急性呼吸窘迫综合征机械通气治疗时自主呼吸的调节

doi:10.12372/jcp.2024.22e1286

摘要/Abstract

摘要：

机械通气是急性呼吸窘迫综合征（ARDS）的主要治疗手段。机械通气时适当的保留自主呼吸能促进肺泡复张、改善通气/血流比例及氧合、减轻膈肌萎缩、改善部分器官灌注，但过强的自主呼吸也可能导致跨肺压过高、肺灌注增加，加重肺损伤。在临床实践中，应注意自主呼吸的调节，选择合适的机械通气方案，以实现更好的肺保护性通气策略。本文就调节自主呼吸在ARDS患者机械通气治疗中的作用进行综述。

关键词: 急性呼吸窘迫综合征, 机械通气, 自主呼吸

Abstract:

Mechanical ventilation is the main treatment for acute respiratory distress syndrome (ARDS). Proper spontaneous breathing during mechanical ventilation can promote lung recruitment, improve ventilation/perfusion ratio and oxygenation, reduce diaphragm atrophy and improve organ perfusion. However, strong spontaneous breathing may lead to high transpulmonary pressure and increased pulmonary perfusion, thus aggravating lung injury. To establish a better lung protective ventilation strategy in clinical practice, emphasis should be devoted to the regulation of spontaneous breathing and the suitable mechanical ventilation system should be selected. This article reviews the role of regulating spontaneous breathing in the treatment of mechanical ventilation in ARDS patients.

Key words: acute respiratory distress syndrome, mechanical ventilation, spontaneous breathing

杜芷祎, 孔祥莓, 朱晓东. 急性呼吸窘迫综合征机械通气治疗时自主呼吸的调节[J]. 临床儿科杂志, 2024, 42(4): 355-360.

DU Zhiyi, KONG Xiangmei, ZHU Xiaodong. Spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome[J]. Journal of Clinical Pediatrics, 2024, 42(4): 355-360.

参考文献 41

[1]	杨妮, 刘春峰. 欧洲急性呼吸窘迫综合征的呼吸支持专家意见解读[J]. 中国小儿急救医学, 2019, 26: 423-426.
[2]	唐雨莹, 邱海波, 孙骎. 保留自主呼吸对轻中度急性呼吸窘迫综合征治疗的益处[J]. 中华医学杂志, 2018, 98: 2374-2376.
[3]	van Haren F, Pham T, Brochard L, et al. Spontaneous breathing in early acute respiratory distress syndrome: insights from the large observational study to UNderstand the global impact of severe acute respiratory FailurE study[J]. Crit Care Med, 2019, 47(2): 229-238. doi: 10.1097/CCM.0000000000003519 pmid: 30379668
[4]	Wrigge H, Zinserling J, Neumann P, et al. Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: a randomized controlled computed tomography trial[J]. Crit Care, 2005, 9(6): R780-R789. doi: 10.1186/cc3908
[5]	Wrigge H, Zinserling J, Neumann P, et al. Spontaneous breathing improves lung aeration in oleic acid-induced lung injury[J]. Anesthesiology, 2003, 99(2): 376-384. pmid: 12883410
[6]	Neumann P, Wrigge H, Zinserling J, et al. Spontaneous breathing affects the spatial ventilation and perfusion distribution during mechanical ventilatory support[J]. Crit Care Med, 2005, 33(5): 1090-1095. doi: 10.1097/01.ccm.0000163226.34868.0a pmid: 15891341
[7]	Yoshida T, Uchiyama A, Matsuura N, et al. The comparison of spontaneous breathing and muscle paralysis in two different severities of experimental lung injury[J]. Crit Care Med, 2013, 41(2): 536-545. doi: 10.1097/CCM.0b013e3182711972 pmid: 23263584
[8]	Yoshida T, Roldan R, Beraldo MA, et al. Spontaneous effort during mechanical ventilation: maximal injury with less positive end-expiratory pressure[J]. Crit Care Med, 2016, 44(8): e678-e688. doi: 10.1097/CCM.0000000000001649
[9]	Lalgudi Ganesan S, Jayashree M, Chandra Singhi S, et al. Airway pressure release ventilation in pediatric acute respiratory distress syndrome. A randomized controlled trial[J]. Am J Respir Crit Care Med, 2018, 198(9): 1199-1207. doi: 10.1164/rccm.201705-0989OC
[10]	Shimatani T, Shime N, Nakamura T, et al. Neurally adjusted ventilatory assist mitigates ventilator-induced diaphragm injury in rabbits[J]. Respir Res, 2019, 20(1): 293. doi: 10.1186/s12931-019-1265-x
[11]	Scharffenberg M, Moraes L, Güldner A, et al. Comparative effects of neurally adjusted ventilatory assist and variable pressure support on lung and diaphragmatic function in a model of acute respiratory distress syndrome: a randomised animal study[J]. Eur J Anaesthesiol, 2021, 38(1): 32-40. doi: 10.1097/EJA.0000000000001261
[12]	李文哲, 李建, 于湘友. 急性呼吸窘迫综合征机械通气中的自主呼吸:兴利除弊[J]. 中华重症医学电子杂志(网络版), 2019, 5(2): 99-103.
[13]	Bertoni M, Spadaro S, Goligher EC. Monitoring patient respiratory effort during mechanical ventilation: lung and diaphragm-protective ventilation[J]. Crit Care, 2020, 24(1): 106. doi: 10.1186/s13054-020-2777-y
[14]	Putensen C, Zech S, Wrigge H, et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury[J]. Am J Respir Crit Care Med, 2001, 164(1): 43-49. doi: 10.1164/ajrccm.164.1.2001078
[15]	Hering R, Peters D, Zinserling J, et al. Effects of spontaneous breathing during airway pressure release ventilation on renal perfusion and function in patients with acute lung injury[J]. Intensive Care Med, 2002, 28(10): 1426-1433. doi: 10.1007/s00134-002-1442-z
[16]	Kreyer S, Putensen C, Berg A, et al. Effects of spontaneous breathing during airway pressure release ventilation on cerebral and spinal cord perfusion in experimental acute lung injury[J]. J Neurosurg Anesthesiol, 2010, 22(4): 323-329. doi: 10.1097/ANA.0b013e3181e775f1
[17]	Hering R, Viehöfer A, Zinserling J, et al. Effects of spontaneous breathing during airway pressure release ventilation on intestinal blood flow in experimental lung injury[J]. Anesthesiology, 2003, 99(5): 1137-1144. pmid: 14576551
[18]	任志国, 朱峰. 自戕性肺损伤的机制和防治研究进展[J]. 中华烧伤杂志, 2021, 37: 801-804.
[19]	Carvalho NC, Güldner A, Beda A, et al. Higher levels of spontaneous breathing reduce lung injury in experimental moderate acute respiratory distress syndrome[J]. Crit Care Med, 2014, 42(11): e702-e715. doi: 10.1097/CCM.0000000000000605
[20]	杨睿, 周垒垒, 薛春菊, 等. 自主呼吸在ARDS机械通气中应用的研究进展[J]. 中华危重病急救医学, 2021, 33: 1277-1280.
[21]	吴晓燕, 殷静静, 於江泉, 等. 不同机械通气模式对人机同步性以及膈肌功能影响的实验研究[J]. 中华医学杂志, 2020, 100: 1662-1667.
[22]	Gama de Abreu M, Spieth PM, Pelosi P, et al. Noisy pressure support ventilation: a pilot study on a new assisted ventilation mode in experimental lung injury[J]. Crit Care Med, 2008, 36(3): 818-827. doi: 10.1097/01.CCM.0000299736.55039.3A pmid: 18431269
[23]	杨依依, 姚尚龙, 尚游. 呼吸机相关性肺损伤发病机制研究新进展[J]. 中华危重病急救医学, 2016, 28: 861-864.
[24]	Yoshida T, Uchiyama A, Matsuura N, et al. Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury[J]. Crit Care Med, 2012, 40(5): 1578-1585. doi: 10.1097/CCM.0b013e3182451c40 pmid: 22430241
[25]	Sottile PD, Albers D, Moss MM. Neuromuscular blockade is associated with the attenuation of biomarkers of epithelial and endothelial injury in patients with moderate-to-severe acute respiratory distress syndrome[J]. Crit Care, 2018, 22(1): 63. doi: 10.1186/s13054-018-1974-4
[26]	Kiss T, Bluth T, Braune A, et al. Effects of positive end-expiratory pressure and spontaneous breathing activity on regional lung inflammation in experimental acute respiratory distress syndrome[J]. Crit Care Med, 2019, 47(4): e358-e365. doi: 10.1097/CCM.0000000000003649
[27]	Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome[J]. N Engl J Med, 2010, 363(12): 1107-1116. doi: 10.1056/NEJMoa1005372
[28]	Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure[J]. Am J Respir Crit Care Med, 2017, 195(4): 438-442. doi: 10.1164/rccm.201605-1081CP
[29]	Pohlman MC, Mccallister KE, Schweickert WD, et al. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury[J]. Crit Care Med, 2008, 36(11): 3019-3023. doi: 10.1097/CCM.0b013e31818b308b pmid: 18824913
[30]	Yoshida T, Nakamura MAM, Morais CCA, et al. Reverse triggering causes an injurious inflation pattern during mechanical ventilation[J]. Am J Respir Crit Care Med, 2018, 198(8): 1096-1099. doi: 10.1164/rccm.201804-0649LE
[31]	Chanques G, Constantin JM, Devlin JW, et al. Analgesia and sedation in patients with ARDS[J]. Intensive Care Med, 2020, 46(12): 2342-2356. doi: 10.1007/s00134-020-06307-9 pmid: 33170331
[32]	Xie Y, Cao L, Qian Y, et al. Effect of deep sedation on mechanical power in moderate to severe acute respiratory distress syndrome: a prospective self-control study[J]. Biomed Res Int, 2020: 2729354.
[33]	Wongtangman K, Grabitz SD, Hammer M, et al. Optimal sedation in patients who receive neuromuscular blocking agent infusions for treatment of acute respiratory distress syndrome-a retrospective cohort study from a new England health care network[J]. Crit Care Med, 2021, 49(7): 1137-1148. doi: 10.1097/CCM.0000000000004951 pmid: 33710031
[34]	Wei XB, Wang ZH, Liao XL, et al. Role of neuromuscular blocking agents in acute respiratory distress syndrome: an updated meta-analysis of randomized controlled trials[J]. Front Pharmacol, 2019, 10: 1637. doi: 10.3389/fphar.2019.01637
[35]	Moss M, Huang DT, Brower RG, et al. Early neuro-muscular blockade in the acute respiratory distress syndrome[J]. N Engl J Med, 2019, 380(21): 1997-2008. doi: 10.1056/NEJMoa1901686
[36]	Murray MJ, Deblock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient[J]. Crit Care Med, 2016, 44(11): 2079-2103. pmid: 27755068
[37]	Alhazzani W, Belley-Cote E, Møller MH, et al. Neuromuscular blockade in patients with ARDS: a rapid practice guideline[J]. Intensive Care Med, 2020, 46(11): 1977-1986. doi: 10.1007/s00134-020-06227-8 pmid: 33104824
[38]	中华医学会呼吸病学分会呼吸危重症医学学组. 急性呼吸窘迫综合征患者机械通气指南(试行)[J]. 中华医学杂志, 2016, 96(6): 404-424.
[39]	Mauri T, Langer T, Zanella A, et al. Extremely high transpulmonary pressure in a spontaneously breathing patient with early severe ARDS on ECMO[J]. Intensive Care Med, 2016, 42(12): 2101-2103. doi: 10.1007/s00134-016-4470-9 pmid: 27515163
[40]	Dubo S, Oviedo V, Garcia A, et al. Low spontaneous breathing effort during extracorporeal membrane oxygenation in a porcine model of severe acute respiratory distress syndrome[J]. Anesthesiology, 2020, 133(5): 1106-1117. doi: 10.1097/ALN.0000000000003538
[41]	Langer T, Vecchi V, Belenkiy SM, et al. Extracorporeal gas exchange and spontaneous breathing for the treatment of acute respiratory distress syndrome: an alternative to mechanical ventilation?*[J]. Crit Care Med, 2014, 42(3): e211-e220. doi: 10.1097/CCM.0000000000000121