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建立肺脏救援团队以改善难治性急性呼吸衰竭患者的治疗

Development of a Lung Rescue Team to Improve Care of Subjects With Refractory Acute Respiratory Failure.

机构信息

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.

Department of Respiratory Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.

出版信息

Respir Care. 2020 Apr;65(4):420-426. doi: 10.4187/respcare.07350. Epub 2020 Feb 4.

Abstract

BACKGROUND

A lung-protective mechanical ventilation strategy has become the hallmark of ventilation management for patients with acute respiratory failure. However, some patients progress to more severe forms of acute respiratory failure with refractory hypoxemia. In such circumstances, individualized titration of mechanical ventilation according to the patient's specific respiratory and cardiovascular pathophysiology is desirable. A lung rescue team (LRT) was recently established at our institution to improve the medical care of patients with acute respiratory failure when conventional treatment fails. The aim of this report is to describe the consultation processes, the cardiopulmonary assessment, and the procedures of the LRT.

METHODS

This was a retrospective review of the LRT management of patients with acute respiratory failure and refractory hypoxemia at Massachusetts General Hospital in Boston, Massachusetts. The LRT is composed of a critical care physician, the ICU respiratory therapist on duty, the ICU nurse on duty, and 2 critical care fellows. In the LRT approach, respiratory mechanics are evaluated through lung recruitment maneuvers and decremental PEEP trials by means of 3 tools: esophageal manometry, echocardiography, and electrical impedance tomography lung imaging.

RESULTS

The LRT was consulted 89 times from 2014 to 2019 for evaluation and management of severely critically ill patients with acute respiratory failure and refractory hypoxemia on mechanical ventilation. The LRT was requested a median of 2 (interquartile range 1-6) d after intubation to optimize mechanical ventilation and to titrate PEEP in 77 (86%) subjects, to manage ventilation in 8 (9%) subjects on extracorporeal membrane oxygenation (ECMO), and to manage weaning strategy from mechanical ventilation in 4 (5%) subjects. The LRT found consolidations with atelectasis responsive to recruitment maneuvers in 79% ( = 70) of consultations. The LRT findings translated into a change of care in 81% ( = 72) of subjects.

CONCLUSIONS

The LRT individualized the management of severe acute respiratory failure. The LRT consultations were shown to be effective, safe, and efficient, with an impact on decision-making in the ICU.

摘要

背景

肺保护性机械通气策略已成为急性呼吸衰竭患者通气管理的标志。然而,一些患者进展为更严重形式的急性呼吸衰竭伴难治性低氧血症。在这种情况下,根据患者特定的呼吸和心血管病理生理学进行个体化的机械通气滴定是理想的。最近,我们机构成立了一个肺救援小组(LRT),以改善常规治疗失败时急性呼吸衰竭患者的医疗护理。本报告的目的是描述 LRT 对急性呼吸衰竭和难治性低氧血症患者的咨询流程、心肺评估和处理程序。

方法

这是对波士顿马萨诸塞州总医院 LRT 管理急性呼吸衰竭和难治性低氧血症患者的回顾性研究。LRT 由一名重症监护医生、值班 ICU 呼吸治疗师、值班 ICU 护士和 2 名重症监护研究员组成。在 LRT 方法中,通过食管测压、超声心动图和电气阻抗断层成像肺成像这 3 种工具来评估呼吸力学,进行肺复张手法和递减 PEEP 试验。

结果

2014 年至 2019 年,LRT 共咨询 89 次,用于评估和管理机械通气时患有严重急性呼吸衰竭和难治性低氧血症的重症患者。LRT 在插管后中位数 2(四分位距 1-6)d 请求以优化机械通气并滴定 PEEP,在 77(86%)名患者中进行,在 8(9%)名患者中进行体外膜氧合(ECMO)的通气管理,在 4(5%)名患者中进行机械通气撤机策略管理。LRT 在 79%(=70)次咨询中发现有反应性复张手法的实变伴肺不张。LRT 的发现转化为 81%(=72)名患者的治疗变化。

结论

LRT 个体化了严重急性呼吸衰竭的管理。LRT 咨询被证明是有效、安全和高效的,对 ICU 的决策产生了影响。

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