Piacherski Valery, Muzyka Lidziya, Zhylynski Dzyanis
Department of Anesthesiology and Intensive Care, Mogilev Regional Clinical Hospital, 212026 A. Kuleshov str., 3-36, Mogilev, Republic of Belarus.
Transl Med Commun. 2022;7(1):15. doi: 10.1186/s41231-022-00122-8. Epub 2022 Jul 8.
Studies have previously been published on a possible differential approach to respiratory therapy in patients with COVID-19 depending on the L- or H-phenotype.The authors believe that early tracheal intubation reduces the risk of lung injury. The use of deep sedation and low PEEP (6-8 cmHO) and early intubation may prevent transition to type H.
Eleven patients with COVID-19 type L pneumonia received respiratory support based on the proposed guidelines. Eight women and three men (ages 45 to 84) with COVID-19 type L pneumonia were treated in the intensive care unit. Did they all receive oxygen therapy up to 15 L/min. high-flow oxygen therapy up to 60 L/ min, non-invasive ventilation of the lungs. If it was impossible to reduce FiO from 100 to 75% within 2-3 h or if the patient was intolerant to NIV, early tracheal intubation was used.The minute ventilation volume was set to maintain CO <60 mmHg. and pH>7.25 in venous blood. Sedation was performed by intravenous titration of fentanyl and propofol. If deeper sedation was required to synchronize the patient to the ventilator, intravenous muscle relaxants were used over 24-48 hours (bolus or intravenous titration) instead of sedation.
All 11 patients were successfully weaned from the mechanical ventilation of the lungs. A differentiated approach to respiratory therapy for COVID-19 L-type pneumonia proved to be an effective approach in these patients.It is probably worth avoiding deep sedation of patients on mechanical ventilation with L-type pneumonia, which would reduce the time spent on mechanical ventilation and reduce the risk of mortality from nosocomial bacterial infection.The new MVL strategy for L-type pneumonia and the problem of deep sedation require more research. But the available data suggests that it probably has benefits.
此前已有研究发表，提出针对新冠病毒肺炎患者，可根据L型或H型表型采用不同的呼吸治疗方法。作者认为早期气管插管可降低肺损伤风险。使用深度镇静和低呼气末正压（6 - 8 cmH₂O）并早期插管可能会防止病情转变为H型。
11例L型新冠病毒肺炎患者根据所提议的指南接受了呼吸支持。8名女性和3名男性（年龄45至84岁）患有L型新冠病毒肺炎，在重症监护病房接受治疗。他们均接受了高达15 L/min的氧疗、高达60 L/min的高流量氧疗以及无创肺通气。如果在2 - 3小时内无法将吸入氧分数从100%降至75%，或者患者不耐受无创通气，则采用早期气管插管。分钟通气量设定为维持静脉血中二氧化碳分压<60 mmHg且pH>7.25。通过静脉滴定芬太尼和丙泊酚进行镇静。如果需要更深的镇静以使患者与呼吸机同步，则在24 - 48小时内使用静脉肌肉松弛剂（推注或静脉滴定）而非镇静剂。
所有11例患者均成功脱机。事实证明，针对L型新冠病毒肺炎采用差异化的呼吸治疗方法对这些患者是有效的。对于L型肺炎机械通气患者，可能值得避免深度镇静，这将减少机械通气时间并降低医院获得性细菌感染导致的死亡风险。针对L型肺炎的新分钟通气量策略以及深度镇静问题需要更多研究。但现有数据表明其可能具有益处。
