Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan.
Department of Emergency and Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS.
Curr Opin Crit Care. 2020 Feb;26(1):59-65. doi: 10.1097/MCC.0000000000000691.
The potential risks of spontaneous effort and their prevention during mechanical ventilation is an important concept for clinicians and patients. The effort-dependent lung injury has been termed 'patient self-inflicted lung injury (P-SILI)' in 2017. As one of the potential strategies to render spontaneous effort less injurious in severe acute respiratory distress syndrome (ARDS), the role of positive end-expiratory pressure (PEEP) is now discussed.
Experimental and clinical data indicate that vigorous spontaneous effort may worsen lung injury, whereas, at the same time, the intensity of spontaneous effort seems difficult to control when lung injury is severe. Experimental studies found that higher PEEP strategy can be effective to reduce lung injury from spontaneous effort while maintaining some muscle activity. The recent clinical trial to reevaluate systemic early neuromuscular blockade in moderate-severe ARDS (i.e., reevaluation of systemic early neuromuscular blockade (ROSE) trial) support that a higher PEEP strategy can facilitate 'safe' spontaneous breathing under the light sedation targets (i.e., no increase in barotrauma nor 90 days mortality versus early muscle paralysis).
To prevent P-SILI in ARDS, it seems feasible to facilitate 'safe' spontaneous breathing in patients using a higher PEEP strategy in severe ARDS.
在机械通气过程中，自主努力的潜在风险及其预防是临床医生和患者都需要关注的重要概念。依赖于自主努力的肺损伤在 2017 年被称为“患者自身引起的肺损伤（P-SILI）”。作为在严重急性呼吸窘迫综合征（ARDS）中降低自主努力致肺损伤程度的潜在策略之一，目前正在讨论呼气末正压（PEEP）的作用。
实验和临床数据表明，剧烈的自主努力可能会加重肺损伤，而在肺损伤严重时，自主努力的强度似乎难以控制。实验研究发现，较高的 PEEP 策略可以有效降低自主努力引起的肺损伤，同时保持一定的肌肉活动。最近一项重新评估中度至重度 ARDS 全身早期神经肌肉阻滞的临床试验（即，重新评估全身早期神经肌肉阻滞（ROSE）试验）支持较高的 PEEP 策略可以在轻度镇静目标下促进“安全”的自主呼吸（即，不会增加气压伤，90 天死亡率也不会高于早期肌肉麻痹）。
为了预防 ARDS 中的 P-SILI，在严重 ARDS 患者中使用较高的 PEEP 策略促进“安全”的自主呼吸似乎是可行的。
