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I-Respiratory Distress Syndrome (i-ARDS): ukwelashwa, ukungena komoya ngomshini, ukuqapha

By UCristiano Antonino On Jun 5, 2022

I-Acute Respiratory Distress Syndrome (yingakho isifinyezo esithi 'ARDS') isifo sokuphefumula esibangelwa yizimbangela ezihlukahlukene futhi sibonakala ngokulimala okusabalele kuma-alveolar capillaries okuholela ekuhlulekeni kokuphefumula okukhulu ne-arterial hypoxaemia refractory to oxygen administration.

Ngakho-ke i-ARDS ibonakala ngokuncipha kokugcwala komoya-mpilo egazini, okungamelana nokwelashwa kwe-O2, okungukuthi lokhu kuhlushwa akuvuki kulandela ukuphathwa komoyampilo esigulini.

Ukuhluleka kokuphefumula kwe-Hypoxemic kungenxa yesilonda solwelwesi lwe-alveolar-capillary, okwandisa ukungeneka kwemithambo yamaphaphu, okuholela edema ye-interstitial kanye ne-alveolar.

IZIDLULI, IZIHLALO ZOKUPHUMA AMALUNGA, IZIHLALO ZOKUPHUMA: IMIKHIQIZO YE-SPENCER E-DOUBLE BOOTH KU-EXPO EZIPHUTHUMAYO

Ukwelashwa kwe-ARDS, ngokuyisisekelo, kuyasekela futhi kuhlanganisa

ukwelashwa kwembangela ekhuphukayo eyabangela i-ARDS;
ukugcinwa kwe-oxygenation yezicubu ezanele (ukungena komoya kanye nosizo lwe-cardiopulmonary);
ukwesekwa kokudla okunomsoco.

I-ARDS yisifo esidalwa yizici eziningi eziholela ekulimaleni okufanayo kwamaphaphu

Kwezinye zezimbangela ze-ARDS akunakwenzeka ukungenelela, kodwa ezimeni lapho lokhu kungenzeka khona (njengokushaqeka noma i-sepsis), ukwelashwa kusenesikhathi futhi okuphumelelayo kuba okubalulekile ukuze kukhawulwe ubunzima be-syndrome nokwandisa amathuba esiguli okusinda.

Ukwelashwa kwe-Pharmacological kwe-ARDS kuhloswe ngayo ukulungisa izinkinga ezikhona kanye nokuhlinzeka ngokusekela ukusebenza kwenhliziyo nemithambo yegazi (isb. ama-antibiotics ekwelapheni ukutheleleka kanye nama-vasopressors ekwelapheni i-hypotension).

I-oxygenation yezicubu incike ekukhululweni komoyampilo owanele (O2del), okuwumsebenzi wamazinga komoyampilo we-arterial kanye nokuphuma kwenhliziyo.

Lokhu kusho ukuthi kokubili ukungena komoya nokusebenza kwenhliziyo kubalulekile ukuze isiguli siphile.

I-Positive end-expiratory pressure (PEEP) i-ventilation mechanical ibalulekile ukuze kuqinisekiswe ukuthi i-arterial oxygenation eyanele ezigulini ezine-ARDS.

I-positive pressure ventilation, nokho, ingakwazi, ngokubambisana ne-oxygenation ethuthukisiwe, ukunciphisa ukukhishwa kwenhliziyo (bheka ngezansi). Ukuthuthukiswa kwe-oxygenation ye-arterial akusebenzi kangako noma akusebenzi nhlobo uma ukwanda ngasikhathi sinye kwengcindezi ye-intrathoracic kubangela ukuncipha okuhambisanayo kokuphuma kwenhliziyo.

Ngenxa yalokho, izinga eliphezulu le-PEEP elibekezelelwa isiguli ngokuvamile lincike ekusebenzeni kwenhliziyo.

I-ARDS enzima ingaholela ekufeni ngenxa ye-thishu hypoxia lapho ukwelashwa okuphezulu koketshezi kanye nama-vasopressor agents kungathuthukisi ngokwanele ukuphuma kwenhliziyo ezingeni elinikeziwe le-PEEP elidingekayo ukuze kuqinisekiswe ukushintshaniswa kwegesi yamaphaphu.

Ezigulini ezinzima kakhulu, ikakhulukazi lezo ezingena umoya ngomshini, kuvame ukuvela ukungondleki kahle.

Imiphumela yokungondleki emaphashini ihlanganisa: ukuzivikela komzimba (ukunciphisa umsebenzi we-macrophage kanye ne-T-lymphocyte), ukukhuthazwa kokuphefumula okubangelwa i-hypoxia ne-hypercapnia, ukungasebenzi kahle kwe-surfactant, ukuncipha kwe-intercostal kanye ne-diaphragm muscle, ukwehla kwamandla okuphefumula kwemisipha yokuphefumula, ngokuphathelene nomzimba. umsebenzi we-catabolic, ngaleyo ndlela ukungondleki kungaba nomthelela ezicini eziningi ezibucayi, hhayi kuphela ekusebenzeni ngempumelelo kokugcinwa nokwelashwa okusekelayo, kodwa nasekulunyulweni emshinini wokuphefumula oyimishini.

Uma kungenzeka, ukuphakelwa kwe-enteral (ukuphatha ukudla nge-nasogastric tube) kungcono; kodwa uma umsebenzi wamathumbu usengozini, ukuphakelwa kwabazali (intravenous) kuba kudingekile ukuze kufakwe isiguli amaprotheni, amafutha, ama-carbohydrate, amavithamini namaminerali anele.

Ukungena komoya ngomshini ku-ARDS

Ukungena komoya ngemishini kanye ne-PEEP akuvimbeli ngokuqondile noma zelaphe i-ARDS kodwa, kunalokho, kugcina isiguli siphila kuze kube yilapho i-pathology engaphansi isixazululiwe futhi kubuyiselwa ukusebenza okwanele kwamaphaphu.

Isisekelo sokungena komoya oqhubekayo ngomshini (CMV) ngesikhathi se-ARDS siqukethe umoya ojwayelekile 'oncike kwivolumu' kusetshenziswa imiqulu engu-10-15 ml/kg.

Ezigabeni ezibucayi zesifo, kusetshenziswa usizo olugcwele lokuphefumula (ngokuvamile kusetshenziswa umoya 'wokulawula ukusiza' noma ukungena komoya okuphoqelekile [IMV]).

Usizo lokuphefumula oluyingxenye ngokuvamile lunikezwa ngesikhathi sokululama noma ukulunyulwa kumshini wokuphefumula.

I-PEEP ingaholela ekuqaliseni kabusha kokungena komoya ezindaweni ze-atelectasis, ukuguqula izindawo zamaphaphu ezazivalekile zibe izingxenye zokuphefumula ezisebenzayo, okuholela ekuthuthukisweni kwe-arterial oxygenation engxenyeni ephansi ye-oxygen ephefumulelwe (FiO2).

Ukungena komoya kwe-alveoli esivele i-atelectatic nakho kwandisa umthamo wokusalela osebenzayo (FRC) nokuhambisana namaphaphu.

Ngokuvamile, umgomo we-CMV nge-PEEP uwukuthola i-PaO2 enkulu kuno-60 mmHg ku-FiO2 engaphansi kuka-0.60.

Nakuba i-PEEP ibalulekile ekugcineni ukushintshana kwegesi yamaphaphu okwanele ezigulini ezine-ARDS, imiphumela emibi ingenzeka.

Ukunciphisa ukuthobela amaphaphu ngenxa ye-alveolar overdistension, ukunciphisa ukubuya kwe-venous kanye nokukhishwa kwenhliziyo, ukwanda kwe-PVR, ukunyuka kwe-ventricular afterload kwesokudla, noma i-barotrauma ingenzeka.

Ngalezi zizathu, amazinga e-PEEP 'alungile' ayaphakanyiswa.

Izinga elilungile le-PEEP ngokuvamile lichazwa njengevelu lapho i-O2del ehamba phambili etholwa khona ku-FiO2 ngaphansi kuka-0.60.

Amanani e-PEEP athuthukisa umoya-mpilo kodwa anciphisa kakhulu ukukhishwa kwenhliziyo awalungile, ngoba kulesi simo i-O2del nayo iyancipha.

Ingxenye yomfutho we-oxygen egazini le-venous exubile (PvO2) inikeza ulwazi mayelana ne-tissue oxygenation.

I-PvO2 engaphansi kuka-35 mmHg iyinkomba ye-suboptimal tissue oxygenation.

Ukuncipha kokuphuma kwenhliziyo (okungenzeka ngesikhathi se-PEEP) kubangela i-PvO2 ephansi.

Ngalesi sizathu, i-PvO2 ingaphinda isetshenziselwe ukunqunywa kwe-PEEP elungile.

Ukwehluleka kwe-PEEP nge-CMV evamile yisizathu esivame kakhulu sokushintshela ekungeneni komoya ngesilinganiso esiphambene noma esiphezulu sokuphefumula/ sokuphefumula (I:E).

Ukuhlehla kwesilinganiso sokungena komoya kwe-I:E okwamanje kwenziwa kaningi kunokungenisa komoya okunemvamisa ephezulu.

Ihlinzeka ngemiphumela engcono ngesiguli esikhubazekile kanye ne-ventilator ifakwe isikhathi ukuze isenzo ngasinye esisha sokuphefumula siqale ngokushesha nje lapho ukukhipha umoya kwangaphambilini sekufinyelele ezingeni elifanele le-PEEP.

Izinga lokuphefumula lingancishiswa ngokwandisa i-apnea ephefumulayo.

Lokhu kuvame ukuholela ekunciphiseni ukucindezela kwe-intrathoracic okusho, naphezu kokwanda kwe-PEEP, futhi ngaleyo ndlela kubangele ukuthuthukiswa kwe-O2del exhunywe ukwanda kokuphuma kwenhliziyo.

I-High-frequency positive pressure ventilation (HFPPV), i-high-frequency oscillation (HFO), kanye ne-high-frequency 'jet' ventilation (HFJV) izindlela ngezinye izikhathi ezikwazi ukwenza ngcono ukugeleza komoya nomoya ngaphandle kokusebenzisa umthamo omkhulu wamaphaphu noma izingcindezi.

I-HFJV kuphela esetshenziswe kabanzi ekwelapheni i-ARDS, ngaphandle kwezinzuzo ezibalulekile ngaphezu kwe-CMV evamile ne-PEEP eboniswa ngokucacile.

I-Membrane extracorporeal oxygenation (ECMO) yafundwa ngeminyaka yawo-1970s njengendlela engaqinisekisa ukutholakala kwe-oxygen eyanele ngaphandle kokusebenzisa noma yiluphi uhlobo lokungenisa umoya ngomshini, okushiya iphaphu likhululekile ukuphola ezilonda ezibhekene ne-ARDS ngaphandle kokulifaka ekucindezelekeni okumelelwe ukucindezela okuhle. ukungena komoya.

Ngeshwa, iziguli ezinzima kangangokuthi azizange zisabele ngokwanele ekungeneni komoya okuvamile futhi ngenxa yalokho zazifaneleka ukuthola i-ECMO, zinezilonda ezimbi kakhulu zamaphaphu kangangokuthi zaqhubeka zithola i-pulmonary fibrosis futhi azizange zilulame ukusebenza kwamaphaphu okuvamile.

Ukukhipha umoya wokungena ngomshini ku-ARDS

Ngaphambi kokukhipha isiguli kumshini wokuphefumula, kuyadingeka ukuthola amathuba aso okusinda ngaphandle kosizo lokuphefumula.

Izinkomba zemishini ezifana ne-maximum inspiratory pressure (MIP), vital capacity (VC), kanye ne-spontaneous tidal volume (VT) zihlola ikhono lesiguli lokuthutha umoya ungena nokuphuma esifubeni.

Azikho kulezi zinyathelo, nokho, ezihlinzeka ngolwazi mayelana nokumelana kwemisipha yokuphefumula ukuze isebenze.

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Ezinye izinkomba ze-physiological, njenge-pH, indawo efile kuya ku-tidal volume ratio, i-P(Aa)O2, isimo somsoco, ukuqina kwenhliziyo nemithambo yegazi, kanye nokulinganisela kwe-acid-base metabolic kubonisa isimo esijwayelekile sesiguli kanye nekhono laso lokubekezelela ukucindezeleka kokulunyulwa komshini wokuphefumula. .

Ukulunyulwa kokuphuma komoya ngomshini kwenzeka kancane kancane, ukuqinisekisa ukuthi isimo sesiguli sanele ukuqinisekisa ukuphefumula okuzenzakalelayo, ngaphambi kokukhipha i-endotracheal cannula.

Lesi sigaba ngokuvamile siqala lapho isiguli sizinzile ngokwezokwelapha, nge-FiO2 engaphansi kuka-0.40, i-PEEP engu-5 cm H2O noma ngaphansi kanye nemingcele yokuphefumula, okukhulunywe ngayo ngaphambili, ibonisa ithuba elizwakalayo lokuqalisa kabusha ukuphuphuma komoya okuzenzakalelayo.

I-IMV iyindlela ethandwayo yokulumula iziguli ezine-ARDS, ngoba ivumela ukusetshenziswa kwe-PEEP enesizotha kuze kube yilapho i-extubation, okuvumela isiguli ukuba sibhekane kancane kancane nomzamo odingekayo wokuphefumula okuzenzakalelayo.

Ngalesi sigaba sokulunyulwa, ukuqapha ngokucophelela kubalulekile ukuze kuqinisekiswe impumelelo.

Izinguquko kumfutho wegazi, izinga lenhliziyo elikhulayo noma izinga lokuphefumula, ukunciphisa ukugcwala komoyampilo emithanjeni njengoba kukalwa nge-pulse oximetry, nokusebenza kwengqondo okuwohlokayo konke kubonisa ukwehluleka kwenqubo.

Ukwehla kancane kancane kokulunyulwa kungasiza ekuvimbeleni ukwehluleka okuhlobene nokukhathala kwemisipha, okungenzeka ngesikhathi kuqalwa kabusha ukuphefumula kokuzimela.

Ukuqapha ngesikhathi se-ARDS

Ukuqapha kwemithambo yamaphaphu kuvumela ukuphuma kwenhliziyo ukuthi kukalwe futhi i-O2del ne-PvO2 ibalwe.

Lezi zinhlaka zibalulekile ekwelapheni okungenzeka kube yizinkinga ze-haemodynamic.

Ukuqapha komthambo wamaphaphu nakho kuvumela ukukalwa kokucindezela kokugcwalisa i-ventricular kwesokudla (CVP) kanye nezingcindezi zokugcwalisa i-ventricular kwesokunxele (PCWP), okuyimingcele ewusizo yokunquma ukuphuma kwenhliziyo okuphelele.

Ukufakwa kwe-catheterization emithanjeni yamaphaphu ukuze kuqashwe i-haemodynamic kuba okubalulekile esimeni lapho umfutho wegazi wehla kakhulu kangangokuthi udinga ukwelashwa ngezidakamizwa ezisebenza nge-vasoactive (isb. i-dopamine, i-norepinephrine) noma uma ukusebenza kwamaphaphu kuwohloka kuze kufike ezingeni lapho kudingeka khona i-PEEP engaphezu kuka-10 cm H2O.

Ngisho nokutholakala kokungaqini kahle komshini wokucindezela, njengokudinga uketshezi olukhulu, esigulini esesivele sisesimweni esibucayi senhliziyo noma sokuphefumula, kungase kudinge ukubekwa kwe-catheter ye-pulmonary artery kanye nokuqapha i-hemodynamic, ngisho nangaphambi kokuba izidakamizwa ze-vasoactive zidinga ukufakwa. iyaphathwa.

Ukungenisa komoya okuhle kwengcindezi kungase kuguqule idatha yokuqapha i-haemodynamic, okuholela ekwenyukeni okungelona iqiniso kwamanani e-PEEP.

Amanani aphezulu e-PEEP angadluliselwa ku-catheter yokuqapha futhi abe nesibopho sokwanda kwamanani okubaliwe e-CVP ne-PCWP angahambisani nokungokoqobo (43).

Lokhu kungenzeka uma ithiphu le-catheter liseduze nodonga lwesifuba sangaphambili (i-zone I), nesiguli silele.

I-Zone I iyindawo yamaphaphu anganqamuki, lapho imithambo yegazi ihlakazeke kancane.

Uma ukuphela kwe-catheter kutholakala ezingeni lomunye wabo, amanani e-PCWP azothonywa kakhulu ukucindezela kwe-alveolar, ngakho-ke azobe engalungile.

I-Zone III ihambisana nendawo yamaphaphu eyonakele kakhulu, lapho imithambo yegazi icishe ihlale igoqekile.

Uma ukuphela kwe-catheter kukule ndawo, izilinganiso ezithathwe zizothinteka kancane kakhulu yizingcindezi zokuphefumula.

Ukubekwa kwe-catheter ezingeni le-zone III kungaqinisekiswa ngokuthatha i-X-ray yesifuba se-lateral, ezobonisa ithiphu le-catheter ngaphansi kwe-atrium yangakwesobunxele.

Ukuthobela ngokuqinile (i-Cst) kunikeza ulwazi oluwusizo mayelana nokuqina kodonga lwamaphaphu nesifuba, kuyilapho ukuthobela okuguquguqukayo (Cdyn) kuhlola ukumelana kwendlela yomoya.

I-Cst ibalwa ngokuhlukanisa ivolumu ye-tidal (VT) ngokucindezela okumile (i-plateau) (Pstat) kukhishwe i-PEEP (Cst = VT/Pstat – PEEP).

I-Pstat ibalwa phakathi ne-apnea emfushane yokuphefumula ngemva kokuphefumula okukhulu.

Ngokwenza lokhu, lokhu kungafezwa ngokusebenzisa umyalo wokumisa isikhashana we-ventilator engumshini noma ngokuvala ngesandla komugqa wokuphelelwa umoya wesekethe.

Ukucindezela kuhlolwa ku-manometer ye-ventilator ngesikhathi se-apnea futhi kufanele kube ngaphansi komfutho womoya omkhulu (Ppk).

Ukuhambisana kwe-Dynamic kubalwa ngendlela efanayo, nakuba kulesi simo i-Ppk isetshenziswa esikhundleni sokucindezela okumile (Cdyn = VT/Ppk - PEEP).

I-Cst evamile iphakathi kuka-60 no-100 ml/cm H2O futhi ingancishiswa ibe cishe ku-15 noma 20 ml/cm H20 ezimeni ezinzima zenyumoniya, i-pulmonary edema, i-atelectasis, i-fibrosis ne-ARDS

Njengoba ingcindezi ethile idingeka ukuze unqobe ukumelana nomgwaqo womoya ngesikhathi sokungenisa umoya, ingxenye yomfutho omkhulu owenziwe ngesikhathi sokuphefumula ngomshini imelela ukumelana nokugeleza okuhlangatshezwana nayo emigwaqweni yomoya kanye namasekhethi okuphefumula.

Ngakho-ke, i-Cdyn ikala ukonakala okuphelele kokugeleza komzila womoya ngenxa yezinguquko kukho kokubili ukuhambisana nokumelana.

I-Cdyn evamile iphakathi kuka-35 no-55 ml / cm H2O, kodwa ingathinteka kabi izifo ezifanayo ezinciphisa i-Cstat, futhi futhi nezici ezingashintsha ukumelana (i-bronchoconstriction, i-edema ye-airway, ukugcinwa kwemfihlo, ukucindezelwa kwe-airway nge-neoplasm).