Serpa Neto Ary, Simonis Fabienne D, Schultz Marcus J
aDepartment of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil bDepartment of Intensive Care cLaboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands.
Curr Opin Crit Care. 2015 Feb;21(1):65-73. doi: 10.1097/MCC.0000000000000165.
There is convincing evidence for benefit from lung-protective mechanical ventilation with lower tidal volumes in patients with the acute respiratory distress syndrome (ARDS). It is uncertain whether this strategy benefits critically ill patients without ARDS also. The present article summarizes the background and clinical evidence for ventilator settings that have the potential to protect against ventilator-induced lung injury.
There has been a paradigm shift from treating ARDS to preventing ARDS. In surgical patients, anesthesiologists should consider ventilating patients with a tidal volume of 6-8 ml/kg predicted body weight (PBW), levels of positive end-expiratory pressure (PEEP) between 0 and 2 cmH(2)O, and higher levels of FiO(2). Finally, in critically ill patients without ARDS, intensive care physicians could consider ventilating with a PEEP level of 5 cmH(2)O and lower levels of FiO(2). There is insufficient evidence for the benefit of lower tidal volumes in these patients. There is, however, some evidence that tidal volumes of 6 ml/kg PBW or less are associated with better outcomes.
There is increasing and convincing evidence that the use of lower tidal volumes during mechanical ventilation of patients without ARDS prevents against ventilator-induced lung injury.
有令人信服的证据表明，急性呼吸窘迫综合征（ARDS）患者采用低潮气量的肺保护性机械通气有益。目前尚不确定该策略对无ARDS的重症患者是否也有益。本文总结了有可能预防呼吸机诱导性肺损伤的呼吸机设置的背景和临床证据。
从治疗ARDS到预防ARDS已经发生了范式转变。对于外科手术患者，麻醉医生应考虑采用6-8 ml/kg预计体重（PBW）的潮气量、0至2 cmH₂O的呼气末正压（PEEP）水平以及较高的吸入氧浓度（FiO₂）对患者进行通气。最后，对于无ARDS的重症患者，重症监护医生可考虑采用5 cmH₂O的PEEP水平和较低的FiO₂水平进行通气。在这些患者中，尚无足够证据证明低潮气量有益。然而，有一些证据表明，6 ml/kg PBW或更低的潮气量与更好的预后相关。
越来越多令人信服的证据表明，在无ARDS患者的机械通气过程中采用较低潮气量可预防呼吸机诱导性肺损伤。
