鄒燕 12 , 李幼平 13 , 楊小東 4 , 盧軍 2 , 杜亮 2 , 陳霖 2
  • 1. 衛(wèi)生部中國(guó)循證醫(yī)學(xué)中心2. 四川大學(xué)華西臨床醫(yī)學(xué)院3. 四川大學(xué)華西醫(yī)院衛(wèi)生部移植工程和移植免疫重點(diǎn)實(shí)驗(yàn)室4. 四川大學(xué)華西醫(yī)院;

目的 　12.9%-50%的SARS病人需要短暫的機(jī)械通氣挽救生命.現(xiàn)已公布的治療原則和指南基于SARS治療經(jīng)驗(yàn)和不很完全的事實(shí),尚無(wú)前瞻性隨機(jī)對(duì)照臨床試驗(yàn)和其它高質(zhì)量證據(jù).通過(guò)對(duì)全世界有關(guān)機(jī)械通氣的臨床指南.系統(tǒng)評(píng)價(jià)、Meta分析、經(jīng)濟(jì)學(xué)評(píng)價(jià)和嚴(yán)重不良反應(yīng)的回顧性總結(jié)和分析,輔以SARS搶救資料,尋求安全、合理的非藥物干預(yù).
方法 　檢索MEDLINE,Cochrane圖書館,根據(jù)納入和排除標(biāo)準(zhǔn)確定納入的文獻(xiàn),進(jìn)行文獻(xiàn)質(zhì)量評(píng)價(jià)和數(shù)據(jù)提取至少2遍,無(wú)異質(zhì)性的文獻(xiàn)作Meta分析.
結(jié)果 　納入14篇,由于納入的文獻(xiàn)間異質(zhì)性明顯,無(wú)法進(jìn)一步作Meta分析,只對(duì)原作者的結(jié)論作描述性分析.
結(jié)論 　PPV的通氣模式優(yōu)于VPV,PPV者死亡率更低.但要注意容積傷,采用低潮氣量和適當(dāng)?shù)腜EEP,降低FiO2,允許高碳酸血癥可能降低死亡率和縮短住院時(shí)間.無(wú)創(chuàng)機(jī)械通氣(N1MV)對(duì)血流動(dòng)力學(xué)穩(wěn)定和有自主呼吸的病人有效,且減少副作用和醫(yī)務(wù)人員感染;但嚴(yán)重呼吸困難、PaO2/FiO2＜200、無(wú)創(chuàng)通氣效果不佳或病人不能耐受者需要?dú)夤懿骞芡?采用俯臥位可明顯改善動(dòng)脈血PaO2/FiO2.NO可提高肺血流量,改善肺V/Q比值和提高血氧,且間斷吸入更好.有證據(jù)表明按計(jì)劃撤機(jī)比按醫(yī)生經(jīng)驗(yàn)撤機(jī)好.

引用本文： 鄒燕,李幼平,楊小東,盧軍,杜亮,陳霖. 急性肺損傷和急性呼吸窘迫征(ARDS)非藥物治療的衛(wèi)生技術(shù)評(píng)估(一). 中國(guó)循證醫(yī)學(xué)雜志, 2003, 03(2): 128-134. doi: 復(fù)制

1. ［1］Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratorydistressinadults[J]. Lancet 1967 ;2(7511):319 23.1.
2. ［2］Freund A, Jorch G. Pediatric characteristics of adult respiratory dist ress syndrome: a meta - analysis [ J ]. Klin Padiat r 1993 Nov-Dec;205(6):411-5.
3. ［3］Bryan At. Cormments of a devil’s advocate [J ]. Am Rev Respir Dis. 1974;110: 143- 144.
4. ［4］Extracorporeal lung assist with heparin- coated systems. RossaintR, Slama K, Lewandowski K, Streich R, Henin P, Hopfe’I ,Barth H, Nienhaus M, Weidemann H, Lemmens P, et al [J ]. IntJ Artif Organs. 1992 Jan; 15( 1 ) :29 - 34.
5. ［5］Krafft P, Fridrich P, Pernerstorfer T, et al. The acute respiriratory distress syndrome: definitions, severity and clinical outcome.An analysis of 101 clinical investigations [J]. Intensive Care Med1996 Jun;22(6) :519 - 29.
6. ［6］Barrington KJ, Finer NN. Inhaled nitric oxide for respiratory fail ure in preterm infants(Cochrane Review). In: Cochrane Library. Issue 1. Oxford, Update Software; 2003.
7. ［7］Sokol J, Jacobs SE, Bohn D. Inhaled nitric oxide for acute hypoxemic respiratory failure in children and adults(Cochrane Review).In: Cochrane Library. Issue 1. Oxford, Update Software; 2003.
8. ［8］Cuthbertson BH, Dellinger P, Dyar OJ, et al. UK guidelines forthe use of inhaled nitric oxide therapy in adult ICUs. American European Consensus Conference on ALI/ARDS [J]. Intensive Care Med 1997 Dec;23(12):1212-8.
9. ［9］Mourgeon E, Gallart L, Rao GS, et al. Distribution of inhaled nitric oxide during sequential and continuous administration into the inspiratory limb of the ventilator [J]. Intensive Care Med 1997;23(8) :849 - 58.
10. ［10］Ball C, Adams J, Boyce S, et al. Clinical guidelines for the use ofthe prone position in acute respiratory distress syndrome [J]. Intensive Crit Care Nurs 2001 Apr; 17(2):94- 104.
11. ［11］Curley MA. Prone positioning of patients with acute respiratory distress syndrome: a systematic review [J ]. Am J Crit Care 1999 Nov;8(6) :397 - 405.
12. ［12］Steltzer H, Hiesmayr M, Mayer N, et al. The relationship be tween oxygen delivery and uptake in the critically ill: is there a critical or optimal therapeutic value? A meta- analysis [J].Anaesthesia 1994 Mar;49(3) :229-36.
13. ［13］Bidani A, Tzouanakis AE, Cardenas VJ Jr, et al. JB. Permissivehypercapnia in acute respiratory failure [J ]. JAMA 1994 Sep 28;272( 12):957 - 62.
14. ［14］Kollef MH, Shapiro SD, Silver P, et al. A randomized, con trolled trial of protocol - directed versus physician - directed weaning from mechanical ventilation [J]. Crit Care Med 1997Apr;25(4) :567 - 74.
15. ［15］Hamel MB, Phillips RS, Davis RB, et al. Outcomes and cost effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respirato ry distress syndrome [ J ]. Am J Med 2000 Dec 1; 109 ( 8): 614 - 20.
16. ［16］Brook AD, Sherman G, Malen J, et al. Early versus late tra cheostomy in patients who require prolonged mechanical ventila tion [J]. Am J Crit Care 2000 Sep;9(5):352 -9.
17. ［17］Armstrong PA, McCarthy MC, Peoples JB. Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma [J]. Surgery 1998 Oct; 124(4):763 - 6.
18. ［18］中國(guó)醫(yī)學(xué)論壇報(bào), 3003. 4. 24.
19. ［19］Rappaport SH, Shpiner R, Yoshihara G, Wright J, Chang P, Abraham E Randomized, prospective trial of pressure- limited versus volume-controlled ventilation in severe respiratory failure [J]. Crit Care Med. 1994; 22(11): 1888-9.
20. ［20］俞森洋.主編.現(xiàn)代機(jī)械通氣的理論和實(shí)踐[J].第一版.北京: 中國(guó)協(xié)和醫(yī)科大學(xué)出版社,2000:854-65.
21. ［21］Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome [J]. Eur Respir J 2002;20(4):1017-28.
22. ［22］俞森洋.主編.現(xiàn)代機(jī)械通氣的監(jiān)護(hù)和臨床應(yīng)用[M]第一版北京:中國(guó)協(xié)和醫(yī)科大學(xué)出版社,2000:420-31.
23. ［23］urchardi H, Sydow M. Artificial ventilation: some unresolvedproblems [J]. EurJ Anaesthesiol 1994 Jan;11(1):53-63.
24. ［24］So LK, Lau AC, Yam LY, Cheung TM, Poon E, Yung RW, Yuen KY. Development of a standard treatment protocol for severe acute respiratory syndrome [J]. Lancet 2003 10; 361 (9369):1615-7.
25. ［25］Booth CM, Matukas LM, Tomlinson GA, Clinical Features and Short-term Outcomes of 144 Patients With SARS in the Greater Toronto Area [J]. JAMA 2003 May 6.
26. ［26］Poutanen SM, Low DE, Henry B, Finkelstein S, et al. ldenlification of severe acute respiratory syndrome in Canada [J ]. N En gl J Med 2003 May 15;348(20):1995 - 2005.
27. ［27］Cheung MT, Yam LY, Lau CW, Ching CK, Lee CH. Use ofnon- invasive positive-pressure ventilation for acute respiratoryfailure: prospective study [J]. Hong Kong Med J 2000; 6(4):361-7.
28. ［28］28 S Krall SP, Zubrow MT, Silverman ME. uccess in using non - invasive mechanical ventilation is predicted by patient patho physiology. A retrospective review of 199 patients [J]. Del Med J. 1999; 71(5):213 -20.
29. ［29］Teba L, Marks P, Benzo R. Non - invasive mechanieal ventila tion: the benefits of the BiPAP system [J]. W V Med J. 1996;92(1):18- 21.
30. ［30］Mollica C, Brunetti G, Buseajoni M, et al. Non-invasive pressure support ventilation in acute hypoxemic (non hypercapnie) respiratory failure. Observations in Respiratory Intemediate In tensive Care Unit [J]. Minerva Anestesiol 2001 ; 67(3): 107-15.
31. ［31］Gregoretti C, Confalonieri M, Navalesi P, et al. Evaluation of patient skin breakdown and comfort with a new face mask fornon- invasive ventilation: a multi- center study [J]. Intensive Care Med. 2002;28(3) :278 - 84.
32. ［32］Khilnani GC, Bhatta N. Non- invasive ventilation: current status [J]. Natl Med J India 2002 Sep- Oct; 15(5):269-74.
33. ［33］Hoffman LA, Miro AM, Tasota FJ, Delgado E, Zullo TG, Lutz J, Pinsky MR. Tracheal gas insufflation, Limits of efficacy inadults with acute respiratory distress syndrome [J ]. Am J Respir Crit Care Med 2000 Aug; 162(2 Pt 1 ): 387 - 92.
34. ［34］Lewandowski K, Weimann J. Can lung protective ventilationmethods modify outcome [J ]? - A critical review Anaesthesiol Reanim 2002;27(5):124-30.
35. ［35］Houston P. An approach to ventilation in acute respiratory dis tress syndrome [J]. Can J Surg 2000 Aug;43(4):263-8.
36. ［36］Lee KH, Lim TK. Ventilatory strategies for acute respiratory distress syndrome [J]. Ann Acad Med Singapore 1998 May; 27(3) :409 - 13.
  1. 1. ［1］Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratorydistressinadults[J]. Lancet 1967 ;2(7511):319 23.1.
  2. 2. ［2］Freund A, Jorch G. Pediatric characteristics of adult respiratory dist ress syndrome: a meta - analysis [ J ]. Klin Padiat r 1993 Nov-Dec;205(6):411-5.
  3. 3. ［3］Bryan At. Cormments of a devil’s advocate [J ]. Am Rev Respir Dis. 1974;110: 143- 144.
  4. 4. ［4］Extracorporeal lung assist with heparin- coated systems. RossaintR, Slama K, Lewandowski K, Streich R, Henin P, Hopfe’I ,Barth H, Nienhaus M, Weidemann H, Lemmens P, et al [J ]. IntJ Artif Organs. 1992 Jan; 15( 1 ) :29 - 34.
  5. 5. ［5］Krafft P, Fridrich P, Pernerstorfer T, et al. The acute respiriratory distress syndrome: definitions, severity and clinical outcome.An analysis of 101 clinical investigations [J]. Intensive Care Med1996 Jun;22(6) :519 - 29.
  6. 6. ［6］Barrington KJ, Finer NN. Inhaled nitric oxide for respiratory fail ure in preterm infants(Cochrane Review). In: Cochrane Library. Issue 1. Oxford, Update Software; 2003.
  7. 7. ［7］Sokol J, Jacobs SE, Bohn D. Inhaled nitric oxide for acute hypoxemic respiratory failure in children and adults(Cochrane Review).In: Cochrane Library. Issue 1. Oxford, Update Software; 2003.
  8. 8. ［8］Cuthbertson BH, Dellinger P, Dyar OJ, et al. UK guidelines forthe use of inhaled nitric oxide therapy in adult ICUs. American European Consensus Conference on ALI/ARDS [J]. Intensive Care Med 1997 Dec;23(12):1212-8.
  9. 9. ［9］Mourgeon E, Gallart L, Rao GS, et al. Distribution of inhaled nitric oxide during sequential and continuous administration into the inspiratory limb of the ventilator [J]. Intensive Care Med 1997;23(8) :849 - 58.
  10. 10. ［10］Ball C, Adams J, Boyce S, et al. Clinical guidelines for the use ofthe prone position in acute respiratory distress syndrome [J]. Intensive Crit Care Nurs 2001 Apr; 17(2):94- 104.
  11. 11. ［11］Curley MA. Prone positioning of patients with acute respiratory distress syndrome: a systematic review [J ]. Am J Crit Care 1999 Nov;8(6) :397 - 405.
  12. 12. ［12］Steltzer H, Hiesmayr M, Mayer N, et al. The relationship be tween oxygen delivery and uptake in the critically ill: is there a critical or optimal therapeutic value? A meta- analysis [J].Anaesthesia 1994 Mar;49(3) :229-36.
  13. 13. ［13］Bidani A, Tzouanakis AE, Cardenas VJ Jr, et al. JB. Permissivehypercapnia in acute respiratory failure [J ]. JAMA 1994 Sep 28;272( 12):957 - 62.
  14. 14. ［14］Kollef MH, Shapiro SD, Silver P, et al. A randomized, con trolled trial of protocol - directed versus physician - directed weaning from mechanical ventilation [J]. Crit Care Med 1997Apr;25(4) :567 - 74.
  15. 15. ［15］Hamel MB, Phillips RS, Davis RB, et al. Outcomes and cost effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respirato ry distress syndrome [ J ]. Am J Med 2000 Dec 1; 109 ( 8): 614 - 20.
  16. 16. ［16］Brook AD, Sherman G, Malen J, et al. Early versus late tra cheostomy in patients who require prolonged mechanical ventila tion [J]. Am J Crit Care 2000 Sep;9(5):352 -9.
  17. 17. ［17］Armstrong PA, McCarthy MC, Peoples JB. Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma [J]. Surgery 1998 Oct; 124(4):763 - 6.
  18. 18. ［18］中國(guó)醫(yī)學(xué)論壇報(bào), 3003. 4. 24.
  19. 19. ［19］Rappaport SH, Shpiner R, Yoshihara G, Wright J, Chang P, Abraham E Randomized, prospective trial of pressure- limited versus volume-controlled ventilation in severe respiratory failure [J]. Crit Care Med. 1994; 22(11): 1888-9.
  20. 20. ［20］俞森洋.主編.現(xiàn)代機(jī)械通氣的理論和實(shí)踐[J].第一版.北京: 中國(guó)協(xié)和醫(yī)科大學(xué)出版社,2000:854-65.
  21. 21. ［21］Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome [J]. Eur Respir J 2002;20(4):1017-28.
  22. 22. ［22］俞森洋.主編.現(xiàn)代機(jī)械通氣的監(jiān)護(hù)和臨床應(yīng)用[M]第一版北京:中國(guó)協(xié)和醫(yī)科大學(xué)出版社,2000:420-31.
  23. 23. ［23］urchardi H, Sydow M. Artificial ventilation: some unresolvedproblems [J]. EurJ Anaesthesiol 1994 Jan;11(1):53-63.
  24. 24. ［24］So LK, Lau AC, Yam LY, Cheung TM, Poon E, Yung RW, Yuen KY. Development of a standard treatment protocol for severe acute respiratory syndrome [J]. Lancet 2003 10; 361 (9369):1615-7.
  25. 25. ［25］Booth CM, Matukas LM, Tomlinson GA, Clinical Features and Short-term Outcomes of 144 Patients With SARS in the Greater Toronto Area [J]. JAMA 2003 May 6.
  26. 26. ［26］Poutanen SM, Low DE, Henry B, Finkelstein S, et al. ldenlification of severe acute respiratory syndrome in Canada [J ]. N En gl J Med 2003 May 15;348(20):1995 - 2005.
  27. 27. ［27］Cheung MT, Yam LY, Lau CW, Ching CK, Lee CH. Use ofnon- invasive positive-pressure ventilation for acute respiratoryfailure: prospective study [J]. Hong Kong Med J 2000; 6(4):361-7.
  28. 28. ［28］28 S Krall SP, Zubrow MT, Silverman ME. uccess in using non - invasive mechanical ventilation is predicted by patient patho physiology. A retrospective review of 199 patients [J]. Del Med J. 1999; 71(5):213 -20.
  29. 29. ［29］Teba L, Marks P, Benzo R. Non - invasive mechanieal ventila tion: the benefits of the BiPAP system [J]. W V Med J. 1996;92(1):18- 21.
  30. 30. ［30］Mollica C, Brunetti G, Buseajoni M, et al. Non-invasive pressure support ventilation in acute hypoxemic (non hypercapnie) respiratory failure. Observations in Respiratory Intemediate In tensive Care Unit [J]. Minerva Anestesiol 2001 ; 67(3): 107-15.
  31. 31. ［31］Gregoretti C, Confalonieri M, Navalesi P, et al. Evaluation of patient skin breakdown and comfort with a new face mask fornon- invasive ventilation: a multi- center study [J]. Intensive Care Med. 2002;28(3) :278 - 84.
  32. 32. ［32］Khilnani GC, Bhatta N. Non- invasive ventilation: current status [J]. Natl Med J India 2002 Sep- Oct; 15(5):269-74.
  33. 33. ［33］Hoffman LA, Miro AM, Tasota FJ, Delgado E, Zullo TG, Lutz J, Pinsky MR. Tracheal gas insufflation, Limits of efficacy inadults with acute respiratory distress syndrome [J ]. Am J Respir Crit Care Med 2000 Aug; 162(2 Pt 1 ): 387 - 92.
  34. 34. ［34］Lewandowski K, Weimann J. Can lung protective ventilationmethods modify outcome [J ]? - A critical review Anaesthesiol Reanim 2002;27(5):124-30.
  35. 35. ［35］Houston P. An approach to ventilation in acute respiratory dis tress syndrome [J]. Can J Surg 2000 Aug;43(4):263-8.
  36. 36. ［36］Lee KH, Lim TK. Ventilatory strategies for acute respiratory distress syndrome [J]. Ann Acad Med Singapore 1998 May; 27(3) :409 - 13.