AdultRespiratorydistresssyndrom(ARDS)

成人呼吸窘迫綜合征急救部AdultRespiratorydistresssyn1.Difinition---定義ALIanditsmoreseveresub-set,ARDS,isacommonclinicaldisordercharacterizedbyinjurytothealveolarepithelialandendothelialbarriersofthelung,acuteinflammation,andprotein-richpulmonaryoedemaleadingtoacuterespiratoryfailure.OftenoccursinthesettingofMOF.急性肺損傷及其更加嚴(yán)重的情況ARDS是一種常見(jiàn)的臨床異常狀況，以肺泡上皮細(xì)胞及肺內(nèi)皮細(xì)胞屏障損害、急性炎癥反應(yīng)、富含蛋白的肺水腫導(dǎo)致的急性呼吸衰竭為特點(diǎn)。經(jīng)常發(fā)生于多器管衰竭的情況下。1.Difinition---定義ALIanditsmDiagnosticcriteriaAcuteonsetofrespiratoryfailurewithoneormoreriskfactors(table,opposite)HypoxaemiaALI:RatioPaO2(kPa):FiO2<40ARDS:RatioPaO2(kPa):FiO2<27BilateralinfiltratesonCXRPulmonarycapillarywedgepressure<19mmHg,withnormalcolloidoncoticpressure(inpatientswithhypoalbuminaemia,thecriticalPCWPisapprox.serumalbumin(g/l)×0.57,seeP282)orclinicalexclusionofcardiacfailure.Diagnosticcriteria診斷標(biāo)準(zhǔn)發(fā)生急性呼吸衰竭，伴有1或多個(gè)危險(xiǎn)因素（見(jiàn)對(duì)側(cè)表）低氧血癥

ALI:PaO2(kPa):FiO2<40FiO2為吸氧濃度之意

ARDS:PaO2(kPa):FiO2<27胸部X線檢查示雙肺浸潤(rùn)肺動(dòng)脈嵌壓（PCWP）小于19mmHg，膠體滲透壓正常（在低蛋白血癥患者，PCWP大約為血清白蛋白(g/l)×0.57）或臨床排除心力衰竭。

診斷標(biāo)準(zhǔn)發(fā)生急性呼吸衰竭，伴有1或多個(gè)危險(xiǎn)因素（見(jiàn)對(duì)側(cè)表）DisordersassociatedwiththedevelopmentofARDSDirectlunginjury直接肺損傷Aspiration誤吸Gastriccontents胃內(nèi)容物Neardrowning淹溺Inhalationinjury吸入性損傷Noxiousgases有毒氣體Smoke煙DisordersassociatedwiththeDisordersassociatedwiththedevelopmentofARDSPneumonia肺炎Anyorganism任何病原菌PCP（Pneumocystispneumonia）卡氏肺囊蟲(chóng)性肺炎Pulmonaryvasculitides肺血管炎Pulmonarycontusion肺挫傷Drugtoxicityoroverdose藥物中毒或過(guò)量Oxygen氧中毒Opiateoverdose阿片劑過(guò)量Bleomycin博來(lái)霉素Salicylates水楊酸鹽DisordersassociatedwiththeIndirect(non-pulmonary)injuryShock休克Septicaemia膿毒血癥Amnioticorfatembolism羊水或脂肪栓塞Acutepancreatitis急性胰腺炎Massivehaemorrhage大出血Multipletransfusions大量輸血DIC（diffusionintravascularcoagulation）Indirect(non-pulmonary)injurIndirect(non-pulmonary)injuryMassiveburns大面積燒傷Majortrauma嚴(yán)重創(chuàng)傷Headinjury頭外傷RaisedICP顱內(nèi)壓升高Intracranialbleed顱內(nèi)出血Cardio-pulmonarybypass心肺旁路術(shù)Acuteliverfailure急性肝衰減Indirect(non-pulmonary)injurInvestigationsCXRABG(considerarteriallineasregularsamplesmayberequired)TakebloodforFBC,U&Es,LFTsandalbumin,coagulation,X-match,andCRPSepticscreen(cultureblood,urine,sputum)ECGConsiderdrugscreen,amylaseifhistorysuggestivePulmonaryarterycathetertomeasurePCWP,cardiacoutput,mixedvenousoxygensaturationandtoallowcalculationofhaemodynamicparametersInvestigationsCXR檢查胸部X線檢查動(dòng)脈血?dú)夥治霾裳槿?xì)胞、腎功、電解質(zhì)、肝功和白蛋白、凝血功能、X-match和CRP感染篩查（血、尿、痰培養(yǎng)）心電圖如有相關(guān)病史行藥物篩查及淀粉酶檢測(cè)肺動(dòng)脈導(dǎo)管測(cè)量PCWP，心輸出、混合靜脈氧濃度并計(jì)算血流動(dòng)力學(xué)參數(shù)。檢查胸部X線檢查Otherinvestigationsifappropriate

其它可用檢查CTchestBroncho-alveolarlavageformicrobiologyandcellcount(?eosinophils)Carboxy-haemoglobinestimation.胸部CT檢查支氣管-肺泡灌洗查微生物及細(xì)胞計(jì)數(shù)（嗜酸性粒細(xì)胞？）碳-氧血紅蛋白測(cè)定OtherinvestigationsifappropManagementAlmostallcasesofALIalonewillrequireHDU/ICUcare:liaiseearlyThemainaimistoidentifyandtreattheunderlyingcausewhilstprovidingsupportfororganfailure:RespiratorysupporttoimprovegasexchangeandcorrecthypoxiaCardiovascularsupporttooptimizeoxygendeliverytotissuesReverseortreattheunderlyingcause.ManagementAlmostallcasesof治療幾乎所有的ALI患者需要重癥監(jiān)護(hù)主要目的是明確診斷，治療原發(fā)病并對(duì)衰竭器管提供支持。呼吸支持以改善通氣、糾正缺氧。心血管系統(tǒng)支持以改善組織供氧逆轉(zhuǎn)和治療原發(fā)病治療幾乎所有的ALI患者需要重癥監(jiān)護(hù)Respiratorysupport---SpontaneouslybreathingpatientInverymildALI,hypoxiacanbecorrectedwithincreasedinspiredoxygenconcentrations(FiO240-60%).However,suchpatientsarerarelyrecognizedashavingALIasacauseoftheirrespiratoryfailure.對(duì)于非常輕癥的ALI患者,增加吸入氧濃度(FiO240-60%)即可糾正缺氧。然而，這樣的輕癥患者很少被診斷出ALI作為其呼吸衰竭的原因。Respiratorysupport---Spontan自主呼吸患者的呼吸支持Patientsinvariablyrequirehigheroxygenconcentrations(non-rebreathermaskswithreservoirFiO2~60-80%)orCPAP(seeP904).ConsidertransfertoHDU/ICU如果患者總是需要高濃度給氧（帶貯氣器的非再呼吸面罩，給氧濃度60%~80%）或持續(xù)正壓通氣支持，考慮轉(zhuǎn)入ICU。自主呼吸患者的呼吸支持PatientsinvariablyMechanicalventilationIndicationsformechanicalventilationInadequateoxygenation(PaO2<8kPaonFiO2>0.6)RisingorelevatedPaCO2(>6kPa)Clinicalsignsofincipientrespiratory/cardiovascularfailure.機(jī)械通氣適應(yīng)癥.

氧合不足（當(dāng)FiO2>0.6時(shí)PaO2<60mmHg）

PaCO2升高(>45mmHg)

臨床出現(xiàn)呼吸或循環(huán)衰竭

MechanicalventilationIndicatiMechanicalventilationThisistherealmoftheICUphysician.Mainaimistoimproveoxygenation/ventilationwhileminimizingtheriskoffurtherventilator-inducedlunginjury;termedlungprotectiveventilation.機(jī)械通氣屬于ICU醫(yī)師的工作范圍。主要目的是改善氧合/通氣同時(shí)最小化通氣誘發(fā)的肺損傷，也就是肺保護(hù)性通氣策略。MechanicalventilationThisisMechanicalventilation---Generalprinciples（一般原則）Controlledmechanicalventilationwithsedation(neuromuscularblockade).用鎮(zhèn)靜劑(神經(jīng)肌肉阻滯劑)實(shí)現(xiàn)可控機(jī)械通氣Aimfortidalvolume~6ml/kg.Recentevidencehasconfirmedthatventilationwithsmallertidalvolumesisassociatedwithimprovedoutcomecomparedtothetraditionalapproach(~10-12ml/kg).目標(biāo)潮氣量~6ml/kg。最近的證據(jù)表明小潮氣量通氣與傳統(tǒng)的方法（10-12ml/kg）比可明顯改善愈后。Mechanicalventilation---GeneMechanicalventilation---GeneralprinciplesStartwithFiO2=1.0.Subsequentadjustmentsaremadetoachieveoxygensaturation>90%withFiO2<0.6.開(kāi)始用純氧，繼而調(diào)整使得在給氧濃度小于0.6時(shí)氧飽和度達(dá)到90%以上。Positiveendexpiratorypressure(PEEP)improvesoxygenationinmostpatientsandallowsreductioninFiO2.Usualstartinglevel,5-10cmH2O,withoptimallevelsintherange10-15cmH2O.Bewarehypotensionduetoreductioninvenousreturn.在大多數(shù)患者，PEEP可以改善氧合從而可降低給氧濃度。通常從5-10cmH2O開(kāi)始，理想水平為10-15cmH2O。需小心因靜脈回流減少而導(dǎo)致的低血壓。Mechanicalventilation---GeneMechanicalventilation---GeneralprinciplesTheuseofsmallertidalvolumesmayimpairCO2clearancewithresultingacidosisdespitehighventilatoryrates(20-25breaths/minute).Furtherincreasesinrateortidalvolumeriskworseningventilator-inducedlunginjury.GradualincreasesinpCO2(upto~13kPa)arewelltoleratedinmostpatientsandacidosis(pH<7.25)canbetreatedwithintravenousbicarbonate,so-calledpermissivehypercapnia.盡管通氣頻率高（20-25次/分），應(yīng)用小潮氣量通氣模式可能降低CO2清除率導(dǎo)致酸中毒。進(jìn)一步增加呼吸頻率或潮氣量則增加通氣誘發(fā)的肺損傷的風(fēng)險(xiǎn)。大多患者可以耐受緩慢增加的pCO2（最高可達(dá)13kPa/97.7mmHg，酸中毒時(shí)(pH<7.25)可以用靜滴碳酸氫鹽糾正，所謂允許性高碳酸血癥.Mechanicalventilation---GeneMechanicalventilation---GeneralprinciplesIfoxygenation/ventilationcannotbeimproveddespitethesemeasures,thefollowingcanbeconsidered;Inverseratioventilation(P906):mayimproveoxygenation,butpCO2mayrisefurtherPronepositioning:improvesoxygenationin~70%ofpatientswithARDSInhaledvasodilators(nitricoxide,nebulizedprostacyclin):mayimproveoxygenationHigh-frequencyventilation:onlyavailableinspecialistcenters.Mechanicalventilation---Gene如果以上措施還不能改善氧合/通氣，可以考慮以下措施。反比通氣可以改善氧合，但可能導(dǎo)致pCO2進(jìn)一步升高。前傾位通氣，可以改善70%的ARDS患者的氧合吸入血管擴(kuò)張劑可以改善氧合：一氧化氮，霧化吸入前列腺素高頻通氣：僅在?？浦行氖褂?。如果以上措施還不能改善氧合/通氣，可以考慮以下措施。Cardiovascularsupport

心血管支持Arteriallineessentialforcontinuousbloodpressuremeasurements.Otherinvasivemonitoringisinvariablyused(PAcatheter,PiCCO,oesophagealDoppler),buttheirindividualrolesandeffectsonoutcomeareunclear.動(dòng)脈置管持續(xù)血壓監(jiān)測(cè)是必要的。其它侵入性監(jiān)測(cè)也總是在使用，如肺動(dòng)脈導(dǎo)管，PICCO，食管多普勒。但這些監(jiān)測(cè)系統(tǒng)的作用的對(duì)愈后的效果尚不清楚。Cardiovascularsupport

心血管支持ArCardiovascularsupportMostpatientsarehaemodynamicallycompromisedduetotheunderlyingconditionand/orventilatorymanagement,andbenefitfromfluidresuscitation.Thismayriskworseningcapillaryleakinthelungandcompromiseoxygenation/ventilation.Aimforalow-normalintravascularvolumewhilstmaintainingcardiacindexandmeanarterialpressure.大多數(shù)患者因潛在疾病和/或機(jī)械通氣治療損害了血流動(dòng)力學(xué)，液體復(fù)蘇有利于改善這種狀況，但可能有加重肺毛細(xì)胞血管滲出的風(fēng)險(xiǎn)，從而損害氧合/通氣功能。因此，支持的目的在于維持一個(gè)低---正常的血管內(nèi)容量，同時(shí)又可保持心輸出指數(shù)及平均動(dòng)脈壓。CardiovascularsupportMostpatCardiovascularsupportInotropeand/orvasopressorsupportiscommonlyrequiredandthechoiceofagentisusuallydecidedonacombinationofclinicalevaluationandinvasivehaemodynamicmonitoring(cardiacindex,oxygendelivery,mixedvenous/centralvenoussaturation,lactate).Agentscommonlyemployedincludedobutamine,dopamine,epinephrine,norepinepherine.Repeatedassessmentisessential.CardiovascularsupportInotrope通常需要正性肌力藥和血管活性藥物支持，藥物的選擇需綜合臨床狀況評(píng)估和侵入性血流動(dòng)力學(xué)監(jiān)測(cè)指標(biāo)（心指數(shù)、氧輸送、混合靜脈/中心靜脈氧飽和度、乳酸鹽濃度等）。常用藥物包括：多巴酚丁胺、多巴胺、腎上腺素、去甲腎上腺素。通常需要正性肌力藥和血管活性藥物支持，藥物的選擇需綜合臨床狀On-goingmanagementLookforandtreataprecipitant(seetable,P231)尋找并治療誘因。SepsisFever,neutrophilia,andraisedinflammatorymarkersarecommoninALI/ARDSanddonotalwaysimplysepsisAtrialofempiricantibioticsguidedbypossiblepathogens,andfollowinganappropriatesepticscreen(considerbronchoalveolarlavageonceintubatedandstable),shouldbeconsidered.AntibioticsshouldbemodifiedordiscontinuedinlightofmicrobiologicalresultsIndwellingCVPcathetersareacommonsourceofsepsisConsiderlow-dosesteroidinfusionif(seebelow)ConsideractivatedproteinC,whichhasbeenshowntoimprovesurvivalinpatientswithsepticshockwithmulti-organfailure.On-goingmanagementLookforan膿毒癥發(fā)熱、中性粒細(xì)胞增多、炎癥標(biāo)志物升高等為ALI/ARDS患者的通常表現(xiàn)，但并不總意味著存在膿毒癥應(yīng)考慮行合理的病原菌篩查（一旦插管，病情穩(wěn)定后可考慮行支氣管肺泡灌洗）并根椐可能病原菌的經(jīng)驗(yàn)性試驗(yàn)性治療?？股貞?yīng)根據(jù)病原菌篩查結(jié)果調(diào)整或終止。留置的中心靜脈導(dǎo)管是膿毒癥一常見(jiàn)病源?？紤]輸注低劑量類固醇（見(jiàn)下文）考慮使用活化蛋白C，已表明該藥可以改善有多臟器衰竭的膿毒癥性休克的生存率。膿毒癥On-goingmanagementRenalfailure.Commonandmayrequirerenalreplacementtherapytocontrolfluidbalanceandbloodbiochemistry.Enteralfeeding.Helpsmaintainintegrityofthegutmucosaandisassociatedwithalowerriskofsystemicsepsiswhencomparedtoparenteralfeeding(TPN).DelayedgastricemptyingandreducedgutmotilityiscommoninICUpatientsandmayrespondtopro-kineticdrugs(metoclopramide,erythromycin)ormayrequirenasojejunalfeeding.Stressulcerprophylaxis(H2-blockers)shouldbeconsideredifmechanicalventilation>48hours,ormulti-organfailure.On-goingmanagementRenalfailu治療腎衰：腎衰常見(jiàn)，可能需要腎臟替代治療以控制液體平衡和血生化。經(jīng)腸道飲食:有助于保持消化道內(nèi)膜的完整性，與全胃腸外營(yíng)養(yǎng)比較落，可以減少全身膿毒癥的風(fēng)險(xiǎn)。胃排空延遲、腸蠕動(dòng)減弱在ICU患者中常見(jiàn)，對(duì)促胃腸動(dòng)力藥物（胃復(fù)安、紅霉素）有反應(yīng)，或需要經(jīng)鼻導(dǎo)管空腸飲食。如果機(jī)械通氣超過(guò)48小時(shí)或有多臟器衰竭，應(yīng)考慮應(yīng)激性潰瘍的預(yù)防（H2-blockers）治療腎衰：腎衰常見(jiàn)，可能需要腎臟替代治療以控制液體平衡和血生On-goingmanagementCoagulopathy.Commonandifmilddoesnotrequiretherapy.Ifsevere/DIC,expertadviceshouldbesought.凝血障礙：常見(jiàn)，如果輕微則不需治療。如出現(xiàn)嚴(yán)重凝血障礙如DIC，則需尋求專家的指導(dǎo)。Steroidtherapy激素治療ALI/ARDS:nobenefitintheacutestage.Treatment(2mg/kg/dayofmethylprednisolone)laterinthecourseofthedisease(7-10days)mayimproveprognosisbutfurtherstudiesareawaited.ALI/ARDS：在急性期使用無(wú)益處。在疾病晚期（7-10天）治療可以改善預(yù)后，但需待進(jìn)一步的研究結(jié)果。On-goingmanagementCoagulopathOn-goingmanagementSepsis:evidencesuggeststhatsomepatientswithrefractorysepticshock(ongoing/increasingvasopressorrequirements)mayhaverelativeorfunctionaladrenalinsufficiencyandmaybenefitfromsupraphysiologicalsteroidreplacement(200-300mg/dayhydrocortisone).Identificationofpatientslikelytobenefitunclearatpresent,butACTHstimulationtestmayhelpdiscriminate.膿毒癥：證據(jù)表明，一些難治性膿毒癥性休克（正在使用或需增加血管活性藥物用量）患者有相對(duì)的功能性腎上腺功能不全，可能從超生理劑量的激素（200-300mg氫化可的松）替代治療獲益。目前如何識(shí)別這些可能獲得益的患者尚不清楚，但ACTH刺激試驗(yàn)可能有助于區(qū)分他們。On-goingmanagementSepsis:eviCausesofsuddendeteriorationinARDS

ARDS患者病情突然惡化的原因Respiratory呼吸系統(tǒng)Pneumothorax氣胸Bronchialplugging支氣管堵塞DisplacedETtube氣管內(nèi)導(dǎo)管移位Pleuraleffusion(haemothorax)胸膜滲出（血胸）Aspiration(e.g.NGfeed)誤吸（如經(jīng)鼻-胃管飲食）Cardiovascular心血管系統(tǒng)Arrhythmia心律失常Cardiactamponade心包添塞Myocardialinfarction心肌梗死GIbleed(stressulcer)消化道出血（應(yīng)激性潰瘍）Septicaemia膿毒血癥CausesofsuddendeteriorationOutcome---愈后TheoutcomeforALI/ARDShasimprovedinrecentyears,withoverallmortalityratesof~40%.近年來(lái)，ALI/ARDS的愈后已大大改善，總死亡率40%。PatientswithALI/ARDSandsepsis,liverdisease,non-pulmonaryorgandysfunction,oradvancedagehavehighermortalityrates.對(duì)于有膿毒癥的ALI/ARDS患者合并肝臟疾病、非肺器管功能不全、高齡等死亡率較高。Outcome---愈后TheoutcomeforALInsurvivors,althoughformallungfunctiontestsareabnormal,respiratorycompromiseat1-2yearsisunusual.在存活患者，盡管正規(guī)的肺功能檢測(cè)異常，但呼吸功能損害在1-2年內(nèi)是罕見(jiàn)的。Thereisincreasingevidencethatsurvivorssufferconsiderableneuromuscularandpsychologicaldisability.ThismayreflecttheperiodofprolongedcriticalillnessratherthanbespecificforALI/ARDS.越來(lái)越多的證據(jù)表明，存活者存在相當(dāng)嚴(yán)重的神經(jīng)肌肉殘疾和心理障礙。這可能是長(zhǎng)期嚴(yán)重疾病的結(jié)果，而不是因?yàn)锳LI/ARDS有什么特殊。Insurvivors,althoughformalAdultRespiratorydistresssyndrom(ARDS)

成人呼吸窘迫綜合征急救部AdultRespiratorydistresssyn1.Difinition---定義ALIanditsmoreseveresub-set,ARDS,isacommonclinicaldisordercharacterizedbyinjurytothealveolarepithelialandendothelialbarriersofthelung,acuteinflammation,andprotein-richpulmonaryoedemaleadingtoacuterespiratoryfailure.OftenoccursinthesettingofMOF.急性肺損傷及其更加嚴(yán)重的情況ARDS是一種常見(jiàn)的臨床異常狀況，以肺泡上皮細(xì)胞及肺內(nèi)皮細(xì)胞屏障損害、急性炎癥反應(yīng)、富含蛋白的肺水腫導(dǎo)致的急性呼吸衰竭為特點(diǎn)。經(jīng)常發(fā)生于多器管衰竭的情況下。1.Difinition---定義ALIanditsmDiagnosticcriteriaAcuteonsetofrespiratoryfailurewithoneormoreriskfactors(table,opposite)HypoxaemiaALI:RatioPaO2(kPa):FiO2<40ARDS:RatioPaO2(kPa):FiO2<27BilateralinfiltratesonCXRPulmonarycapillarywedgepressure<19mmHg,withnormalcolloidoncoticpressure(inpatientswithhypoalbuminaemia,thecriticalPCWPisapprox.serumalbumin(g/l)×0.57,seeP282)orclinicalexclusionofcardiacfailure.Diagnosticcriteria診斷標(biāo)準(zhǔn)發(fā)生急性呼吸衰竭，伴有1或多個(gè)危險(xiǎn)因素（見(jiàn)對(duì)側(cè)表）低氧血癥

ALI:PaO2(kPa):FiO2<40FiO2為吸氧濃度之意

ARDS:PaO2(kPa):FiO2<27胸部X線檢查示雙肺浸潤(rùn)肺動(dòng)脈嵌壓（PCWP）小于19mmHg，膠體滲透壓正常（在低蛋白血癥患者，PCWP大約為血清白蛋白(g/l)×0.57）或臨床排除心力衰竭。

診斷標(biāo)準(zhǔn)發(fā)生急性呼吸衰竭，伴有1或多個(gè)危險(xiǎn)因素（見(jiàn)對(duì)側(cè)表）DisordersassociatedwiththedevelopmentofARDSDirectlunginjury直接肺損傷Aspiration誤吸Gastriccontents胃內(nèi)容物Neardrowning淹溺Inhalationinjury吸入性損傷Noxiousgases有毒氣體Smoke煙DisordersassociatedwiththeDisordersassociatedwiththedevelopmentofARDSPneumonia肺炎Anyorganism任何病原菌PCP（Pneumocystispneumonia）卡氏肺囊蟲(chóng)性肺炎Pulmonaryvasculitides肺血管炎Pulmonarycontusion肺挫傷Drugtoxicityoroverdose藥物中毒或過(guò)量Oxygen氧中毒Opiateoverdose阿片劑過(guò)量Bleomycin博來(lái)霉素Salicylates水楊酸鹽DisordersassociatedwiththeIndirect(non-pulmonary)injuryShock休克Septicaemia膿毒血癥Amnioticorfatembolism羊水或脂肪栓塞Acutepancreatitis急性胰腺炎Massivehaemorrhage大出血Multipletransfusions大量輸血DIC（diffusionintravascularcoagulation）Indirect(non-pulmonary)injurIndirect(non-pulmonary)injuryMassiveburns大面積燒傷Majortrauma嚴(yán)重創(chuàng)傷Headinjury頭外傷RaisedICP顱內(nèi)壓升高Intracranialbleed顱內(nèi)出血Cardio-pulmonarybypass心肺旁路術(shù)Acuteliverfailure急性肝衰減Indirect(non-pulmonary)injurInvestigationsCXRABG(considerarteriallineasregularsamplesmayberequired)TakebloodforFBC,U&Es,LFTsandalbumin,coagulation,X-match,andCRPSepticscreen(cultureblood,urine,sputum)ECGConsiderdrugscreen,amylaseifhistorysuggestivePulmonaryarterycathetertomeasurePCWP,cardiacoutput,mixedvenousoxygensaturationandtoallowcalculationofhaemodynamicparametersInvestigationsCXR檢查胸部X線檢查動(dòng)脈血?dú)夥治霾裳槿?xì)胞、腎功、電解質(zhì)、肝功和白蛋白、凝血功能、X-match和CRP感染篩查（血、尿、痰培養(yǎng)）心電圖如有相關(guān)病史行藥物篩查及淀粉酶檢測(cè)肺動(dòng)脈導(dǎo)管測(cè)量PCWP，心輸出、混合靜脈氧濃度并計(jì)算血流動(dòng)力學(xué)參數(shù)。檢查胸部X線檢查Otherinvestigationsifappropriate

其它可用檢查CTchestBroncho-alveolarlavageformicrobiologyandcellcount(?eosinophils)Carboxy-haemoglobinestimation.胸部CT檢查支氣管-肺泡灌洗查微生物及細(xì)胞計(jì)數(shù)（嗜酸性粒細(xì)胞？）碳-氧血紅蛋白測(cè)定OtherinvestigationsifappropManagementAlmostallcasesofALIalonewillrequireHDU/ICUcare:liaiseearlyThemainaimistoidentifyandtreattheunderlyingcausewhilstprovidingsupportfororganfailure:RespiratorysupporttoimprovegasexchangeandcorrecthypoxiaCardiovascularsupporttooptimizeoxygendeliverytotissuesReverseortreattheunderlyingcause.ManagementAlmostallcasesof治療幾乎所有的ALI患者需要重癥監(jiān)護(hù)主要目的是明確診斷，治療原發(fā)病并對(duì)衰竭器管提供支持。呼吸支持以改善通氣、糾正缺氧。心血管系統(tǒng)支持以改善組織供氧逆轉(zhuǎn)和治療原發(fā)病治療幾乎所有的ALI患者需要重癥監(jiān)護(hù)Respiratorysupport---SpontaneouslybreathingpatientInverymildALI,hypoxiacanbecorrectedwithincreasedinspiredoxygenconcentrations(FiO240-60%).However,suchpatientsarerarelyrecognizedashavingALIasacauseoftheirrespiratoryfailure.對(duì)于非常輕癥的ALI患者,增加吸入氧濃度(FiO240-60%)即可糾正缺氧。然而，這樣的輕癥患者很少被診斷出ALI作為其呼吸衰竭的原因。Respiratorysupport---Spontan自主呼吸患者的呼吸支持Patientsinvariablyrequirehigheroxygenconcentrations(non-rebreathermaskswithreservoirFiO2~60-80%)orCPAP(seeP904).ConsidertransfertoHDU/ICU如果患者總是需要高濃度給氧（帶貯氣器的非再呼吸面罩，給氧濃度60%~80%）或持續(xù)正壓通氣支持，考慮轉(zhuǎn)入ICU。自主呼吸患者的呼吸支持PatientsinvariablyMechanicalventilationIndicationsformechanicalventilationInadequateoxygenation(PaO2<8kPaonFiO2>0.6)RisingorelevatedPaCO2(>6kPa)Clinicalsignsofincipientrespiratory/cardiovascularfailure.機(jī)械通氣適應(yīng)癥.

氧合不足（當(dāng)FiO2>0.6時(shí)PaO2<60mmHg）

PaCO2升高(>45mmHg)

臨床出現(xiàn)呼吸或循環(huán)衰竭

MechanicalventilationIndicatiMechanicalventilationThisistherealmoftheICUphysician.Mainaimistoimproveoxygenation/ventilationwhileminimizingtheriskoffurtherventilator-inducedlunginjury;termedlungprotectiveventilation.機(jī)械通氣屬于ICU醫(yī)師的工作范圍。主要目的是改善氧合/通氣同時(shí)最小化通氣誘發(fā)的肺損傷，也就是肺保護(hù)性通氣策略。MechanicalventilationThisisMechanicalventilation---Generalprinciples（一般原則）Controlledmechanicalventilationwithsedation(neuromuscularblockade).用鎮(zhèn)靜劑(神經(jīng)肌肉阻滯劑)實(shí)現(xiàn)可控機(jī)械通氣Aimfortidalvolume~6ml/kg.Recentevidencehasconfirmedthatventilationwithsmallertidalvolumesisassociatedwithimprovedoutcomecomparedtothetraditionalapproach(~10-12ml/kg).目標(biāo)潮氣量~6ml/kg。最近的證據(jù)表明小潮氣量通氣與傳統(tǒng)的方法（10-12ml/kg）比可明顯改善愈后。Mechanicalventilation---GeneMechanicalventilation---GeneralprinciplesStartwithFiO2=1.0.Subsequentadjustmentsaremadetoachieveoxygensaturation>90%withFiO2<0.6.開(kāi)始用純氧，繼而調(diào)整使得在給氧濃度小于0.6時(shí)氧飽和度達(dá)到90%以上。Positiveendexpiratorypressure(PEEP)improvesoxygenationinmostpatientsandallowsreductioninFiO2.Usualstartinglevel,5-10cmH2O,withoptimallevelsintherange10-15cmH2O.Bewarehypotensionduetoreductioninvenousreturn.在大多數(shù)患者，PEEP可以改善氧合從而可降低給氧濃度。通常從5-10cmH2O開(kāi)始，理想水平為10-15cmH2O。需小心因靜脈回流減少而導(dǎo)致的低血壓。Mechanicalventilation---GeneMechanicalventilation---GeneralprinciplesTheuseofsmallertidalvolumesmayimpairCO2clearancewithresultingacidosisdespitehighventilatoryrates(20-25breaths/minute).Furtherincreasesinrateortidalvolumeriskworseningventilator-inducedlunginjury.GradualincreasesinpCO2(upto~13kPa)arewelltoleratedinmostpatientsandacidosis(pH<7.25)canbetreatedwithintravenousbicarbonate,so-calledpermissivehypercapnia.盡管通氣頻率高（20-25次/分），應(yīng)用小潮氣量通氣模式可能降低CO2清除率導(dǎo)致酸中毒。進(jìn)一步增加呼吸頻率或潮氣量則增加通氣誘發(fā)的肺損傷的風(fēng)險(xiǎn)。大多患者可以耐受緩慢增加的pCO2（最高可達(dá)13kPa/97.7mmHg，酸中毒時(shí)(pH<7.25)可以用靜滴碳酸氫鹽糾正，所謂允許性高碳酸血癥.Mechanicalventilation---GeneMechanicalventilation---GeneralprinciplesIfoxygenation/ventilationcannotbeimproveddespitethesemeasures,thefollowingcanbeconsidered;Inverseratioventilation(P906):mayimproveoxygenation,butpCO2mayrisefurtherPronepositioning:improvesoxygenationin~70%ofpatientswithARDSInhaledvasodilators(nitricoxide,nebulizedprostacyclin):mayimproveoxygenationHigh-frequencyventilation:onlyavailableinspecialistcenters.Mechanicalventilation---Gene如果以上措施還不能改善氧合/通氣，可以考慮以下措施。反比通氣可以改善氧合，但可能導(dǎo)致pCO2進(jìn)一步升高。前傾位通氣，可以改善70%的ARDS患者的氧合吸入血管擴(kuò)張劑可以改善氧合：一氧化氮，霧化吸入前列腺素高頻通氣：僅在?？浦行氖褂?。如果以上措施還不能改善氧合/通氣，可以考慮以下措施。Cardiovascularsupport

心血管支持Arteriallineessentialforcontinuousbloodpressuremeasurements.Otherinvasivemonitoringisinvariablyused(PAcatheter,PiCCO,oesophagealDoppler),buttheirindividualrolesandeffectsonoutcomeareunclear.動(dòng)脈置管持續(xù)血壓監(jiān)測(cè)是必要的。其它侵入性監(jiān)測(cè)也總是在使用，如肺動(dòng)脈導(dǎo)管，PICCO，食管多普勒。但這些監(jiān)測(cè)系統(tǒng)的作用的對(duì)愈后的效果尚不清楚。Cardiovascularsupport

心血管支持ArCardiovascularsupportMostpatientsarehaemodynamicallycompromisedduetotheunderlyingconditionand/orventilatorymanagement,andbenefitfromfluidresuscitation.Thismayriskworseningcapillaryleakinthelungandcompromiseoxygenation/ventilation.Aimforalow-normalintravascularvolumewhilstmaintainingcardiacindexandmeanarterialpressure.大多數(shù)患者因潛在疾病和/或機(jī)械通氣治療損害了血流動(dòng)力學(xué)，液體復(fù)蘇有利于改善這種狀況，但可能有加重肺毛細(xì)胞血管滲出的風(fēng)險(xiǎn)，從而損害氧合/通氣功能。因此，支持的目的在于維持一個(gè)低---正常的血管內(nèi)容量，同時(shí)又可保持心輸出指數(shù)及平均動(dòng)脈壓。CardiovascularsupportMostpatCardiovascularsupportInotropeand/orvasopressorsupportiscommonlyrequiredandthechoiceofagentisusuallydecidedonacombinationofclinicalevaluationandinvasivehaemodynamicmonitoring(cardiacindex,oxygendelivery,mixedvenous/centralvenoussaturation,lactate).Agentscommonlyemployedincludedobutamine,dopamine,epinephrine,norepinepherine.Repeatedassessmentisessential.CardiovascularsupportInotrope通常需要正性肌力藥和血管活性藥物支持，藥物的選擇需綜合臨床狀況評(píng)估和侵入性血流動(dòng)力學(xué)監(jiān)測(cè)指標(biāo)（心指數(shù)、氧輸送、混合靜脈/中心靜脈氧飽和度、乳酸鹽濃度等）。常用藥物包括：多巴酚丁胺、多巴胺、腎上腺素、去甲腎上腺素。通常需要正性肌力藥和血管活性藥物支持，藥物的選擇需綜合臨床狀On-goingmanagementLookforandtreataprecipitant(seetable,P231)尋找并治療誘因。SepsisFever,neutrophilia,andraisedinflammatorymarkersarecommoninALI/ARDSanddonotalwaysimplysepsisAtrialofempiricantibioticsguidedbypossiblepathogens,andfollowinganappropriatesepticscreen(considerbronchoalveolarlavageonceintubatedandstable),shouldbeconsidered.AntibioticsshouldbemodifiedordiscontinuedinlightofmicrobiologicalresultsIndwellingCVPcathetersareacommonsourceofsepsisConsiderlow-dosesteroidinfusionif(seebelow)ConsideractivatedproteinC,whichhasbeenshowntoimprovesurvivalinpatientswithsepticshockwithmulti-organfailure.On-goingmanagementLookforan膿毒癥發(fā)熱、中性粒細(xì)胞增多、炎癥標(biāo)志物升高等為ALI/ARDS患者的通常表現(xiàn)，但并不總意味著存在膿毒癥應(yīng)考慮行合理的病原菌篩查（一旦插管，病情穩(wěn)定后可考慮行支氣管肺泡灌洗）并根椐可能病原菌的經(jīng)驗(yàn)性試驗(yàn)性治療。抗生素應(yīng)根據(jù)病原菌篩查結(jié)果調(diào)整或終止。留置的中心靜脈導(dǎo)管是膿毒癥一常見(jiàn)病源。考慮輸注低劑量類固醇（見(jiàn)下文）考慮使用活化蛋白C，已表明該藥可以改善有多臟器衰竭的膿毒癥性休克的生存率。膿毒癥On-goingmanagementRenalfailure.Commonandmayrequirerenalreplacementtherapytocontrolfluidbalanceandbloodbiochemistry.Enteralfeeding.Helpsmaintainintegrityofthegutmucosaandisassociatedwithalowerriskofsystemicsepsiswhencomparedtoparenteralfeeding(TPN).DelayedgastricemptyingandreducedgutmotilityiscommoninICUpatientsandmayrespondtopro-kineticdrugs(metoclopramide,erythromycin)ormayrequirenasojejunalfeeding.Stressulcerprophylaxis(H2-blockers)shouldbeconsideredifmechanicalventilation>48hours,ormulti-organfailure.On-goingmanagementRenalfailu治療腎衰：腎衰常見(jiàn)，可能需要腎臟替代治療以控制液體平衡和血生化。經(jīng)腸道