Banach Marta, Soukup Jens, Bucher Michael, Andres Janusz
Klinik für Anästhesiologie und Operative Intensivmedizin der Martin-Luther-Universität, Halle, Ernst-Grube Str. 40, 06120 Halle.
Anestezjol Intens Ter. 2010 Oct-Dec;42(4):201-5.
The protective lung strategy for severe ARDS, has markedly decreased the associated morbidity and mortality. Sometimes, even the best instrumentation and therapeutic strategy may be insufficient, and extracorporeal gas exchange support is necessary. We describe a desperate case of ARDS, in which various modes of ventilation, combined with vigorous extracorporeal support, resulted in a successful outcome.
A 35-year-old man, a heavy smoker, was admitted to the hospital because of lobar pneumonia. Despite wide spectrum antimicrobial therapy, he developed ARDS and was placed on a ventilator. Standard ventilation was ineffective and veno-venous ECMO was instituted. The extravascular lung water index (EVLWI) was extremely high (over 30 mL kg-1) and signs of a hyperdynamic circulation (CI 6.1 L m-2 min-1) were observed. Modification of the inotropic support and continuous infusion of furosemide resulted in normalisation of the hydration status, and over a week of ECMO therapy, the patient's general condition improved to the stage that he was scheduled to be weaned from extracorporeal treatment. On the 7th day however, he suddenly deteriorated. A lung CT-scan revealed bilateral pneumothoraces and diffuse pulmonary embolism. Three thoracic drains were inserted, but unfortunately, the drainage was complicated by massive bleeding and a subsequent thoracotomy. Two days later, a gastrointestinal haemorrhage occurred. Heparin dosage was reduced, and ECMO was discontinued and replaced with HFOV. This resulted in adequate oxygenation, however because of ineffective CO2 elimination, pumpless arteriovenous extracorporeal lung assist (PECLA) was instituted, allowing conventional ventilation to be resumed after 8 days. The further clinical course was complicated by persistent bilateral pneumothoraces, pleural effusion and Pseudomonas nosocomial infection. The man eventually recovered after 54 days in the ICU, and was transferred to a rehabilitation department.
ECMO has been recommended for severe ARDS since it avoids overdistension of the lungs and the use of high oxygen concentrations. Early institution of ECMO decreases mortality and morbidity in rapidly progressing ARDS. In the described case, ECMO was probably started too late, after volutrauma has already occurred. A combination of HFOV and PECLA may be recommended in selected cases, in which CO2 retention poses a serious problem.
针对重症急性呼吸窘迫综合征（ARDS）的肺保护策略已显著降低了相关的发病率和死亡率。有时，即便采用最佳的仪器设备和治疗策略仍可能不足，此时体外气体交换支持就很有必要。我们描述了一例危急的ARDS病例，在该病例中，多种通气模式与积极的体外支持相结合，最终取得了成功的治疗结果。
一名35岁男性，重度吸烟者，因大叶性肺炎入院。尽管接受了广谱抗菌治疗，他仍发展为ARDS并接受了机械通气。标准通气无效后启动了静脉-静脉体外膜肺氧合（ECMO）。血管外肺水指数（EVLWI）极高（超过30 mL·kg-1），并观察到高动力循环体征（心脏指数6.1 L·m-2·min-1）。调整血管活性药物支持并持续输注呋塞米使水化状态恢复正常，经过一周多的ECMO治疗，患者的一般状况改善到了计划撤离体外治疗的阶段。然而，在第7天，他突然病情恶化。肺部CT扫描显示双侧气胸和弥漫性肺栓塞。插入了三根胸腔引流管，但不幸的是，引流过程中出现大量出血并随后进行了开胸手术。两天后，发生了胃肠道出血。减少肝素剂量，停用ECMO并改用高频振荡通气（HFOV）。这实现了充分的氧合，但由于二氧化碳清除无效，启动了无泵动静脉体外肺辅助（PECLA），8天后得以恢复传统通气。后续临床过程因持续的双侧气胸、胸腔积液和医院内假单胞菌感染而复杂化。该男子最终在重症监护病房（ICU）住了54天后康复，并被转至康复科。
ECMO已被推荐用于重症ARDS，因为它可避免肺过度扩张和高氧浓度的使用。早期启动ECMO可降低快速进展性ARDS的死亡率和发病率。在所描述的病例中，ECMO可能启动得太晚，此时容积伤已经发生。对于二氧化碳潴留成为严重问题的特定病例，可推荐联合使用HFOV和PECLA。
