- 期刊
急性呼吸窘迫症候群之前哨戰－肺泡動員術之臨床應用
The Outpost of Acute Respiratory Distress Syndrome-Clinical Applications of Lung Recruitment Maneuvers
摘要
急性呼吸窘迫症候群(acute respiratory distress syndrome, ARDS)－爲一種常見且致命的情況，幾乎每個加護病房都會遇到。臨床特徵爲呼吸困難、頑固性低血氧、肺順應性變差以及胸部X光呈現兩側瀰漫性浸潤陰影。一個廣爲接受的策略，使用較低的潮氣量及較大的吐氣末陽壓(positive end-expiratory pressure, PEEP)對急性呼吸窘迫症候群病患的治療較爲有利。因此，“肺泡動員術(lung recruitment maneuver, RM)”對急性呼吸窘迫症候群的治療就相形地特別重要。肺泡動員術可以打開塌陷的肺泡及防止肺泡萎縮，進而改善氧合作用和分流現象。此外，尚可藉由減少肺泡反覆開關，達成換氣功能及避免呼吸器導致之肺損傷(ventilator-induced lung injury, VILI)的產生。儘管如此，這樣的處理在很多情況下還是不太足夠；不論對使用肺泡動員術(lung recruitment maneuver, RM)的抉擇或合宜的用法、時機、和病患選擇應更明確，希冀有效預防呼吸器導致之肺損傷所延伸出其他棘手的問題。然而，在大多數情況下對個別病患而言，相同的設定卻會導致不同的結果，每個病患的安全範圍不盡相同。爲了使肺泡動員術在急性呼吸窘迫症候群患者使用上更精準，有必要界定一個標準的操作方法。過去精確計算出”Optimal PEEP”被認爲是臨床使用肺泡動員術時最難以克服的問題之一。如此，如何針對每個病患達到最理想之設定，正考驗著呼吸治療師。本文藉由文獻查證及回顧，來探討急性呼吸窘迫症候群病理生理學及肺泡動員術之臨床運用來克服執行肺泡動員術的困境。
並列摘要
Acute respiratory distress syndrome (ARDS) is a common, life-threatening condition encountered in all intensive care units (ICUS). Clinically, it is characterized by dyspnea, refractory hypoxemia, decreased lung compliance, and bilateral diffuse pulmonary infiltrates. Increasing evidence now suggests that lung recruitment maneuver (RM) with a sustained increase in airway pressure can improve the gas exchange function. Improvement of the gas exchange function occurs when the collapsed alveoli open, after which sufficient positive end-expiratory pressure (PEEP) is applied to avoid de-recruitment and prevent cyclic end-expiratory alveolar collapse in the injured lung. The variety of treatment outcomes in patients with ARDS indicated that the ”optimal peep,” defined as the lowest PEEP at which tissue oxygen delivery is maximized and the most alveoli are recruited, is patient specific. It is important to set up a criterion for a standard protocol to better determine the optimal PEEP level and the appropriate treatment procedure of lung recruitment maneuver in patients with ARDS. Herein we review the current understanding of the pathophysiology and management of ARDS, and the experimental, clinical, and technical aspects of recruitment maneuvers.