1 Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.
2 Sorbonne University Paris, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
Am J Respir Crit Care Med. 2017 May 1;195(9):1161-1170. doi: 10.1164/rccm.201701-0217CP.
Mechanical ventilation (MV) remains the cornerstone of acute respiratory distress syndrome (ARDS) management. It guarantees sufficient alveolar ventilation, high Fi concentration, and high positive end-expiratory pressure levels. However, experimental and clinical studies have accumulated, demonstrating that MV also contributes to the high mortality observed in patients with ARDS by creating ventilator-induced lung injury. Under these circumstances, extracorporeal lung support (ECLS) may be beneficial in two distinct clinical settings: to rescue patients from the high risk for death associated with severe hypoxemia, hypercapnia, or both not responding to maximized conventional MV, and to replace MV and minimize/abolish the harmful effects of ventilator-induced lung injury. High extracorporeal blood flow venovenous extracorporeal membrane oxygenation (ECMO) may therefore rescue the sickest patients with ARDS from the high risk for death associated with severe hypoxemia, hypercapnia, or both not responding to maximized conventional MV. Successful venovenous ECMO treatment in patients with extremely severe H1N1-associated ARDS and positive results of the CESAR trial have led to an exponential use of the technology in recent years. Alternatively, lower-flow extracorporeal CO removal devices may be used to reduce the intensity of MV (by reducing Vt from 6 to 3-4 ml/kg) and to minimize or even abolish the harmful effects of ventilator-induced lung injury if used as an alternative to conventional MV in nonintubated, nonsedated, and spontaneously breathing patients. Although conceptually very attractive, the use of ECLS in patients with ARDS remains controversial, and high-quality research is needed to further advance our knowledge in the field.
机械通气（MV）仍然是急性呼吸窘迫综合征（ARDS）管理的基石。它可确保充足的肺泡通气、高 Fi 浓度和高呼气末正压水平。然而，实验和临床研究已经积累了大量证据，表明 MV 通过造成呼吸机相关性肺损伤，也会导致 ARDS 患者的高死亡率。在这种情况下，体外肺支持（ECLS）可能在两种不同的临床情况下有益：一是抢救因严重低氧血症、高碳酸血症或两者均对最大化常规 MV 治疗无反应而面临高死亡风险的患者；二是替代 MV 并最小化/消除呼吸机相关性肺损伤的有害影响。因此，高体外血流的静脉-静脉体外膜氧合（ECMO）可能会挽救因严重低氧血症、高碳酸血症或两者均对最大化常规 MV 治疗无反应而面临高死亡风险的 ARDS 最危重患者。在极重度 H1N1 相关性 ARDS 患者中成功进行的静脉-静脉 ECMO 治疗以及 CESAR 试验的阳性结果，导致近年来该技术的应用呈指数级增长。或者，可以使用低流量体外 CO 去除设备来降低 MV 的强度（将潮气量从 6 毫升/公斤降至 3-4 毫升/公斤），并在非插管、非镇静和自主呼吸的患者中替代常规 MV 时，最小化或甚至消除呼吸机相关性肺损伤的有害影响。尽管从概念上讲非常有吸引力，但 ARDS 患者使用 ECLS 仍然存在争议，需要高质量的研究来进一步推进该领域的知识。
