ards高危因素课件

ARDS预防：高危因素评估和干预ARDS的柏林定义与诊断标准急性呼吸窘迫综合征发病时机在已知诱因后，或新出现或原有呼吸系统症状加重后一周内发病胸部影像学a双肺透光度减低，且不能完全用胸腔积液、肺叶不张或结节解释肺水肿来源无法用心功能衰竭或液体负荷过多解释的呼吸衰竭

如果没有危险因素，则需要客观评估（如心脏超声检查）排除静水压升高的肺水肿低氧血症b轻度：PEEP/CPAP

≥5cmH2O时200mmHg<PaO2/FiO2≤300mmHgc

中度：PEEP/CPAP

≥5cmH2O时100mmHg<PaO2/FiO2≤200

mmHg

重度：PEEP/CPAP

≥5cmH2O时PaO2/FiO2≤100

mmHgCPAP，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的危险因素直接间接•肺炎•误吸•吸入性损伤•肺挫伤•肺血管炎•溺水•脂肪栓塞•肺移植或肺动脉取栓术后再灌注肺水肿•非肺源性脓毒血症

•创伤•胰腺炎•严重烧伤•非心源性休克•药物过量•多次输血（24h内大于15u）或输血相关性ALI•神经源性肺水肿•羊水栓塞•骨髓移植后

Modrykamien,ArielM.,andPoojaGupta."Theacuterespiratorydistresssyndrome."

Proceedings(BaylorUniversity.MedicalCenter)

28.2(2015):163.ARDS与酗酒酗酒与ARDS相关性研究MoazedF,

CalfeeCS

.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2014Dec;35(4):625-37.doi:10.1016/j.ccm.2014.08.003.Epub2014Sep30.酗酒引起ARDS的机制MoazedF,

CalfeeCS

.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2014Dec;35(4):625-37.doi:10.1016/j.ccm.2014.08.003.Epub2014Sep30.吸烟与ARDS相关性研究MoazedF,

CalfeeCS

.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2014Dec;35(4):625-37.doi:10.1016/j.ccm.2014.08.003.Epub2014Sep30.吸烟引起ARDS的机制MoazedF,

CalfeeCS

.Environmental

riskfactors

for

acuterespiratorydistresssyndrome.ClinChestMed.

2014Dec;35(4):625-37.doi:10.1016/j.ccm.2014.08.003.Epub2014Sep30.【疾病因素】MayoClinic的研究（2015）5584个患者，其中4646名有SpO2/FiO2记录FesticE,BansalV,KorDJ,etal.SpO2/FiO2RatioonHospitalAdmissionIsanIndicatorofEarlyAcuteRespiratoryDistressSyndromeDevelopmentAmongPatientsatRisk[J].Journalofintensivecaremedicine,2013:16411.SpO2/FiO2优势比(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)GuWJ,WanYD,TieHT,etal.Riskofacutelunginjury/acuterespiratorydistresssyndromeincriticallyilladultpatientswithpre-existingdiabetes:ameta-analysis[J].PloSone,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severesepsisMikkelsenME,ShahCV,MeyerNJ,etal.Theepidemiologyofacuterespiratorydistresssyndromeinpatientspresentingtotheemergencydepartmentwithseveresepsis[J].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10~25%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.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ZhouMT,ChenCS,ChenBC,etal.AcutelunginjuryandARDSinacutepancreatitis:mechanismsandpotentialintervention[J].Worldjournalofgastroenterology: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。ZhouMT,ChenCS,ChenBC,etal.AcutelunginjuryandARDSinacutepancreatitis:mechanismsandpotentialintervention[J].Worldjournalofgastroenterology:WJG,2010,16(17):2094.低蛋白血症和ARDS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。MangialardiRJ,MartinGS,BernardGR,etal.Hypoproteinemiapredictsacuterespiratorydistresssyndromedevelopment,weightgain,anddeathinpatientswithsepsis[J].Criticalcaremedicine,2000,28(9):3137-3145.其他相关指标LungInjuryPredictionScore（LIPS评分）诱因LIPS分值休克2误吸2脓毒症1肺炎1.5高危手术a

脊柱急腹症

心脏主动脉血管

122.53.5高危创伤脑外伤烟尘吸入伤淹溺肺挫伤多发性骨折2221.51.5危险因素LIPS分值酗酒1肥胖（BMI>30）1低蛋白血症1化疗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

急诊手术加1.5分.b

仅脓毒症时计算.ReprintedfromGajicetal,2011(33)withpermissionoftheAmericanThoracicSociety.Copyright©AmericanThoracicSociety.TheAmericanJournalofRespiratoryandCriticalCareMedicineisanofficialjournaloftheAmericanThoracicSociety.LIPS≥4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0.97GajicO,DabbaghO,ParkPK,AdesanyaA,ChangSY,HouP,AndersonH3rd,HothJJ,MikkelsenME,GentileNT,GongMN,TalmorD,BajwaE,WatkinsTR,FesticE,YilmazM,IscimenR,KaufmanDA,EsperAM,SadikotR,DouglasI,SevranskyJ,MalinchocM.Earlyidentificationofpatientsatriskofacutelunginjury:evaluationoflunginjurypredictionscoreinamulticentercohortstudy.AmJRespirCritCareMed2011;183(4):462–470.【如何预防ARDS】早期发现存在高危因素的患者依靠评分LIPS≥4分（阳性预测值为0.18，阴性预测值为0.97）early

acute

lung

injury

scoreEarly

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LevittJE,CalfeeCS,GoldsteinBA,etal.Earlyacutelunginjury:criteriaforidentifyinglunginjurypriortotheneedforpositivepressureventilation.CritCareMed2013;41:1929–1937.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。LevittJE,CalfeeCS,GoldsteinBA,etal.Earlyacutelunginjury:criteriaforidentifyinglunginjurypriortotheneedforpositivepressureventilation.CritCareMed2013;41:1929–1937.GajicO,DabbaghO,ParkPK,etal.Earlyidentificationofpatientsatriskofacutelunginjury:evaluationoflunginjurypredictionscoreinamulticentercohortstudy.AmJRespirCritCareMed2011;183:462–470.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。KalletRH,MatthayMA.Hyperoxicacutelunginjury.RespirCare2013;58:123–141.AlbertRK.Theroleofventilation-inducedsurfactantdysfunctionandatelectasisincausingacuterespiratorydistresssyndrome.AmJRespirCritCareMed2012;185:702–708.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。GajicO,RanaR,WintersJL,etal.Transfusion-relatedacutelunginjuryinthecriticallyill:prospectivenestedcase–controlstudy.AmJRespirCritCareMed2007;176:886–891.IscimenR,Cartin-CebaR,YilmazM,etal.Riskfactorsforthedevelopmentofacutelunginjuryinpatientswithsepticshock:anobservationalcohortstudy.CritCareMed2008;36:1518–1522.DellingerRP,LevyMM,RhodesA,etal.Survivingsepsiscampaign:internationalguidelinesformanagementofseveresepsisandsepticshock:2012.CritCareMed2013;41:580–637.AlbertRK.Theroleofventilation-inducedsurfactantdysfunctionandatelectasisincausingacuterespiratorydistresssyndrome.AmJRespirCritCareMed2012;185:702–708.肺创伤预防（CLIP）的评估表FesticE,KorDJ,GajicO.Preventionofacuterespiratorydistresssyndrome[J].Currentopinionincriticalcare,2015,21(1):82-90.药物预防药物预防FesticE,KorDJ,GajicO.Preventionofacuterespiratorydistresssyndrome[J].Currentopinionincriticalcare,2015,21(1):82-90.药物机制阿司匹林Inhibitionofplatelet-mediatedcyclooxygenasemetabolisminvolvedinbronchoconstrictionandvasoconstrictionandinhibitsplatelet–neutrophil–endothelialinteractions全身使用皮质类固醇Multipotent;inhibitinflammatorycytokines;inducedapoptosisofmacrophages;maintainendothelialcellularbarrier吸入肝素InadditiontopotentiatingantithrombinIII,inhibitsadhesionofneutrophilstoendotheliumanddegradesintravascularandbronchialfibrin吸入皮质类固醇Sameassystemiccorticosteroids.Intheory,maysparepatientsfromhyperglycemia,myopathy,superinfection,etc.药物预防FesticE,KorDJ,GajicO.Preventionofacuterespiratorydistresssyndrome[J].Currentopinioni