Koulouras Vasilios, Papathanakos Georgios, Papathanasiou Athanasios, Nakos Georgios
Vasilios Koulouras, Georgios Papathanakos, Athanasios Papathanasiou, Georgios Nakos, Intensive Care Unit, University Hospital of Ioannina, 45500 Ioannina, Greece.
World J Crit Care Med. 2016 May 4;5(2):121-36. doi: 10.5492/wjccm.v5.i2.121.
Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the "sponge lung" - and the "shape matching" -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients' response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.
急性呼吸窘迫综合征（ARDS）是一种潜在病理过程具有异质性的综合征。它是重症监护病房患者常见的临床问题，其特点是死亡率高。ARDS的主要治疗方法是采用低潮气量和足以实现肺泡复张的呼气末正压进行肺保护性通气。俯卧位是治疗ARDS患者的一种辅助策略。它于40年前首次被描述，事实证明它与ARDS的两种主要病理生理肺模型相符，即“海绵肺”模型和“形状匹配”模型。目前的证据有力地支持俯卧位对气体交换、呼吸力学、肺保护和血流动力学有益，因为它能在整个肺内重新分布跨肺压、压力和应变，并减轻右心室负荷。单独影响俯卧位期间肺泡复张时间进程和氧合改善的因素尚未得到很好的描述。尽管患者对俯卧位的反应差异很大且难以预测，但大型随机试验和近期的荟萃分析表明，俯卧位与肺保护策略相结合，在早期且持续足够时间进行时，可能会提高ARDS患者的生存率。这篇基于病理生理学的综述和近期的临床证据有力地支持在重症ARDS的早期管理中系统地使用俯卧位，而不是作为一种抢救手段或最后一搏。
