儿童急性呼吸窘迫综合征的治疗进展(英文)

Acute respiratory distress syndrome in the pediatric age: an update on advanced treatment

急性呼吸窘迫综合征（ARDS）是一种具有复杂病理和发病机制的异质性综合征，目前仍没有一个明确和有效的治疗对策。根据低氧血症程度，ARDS分成三类：轻度（200mmHg〈氧合指数≤300mmHg）、中度（100mmHg〈氧合指数≤200mmHg）、严重（氧合指数≤100mmHg）。治疗ARDS的基础是正确的重症监护治疗。早期管理可以改善预后，避免副作用和并发症，并提高存活率。治疗诱因（如败血症、肺炎），最大限度地减少多器官功能衰竭（MOF）、功能障碍和呼吸机相关性肺损伤（VILI）的风险在治疗过程中是至关重要的。

Acute respiratory distress syndrome （ARDS） is a heterogeneous syndrome that lacks definitive treatment. The cornerstone of management is sound intensive care treatment and early anticipatory ventilation support. A mechanical ventilation strategy aiming at optimal alveolar recruitment, judicious use of positive end-respiratory pressure （PEEP） and low tidal volumes （VT） remains the mainstay for managing this lung disease. Several treatments have been proposed in rescue settings, but confirmation is needed from large controlled clinical trials before they be recommended for routine care. Non-invasive ventilation （NIV） is suggested with a cautious approach and a strict selection of candidates for treatment. Mild and moderate cases can be efficiently treated by NIV, but this is contra-indicated with severe ARDS. The extra-corporeal carbon dioxide removal （ECCO2R）, used as an integrated tool with conventional ventilation, is playing a new role in adjusting respiratory acidosis and CO2. The proposed benefits of ECCO2R over extra-corporeal membrane oxygenation （ECMO） consist in a reduction of artificial surface contact, avoidance of pump-related side effects and technical complications, as well as lower costs. The advantages and disadvantages of inhaled nitric oxide （iNO） are better recognized today and iNO is not recommended for ARDS and acute lung injury （ALI） in children and adults because iNO results in a transient improvement in oxygenation but does not reduce mortality, and may be harmful. Several trials have found no clinical benefit from various surfactant supplementation methods in adult patients with ARDS. However, studies which are still controversial have shown that surfactant supplementation can improve oxygenation and decrease mortality in pediatric and adolescent patients in specific conditions and, when applied in different modes and doses, also in neonatal respiratory distress syndrome （RDS） of preemies. Management of ARDS remains supportive, aimed at improving gas exchange and preventing complications. Progress in the treatment of ARDS must be addressed toward the new paradigm of the disease pathobiology to be applied to the disease definition and to predict the treatment outcome, also with the perspective to develop predictive and personalized medicine that highlights new and challenging opportunities in terms of benefit for patient＇s safety and doctor＇s responsibility, with further medico-legal implication.