急性呼吸窘迫症候群（ARDS）使用俯臥式通氣模式（Prone positioning）之預後影響因子探討

Factors Associated with Survival in Patients Received Prone positioning for Acute Respiratory Distress Syndrome (ARDS)

李柏昕(Po-Hsin Lee) ； 王振宇(Chen-Yu Wang) ； 黃彥翔(Yen-Hsiang Huang) ； 李博仁(Bor-Jen Lee) ； 傅彬貴(Pin-Kuei Fu)

《內科學誌》 30卷2期 (2019/04) Pp. 96-106

https://doi.org/10.6314/JIMT.201904_30(2).06

摘要

急性呼吸窘迫症候群（Acute Respiratory Distress Syndrome，簡稱ARDS），死亡率高且不易治療，直到2000年低潮氣容積通氣的觀念引入後才讓死亡率略為下降，而使用俯臥通氣模式（Prone Positioning，簡稱PP）則是另一個改善ARDS預後的重要突破。經過10幾年多篇隨機對照試驗以及系統性回顧，證實於嚴重程度較高之ARDS病患，及早接受PP、延長每日使用PP的時間，且合併保護性換氣策略之呼吸器設定，三者兼具才能下降病患之死亡率。然而ARDS病患彼此異質性高，因此對於使用PP之反應不盡相同。本文目的有二，首先綜合整理PP於ARDS應用的生理機轉及常見併發症；其次，從「醫療決策操作因素」及「病患本身因素」兩個面向，綜合整理近20年來相關原著及系統性分析文獻，以探討影響PP於ARDS應用之預後因子。結果顯示使用PP反應較佳的因子為「肺外因素造成之ARDS」、「BMI≥30kg／m^2」及「ARDS合併心臟肥大」；使用PP預後較不佳的因子為「疾病綜合嚴重度高」、「驅使壓力（driving pressure）高」及「肺纖維化」。

關鍵字

急性呼吸窘迫症候群（Acute respiratory distress syndrome，ARDS） ； 俯臥通氣模式（Prone positioning，PP） ； 保護性通氣策略（Lung protective strategy，LPS） ； PaO_2／FiO_2比例（PFR） ； 通氣和血液灌注比例（Ventilation-perfusion ratio，V／Q）

並列摘要

The mortality rate of acute respiratory distress syndrome (ARDS) remains high. Not until the concept of ventilation with lower tidal volumes was introduced in 2000 did the mortality rate lower by 8.8%. Prone positioning (PP) is another important management in reducing mortality rates in patients with ARDS. Based on numerous randomized controlled trials and systemic review literatures, prone positioning combined with applying early prone positioning, prolonging prone positioning and lung protective ventilatory strategies reduces the mortality in patients with more severe ARDS. High heterogeneity of ARDS patients results in different responses to prone positioning treatment. We aim to summary the pathophysiology of applying PP in ARDS firstly and to identify factors associated with survival benefits in ARDS patients that treated with PP. We conclude that the good predicting factors are extrapulmonary ARDS, BMI≥30 kg/m2, and ARDS with cardiomegaly. Besides, high APACHE II score, high driving pressure, and underlying interstitial lung disease indicate poor prognosis.