Hraiech Sami, Yoshida Takeshi, Papazian Laurent
aAssistance Publique - Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères bAix-Marseille Université, Faculté de Médecine, Marseille, France cDepartment of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
Curr Opin Crit Care. 2015 Feb;21(1):26-33. doi: 10.1097/MCC.0000000000000175.
Acute respiratory distress syndrome (ARDS) is still associated with a high mortality. The best way to ensure mechanical ventilation in ARDS patients is still debated, recent data arguing for a muscle paralysis and a controlled ventilation whereas other elements being in favor of a preserved spontaneous breathing. The purpose of this review is to discuss the benefits and the disadvantages of both strategies.
Randomized controlled trials have brought the evidence that at the acute phase of ARDS, a 48-h administration of cisatracurium is associated with a decrease in mortality for the most severe hypoxemic patients. Other studies suggest that spontaneous breathing could be deleterious at this period. In the less severe patients (mild ARDS), however, a few studies have demonstrated the benefits of preserving spontaneous breathing with an improvement in oxygenation and a decrease in the length of mechanical ventilation.
In ARDS patients, the ventilator strategy should be a balance between muscle paralysis in the most hypoxemic patients and preserved spontaneous breathing after improvement or from the acute phase in less severe forms. However, monitoring plateau pressure, tidal volume and perhaps also transpulmonary pressure seems crucial to limit the occurrence of ventilator-induced lung injury.
急性呼吸窘迫综合征（ARDS）的死亡率仍然很高。对于ARDS患者，确保机械通气的最佳方式仍存在争议，近期数据支持肌肉松弛和控制通气，而其他因素则支持保留自主呼吸。本综述的目的是讨论这两种策略的利弊。
随机对照试验已证实，在ARDS急性期，对于最严重的低氧血症患者，给予48小时的顺式阿曲库铵与死亡率降低相关。其他研究表明，在此期间自主呼吸可能有害。然而，在病情较轻的患者（轻度ARDS）中，一些研究已证明保留自主呼吸可改善氧合并缩短机械通气时间。
对于ARDS患者，通气策略应在最严重低氧血症患者的肌肉松弛与病情改善后或病情较轻类型的急性期保留自主呼吸之间取得平衡。然而，监测平台压、潮气量以及可能的跨肺压对于限制呼吸机诱发的肺损伤的发生似乎至关重要。
