ARDS預(yù)防：高危因素評估和干預(yù)華東醫(yī)院宋曉華ARDS的柏林定義與診斷標(biāo)準(zhǔn)急性呼吸窘迫綜合征發(fā)病時(shí)機(jī)在已知誘因后，或新出現(xiàn)或原有呼吸系統(tǒng)癥狀加重后一周內(nèi)發(fā)病胸部影像學(xué)a雙肺透光度減低，且不能完全用胸腔積液、肺葉不張或結(jié)節(jié)解釋肺水腫來源無法用心功能衰竭或液體負(fù)荷過多解釋的呼吸衰竭

如果沒有危險(xiǎn)因素，則需要客觀評估（如心臟超聲檢查）排除靜水壓升高的肺水腫低氧血癥b輕度：PEEP/CPAP

≥5cmH2O時(shí)200mmHg<PaO2/FiO2≤300mmHgc

中度：PEEP/CPAP

≥5cmH2O時(shí)100mmHg<PaO2/FiO2≤200

mmHg

重度：PEEP/CPAP

≥5cmH2O時(shí)PaO2/FiO2≤100

mmHgCPAP，持續(xù)氣道正壓；PEEP，呼氣末正壓胸片或CT掃描如果海拔超過1000m，應(yīng)根據(jù)如下公式進(jìn)行校正：[PaO2/FiO2

x(大氣壓/760)]輕度ARDS患者可能接受無創(chuàng)通氣ARDS/ALI的危險(xiǎn)因素直接間接?肺炎

?誤吸?吸入性損傷?肺挫傷?肺血管炎?溺水

?脂肪栓塞?肺移植或肺動(dòng)脈取栓術(shù)后再灌注肺水腫?非肺源性膿毒血癥

?創(chuàng)傷?胰腺炎?嚴(yán)重?zé)齻?非心源性休克?藥物過量?多次輸血（24h內(nèi)大于15u）或輸血相關(guān)性ALI?神經(jīng)源性肺水腫?羊水栓塞?骨髓移植后

Modrykamien,ArielM.,andPoojaGupta."Theacuterespiratorydistresssyndrome."

Proceedings(BaylorUniversity.MedicalCenter)

28.2(2021):163.【個(gè)體因素】ARDS與酗酒酗酒與ARDS相關(guān)性研究MoazedF,

CalfeeCS.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2021Dec;35(4):625-37.doi:10.1016/j.ccm.2021.08.003.Epub2021Sep30.酗酒引起ARDS的機(jī)制MoazedF,

CalfeeCS.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2021Dec;35(4):625-37.doi:10.1016/j.ccm.2021.08.003.Epub2021Sep30.ARDS與吸煙吸煙與ARDS相關(guān)性研究MoazedF,

CalfeeCS.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2021Dec;35(4):625-37.doi:10.1016/j.ccm.2021.08.003.Epub2021Sep30.吸煙引起ARDS的機(jī)制MoazedF,

CalfeeCS.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2021Dec;35(4):625-37.doi:10.1016/j.ccm.2021.08.003.Epub2021Sep30.【疾病因素】SpO2/FiO2MayoClinic的研究〔2021〕5584個(gè)患者，其中4646名有SpO2/FiO2記錄FesticE,BansalV,KorDJ,etal.SpO2/FiO2RatioonHospitalAdmissionIsanIndicatorofEarlyAcuteRespiratoryDistressSyndromeDevelopmentAmongPatientsatRisk[J].Journalofintensivecaremedicine,2021:0885066613516411.SpO2/FiO2優(yōu)勢比(OR)P值<1002.49(1.69-3.64)<.001100<2001.75(1.16-2.58)=.007200<3001.62(1.06-2.42)=.025入院后6h內(nèi)的SpO2/FiO2，是ARDS早期的獨(dú)立危險(xiǎn)因素糖尿病與ARDS薈萃分析Gu等，至2021年9月的相關(guān)研究12,794人入選(2,937人既往有糖尿病史，2,457例ALI/ARDS)GuWJ,WanYD,TieHT,etal.Riskofacutelunginjury/acuterespiratorydistresssyndromeincriticallyilladultpatientswithpre-existingdiabetes:ameta-analysis[J].PloSone,2021,9(2):e90426.既往存在糖尿病病史的患者發(fā)生ALI/ARDS的風(fēng)險(xiǎn)降低乳酸與ARDS膿毒癥患者乳酸值升高與發(fā)生ARDS相關(guān)單中心，隨機(jī)研究，778例severesepsisMikkelsenME,ShahCV,MeyerNJ,etal.Theepidemiologyofacuterespiratorydistresssyndromeinpatientspresentingtotheemergencydepartmentwithseveresepsis[J].Shock(Augusta,Ga.),2021,40(5):375-381.膿毒癥患者乳酸值≥2

mmol/L是發(fā)生ARDS的獨(dú)立危險(xiǎn)因素胰腺炎和ARDS胰腺炎和ARDS多因素回歸分析，243例重癥胰腺炎患者10~25%的急性胰腺炎患者發(fā)生ARDS。急性重癥胰腺炎患者發(fā)生ARDS與性別，低蛋白血癥，高甘油三酯存在相關(guān)性

邵斌霞,何斌,劉紅梅,邵旦兵,孫兆瑞,林金鋒,張煒,任藝,聶時(shí)南.急性重癥胰腺炎并發(fā)ARDS多因素回歸分析[J].臨床急診雜志,2021,08:449-451+455.急性胰腺炎的病程ZhouMT,ChenCS,ChenBC,etal.AcutelunginjuryandARDSinacutepancreatitis:mechanismsandpotentialintervention[J].Worldjournalofgastroenterology:WJG,2021,16(17):2094.胰腺炎引起ARDS的機(jī)制—肺血管內(nèi)皮屏障破壞，中性粒細(xì)胞浸潤損傷肺實(shí)質(zhì)ZhouMT,ChenCS,ChenBC,etal.AcutelunginjuryandARDSinacutepancreatitis:mechanismsandpotentialintervention[J].Worldjournalofgastroenterology:WJG,2021,16(17):2094.胰腺炎引起ARDS的機(jī)制–胃腸道胃腸道通透性增加，細(xì)菌和內(nèi)毒素移位。激活炎癥介質(zhì)，引起SIRS和MODS。ZhouMT,ChenCS,ChenBC,etal.AcutelunginjuryandARDSinacutepancreatitis:mechanismsandpotentialintervention[J].Worldjournalofgastroenterology:WJG,2021,16(17):2094.低蛋白血癥和ARDS低蛋白血癥與ARDS發(fā)病率相關(guān)回歸分析，455例sepsis，178例發(fā)生ARDS92%的ARDS患者血清總蛋白低于6g/dlMangialardiRJ,MartinGS,BernardGR,etal.Hypoproteinemiapredictsacuterespiratorydistresssyndromedevelopment,weightgain,anddeathinpatientswithsepsis[J].Criticalcaremedicine,2000,28(9):3137-3145.低蛋白血癥引起ARDS的機(jī)制血漿膠體滲透壓下降。血液中的水分更易向肺間質(zhì)內(nèi)轉(zhuǎn)移。MangialardiRJ,MartinGS,BernardGR,etal.Hypoproteinemiapredictsacuterespiratorydistresssyndromedevelopment,weightgain,anddeathinpatientswithsepsis[J].Criticalcaremedicine,2000,28(9):3137-3145.其他相關(guān)指標(biāo)其他指標(biāo)肺泡蛋白的測定細(xì)胞特異性標(biāo)志物

內(nèi)皮細(xì)胞產(chǎn)生的血管緊張肽轉(zhuǎn)化酶〔PCEB-ACE〕

內(nèi)皮肽1

血管性假血友病因子抗原

E/P-選擇蛋白

上皮細(xì)胞分泌的外表活性物質(zhì)

肺泡上皮細(xì)胞抗原Gajic和Trillo-Alvarez等在多中心大樣本對照研究根底上提出：肺損傷預(yù)測評分〔lung

injury

prediction

score,LIPS〕系統(tǒng)可以早期預(yù)測ALI/ARDSLungInjuryPredictionScore〔LIPS評分〕誘因LIPS分值休克2誤吸2膿毒癥1肺炎1.5高危手術(shù)a

脊柱急腹癥

心臟主動(dòng)脈血管

122.53.5高危創(chuàng)傷

腦外傷煙塵吸入傷淹溺肺挫傷多發(fā)性骨折2221.51.5危險(xiǎn)因素LIPS分值酗酒1肥胖（BMI>30）1低蛋白血癥1化療1FiO2>0.35（>4L/min）2呼吸急促（RR>30bpm）1.5SpO2<95%1酸中毒（pH<7.35）1.5糖尿病b-1a

急診手術(shù)加1.5分.b

僅膿毒癥時(shí)計(jì)算.ReprintedfromGajicetal,2021(33)withpermissionoftheAmericanThoracicSociety.Copyright?AmericanThoracicSociety.TheAmericanJournalofRespiratoryandCriticalCareMedicineisanofficialjournaloftheAmericanThoracicSociety.LIPS≥4分預(yù)測ARDS

敏感性為0.69

特異性為0.78

陽性預(yù)測值為0.18

陰性預(yù)測值為0.97GajicO,DabbaghO,ParkPK,AdesanyaA,ChangSY,HouP,AndersonH3rd,HothJJ,MikkelsenME,GentileNT,GongMN,TalmorD,BajwaE,WatkinsTR,FesticE,YilmazM,IscimenR,KaufmanDA,EsperAM,SadikotR,DouglasI,SevranskyJ,MalinchocM.Earlyidenti?cationofpatientsatriskofacutelunginjury:evaluationoflunginjurypredictionscoreinamulticentercohortstudy.AmJRespirCritCareMed2021;183(4):462–470.【如何預(yù)防ARDS】早期發(fā)現(xiàn)存在高危因素的患者依靠評分LIPS≥4分〔陽性預(yù)測值為0.18，陰性預(yù)測值為0.97〕early

acute

lung

injury

scoreEarly

Acute

Lung

Injury

Score由Levitt等人提出包括3局部吸氧濃度〔2-6

L/min記1分，>6

L/min記2分〕呼吸頻率〔≥30次/min記1分〕存在免疫抑制〔存在記1分〕評分≥2分發(fā)生ALI的敏感性為0.89,特異性為0.75分缺點(diǎn)：單中心研究LevittJE,CalfeeCS,GoldsteinBA,etal.Earlyacutelunginjury:criteriaforidentifyinglunginjurypriortotheneedforpositivepressureventilation.CritCareMed2021;41:1929–1937.改善臨床策略ARDS的時(shí)間特點(diǎn)ARDS很少發(fā)生在疾病之初1。ARDS一般發(fā)生于患者出現(xiàn)高危因素后2-5天2。LevittJE,CalfeeCS,GoldsteinBA,etal.Earlyacutelunginjury:criteriaforidentifyinglunginjurypriortotheneedforpositivepressureventilation.CritCareMed2021;41:1929–1937.GajicO,DabbaghO,ParkPK,etal.Earlyidentificationofpatientsatriskofacutelunginjury:evaluationoflunginjurypredictionscoreinamulticentercohortstudy.AmJRespirCritCareMed2021;183:462–470.呼吸治療早期治療肺不張。減少過度通氣。對于低氧飽和度患者改善供氧2。機(jī)械通氣患者爭取早期拔管4。預(yù)防誤吸。KalletRH,MatthayMA.Hyperoxicacutelunginjury.RespirCare2021;58:123–141.AlbertRK.Theroleofventilation-inducedsurfactantdysfunctionandatelectasisincausingacuterespiratorydistresssyndrome.AmJRespirCritCareMed2021;185:702–708.全身治療減少臥床時(shí)間。早期活動(dòng)3。減少神經(jīng)肌肉阻斷劑的使用。嚴(yán)格輸血指證1。盡早治療sepsis2。目標(biāo)液體復(fù)蘇4。GajicO,RanaR,WintersJL,etal.Transfusion-relatedacutelunginjuryinthecriticallyill:prospectivenestedcase–controlstudy.AmJRespirCritCareMed2007;176:886–891.IscimenR,Cartin-CebaR,YilmazM,etal.Riskfactorsforthedevelopmentofacutelunginjuryinpatientswithsepticshock:anobservationalcohortstudy.CritCareMed2021;36:1518–1522.DellingerRP,LevyMM,RhodesA,etal.Survivingsepsiscampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2021.CritCareMed2021;41:580–637.AlbertRK.Theroleofventilation-inducedsurfactantdysfunctionandatelectasisincausingacuterespiratorydistresssyndrome.AmJRespirCritCareMed2021;185:702–708.肺創(chuàng)傷預(yù)防〔CLIP〕的評估表FesticE,KorDJ,GajicO.Preventionofacuterespiratorydistresssyndrome[J].Currentopinionincriticalcare,2021,21(1):82-90.藥物預(yù)防藥物預(yù)防FesticE,KorDJ,GajicO.Preventionofacuterespiratorydistresssyndrome[J].Currentopinionincriticalcare,2021,21(1):82-90.藥物機(jī)制阿司匹林Inhibitionofplatelet-mediatedcyclooxygenasemetabolisminvolvedinbronchoconstrictionandvasoconstrictionandinhibitsplatelet–neutrophil–endothelialinteractions全身使用皮質(zhì)類固醇Multipotent;inhibitinflammatorycytokines;inducedapoptosisofmacrophages;maintainendothelialcellularbarrier吸入肝素InadditiontopotentiatingantithrombinIII,inhibitsadhesionofneutrophilstoendotheliumanddegradesintravascularandbronchialfibrin吸入皮質(zhì)類固醇Sameassystemiccorticosteroids.Intheory,maysparepatientsfromhyperglycemia,myopathy,superinfection,etc.藥物預(yù)防FesticE,KorDJ,GajicO.Prevent