Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Edgbaston; Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham.
Department of Critical Care Medicine, the University of Calgary, Calgary, AB, Canada.
Chest. 2017 Jul;152(1):181-193. doi: 10.1016/j.chest.2017.02.019. Epub 2017 Mar 4.
ARDS is associated with poor clinical outcomes, with a pooled mortality rate of approximately 40% despite best standards of care. Current therapeutic strategies are based on improving oxygenation and pulmonary compliance while minimizing ventilator-induced lung injury. It has been demonstrated that relative hypoxemia can be well tolerated, and improvements in oxygenation do not necessarily translate into survival benefit. Cardiac failure, in particular right ventricular dysfunction (RVD), is commonly encountered in moderate to severe ARDS and is reported to be one of the major determinants of mortality. The prevalence rate of echocardiographically evident RVD in ARDS varies across studies, ranging from 22% to 50%. Although there is no definitive causal relationship between RVD and mortality, severe RVD is associated with increased mortality. Factors that can adversely affect RV function include hypoxic pulmonary vasoconstriction, hypercapnia, and invasive ventilation with high driving pressure. It might be expected that early diagnosis of RVD would be of benefit; however, echocardiographic markers (qualitative and quantitative) used to prospectively evaluate the right ventricle in ARDS have not been tested in adequately powered studies. In this review, we examine the prognostic implications and pathophysiology of RVD in ARDS and discuss available diagnostic modalities and treatment options. We aim to identify gaps in knowledge and directions for future research that could potentially improve clinical outcomes in this patient population.
急性呼吸窘迫综合征（ARDS）与较差的临床预后相关，即使采用最佳的治疗标准，其死亡率仍约为 40%。目前的治疗策略基于改善氧合和肺顺应性，同时最大限度地减少呼吸机相关肺损伤。已经证明，相对低氧血症可以很好地耐受，并且氧合的改善不一定转化为生存获益。心力衰竭，特别是右心室功能障碍（RVD），在中重度 ARDS 中很常见，并且被认为是死亡率的主要决定因素之一。ARDS 中超声心动图证实的 RVD 的患病率在不同研究中差异很大，范围从 22%到 50%。虽然 RVD 与死亡率之间没有明确的因果关系，但严重的 RVD 与死亡率增加相关。可能对 RV 功能产生不利影响的因素包括低氧性肺血管收缩、高碳酸血症和具有高驱动压的有创通气。人们可能期望早期诊断 RVD 会有好处；然而，用于前瞻性评估 ARDS 中右心室的超声心动图标志物（定性和定量）尚未在充分有力的研究中进行测试。在这篇综述中，我们研究了 RVD 在 ARDS 中的预后意义和病理生理学，并讨论了现有的诊断方法和治疗选择。我们旨在确定知识空白和未来研究方向，这可能会改善该患者群体的临床结局。
