• 【15岁患者烧伤和吸入性损伤后严重ARDS并伴有五器官系统衰竭的生存。】 复制标题 收藏 收藏
    DOI:10.1016/s0305-4179(03)00010-x 复制DOI
    作者列表:Cedidi C,Hierner R,Pichlmaier M,Forssmann WG,Meyer M
    BACKGROUND & AIMS: OBJECTIVE:To show the effectiveness of an integrated therapeutical approach in a severe case of acute respiratory distress syndrome (ARDS) following burns, inhalation injury with therapy-refractory oxygenation under maximized ventilatory settings, and an overall complicated clinical course. PATIENT AND METHODS:Case report of a patient with severe inhalation injury and burns in an intensive care unit setting, undergoing cardiopulmonary resuscitation (CPR), nitric oxide (NO)-inhalation, surfactant-, kinetic-, and urodilatin-therapy. CASE REPORT:A 15-year-old male presented with deep dermal and full thickness thermal injuries involving 25% of his total body surface area. Shortly after presentation, the patient developed therapy-refractory respiratory failure, cardiac arrest, and subsequently suffered five-organ system failure (lung, heart, gastrointestinal, liver, kidney), in addition to burn injury, and ischemia related cerebral lesions. The patient was successfully treated with cardiac resuscitation, extra corporeal membrane oxygenation (ECMO), NO, kinetic therapy, surfactant, urodilatin, and other standard intensive care regimens. Three months post-trauma the patient was discharged home, nearly fully recovered. CONCLUSIONS:In a patient with severe ARDS, oxygenation failure under maximized ventilatory settings, and subsequent five-organ system failure, an integrated therapeutical approach comprising ECMO, NO, kinetic therapy, surfactant, and urodilatin did cross-bridge respiratory and vital functions, enabling overall survival.
    背景与目标:
  • 【严重低氧血症的ARDS患者的生存率增加 (ECMO标准)。】 复制标题 收藏 收藏
    DOI:10.1378/chest.99.4.951 复制DOI
    作者列表:Suchyta MR,Clemmer TP,Orme JF Jr,Morris AH,Elliott CG
    BACKGROUND & AIMS: :The adult respiratory distress syndrome (ARDS) is a form of diffuse lung injury associated with multiple risk factors. Patients with severe hypoxemia who meet blood gas criteria defined by the extracorporeal membrane oxygenation trial (ECMO) of 1974 to 1977 have a reported survival of 11 percent. The reported survival has remained unchanged for 15 years despite numerous technologic advances. We prospectively studied ARDS patients who met ECMO blood gas criteria. One hundred seventy-eight ARDS patients were prospectively screened over a 30-month period. Fifty-one of these patients met ECMO blood gas criteria and 23 (45 percent) survived (p less than 0.001 vs ECMO trial). No obvious differences in etiology, APACHE II score, organ system failure, or the incidence of sepsis was found between survivors and nonsurvivors. We conclude that survival of ARDS patients who met ECMO blood gas criteria in our institution is higher than that previously reported from both other centers and our own hospital.
    背景与目标: : 成人呼吸窘迫综合征 (ARDS) 是一种与多种危险因素相关的弥漫性肺损伤。符合体外膜氧合试验 (ECMO) 1974年定义的血气标准的严重低氧血症患者1977年的生存率为11%。尽管有许多技术进步,但报告的生存率仍保持15年不变。我们前瞻性地研究了符合ECMO血气标准的ARDS患者。在30个月的时间内,对78名ARDS患者进行了前瞻性筛查。这些患者中有51名符合ECMO血气标准,23名 (45% 名) 存活 (与ECMO试验相比,p小于0.001)。幸存者和非幸存者在病因,APACHE II评分,器官系统衰竭或败血症发生率方面没有明显差异。我们得出的结论是,在我们机构中符合ECMO血气标准的ARDS患者的生存率高于其他中心和我们自己的医院先前报告的生存率。
  • 【伊洛前列素治疗急性呼吸窘迫综合征 (ARDS) (ThIlo试验): 一项前瞻性,随机,多中心II期研究。】 复制标题 收藏 收藏
    DOI:10.1186/s13063-020-4163-0 复制DOI
    作者列表:Haeberle H,Prohaska S,Martus P,Straub A,Zarbock A,Marx G,Zago M,Giera M,Koeppen M,Rosenberger P
    BACKGROUND & AIMS: BACKGROUND:Acute respiratory distress syndrome (ARDS) is caused by rapid-onset (within hours) acute inflammatory processes in lung tissue, and it is a life-threatening condition with high mortality. The treatment of ARDS to date is focused on the prevention of further iatrogenic damage of the lung rather than the treatment of the initial inflammatory process. Several preclinical studies have revealed a beneficial effect of iloprost on the control of pulmonary inflammation, and in a small number of patients with ARDS, iloprost treatment resulted in improved oxygenation. Therefore, we plan to conduct a large multicenter trial to evaluate the effect of iloprost on ARDS. METHODS:The Therapeutic Iloprost during ARDS trial (ThIlo trial) is a multicenter, randomized, single blinded, clinical phase II trial assessing the efficacy of inhaled iloprost for the prevention of the development and progression of ARDS in critically ill patients. One hundred fifty critically ill patients suffering from acute ARDS will be treated either by nebulized iloprost or NaCl 0.9% for 5 days. Blood samples will be drawn at defined time points to elucidate the serum levels of iloprost and inflammatory markers during treatment. Mechanical ventilation will be standardized. In follow-up visits at days 28 and 90 as well as 6 months after enrollment, functional status according to the Barthel Index and a health care-related questionnaire, and frailty (Vulnerable Elders Survey) will be evaluated. The primary endpoint is the improvement of oxygenation, defined as the ratio of PaO2/FiO2. Secondary endpoints include 90-day all-cause mortality, Sequential Organ Failure Assessment scores during the study period up to day 90, the duration of mechanical ventilation, the length of intensive care unit (ICU) stay, ventilator-associated pneumonia, delirium, ICU-acquired weakness, and discharge localization. The study will be conducted in three university ARDS centers in Germany. DISCUSSION:The results of the ThIlo trial will highlight the anti-inflammatory effect of iloprost on early inflammatory processes during ARDS, resulting in the improvement of outcome parameters in patients with ARDS. TRIAL REGISTRATION:EUDRA-CT: 2016-003168-37. Registered on 12 April 2017. ClinicalTrials.gov: NCT03111212. Registered on 4 June 2017.
    背景与目标:
  • 4 [ARDS--an update]. 复制标题 收藏 收藏

    【[ARDS-更新]。】 复制标题 收藏 收藏
    DOI:10.1055/s-0032-1333051 复制DOI
    作者列表:Braune S,Kluge S
    BACKGROUND & AIMS: :The acute respiratory distress syndrome (ARDS) is characterized by severe impairment of gas exchange and remains a challenge for modern intensive care medicine. The most common causes of ARDS are pneumonia and sepsis. The mortality in severe ARDS is as high as 50 %. The new definition of ARDS differentiates three levels of severity depending on the degree of hypoxaemia. The fundamental basis of therapy is to treat the underlying cause of ARDS. Furthermore, lung protective mechanical ventilation must be applied using low tidal volumes and limiting inspiratory pressures. Intermittent prone positioning can reduce mortality in severe cases of ARDS. In extreme, life threatening cases extracorporeal membrane oxygenation can stabilize gas exchange and serve as a bridge to recovery and means to enable lung protective ventilation.
    背景与目标: : 急性呼吸窘迫综合征 (ARDS) 的特点是气体交换严重受损,仍然是现代重症监护医学的挑战。ARDS最常见的原因是肺炎和败血症。严重ARDS的死亡率高达50%。ARDS的新定义根据低氧血症的程度区分了三个严重程度。治疗的根本基础是治疗ARDS的根本原因。此外,必须使用低潮气量和限制吸气压力进行肺保护性机械通气。间歇性俯卧定位可以降低严重ARDS病例的死亡率。在极端情况下,危及生命的情况下,体外膜氧合可以稳定气体交换,并作为恢复的桥梁和实现肺保护性通气的手段。
  • 【ALI/ARDS期间表面活性剂治疗的未来。】 复制标题 收藏 收藏
    DOI:10.1055/s-2006-948291 复制DOI
    作者列表:Lewis JF,Veldhuizen RA
    BACKGROUND & AIMS: :The importance of pulmonary surfactant in maintaining normal lung function, and the observations that alterations in endogenous surfactant contribute to the lung dysfunction associated with acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS), provide a rationale for administering exogenous surfactant in this setting. The results of clinical trials have been variable, however, in part due to the various surfactant preparations used, the different delivery and dosing methods employed, and the types of patients targeted for this therapy. Based on the insight gained from these studies, ongoing trials have modified these factors to optimize outcome, including one trial that is focusing on patients with direct lung insults such as pneumonia and aspiration. The future of surfactant therapy may well take advantage of the recently described host defense functions of this material. Based on extensive in vitro data as well as in vivo animal studies demonstrating the anti-inflammatory and antibacterial functions of various surfactant components, administration of surfactant earlier in the course of the disease, when lung inflammation is present but before severe lung dysfunction occurs, may prove to be optimal. This review discusses both the biophysical and host defense functions of surfactant in the context of novel therapeutic approaches for patients with ALI/ARDS.
    背景与目标: : 肺表面活性剂在维持正常肺功能中的重要性,以及内源性表面活性剂的改变导致与急性肺损伤 (ALI) 和急性呼吸窘迫综合征 (ARDS) 相关的肺功能障碍的观察结果,为在这种情况下施用外源性表面活性剂提供了依据。但是,临床试验的结果是可变的,部分原因是所使用的各种表面活性剂制剂,所采用的不同给药和给药方法以及针对该疗法的患者类型。基于从这些研究中获得的见解,正在进行的试验已经修改了这些因素以优化结果,其中包括一项针对患有直接肺损伤 (如肺炎和误吸) 的患者的试验。表面活性剂疗法的未来很可能会利用这种材料最近描述的宿主防御功能。基于广泛的体外数据以及体内动物研究,证明了各种表面活性剂成分的抗炎和抗菌功能,在疾病过程中,当存在肺部炎症时,但在严重的肺部功能障碍发生之前,可以证明是最佳的。本文在针对ALI/ARDS患者的新型治疗方法的背景下讨论了表面活性剂的生物物理和宿主防御功能。
  • 【院前抗血小板治疗对ARDS发生率的影响。】 复制标题 收藏 收藏
    DOI:10.4187/respcare.07177 复制DOI
    作者列表:Jin W,Chuang CC,Jin H,Ye J,Kandaswamy E,Wang L,Zuo L
    BACKGROUND & AIMS: BACKGROUND:Clinical observations on the potential of pre-hospital antiplatelet therapy in preventing ARDS have been inconsistent. To further the correlation between antiplatelet therapy and ARDS, we conducted a meta-analysis to evaluate the effects of pre-hospital antiplatelet therapy on subjects with ARDS. METHODS:A literature search in major data banks was performed. We included prospective and retrospective cohorts, case-control trials, and randomized controlled trials that compared the ARDS incidence in subjects with or without pre-hospital antiplatelet agents. RESULTS:Meta-analysis of 7 studies (a total of 30,291 subjects) showed significantly lower odds of ARDS in the pre-hospital antiplatelet therapy group compared with subjects with no pre-hospital antiplatelet therapy (odds ratio 0.68, 95% CI 0.56-0.83; P < .001). However, ARDS mortalities in the hospital and ICUs were not affected. CONCLUSIONS:These findings indicated that pre-hospital antiplatelet therapy was associated with a reduced rate of ARDS but had no effect on the mortality in the subjects at high risk.
    背景与目标:
  • 【特发性成人呼吸窘迫综合征 (ARDS)/弥漫性肺泡损伤 (DAD) 的诊断影像学与放射学的相关性。】 复制标题 收藏 收藏
    DOI:10.1016/0899-7071(94)00057-3 复制DOI
    作者列表:Kobayashi H,Itoh T,Sasaki Y,Konishi J
    BACKGROUND & AIMS: :In ten patients with idiopathic adult respiratory distress syndrome (ARDS) who had histopathologically diffuse alveolar damage (DAD), and who did not have specific underlying diseases, we compared the histopathological findings with their radiographic images in order to study the detail analysis of radiographic images and the clinical courses. These patients were roughly classified as having the interstitial pneumonia dominant type (type IP) of idiopathic ARDS, in which alveolar septal thickening, alveolitis, or both were the predominant histological findings and images showed increasing attenuation of lung fields with small honeycomb lung, or the organizing pneumonia dominant type (type OP), in which organizing exudate predominantly filled the alveoli histologically and images showed consolidation shadows with some air. Hyaline membrane was seen very frequently in patients with a short clinical course, and in accordance with a longer clinical course, widespread fibrosis and honeycomb lung covered by organizing hyaline membrane was seen with both types. Patients with type OP in whom collapse of the normal pulmonary structure was less and for whom changes on radiographic images were larger seemed to respond relatively favorably to steroid treatment, as judged from pulmonary function and radiographic images.
    背景与目标: : 在十名患有组织病理学弥漫性肺泡损伤 (DAD) 且没有特定基础疾病的特发性成人呼吸窘迫综合征 (ARDS) 患者中,我们将组织病理学发现与他们的影像学图像进行了比较,以研究影像学图像的详细分析和临床过程。这些患者被大致归类为特发性ARDS的间质性肺炎显性类型 (IP型),其中肺泡间隔增厚,肺泡炎或两者都是主要的组织学发现,并且图像显示小蜂窝肺的肺视野衰减增加,或组织肺炎显性类型 (OP型),其中组织渗出液在组织学上主要填充肺泡,图像显示有一些空气的巩固阴影。在临床病程较短的患者中,透明膜非常常见,并且根据较长的临床病程,两种类型的透明膜均被组织透明膜覆盖,广泛的纤维化和蜂窝状肺。根据肺功能和影像学图像判断,正常肺部结构塌陷较少且影像学变化较大的OP型患者似乎对类固醇治疗反应相对有利。
  • 【在ARDS猪模型中应用死空间分数滴定最佳呼气末正压。】 复制标题 收藏 收藏
    DOI:10.3892/etm.2017.4117 复制DOI
    作者列表:Bian W,Chen W,Chao Y,Wang L,Li L,Guan J,Zang X,Zhen J,Sheng B,Zhu X
    BACKGROUND & AIMS: :This study aimed to apply the dead space fraction [ratio of dead space to tidal volume (VD/VT)] to titrate the optimal positive end-expiratory pressure (PEEP) in a swine model of acute respiratory distress syndrome (ARDS). Twelve swine models of ARDS were constructed. A lung recruitment maneuver was then conducted and the PEEP was set at 20 cm H2O. The PEEP was reduced by 2 cm H2O every 10 min until 0 cm H2O was reached, and VD/VT was measured after each decrement step. VD/VT was measured using single-breath analysis of CO2, and calculated from arterial CO2 partial pressure (PaCO2) and mixed expired CO2 (PeCO2) using the following formula: VD/VT = (PaCO2 - PeCO2)/PaCO2. The optimal PEEP was identified by the lowest VD/VT method. Respiration and hemodynamic parameters were recorded during the periods of pre-injury and injury, and at 4 and 2 cm H2O below and above the optimal PEEP (Po). The optimal PEEP in this study was found to be 13.25±1.36 cm H2O. During the Po period, VD/VT decreased to a lower value (0.44±0.08) compared with that during the injury period (0.68±0.10) (P<0.05), while the intrapulmonary shunt fraction reached its lowest value. In addition, a significant change of dynamic tidal respiratory compliance and oxygenation index was induced by PEEP titration. These results indicate that minimal VD/VT can be used for PEEP titration in ARDS.
    背景与目标: : 本研究旨在应用死空间分数 [死空间与潮气量的比率 (VD/VT)] 来滴定猪急性呼吸窘迫综合征模型 (ARDS) 中的最佳呼气末正压 (PEEP)。构建了12个ARDS猪模型。然后进行肺募集操作,并将PEEP设定为20厘米H2O。每10分钟通过2厘米H2O降低PEEP,直到达到0厘米H2O,并且在每个减量步骤之后测量VD/VT。VD/VT使用CO2的单次呼吸分析进行测量,并使用以下公式从动脉CO2分压 (PaCO2) 和混合呼气CO2 (PeCO2) 计算: VD/VT = (PaCO2-PeCO2)/PaCO2。通过最低VD/VT方法确定最佳PEEP。在损伤前和损伤期间以及在最佳PEEP (Po) 之下和之上的4和2厘米H2O处记录呼吸和血液动力学参数。发现本研究中的最佳PEEP为13.25 ± 1.36厘米H2O。与损伤期间 (0.68 ± 0.10) 相比,在Po期间VD/VT降低至较低值 (0.44 ± 0.08) (P<0.05),而肺内分流分数达到最低值。此外,通过PEEP滴定引起动态潮气呼吸顺应性和氧合指数的显着变化。这些结果表明,最小VD/VT可用于ARDS中的PEEP滴定。
  • 【皮质类固醇治疗芽生菌病诱导的ARDS: 两名患者的报告和文献复习。】 复制标题 收藏 收藏
    DOI:10.1378/chest.07-2778 复制DOI
    作者列表:Lahm T,Neese S,Thornburg AT,Ober MD,Sarosi GA,Hage CA
    BACKGROUND & AIMS: :ARDS secondary to blastomycosis is associated with a high mortality rate despite appropriate antifungal therapy. Corticosteroids are of proven benefit in the treatment of severe Pneumocystis jiroveci pneumonia and are recommended for the treatment of severe pulmonary infections with Histoplasma capsulatum. However, their role in the treatment of severe pulmonary infections with Blastomyces dermatitidis has not been established. We report the cases of two previously healthy men who presented with severe ARDS secondary to blastomycosis. Refractory hypoxemia developed in both patients despite adequate antifungal coverage with amphotericin B. Dramatic improvement was seen in each patient after initiation of corticosteroids in addition to amphotericin B. Both patients survived and did well on follow-up. We suggest that treatment with corticosteroids may be of benefit in patients with blastomycosis-induced ARDS. This may be due to a decrease in the severity of the inflammatory response.
    背景与目标: : 尽管进行了适当的抗真菌治疗,但继发于芽生菌病的ARDS仍具有较高的死亡率。皮质类固醇在治疗严重的肺孢子虫性肺炎中被证明是有益的,并被推荐用于治疗严重的肺部感染,并带有组织胞浆菌。然而,尚未确定它们在治疗严重的肺部感染中的作用。我们报告了两名先前健康的男性的病例,这些男性继发于芽生菌病而患有严重的ARDS。尽管两性霉素b有足够的抗真菌覆盖,但两名患者均出现了难治性低氧血症。除两性霉素b外,每位患者在开始使用皮质类固醇后均得到显着改善。两名患者均存活,并在随访中表现良好。我们建议皮质类固醇治疗可能对芽生菌病诱导的ARDS患者有益。这可能是由于炎症反应的严重程度降低所致。
  • 【[成人呼吸窘迫综合征 (ARDS) 的病理生理和治疗方面]。】 复制标题 收藏 收藏
    DOI:10.1055/s-2007-1000529 复制DOI
    作者列表:Thiel M,Forst H,Peter K
    BACKGROUND & AIMS: :Since the first characterization of the adult respiratory distress syndrome (ARDS), knowledge of its aetiology and pathogenesis has grown considerably. In spite of this, mortality remains up to 50 to 90%, particularly if multiple organ failure is present. Because no causative clinical therapy is available up to now, significant attention is given to preventive measures like early operative stabilisation of long bone fractures, or prophylaxis of nosocomial infections. After clinical manifestation of ARDS, treatment focuses on functional disturbances of the cardiopulmonary system and on the underlying disease. The aim of this symptomatic therapy is to ensure oxygen supply according to the organisms demand. It is still unknown, however, whether the mortality of patients with ARDS can be reduced by optimising the oxygen supply. In general, oxygen supply can be enhanced by improving pulmonary gas exchange, cardiac output and blood oxygen transport capacity. For practical use the therapy often ends up with a therapeutical dilemma: On one hand, the improvement of the pulmonary gas exchange by application of PEEP can be associated with a critical decline in cardiac output, particularly if the afterload of the right ventricle is elevated. On the other hand, to increase cardiac output, both volume replacement and vasodilators can severely affect pulmonary gas exchange if the alveolo-capillary permeability is increased and pulmonary hypoxic vasoconstriction is disturbed. Thus, oxygen supply can be optimised only via invasive monitoring of the cardiorespiratory system. Although still experimental, the most promising approaches seem to be pharmacological interventions directed at suppressing the formation and effects of various humoral and cellular mediators. An improved understanding of the inflammatory processes might provide new insights in the pathophysiology of ARDS and the related therapeutic interventions.
    背景与目标: : 自成人呼吸窘迫综合征 (ARDS) 首次表征以来,对其病因和发病机理的了解已大大增加。尽管如此,死亡率仍然高达50至90%,特别是如果存在多器官功能衰竭。由于到目前为止尚无致病的临床治疗方法,因此应特别注意预防措施,例如早期手术稳定长骨骨折或预防医院感染。在ARDS的临床表现之后,治疗的重点是心肺系统的功能障碍和潜在的疾病。这种对症疗法的目的是根据生物体的需求确保氧气供应。然而,是否可以通过优化氧气供应来降低ARDS患者的死亡率仍然未知。通常,可以通过改善肺气体交换,心输出量和血氧输送能力来增强氧气供应。对于实际使用,该疗法通常会导致治疗上的困境: 一方面,通过使用PEEP来改善肺气体交换可能与心输出量的严重下降有关,特别是如果右心室的后负荷升高。另一方面,如果肺泡毛细血管通透性增加并且肺缺氧血管收缩受到干扰,则为了增加心输出量,容量置换和血管扩张剂都会严重影响肺气体交换。因此,只能通过对心肺系统的侵入性监测来优化氧气供应。尽管仍是实验性的,但最有前途的方法似乎是旨在抑制各种体液和细胞介质的形成和作用的药理干预。对炎症过程的更好理解可能会为ARDS的病理生理学和相关的治疗干预提供新的见解。
  • 【对ARDS患者中学术强化者使用神经肌肉阻滞的调查。】 复制标题 收藏 收藏
    DOI:10.4187/respcare.07026 复制DOI
    作者列表:Dodia NN,Richert ME,Deitchman AR,Quinn CC,Marciniak ET,Brown CH,Terrin ML,Amariei DE,Shanholtz CB,Hasday JD
    BACKGROUND & AIMS: BACKGROUND:Our Cooling to Help Injured Lungs (CHILL) trial of therapeutic hypothermia in ARDS includes neuromuscular blockade (NMB) as an inclusion criterion to avoid shivering. NMB has been used to facilitate mechanical ventilation in ARDS and was shown to reduce mortality in the ACURASYS trial. To assess the feasibility of a multi-center CHILL trial, we conducted a survey of academic intensivists about their NMB use in patients with ARDS. METHODS:We distributed via email a 16-question survey about NMB use in patients with ARDS including frequency, indications, and dosing strategy. RESULTS:212 (24.3%) of 871 respondents completed the survey: 94.7% were board-certified in internal medicine, 88% in pulmonary and critical care; 90.3% practiced in academic medical centers, with 87% working in medical ICUs; 96.6% of respondents who treat ARDS use NMB, and 39.7% use NMB in ≥ 50% of these patients. Of 4 listed indications for initiating NMB in ARDS, allowing adherence with lung-protective ventilator strategies and patient-ventilator synchrony were cited as the most important reasons, followed by the results of the ACURASYS trial and facilitating prone positioning. CONCLUSIONS:We conclude that NMB is frequently used by academic intensivists to facilitate mechanical ventilation in patients with moderate to severe ARDS.
    背景与目标:
  • 【严重ARDS治疗优化策略的兴趣。】 复制标题 收藏 收藏
    DOI:10.1378/chest.111.4.1000 复制DOI
    作者列表:Guinard N,Beloucif S,Gatecel C,Mateo J,Payen D
    BACKGROUND & AIMS: STUDY OBJECTIVE:Evaluate the interest of the response to a therapeutic optimization as a predictor of prognosis in ARDS. DESIGN:Prospective study. SETTING:ICU of a University Hospital. PATIENTS:Thirty-six consecutive patients with severe ARDS addressed for extracorporeal carbon dioxide removal (ECCO2R). INTERVENTIONS:We studied the response during the first 2 days after arrival to the therapeutic optimization strategy consisting in a combination of the following: (1) decrease in extravascular lung water (diuretics or hemofiltration); (2) selection of the best ventilatory mode; (3) permissive hypercarbia; and (4) correction of hypoxemia by alveolar recruitment, additional continuous oxygen insufflation, body position changes (prone position), inhaled nitric oxide, enhancement of hypoxic pulmonary vasoconstriction with almitrine, and drainage of pleural or mediastinal effusions. In patients remaining severely hypoxemic despite these modalities, ECCO2R was then proposed. MEASUREMENTS AND RESULTS:Thirty-six patients were addressed after 8.3+/-5.5 days of mechanical ventilation. On arrival, mean simplified acute physiologic score was 46.8+/-14.2, multiple system organ failure score was 1.8+/-1.6, Murray score was 3.4+/-0.4, PaO2 was 75.3+/-31.3 (fraction of inspired oxygen [FIO2]=1) for a positive end-expiratory pressure level of 12.3+/-3.4 cm H2O. Nineteen of 36 patients improved their gas exchange within 2 days and their mortality was 21%. The seventeen remaining patients did not improve PaO2/FIO2; PaCO2 and airway pressures remained high and their mortality was 88%. This different response to therapeutic optimization appeared using stepwise logistic regression as the most predictive factor for mortality (p<0.05). CONCLUSIONS:In patients with severe ARDS, the response to an early performed therapeutic optimization used to improve hypoxemia appeared to be a highly discriminant factor distinguishing deceased from surviving patients.
    背景与目标:
  • 【心脏在充气损失中的作用表征了急性呼吸窘迫综合征的下叶。Ct扫描ARDS研究组。】 复制标题 收藏 收藏
    DOI:10.1164/ajrccm.161.6.9907067 复制DOI
    作者列表:Malbouisson LM,Busch CJ,Puybasset L,Lu Q,Cluzel P,Rouby JJ
    BACKGROUND & AIMS: :In the acute respiratory distress syndrome (ARDS), lower lobes appear essentially non-aerated in contrast to upper lobes whose aeration can be preserved in some patients. The aim of this study was to assess the mechanical compression exerted by the heart on lower lobes in patients with ARDS. Fourteen healthy volunteers and 38 patients with ARDS free of left ventricular failure were studied. Cardiorespiratory parameters were recorded and the cardiac dimensions, the pressure exerted by the heart on subjacent lower lobes, and the gas tissue ratio of lower lobes in the supine position were measured using computer tomography and Lungview, a specifically designed software. In patients with ARDS, the heart was larger and heavier than in healthy volunteers. The enlargement of the heart was mainly related to a left cardiac protrusion and the pressure exerted by the left heart on the lower lobes was higher in patients with ARDS than in healthy volunteers (8 +/- 3 g. cm(-)(2) versus 6 +/- 1 g. cm(-)(2), p < 0.01). As a consequence, the faction of gas represented 62% of the left lower lobes in healthy volunteers and 12% only in patients with ARDS. The present study demonstrates that apart from the already known anteroposterior and cephalocaudal gradients of pressure depending on the lung weight and abdominal pressure, the heart plays an important role in the dramatic loss of aeration characterizing lower lobes of patients with ARDS lying in the supine position.
    背景与目标: : 在急性呼吸窘迫综合征 (ARDS) 中,与某些患者可以保留通气的上叶相比,下叶基本上没有通气。这项研究的目的是评估ARDS患者心脏对下叶的机械压迫。研究了14名健康志愿者和38名无左心衰竭的ARDS患者。记录心肺参数,并使用计算机断层扫描和专门设计的软件Lungview测量心脏尺寸,心脏在下下下叶施加的压力以及仰卧位下叶的气体组织比。在ARDS患者中,心脏比健康志愿者更大,更重。ARDS患者的心脏增大主要与左心突出有关,左心对下叶施加的压力高于健康志愿者 (8/- 3g. cm(-)(2) 与6/- 1g. cm(-)(2),p <0.01)。结果,在健康志愿者中,气体的派系代表左下叶的62%,并且仅在ARDS患者中12%。本研究表明,除了已知的取决于肺重量和腹压的前后和头尾压力梯度外,心脏在仰卧位的ARDS患者下叶的通气急剧丧失中起着重要作用。
  • 【在新型冠状病毒肺炎大流行和其他新发传染病暴发期间,为严重ARDS规划和提供ECMO服务。】 复制标题 收藏 收藏
    DOI:10.1016/S2213-2600(20)30121-1 复制DOI
    作者列表:Ramanathan K,Antognini D,Combes A,Paden M,Zakhary B,Ogino M,MacLaren G,Brodie D,Shekar K
    BACKGROUND & AIMS: :WHO interim guidelines recommend offering extracorporeal membrane oxygenation (ECMO) to eligible patients with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). The number of patients with COVID-19 infection who might develop severe ARDS that is refractory to maximal medical management and require this level of support is currently unknown. Available evidence from similar patient populations suggests that carefully selected patients with severe ARDS who do not benefit from conventional treatment might be successfully supported with venovenous ECMO. The need for ECMO is relatively low and its use is mostly restricted to specialised centres globally. Providing complex therapies such as ECMO during outbreaks of emerging infectious diseases has unique challenges. Careful planning, judicious resource allocation, and training of personnel to provide complex therapeutic interventions while adhering to strict infection control measures are all crucial components of an ECMO action plan. ECMO can be initiated in specialist centres, or patients can receive ECMO during transportation from a centre that is not specialised for this procedure to an expert ECMO centre. Ensuring that systems enable safe and coordinated movement of critically ill patients, staff, and equipment is important to improve ECMO access. ECMO preparedness for the COVID-19 pandemic is important in view of the high transmission rate of the virus and respiratory-related mortality.
    背景与目标: : 世卫组织临时指南建议向符合条件的与冠状病毒病2019 (新型冠状病毒肺炎) 相关的急性呼吸窘迫综合征 (ARDS) 患者提供体外膜氧合 (ECMO)。目前尚不清楚可能发生严重ARDS的COVID-19感染患者的数量,这些ARDS难以接受最大程度的医疗管理并需要这种水平的支持。来自类似患者人群的现有证据表明,精心选择的无法从常规治疗中受益的严重ARDS患者可能会成功地接受静脉ECMO支持。对ECMO的需求相对较低,其使用主要限于全球专业中心。在新兴传染病爆发期间提供复杂的疗法 (例如ECMO) 具有独特的挑战。仔细的计划,明智的资源分配以及人员培训以提供复杂的治疗干预措施,同时坚持严格的感染控制措施,都是ECMO行动计划的关键组成部分。ECMO可以在专科中心启动,或者患者可以在从不专门从事此程序的中心到专家ECMO中心的运输过程中接受ECMO。确保系统能够安全,协调地移动重症患者,工作人员和设备对于改善ECMO访问非常重要。鉴于病毒的高传播率和与呼吸相关的死亡率,ECMO为COVID-19大流行做好准备非常重要。
  • 【小鼠间充质干细胞中TGFβ1的过表达通过影响LPS诱导的ARDS小鼠的Th17/Treg平衡来改善肺部炎症。】 复制标题 收藏 收藏
    DOI:10.1186/s13287-020-01826-0 复制DOI
    作者列表:Chen J,Zhang X,Xie J,Xue M,Liu L,Yang Y,Qiu H
    BACKGROUND & AIMS: BACKGROUND:T helper 17 cells (Th17)/regulatory T cells (Treg), as subtypes of CD4+ T cells, play an important role in the inflammatory response of acute respiratory distress syndrome (ARDS). However, there is still a lack of effective methods to regulate the differentiation balance of Th17/Treg. It was proven that mesenchymal stem cells (MSCs) could regulate the differentiation of CD4+ T cells, but the mechanism is still unclear. TGFβ1, a paracrine cytokine of MSCs, could also regulate the differentiation of Th17/Treg but is lowly expressed in MSCs. Therefore, mouse MSCs (mMSCs) overexpressing TGFβ1 were constructed by lentivirus transduction and intratracheally transplanted into LPS-induced ARDS mice in our study. The aim of this study was to evaluate the therapeutic effects of mMSCs overexpressing TGFβ1 on inflammation and immunoregulation by impacting the Th17/Treg balance in LPS-induced ARDS mice. METHODS:mMSCs overexpressing TGFβ1 were constructed using lentiviral vectors. Then, mouse bone-marrow-derived MSCs (mBM-MSC) and mBM-MSC-TGFβ1 (mBM-MSC overexpressing TGFβ1) were transplanted intratracheally into ARDS mice induced by lipopolysaccharide. At 3 and 7 days after transplantation, the mice were sacrificed, and the homing of the mMSCs was assayed by ex vivo optical imaging. The relative numbers of Th17 and Treg in the lungs and spleens of mice were detected by FCM. IL-17A and IL-10 levels in the lungs of mice were analysed by western blot. Permeability and inflammatory cytokines were evaluated by analysing the protein concentration of BALF using ELISA. Histopathology of the lungs was assessed by haematoxylin and eosin staining and lung injury scoring. Alveolar lung fibrosis was assessed by Masson's trichrome staining and Ashcroft scoring. The mortality of ARDS mice was followed until 7 days after transplantation. RESULTS:The transduction efficiencies mediated by the lentiviral vectors ranged from 82.3 to 88.6%. Overexpressing TGFβ1 inhibited the proliferation of mMSCs during days 5-7 (p < 0.05) but had no effect on mMSC differentiation or migration (p > 0.05). Compared to that in the LPS + mBM-MSC-NC group mice, engraftment of mMSCs overexpressing TGFβ1 led to much more differentiation of T cells into Th17 or Treg (p < 0.05), improved permeability of injured lungs (p < 0.05) and ameliorative histopathology of lung tissue in ARDS mice (p < 0.05). Moreover, IL-17A content was also decreased while IL-10 content was increased in the LPS + mBM-MSC-TGFβ1 group compared with those in the LPS + mBM-MSC-NC group (p < 0.05). Finally, mMSCs overexpressing TGFβ1 did not aggravate lung fibrosis in ARDS mice (p > 0.05). CONCLUSION:MSCs overexpressing TGFβ1 could regulate lung inflammation and attenuate lung injuries by modulating the imbalance of Th17/Treg in the lungs of ARDS mice.
    背景与目标:

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