I-Acute Respiratory Distress Syndrome (kungoko igama elithi 'ARDS') sisifo sokuphefumla esibangelwa zizizathu ezahlukeneyo kwaye siphawulwa ngumonakalo osasazekileyo kwi-alveolar capillaries ekhokelela ekungaphumelelini kokuphefumla okukhulu kunye ne-arterial hypoxaemia refractory to oxygen administration.

I-ARDS ngoko ibonakaliswe ngokuhla kwe-oksijini egazini, echasene nonyango lwe-O2, oko kukuthi le ngqungquthela ayiphakamisi emva kokulawulwa kwe-oksijini kwisigulane.

Ukungaphumeleli kokuphefumla kwe-Hypoxaemic kungenxa yokwenzakala kwinwebu ye-alveolar-capillary, enyusa ukungeneka kwemithambo ye-pulmonary, ekhokelela kwi-interstitial kunye ne-alveolar edema.

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Unyango lwe-ARDS, ngokusisiseko, luxhasa kwaye lubandakanya

• unyango lwesizathu esinyukayo esibangele i-ARDS;
• ukugcinwa kwe-oxygen ye-tissue eyaneleyo (i-ventilation kunye noncedo lwe-cardiopulmonary);
• inkxaso yesondlo.

I-ARDS yi-syndrome ebangelwa zizinto ezininzi ezahlukeneyo ezikhokelela kumonakalo wemiphunga efanayo

Kwezinye zezizathu ze-ARDS akunakwenzeka ukungenelela, kodwa kwiimeko apho oku kunokwenzeka (njengakwimeko yokothuka okanye i-sepsis), unyango lwangethuba kwaye olusebenzayo luba lubalulekile ukunciphisa ubunzulu be-syndrome kunye nokwandisa i-syndrome. amathuba esigulana okusinda.

Unyango lwe-Pharmacological ye-ARDS lujolise ekulungiseni ukuphazamiseka okusisiseko kunye nokubonelela ngenkxaso yokusebenza kwentliziyo (umzekelo, i-antibiotics ukunyanga usulelo kunye ne-vasopressors ukunyanga i-hypotension).

I-oxygenation ye-tissue ixhomekeke ekukhutshweni kwe-oksijini eyaneleyo (i-O2del), engumsebenzi wezinga le-oksijini ye-arterial kunye nokuphuma kwentliziyo.

Oku kuthetha ukuba zombini ukungena komoya kunye nomsebenzi wentliziyo zibalulekile kubomi besigulane.

Uxinzelelo olulungileyo lokuphelelwa umoya (PEEP) umoya wokuphefumula ngomatshini uyimfuneko ukuze kuqinisekiswe i-oxygenation ye-arterial eyaneleyo kwizigulane ezine-ARDS.

I-ventilation yoxinzelelo oluhle, nangona kunjalo, ngokubambisana nokuphucula i-oxygenation, ukunciphisa ukukhutshwa kwentliziyo (jonga ngezantsi). Ukuphuculwa kwe-oksijini ye-arterial akusebenzi kangako okanye akukho nto ukuba ukunyuka kwangaxeshanye kwingcinezelo ye-intrathoracic kubangela ukunciphisa okuhambelanayo kwimveliso yenhliziyo.

Ngenxa yoko, inqanaba eliphezulu le-PEEP elinyamezelwa sisigulane ngokubanzi lixhomekeke kumsebenzi wenhliziyo.

I-ARDS enzima inokubangela ukufa ngenxa ye-tissue hypoxia xa unyango oluphezulu lwe-fluid kunye nee-agent ze-vasopressor zingaphuculi ngokwaneleyo ukukhutshwa kwentliziyo kwinqanaba elinikiweyo le-PEEP eliyimfuneko ukuze kuqinisekiswe ukutshintshiselana kwegesi ye-pulmonary.

Kwezona zigulana ziqatha, ngakumbi ezo zingena umoya ngoomatshini, imeko yokungondleki ihlala iphumela.

Imiphumo yokungondleki kwimiphunga ibandakanya: i-immunosuppression (ukunciphisa i-macrophage kunye nomsebenzi we-T-lymphocyte), ukunyanzeliswa kokuphefumula kokuphefumla nge-hypoxia kunye ne-hypercapnia, ukungasebenzi kakuhle kwe-surfactant, ukunciphisa ubunzima be-intercostal kunye ne-diaphragm muscle, ukunciphisa amandla okuphefumla kwemisipha yokuphefumula, ngokumalunga nomzimba. Umsebenzi we-catabolic, ke ngoko ukungondleki kunokuchaphazela izinto ezininzi ezibalulekileyo, kungekuphela nje ekusebenzeni kogcino kunye nonyango oluxhasayo, kodwa kunye nokulunyulwa kwi-ventilator yoomatshini.

Ukuba kunokwenzeka, ukutya kwe-enteral (ukulawulwa kokutya kusetyenziswa ityhubhu ye-nasogastric) kukhethwa; kodwa ukuba umsebenzi wamathumbu uphazamiseka, ukutya kwe-parenteral (intravenous) kuya kuba yimfuneko ukufaka isigulane ngeprotheni eyaneleyo, amafutha, i-carbohydrates, iivithamini kunye neemaminerali.

Ukungenisa umoya koomatshini kwi-ARDS

I-ventilation yomatshini kunye ne-PEEP ayithinteli ngokuthe ngqo okanye iphathe i-ARDS kodwa, kunoko, gcina isigulane siphila de i-pathology ephantsi isonjululwe kwaye umsebenzi wemiphunga owaneleyo ubuyiselwe.

Undoqo wokungena komoya oqhubekayo ngoomatshini (CMV) ngexesha le-ARDS ubandakanya umoya oqhelekileyo 'oxhomekeke kumthamo' kusetyenziswa umthamo wamaza we-10-15 ml/kg.

Kwizigaba ezimandundu zesi sifo, uncedo olupheleleyo lokuphefumla luyasetyenziswa (ludla ngokusetyenziswa 'ngolawulo oluncedisayo' ukungena komoya okanye ukuphefumla ngenkani ngekhefu [IMV]).

Uncedo lokuphefumla kancinci ludla ngokunikezelwa ngexesha lokuchacha okanye ukulunyulwa kwisixhobo sokuphefumla.

I-PEEP inokukhokelela ekuqaliseni ukuphuphuma komoya kwiindawo ze-atelectasis, ukuguqula iindawo zemiphunga ezivaliweyo ngaphambili zibe ziiyunithi zokuphefumula ezisebenzayo, okukhokelela ekuphuculeni i-oxygenation ye-arterial kwi-fraction ephantsi ye-oxygen ephefumlelweyo (FiO2).

Ukungena komoya kwe-alveoli esele i-atelectatic nako kwandisa amandla okusebenza okushiyekileyo (FRC) kunye nokuthotyelwa kwemiphunga.

Ngokuqhelekileyo, injongo ye-CMV nge-PEEP kukufezekisa i-PaO2 enkulu kune-60 mmHg kwi-FiO2 engaphantsi kwe-0.60.

Nangona i-PEEP ibalulekile ekugcineni utshintshiselwano lwegesi ye-pulmonary eyaneleyo kwizigulane ezine-ARDS, iziphumo ebezingalindelekanga zinokwenzeka.

Ukunciphisa ukuthotyelwa kwemiphunga ngenxa ye-alveolar overdistension, ukunciphisa ukubuya kwe-venous kunye nokuphuma kwentliziyo, ukunyuka kwe-PVR, ukunyuka kwe-ventricular afterload, okanye i-barotrauma ingenzeka.

Ngenxa yezi zizathu, amanqanaba 'eyona nto ilungileyo' e-PEEP ayacetyiswa.

Inqanaba eliphezulu le-PEEP lichazwa ngokubanzi njengexabiso apho i-O2del engcono kakhulu ifunyenwe kwi-FiO2 ngaphantsi kwe-0.60.

Amaxabiso e-PEEP aphucula i-oxygenation kodwa anciphisa kakhulu imveliso yenhliziyo ayilunganga, kuba kule meko i-O2del nayo iyancitshiswa.

Uxinzelelo oluyinxenye lweoksijini kwigazi elixubeneyo le-venous (PvO2) libonelela ngolwazi malunga ne-tissue oxygenation.

I-PvO2 engaphantsi kwe-35 mmHg ibonisa i-oksijini yezicubu ezisezantsi.

Ukunciphisa imveliso yenhliziyo (enokuthi yenzeke ngexesha le-PEEP) iphumela kwi-PvO2 ephantsi.

Ngesi sizathu, i-PvO2 inokusetyenziselwa ukumisela eyona PEEP ilungileyo.

Ukungaphumeleli kwe-PEEP kunye ne-CMV eqhelekileyo sesona sizathu siqhelekileyo sokutshintshela kwi-ventilation kunye ne-inverse okanye i-inspiratory / expiratory ratio (I: E) ephezulu.

Ukubuyisela umva I:E umlinganiselo wokungenisa umoya ngoku usetyenziswa rhoqo kunomoya ohamba rhoqo.

Inika iziphumo ezingcono kunye nesigulana esikhubazekileyo kunye ne-ventilator yexesha ukwenzela ukuba isenzo esitsha sokuphefumla siqale ngokukhawuleza ukuba ukuphefumla kwangaphambili kufikelele kwinqanaba eliphezulu le-PEEP.

Izinga lokuphefumla lingancitshiswa ngokongeza i-apnea ephefumlayo.

Oku kudla ngokukhokelela ekunciphiseni uxinzelelo lwe-intrathoracic, nangona ukunyuka kwe-PEEP, kwaye ngaloo ndlela kubangele ukuphuculwa kwe-O2del edibeneyo ngokunyuka kwemveliso yenhliziyo.

I-high-frequency positive pressure ventilation (HFPPV), i-high-frequency oscillation (HFO), kunye ne-high-frequency 'jet' ventilation (HFJV) ziindlela ezinokuthi ngamanye amaxesha zikwazi ukuphucula umoya kunye ne-oxygen ngaphandle kokubhenela kwimibhobho ephezulu okanye uxinzelelo.

Kuphela i-HFJV isetyenziswe ngokubanzi kunyango lwe-ARDS, ngaphandle kweenzuzo ezibalulekileyo kwi-CMV eqhelekileyo kunye ne-PEEP eboniswa ngokucacileyo.

I-Membrane extracorporeal oxygenation (ECMO) yafundwa kwi-1970s njengendlela enokuqinisekisa i-oxygenation eyaneleyo ngaphandle kokusebenzisa nayiphi na indlela yokungena komoya, ishiya imiphunga ikhululekile ukuba iphile kwizilonda ezijongene ne-ARDS ngaphandle kokubeka uxinzelelo olubonakaliswa luxinzelelo oluhle. ukungena komoya.

Ngelishwa, izigulana ezibukhali kangangokuba azizange ziphendule ngokwaneleyo ekungeneni komoya okuqhelekileyo kwaye ke ngoko zazifanelekela i-ECMO, zinezilonda ezimandundu emiphungeni kangangokuba zaqhubeka ne-pulmonary fibrosis kwaye zange ziphinde ziphinde zisebenze njengesiqhelo.

Ukulunyulwa kokungena komoya koomatshini kwi-ARDS

Ngaphambi kokuthatha isigulane kwi-ventilator, kuyimfuneko ukuqinisekisa amathuba akhe okuphila ngaphandle koncedo lokuphefumula.

Izalathisi zeMechanical ezifana ne-high inspiratory pressure (MIP), umthamo obalulekileyo (VC), kunye nomthamo we-spontaneous tidal volume (VT) uvavanya ukukwazi kwesigulane ukuthutha umoya ngaphakathi nangaphandle kwesifuba.

Akukho nanye yale milinganiselo, nangona kunjalo, inika ulwazi malunga nokuchasana kwemisipha yokuphefumula ukusebenza.

Ezinye iimpawu ze-physiological, ezifana ne-pH, indawo efileyo kumlinganiselo womthamo we-tidal volume, i-P (Aa) O2, imeko yesondlo, ukuzinza kwe-cardiovascular stability, kunye ne-acid-base metabolic balance ibonisa imeko yesigulana kunye nokukwazi kwakhe ukunyamezela uxinzelelo lokulunyulwa kwi-ventilator. .

Ukulunyulwa kwi-ventilation yomatshini kwenzeka ngokuqhubekayo, ukuqinisekisa ukuba imeko yesigulane yanele ukuqinisekisa ukuphefumla ngokuzenzekelayo, ngaphambi kokususa i-cannula endotracheal.

Esi sigaba ngokuqhelekileyo siqala xa isigulane sisisigxina sonyango, kunye ne-FiO2 engaphantsi kwe-0.40, i-PEEP ye-5 cm ye-H2O okanye ngaphantsi kunye neeparitha zokuphefumula, ezichazwe ngaphambili, zibonisa ithuba elifanelekileyo lokuqalisa ngokutsha ngokuzenzekelayo umoya.

I-IMV yindlela ethandwayo yokulumla izigulane ezine-ARDS, kuba ivumela ukusetyenziswa kwe-PEEP ethobekileyo kude kube yi-extubation, ivumela isigulane ukuba sibhekane ngokuthe ngcembe nomgudu ofunekayo wokuphefumla ngokuzenzekelayo.

Ngesi sigaba sokulunyulwa, ukubekwa esweni ngononophelo kubalulekile ukuqinisekisa impumelelo.

Utshintsho kwixinzelelo lwegazi, ukunyuka kwentliziyo okanye ukuphefumula kokuphefumula, ukunciphisa i-oxygen saturation ye-arterial njengoko kulinganiswe yi-pulse oximetry, kunye nokusebenza kwengqondo okubi kakhulu kubonisa ukungaphumeleli kwenkqubo.

Ukucotha ngokuthe ngcembe kokulunyulwa kunokunceda ukuthintela ukungaphumeleli okunxulumene nokudinwa kwemisipha, okunokuthi kwenzeke ngexesha lokuqalisa kwakhona ukuphefumla ngokuzimeleyo.

Ukubeka iliso ngexesha le-ARDS

Ukujongwa kwe-pulmonary arterial kuvumela ukuphuma kwentliziyo ukuba kulinganiswe kwaye i-O2del kunye ne-PvO2 zibalwe.

Ezi parameters zibalulekile kunyango lweengxaki ezinokwenzeka zehaemodynamic.

Ukujongwa kwe-pulmonary arterial kwakhona kuvumela ukulinganiswa koxinzelelo lokuzaliswa kwe-ventricular yasekunene (CVP) kunye noxinzelelo lokuzaliswa kwe-ventricular yasekhohlo (PCWP), eziziiparamitha eziluncedo ekumiseleni isiphumo esilungileyo senhliziyo.

I-pulmonary arterial catheterization ye-pulmonary monitoring ibaluleke kakhulu kwimeko apho uxinzelelo lwegazi lwehla kakhulu kangangokuba lufuna unyango ngamachiza e-vasoactive (umzekelo, i-dopamine, i-norepinephrine) okanye ukuba ukusebenza kwemiphunga kuyehla de kufike kwinqanaba apho kufuneka i-PEEP engaphezu kwe-10 cm ye-H2O.

Nokuba ukufumanisa ukungazinzi komcinezeli, njengokufuna infusions enkulu yolwelo, kwisigulana esele sikwimeko yentliziyo okanye yokuphefumla, inokufuna ukubekwa kwecatheter ye-pulmonary artery catheter kunye ne-haemodynamic monitoring, nangaphambi kokuba amachiza e-vasoactive afuneke ilawulwa.

Umoya ofanelekileyo woxinzelelo lomoya unokuguqula idatha yokubeka iliso kwi-haemodynamic, ekhokelela ekunyukeni okungeyonyani kumaxabiso e-PEEP.

Amaxabiso aphezulu e-PEEP anokudluliselwa kwi-catheter yokubeka iliso kwaye abe noxanduva lokunyuka kwexabiso elibaliweyo le-CVP kunye ne-PCWP engahambelani nenyani (43).

Oku kunokwenzeka ngakumbi ukuba incam yecatheter ibekwe kufuphi nodonga lwesifuba sangaphambili (indawo I), kunye nesigulane esisezantsi.

I-Zone I yindawo ye-non-declivity ye-miphunga, apho imithambo yegazi ihlulwe kancinane.

Ukuba isiphelo se-catheter sibekwe kwinqanaba elinye lazo, ixabiso le-PCWP liya kuba nefuthe kakhulu kwiingcinezelo ze-alveolar, kwaye ngoko ke ziya kuba zingachanekanga.

I-Zone III ihambelana neyona ndawo ye-lung declivous, apho imithambo yegazi iphantse ihlale ikhutshwe.

Ukuba isiphelo secatheter sikule ndawo, imilinganiselo ethathiweyo iya kuchaphazeleka kancinci kakhulu ngoxinzelelo lomoya.

Ukubekwa kwe-catheter kwinqanaba le-III kunokuqinisekiswa ngokuthatha i-X-ray yesifuba se-lateral, eya kubonisa i-catheter tip engezantsi kwe-atrium yasekhohlo.

Ukuthotyelwa kwe-Static (Cst) inikezela ngolwazi oluluncedo kwimiphunga kunye nokuqina kodonga lwesifuba, ngelixa ukuthotyelwa okuguquguqukayo (i-Cdyn) kuhlola ukuxhathisa kwendlela yomoya.

I-Cst ibalwa ngokwahlula umthamo we-tidal (VT) nge-static (plateau) uxinzelelo (Pstat) thabatha i-PEEP (Cst = VT / Pstat - PEEP).

I-Pstat ibalwa ngexesha le-apnea emfutshane yokuphefumula emva kokuphefumula okukhulu.

Ngokwenza oku, oku kunokufezekiswa ngokusebenzisa umyalelo wokumisa we-ventilator yomatshini okanye ngokuvalelwa ngesandla komgca wokuphelelwa umoya wesekethe.

Uxinzelelo luhlolwe kwi-manometer ye-ventilator ngexesha le-apnea kwaye kufuneka ibe ngaphantsi koxinzelelo oluphezulu lomoya (Ppk).

Ukuthotyelwa kweDynamic kubalwa ngendlela efanayo, nangona kule meko iPpk isetyenziswe endaweni yoxinzelelo lwe-static (Cdyn = VT / Ppk - PEEP).

I-Cst eqhelekileyo iphakathi kwe-60 kunye ne-100 ml / cm i-H2O kwaye ingancitshiswa ukuya kwi-15 okanye i-20 ml / i-cm H20 kwiimeko ezinzima ze-pneumonia, i-pulmonary edema, i-atelectasis, i-fibrosis kunye ne-ARDS.

Kuba uxinzelelo oluthile luyafuneka ukoyisa ukuchasana kwendlela yomoya ngexesha lokungena komoya, inxalenye yoxinzelelo oluphezulu oluphuhliswe ngexesha lokuphefumla ngoomatshini imele ukuchasana nokuhamba okufunyanwa kwiindlela zomoya kunye neesekethe zokungenisa umoya.

Ke, i-Cdyn ilinganisa ukonakaliswa ngokubanzi kokuhamba komoya ngenxa yotshintsho ekuthotyelweni nasekuchaseni.

I-Cdyn eqhelekileyo iphakathi kwe-35 kunye ne-55 ml / cm i-H2O, kodwa inokuchaphazeleka kakubi zizifo ezifanayo ezinciphisa i-Cstat, kunye nezinto ezinokutshintsha ukuchasana (i-bronchoconstriction, i-edema ye-airway, ukugcinwa kweemfihlo, ukunyanzeliswa kwe-airway nge-neoplasm).

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umthombo:

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