Paternot Alexis, Repessé Xavier, Vieillard-Baron Antoine
Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Boulogne-Billancourt, France. Faculty of Medicine, University of Versailles Saint-Quentin en Yvelines, Paris Ile-de-France Ouest, Saint-Quentin en Yvelines, France.
Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Boulogne-Billancourt, France.
Respir Care. 2016 Oct;61(10):1391-6. doi: 10.4187/respcare.04943. Epub 2016 Aug 2.
Pulmonary vascular dysfunction is associated with ARDS and leads to increased right-ventricular afterload and eventually right-ventricular failure, also called acute cor pulmonale. Interest in acute cor pulmonale and its negative impact on outcome in patients with ARDS has grown in recent years. Right-ventricular function in these patients should be closely monitored, and this is helped by the widespread use of echocardiography in intensive care units. Because mechanical ventilation may worsen right-ventricular failure, the interaction between the lungs and the right ventricle appears to be a key factor in the ventilation strategy. In this review, a rationale for a right ventricle-protective ventilation approach is provided, and such a strategy is described, including the reduction of lung stress (ie, the limitation of plateau pressure and driving pressure), the reduction of PaCO2 , and the improvement of oxygenation. Prone positioning seems to be a crucial part of this strategy by protecting both the lungs and the right ventricle, resulting in increased survival of patients with ARDS. Further studies are required to validate the positive impact on prognosis of right ventricle-protective mechanical ventilation.
肺血管功能障碍与急性呼吸窘迫综合征（ARDS）相关，会导致右心室后负荷增加，最终引发右心室衰竭，即所谓的急性肺源性心脏病。近年来，人们对急性肺源性心脏病及其对ARDS患者预后的负面影响的关注度不断提高。这些患者的右心室功能应密切监测，重症监护病房中超声心动图的广泛应用有助于实现这一点。由于机械通气可能会加重右心室衰竭，肺与右心室之间的相互作用似乎是通气策略中的一个关键因素。在本综述中，我们提供了一种右心室保护性通气方法的理论依据，并描述了这样一种策略，包括降低肺应力（即限制平台压和驱动压）、降低动脉血二氧化碳分压（PaCO2）以及改善氧合。俯卧位似乎是该策略的关键部分，通过保护肺和右心室，可提高ARDS患者的生存率。需要进一步研究来验证右心室保护性机械通气对预后的积极影响。
