Ten Irina S, Anderson Michael R
Division of Pediatric Pharmacology and Critical Care, Rainbow Babies and Children's Hospital, Case School of Medicine, 11100 Euclid Avenue Cleveland, OH 44106, USA.
Respir Care Clin N Am. 2006 Sep;12(3):437-51. doi: 10.1016/j.rcc.2006.05.004.
The ventilator goals of the ICU clinician faced with caring for a critically ill child who has ALI/ARDS remain relatively simple: provide adequate ventilation and oxygenation without overdistending alveoli or furthering lung injury. How one obtains these goals is much less simple. The current use of CV calls for the use of relatively low V(T)s and limiting peak inspiratory pressure and plateau pressure while accepting a certain degree of respiratory acidosis. The ICU team can also often achieve these same goals with HFOV. How, then, does one use evidenced-based medicine to pick the best mode of mechanical ventilation for a particular patient? The answer is controversial, to say the least. Does one start with a gentle, open-lung mode of CV then switch to HFOV if the child deteriorates? Or does one use HFOV from the very early stages of ALI? Animal data appear to point to advantages of HFOV when used early in the course of ALI. Most of these studies report a beneficial effect of HFOV when applied on expanded lungs in the early stages of the disease process. These beneficial effects encompass improved gas exchange, oxygenation, lung tissue morphology and pulmonary mechanics. The studies by Arnold and colleagues in the pediatric population also help to answer our questions. In their work, the early initiation of HFOV was associated with improved gas exchange and a trend toward a lower mortality. In adults, Derdak and colleagues demonstrated the superiority of HFOV in terms of gas exchange and oxygenation; however, no statistical significant difference was found for mortality. So, where is the clinician left after a review of these data? It would appear that (1) low-V(T) CV remains a cornerstone of therapy for the pediatric patient who has ALI/ARDS; (2) HFOV is a safe and well-tolerated mode of mechanical ventilation; (3) early use of HFOV (as opposed to the rescue use of this mode) may be of benefit based on animal and human data; and (4) like so many areas of pediatric critical care, clinicians must await new data and trials that will help them continue to improve the care they provide.
对于负责护理患有急性肺损伤/急性呼吸窘迫综合征（ALI/ARDS）危重症患儿的重症监护病房（ICU）医生来说，呼吸机治疗目标相对简单：提供足够的通气和氧合，同时避免肺泡过度扩张或加重肺损伤。但如何实现这些目标就复杂得多了。目前使用容量控制通气（CV）要求使用相对较低的潮气量（V(T)s），限制吸气峰压和平台压，同时接受一定程度的呼吸性酸中毒。ICU团队通常也可以通过高频振荡通气（HFOV）实现同样的目标。那么，如何运用循证医学为特定患者选择最佳的机械通气模式呢？至少可以说，答案存在争议。是先采用温和的开放肺模式的CV，如果患儿病情恶化再切换到HFOV？还是在ALI的早期阶段就使用HFOV？动物实验数据似乎表明在ALI病程早期使用HFOV有优势。这些研究大多报告了在疾病进程早期对扩张肺应用HFOV的有益效果。这些有益效果包括改善气体交换、氧合、肺组织形态和肺力学。阿诺德及其同事在儿科人群中的研究也有助于回答我们的问题。在他们的研究中，早期启动HFOV与改善气体交换以及死亡率降低趋势相关。在成人中，德尔达克及其同事证明了HFOV在气体交换和氧合方面的优越性；然而，在死亡率方面未发现统计学显著差异。那么，临床医生在审视这些数据后该何去何从呢？似乎（1）低V(T)的CV仍然是患有ALI/ARDS儿科患者治疗的基石；（2）HFOV是一种安全且耐受性良好的机械通气模式；（3）基于动物和人体数据，早期使用HFOV（而非该模式的挽救性使用）可能有益；（4）与儿科重症监护的许多领域一样，临床医生必须等待新的数据和试验，以帮助他们持续改善所提供的护理。
