Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil.
Crit Care. 2024 Aug 26;28(1):277. doi: 10.1186/s13054-024-05059-y.
The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.
在严重急性呼吸窘迫综合征（ARDS）患者的管理中，确定最佳的呼气末正压（PEEP）滴定策略仍不明确。目前的指南强调，在这些患者的心肺功能方面，对 PEEP 滴定进行仔细的风险-获益评估非常重要。在过去的几十年中，PEEP 使用的主要目标已经从单纯改善氧合转向强调肺保护，越来越关注个体肺损伤模式、肺和胸壁力学以及 PEEP 的血流动力学后果。在中重度 ARDS 患者中，推荐俯卧位（PP）作为肺保护性通气策略的一部分，以降低死亡率。然而，PP 期间呼吸力学和血流动力学的生理变化可能需要仔细重新评估通气策略，包括 PEEP。对于最严重的 ARDS 患者，由于气体交换障碍难以纠正，无法进行肺保护性通气，静脉-静脉体外膜肺氧合（V-V ECMO）有助于气体交换，并允许使用“超保护性”通气进行“肺休息”策略。因此，与保守治疗相比，在接受 V-V ECMO 治疗的严重 ARDS 患者中，通过肺复张来改善氧合和通过足够的 PEEP 均匀通气的重要性可能有所不同。本文讨论了严重 ARDS 患者的 PEEP 管理以及在 PP 或 V-V ECMO 管理方面对呼吸力学和血流动力学功能的影响。
