呼吸危重症年度进展2022

Clinical update in critical care of pulmonary medicine 2022

本文回顾国内外呼吸危重症领域在2022年度(2021年10月1日到2022年9月30日)的临床进展。研究发现发病前虚弱体质和有创机械通气中呼吸困难主诉是危重症患者预后不利因素,冷冻肺活检或可有效提高危重症患者疾病诊断准确率,床旁微生物形态学快速诊断技术(M-ROSE)能够在床旁快速明确是否感染和感染致病原;电阻抗成像技术(EIT)、跨肺驱动压(DPL)、气道驱动压(DPaw)在动态评估、指导个体化呼吸支持和预后评价方面具有积极的意义;巴瑞克替尼可能对合并有高炎症反应的重症感染患者具有积极的疗效,而延迟应用抗菌素会明显增加重症感染发生率及休克患者的病死率,抗菌素应用时机和感染源控制至关重要;无创正压通气会降低拔管后高风险肥胖或超体重患者再插管风险和ICU病死率,跨肺压滴定呼气末正压(PEEP)能对病情更为危重的ARDS患者(APACHEⅡ>27.5)带来获益,ECMO联合俯卧位通气能够进一步改善重症ARDS患者预后,因此对危重症患者在动态监测和评估的基础上采取个体化呼吸支持策略至关重要。

In this review,we outlined the clinical studies in critical care field of pulmonary medicine from October 1,2021 to September 30,2022.For critically ill patients,frailty before disease onset was a predictor of mortality with increasing ICU length of stay,and the complaints of dyspnea in intubated phase was independently associated with posttraumatic stress disorder.Compared with transbronchial lung biopsy(TBLB)for patients with acute hypoxemic respiratory failure,transbronchial lung cryobiopsy(TBLC)had a positive significance to in leading to an increased chance of establishing a more accurate diagnosis,which could significantly improve the patients′prognosis.M-ROSE(microbiological rapid on-site evaluation)had high diagnostic value for lower respiratory tract pathogens,and the application of M-ROSE in the ICU could contribute to promoting a decrease in patients′inflammation levels and reducing the mortality of patients with invasive mechanical ventilation.EIT(electrical impedance tomography),DPL(transpulmonary driving pressure)and DPaw(airway driving pressure)had excellent positive values on dynamic assessment,guiding individualized respiratory support and prognostic evaluation.In critically ill hospitalized patients with COVID-19 who had received invasive mechanical ventilation or extracorporeal membrane oxygenation,treatment with baricitinib compared with placebo(in combination with standard of care,including corticosteroids)might reduce mortality.Delayed antimicrobial treatment significantly increased the incidence of severe infection and the mortality of shock patients,however,timing of antimicrobial therapy and control of the source of infection was critical.NIV(non-invasive ventilation)alternating with high-flow nasal oxygen immediately after extubation significantly decreased the risk of reintubation and death compared with high-flow nasal oxygen alone in obese or overweight patients at high risk of extubation failure.The effect of Pes-guided positive end-expiratory pressure(PEEP),compared with empirical high PEEP,was associated with lower mortality for more severe acute respiratory distress syndrome(ARDS)ventilated patients(APACHEⅡ>27.5).Prone-positioning during veno-venous extracorporeal membrane oxygenation was safe and effective and was associated with a higher probability of surviving and being weaned-off extracorporeal membrane oxygenation at 90 days.Therefore,individualized respiratory support strategies based on dynamic monitoring and assessment were essential for critically ill patients.