《ards高危因素》PPT课件.pptx

ARDS预防：高危因素评估和干预,华东医院 宋晓华,ARDS的柏林定义与诊断标准,CPAP，持续气道正压； PEEP，呼气末正压,胸片或CT扫描 如果海拔超过1000m，应根据如下公式进行校正：PaO2/FiO2 x (大气压/760) 轻度ARDS患者可能接受无创通气,ARDS/ALI的危险因素,Modrykamien, Ariel M., and Pooja Gupta. “The acute respiratory distress syndrome.“ Proceedings (Baylor University. Medical Center) 28.2 (2015): 163.,【个体因素】,ARDS与酗酒,酗酒与ARDS相关性研究,Moazed F, Calfee CS .Environmental risk factors for acute respiratory distress syndrome. Clin Chest Med. 2014 Dec;35(4):625-37. doi: 10.1016/j.ccm.2014.08.003. Epub 2014 Sep 30.,酗酒引起ARDS的机制,Moazed F, Calfee CS .Environmental risk factors for acute respiratory distress syndrome. Clin Chest Med. 2014 Dec;35(4):625-37. doi: 10.1016/j.ccm.2014.08.003. Epub 2014 Sep 30.,ARDS与吸烟,吸烟与ARDS相关性研究,Moazed F, Calfee CS .Environmental risk factors for acute respiratory distress syndrome. Clin Chest Med. 2014 Dec;35(4):625-37. doi: 10.1016/j.ccm.2014.08.003. Epub 2014 Sep 30.,吸烟引起ARDS的机制,Moazed F, Calfee CS .Environmental risk factors for acute respiratory distress syndrome. Clin Chest Med. 2014 Dec;35(4):625-37. doi: 10.1016/j.ccm.2014.08.003. Epub 2014 Sep 30.,【疾病因素】,SpO2/FiO2,Mayo Clinic的研究（2015）,5584个患者，其中4646名有SpO2/FiO2记录,Festic E, Bansal V, Kor D J, et al. SpO2/FiO2 Ratio on Hospital Admission Is an Indicator of Early Acute Respiratory Distress Syndrome Development Among Patients at RiskJ. Journal of intensive care medicine, 2013: 0885066613516411.,入院后6h内的SpO2/FiO2，是ARDS早期的独立危险因素,糖尿病与ARDS,荟萃分析,Gu等，至2013年9月的相关研究 12,794人入选(2,937人既往有糖尿病史，2,457例ALI/ARDS),Gu W J, Wan Y D, Tie H T, et al. Risk of acute lung injury/acute respiratory distress syndrome in critically ill adult patients with pre-existing diabetes: a meta-analysisJ. PloS one, 2014, 9(2): e90426.,既往存在糖尿病病史的患者发生ALI/ARDS的风险降低,乳酸与ARDS,脓毒症患者乳酸值升高与发生ARDS相关,单中心，随机研究，778例severe sepsis,Mikkelsen M E, Shah C V, Meyer N J, et al. The epidemiology of acute respiratory distress syndrome in patients presenting to the emergency department with severe sepsisJ. Shock (Augusta, Ga.), 2013, 40(5): 375-381.,脓毒症患者乳酸值2 mmol/L是发生ARDS的独立危险因素,胰腺炎和ARDS,胰腺炎和ARDS,多因素回归分析，243例重症胰腺炎患者 1025%的急性胰腺炎患者发生ARDS。,急性重症胰腺炎患者发生ARDS与性别，低蛋白血症，高甘油三酯存在相关性,邵斌霞,何斌,刘红梅,邵旦兵,孙兆瑞,林金锋,张炜,任艺,聂时南. 急性重症胰腺炎并发ARDS多因素回归分析J. 临床急诊杂志,2014,08:449-451+455.,急性胰腺炎的病程,Zhou M T, Chen C S, Chen B C, et al. Acute lung injury and ARDS in acute pancreatitis: mechanisms and potential interventionJ. World journal of gastroenterology: WJG, 2010, 16(17): 2094.,胰腺炎引起ARDS的机制 肺,血管内皮屏障破坏，中性粒细胞浸润损伤肺实质,Zhou M T, Chen C S, Chen B C, et al. Acute lung injury and ARDS in acute pancreatitis: mechanisms and potential interventionJ. World journal of gastroenterology: WJG, 2010, 16(17): 2094.,胰腺炎引起ARDS的机制 胃肠道,胃肠道通透性增加，细菌和内毒素移位。 激活炎症介质，引起SIRS和MODS。,Zhou M T, Chen C S, Chen B C, et al. Acute lung injury and ARDS in acute pancreatitis: mechanisms and potential interventionJ. World journal of gastroenterology: WJG, 2010, 16(17): 2094.,低蛋白血症和ARDS,低蛋白血症与ARDS发病率相关,回归分析，455例sepsis，178例发生ARDS 92%的ARDS患者血清总蛋白低于6 g/dl,Mangialardi R J, Martin G S, Bernard G R, et al. Hypoproteinemia predicts acute respiratory distress syndrome development, weight gain, and death in patients with sepsisJ. Critical care medicine, 2000, 28(9): 3137-3145.,低蛋白血症引起ARDS的机制,血浆胶体渗透压下降。 血液中的水分更易向肺间质内转移。,Mangialardi R J, Martin G S, Bernard G R, et al. Hypoproteinemia predicts acute respiratory distress syndrome development, weight gain, and death in patients with sepsisJ. Critical care medicine, 2000, 28(9): 3137-3145.,其他相关指标,其他指标,肺泡蛋白的测定 细胞特异性标志物 内皮细胞产生的血管紧张肽转化酶（PCEBACE） 内皮肽1 血管性假血友病因子抗原 E/P选择蛋白 上皮细胞分泌的表面活性物质 肺泡上皮细胞抗原,Gajic和TrilloAlvarez等在多中心大样本对照研究基础上提出： 肺损伤预测评分（lung injury prediction score,LIPS）系统 可以早期预测ALI/ARDS,Lung Injury Prediction Score（LIPS评分）,a 急诊手术加1.5分. b 仅脓毒症时计算.,Reprinted from Gajic et al, 2011 (33) with permission of the American Thoracic Society. Copyright American Thoracic Society. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.,LIPS4分预测ARDS 敏感性为0.69 特异性为0.78 阳性预测值为0.18 阴性预测值为0.97,Gajic O, Dabbagh O, Park PK, Adesanya A, Chang SY, Hou P, Anderson H 3rd, Hoth JJ, Mikkelsen ME, Gentile NT, Gong MN, Talmor D, Bajwa E, Watkins TR, Festic E, Yilmaz M, Iscimen R, Kaufman DA, Esper AM, Sadikot R, Douglas I, Sevransky J, Malinchoc M. Early identi cation of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2011;183(4):462470.,【如何预防ARDS】,早期发现存在高危因素的患者,依靠评分,LIPS4分（阳性预测值为0.18，阴性预测值为0.97） early acute lung injury score,Early Acute Lung Injury Score,由Levitt等人提出 包括3部分 吸氧浓度（2-6 L/min记1分，6 L/min记2分） 呼吸频率（30次/min记1分） 存在免疫抑制（存在记1分） 评分2分发生ALI的敏感性为0.89,特异性为0.75分 缺点：单中心研究,Levitt JE, Calfee CS, Goldstein BA, et al. Early acute lung injury: criteria for identifying lung injury prior to the need for positive pressure ventilation. Crit Care Med 2013; 41:19291937.,改善临床策略,ARDS的时间特点,ARDS很少发生在疾病之初1。 ARDS一般发生于患者出现高危因素后2-5天2。,Levitt JE, Calfee CS, Goldstein BA, et al. Early acute lung injury: criteria for identifying lung injury prior to the need for positive pressure ventilation. Crit Care Med 2013; 41:19291937. Gajic O, Dabbagh O, Park PK, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2011; 183:462470.,呼吸治疗,早期治疗肺不张。 减少过度通气。 对于低氧饱和度患者改善供氧2。 机械通气患者争取早期拔管4。 预防误吸。,Kallet RH, Matthay MA. Hyperoxic acute lung injury. Respir Care 2013; 58:123141. Albert RK. The role of ventilation-induced surfactant dysfunction and atelectasis in causing acute respiratory distress syndrome. Am J Respir Crit Care Med 2012; 185:702708.,全身治疗,减少卧床时间。 早期活动3。 减少神经肌肉阻断剂的使用。 严格输血指证1。 尽早治疗sepsis2。 目标液体复苏4。,Gajic O, Rana R, Winters JL, et al. Transfusion-related acute lung injury in the critically ill: prospective nested casecontrol study. Am J Respir Crit Care Med 2007; 176:886891. Iscimen R, Cartin-Ceba R, Yilmaz M, et al. Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study. Crit Care Med 2008; 36:15181522. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management