Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig
Center for Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen
Dtsch Arztebl Int. 2018 Dec 14;115(50):840-847. doi: 10.3238/arztebl.2018.0840.
Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, ac- companying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care).
This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus.
Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-in- vasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone posi- tioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate).
Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early sponta- neous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.
机械通气是急性呼吸功能不全患者的救命措施。在一项德国患病率研究中，13.6%的重症监护病房患者接受了超过 12 小时的机械通气；其中 20%的患者接受机械通气治疗急性呼吸窘迫综合征（ARDS）。新的 S3 指南是第一个包含这些患者治疗全过程建议的指南（适应证、通气模式/参数、伴随措施、治疗难治性气体交换障碍、脱机和随访护理）。
本指南按照 GRADE 方法制定。通过系统文献检索确定相关文献，评估证据质量，进行风险/效益评估，并通过跨学科共识发布建议。
机械通气推荐用于严重 ARDS 患者的主要治疗方法。在其他患者群体中，无创通气可降低死亡率。如果需要机械通气，允许自主呼吸的通气模式似乎有益（证据质量[QoE]：极低）。保护性通气（高呼气末正压、小潮气量、限制峰压）可改善 ARDS 患者的生存率（QoE：高）。如果存在严重的气体交换障碍，俯卧位可降低死亡率（QoE：高）。静脉-静脉体外膜肺氧合（vvECMO）尚未明确证明可提高生存率。早期活动和脱机方案可缩短通气时间（QoE：中等）。
对接受机械通气的患者的建议包括肺保护性通气、早期自主呼吸和活动、脱机方案，以及对于严重气体交换障碍的患者，推荐俯卧位。还建议将 ARDS 和难治性气体交换障碍患者转至 ARDS/ECMO 中心，仅在应用所有其他治疗选择后，才应应用体外方法。
