床预测因素分析[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 446-453.
阅读次数
全文


摘要