UO Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milano, Italy.
UOC Anestesia e Terapia Intensiva Adulti, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
Semin Respir Crit Care Med. 2019 Feb;40(1):40-56. doi: 10.1055/s-0039-1685179. Epub 2019 May 6.
A rising prevalence of obesity is reported over time and throughout the world. At the same time, the acute respiratory distress syndrome (ARDS) remains an important public health problem, accounting for approximately 10% of intensive care unit admissions and leading to significant hospital mortality. Even in the absence of acute illnesses, obesity affects respiratory mechanics and gas exchange in the setting of a restrictive disease. In the presence of ARDS, obesity adds various challenges to a safe and effective management of respiratory support. Difficult airway management, altered lung and chest wall physiology, and positional gas trapping are routinely encountered. The management of such difficult cases is generally empiric, as it is based on small-sized, physiologic studies or on suggestions from the general anesthesia literature. The present review focuses on those cases in which ARDS is coincident with obesity, with the aim of presenting treatment options based on the current evidence. The first part summarizes the epidemiology of obesity and ARDS. Then the diagnostic challenges due to obesity-related artifacts of the different imaging techniques will be presented. A subsequent, detailed description of the altered respiratory anatomy and physiology of obesity will provide help in selecting an optimal, individually tailored strategy of support. Furthermore, we will discuss how esophageal manometry should be used to adjust the settings of positive end-expiratory pressure and tidal volume; the challenges of prone positioning and extracorporeal support; and the optimal strategies for weaning from mechanical ventilation, including when and how to perform a tracheostomy.
肥胖的患病率呈上升趋势，且在全球范围内均有报道。与此同时，急性呼吸窘迫综合征（ARDS）仍然是一个重要的公共卫生问题，约占重症监护病房入院人数的 10%，并导致显著的医院死亡率。即使没有急性疾病，肥胖也会影响限制性疾病患者的呼吸力学和气体交换。在 ARDS 存在的情况下，肥胖给呼吸支持的安全有效管理带来了各种挑战。困难的气道管理、改变的肺和胸壁生理学以及体位性气体陷闭是经常遇到的。此类困难病例的管理通常是经验性的，因为它基于小型的、生理学研究或一般麻醉文献中的建议。本综述重点关注 ARDS 与肥胖同时存在的情况，旨在根据现有证据提出治疗选择。第一部分总结了肥胖和 ARDS 的流行病学。然后将介绍由于肥胖相关的不同影像学技术的伪影而导致的诊断挑战。肥胖的改变的呼吸解剖和生理学的详细描述将有助于选择最佳的个体化支持策略。此外，我们将讨论如何使用食管测压术来调整呼气末正压和潮气量的设置；俯卧位和体外支持的挑战；以及从机械通气中撤机的最佳策略，包括何时以及如何进行气管切开术。
