Virus induced acute respiratory distress syndrome

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Source: pediatric | assistant: Sarah
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病毒所致急性呼吸窘迫综合征
Virus induced acute respiratory distress syndrome
急性呼吸窘迫综合征(acuterespiratory distress syndrome,ARDS)是1967年由Ashbough发现的一种急性进行性低氧性呼吸衰竭,其特征为肺泡毛细血管屏障广泛破坏、蛋白渗出性肺水肿、进行性呼吸困难和顽固性低氧血症。ARDS一直是重症医学工作者关注的焦点。ARDS病死率的高低在一定程度上折射出该地区ICU救治水平的高低。
Acute respiratory distress syndrome (acuterespiratory distress, syndrome, ARDS) is a kind of acute hypoxic respiratory failure was found in 1967 by Ashbough, characterized by extensive destruction of alveolar capillary barrier, protein exudative pulmonary edema, dyspnea and intractable hypoxemia. ARDS has been the focus of attention of critical care workers. The mortality rate of ARDS reflects the level of ICU treatment in a certain extent.
自2003年严重急性呼吸综合征(SARS)爆发以来,我国儿科界先后经历了禽流感、手足口病、甲型流感、麻疹、腺病毒肺炎等病毒性疾病的局部或大规模流行,其最严重形式均为ARDS。病毒所致ARDS已经成为儿科重症医师急待攻克的最重要疾病之一。
Since 2003, severe acute respiratory syndrome (SARS) outbreak in China has experienced the pediatric community local epidemic or large-scale avian flu, foot and mouth disease, influenza, measles, adenovirus pneumonia and other viral diseases, the most serious form is ARDS. Virus induced ARDS has become one of the most important diseases in pediatric intensive care physicians.
一、病因与常见临床表现
Etiology and common clinical manifestations
1.季节性病毒感染有文献认为病毒性肺炎占社区获得性肺炎的10%~40%。国外报道流感病毒及鼻病毒最常见,其他呼吸道病毒如偏肺病毒、腺病毒、呼吸道合胞病毒及冠状病毒次之。这些病毒均可引起严重病毒性肺炎,导致ARDS。在我国临床中,近年来引起ARDS的季节性病毒性肺炎,主要是腺病毒、季节性流感病毒及偏肺病毒。关于其由这些病毒性肺炎引起ARDS的发生率,目前尚无临床流行病学数据支持。由于相当一部分肺炎在门诊、观察室及普通病区治疗,客观上使得其临床流行病学研究几无可能。

文思海辉ISMS倡导企业信息安全”泛安全”理念

1 the seasonal viral infection is that the virus pneumonia accounts for the community acquired pneumonia of 10% ~ 40%. Foreign reports of influenza virus and rhinovirus are the most common, other respiratory viruses such as hepatitis C virus, adenovirus, respiratory syncytial virus and coronavirus. These viruses can cause severe viral pneumonia, leading to ARDS. In our country, in recent years, ARDS has been caused by seasonal viral pneumonia, including adenovirus, seasonal influenza virus and. There is no clinical epidemiological data on the incidence of ARDS caused by these viral pneumonia. Because a considerable part of the pneumonia in the clinic, observation room and the general treatment of the disease, the objective of making its clinical epidemiological study is impossible.
腺病毒肺炎是近年来在我国较为常见的可引起ARDS的疾病。其多发于春夏季,发生率占所有病毒性肺炎的8%~10%。患儿常见症状为高热、咳嗽、面色差、进行性呼吸困难。有些患儿合并有心功能不全、休克,X线胸片示进行性加重的肺部浸润影。其治疗主要是西多福韦抗感染,给予呼吸支持。
Adenovirus pneumonia is a common disease which can cause ARDS in China in recent years. It occurred in spring and summer, which accounted for 8% to 10% of all viral pneumonia. The common symptoms were fever, cough, poor complexion and progressive dyspnea. Some patients with heart failure, shock, chest X-ray showed progressive exacerbation of pulmonary infiltrates. The treatment is mainly cidofovir resistance to infection, provide respiratory support.
2.流行性病毒感染近十余年,在我国儿童中能引起呼吸衰竭与ARDS的流行性病毒感染主要有4种病种:引起SARS的冠状病毒、引起禽流感肺炎的H5N1、引起甲型流感的H1N1和麻疹病毒。
The 2 pandemic virus infection in recent ten years, the epidemic virus infection can cause respiratory failure and ARDS are 4 kinds of diseases in Chinese children: caused by SARS coronavirus, caused by avian influenza pneumonia caused by influenza H5N1, H1N1 virus and measles.
(1)SARSSARS于2002年首先在中国广东发现,波及5大洲26个国家,有8000多人罹患该病,774人病死。其起病症状多为发热、寒颤、肌痛、咳嗽、气短、呼吸增快。X线胸片示近100%患者两肺浸润影。流行期间仅有1/3为普通经过,2/3均合并严重并发症,其中最严重的均为ARDS。该病主要侵犯成人,儿科患儿相对较少。该病无特效治疗措施。
(1) SARSSARS was first discovered in Guangdong, China in 2002 and has spread to more than 26 countries on 5 continents, with a total of more than 8 thousand people suffering from the disease and the death of 774 people. The onset of symptoms were fever, chills, muscle pain, cough, shortness of breath, breathing faster. Chest X-ray showed that nearly 100% of patients with pulmonary infiltrates two. During the epidemic period, only 1 \/ 3 of the patients were normal, and severe complications were found in both the 2 and 3 of the patients. The most severe cases were ARDS. The disease mainly affects adults, pediatric patients are relatively small. There is no specific treatment for this disease.
(2)禽流感禽流感由H5N1引起,1998年首次发现,可导致严重肺炎,常迅速进展为ARDS,其病死率高达60%。其起病症状极普通且无特异性,发热、气促、咳嗽、呕吐、腹泻、头痛等。大部分病例迅速进展为呼吸衰竭和ARDS。尸体解剖发现弥漫性肺泡损害、肺透明膜形成、小叶性间质淋巴浆细胞性浸润、细支气管炎伴局部鳞状细胞化生、肺充血、肺出血等。治疗除呼吸支持外,可给予奥司他韦、帕那米韦治疗。该病亦主要见于成人,但小儿也时有报道。
(2) avian influenza caused by H5N1, first discovered in 1998, can lead to severe pneumonia, often rapid progress of ARDS, the mortality rate as high as 60%. The most common symptoms and nonspecific, fever, shortness of breath, cough, vomiting, diarrhea, headache, etc.. The majority of cases rapidly progressed to respiratory failure and ARDS. Autopsy revealed diffuse alveolar damage, hyaline membrane formation, lobular interstitial plasma cell infiltration, bronchiolitis with localized squamous metaplasia, pulmonary congestion, pulmonary hemorrhage, etc.. In the treatment of respiratory support, given oseltamivir and Pana Mi Vee therapy. The disease is mainly seen in adults, but children also reported.

鹤壁一女子将平板电脑放在暖气包上 屏幕炸裂

(3)甲型流感甲型流感由H1N1引起,2009年在美国加利福尼亚州率先发生,引发全球流行,我国小儿发病数很高,几乎每一个PICU在流行期间均收治许多患儿。其起病症状多为呼吸道症状,进展为病毒性肺炎,大多呈良性经过,严重者进展为ARDS。2009年甲型流感严重者多见于小于1岁的婴儿、孕妇、慢性心血管疾病、慢性肺疾病、病理性肥胖、慢性肾病、血红蛋白病、硬化病等。但在住院或死亡的患儿中,有一半患儿并无上述合并症。病毒性肺炎伴低氧血症、ARDS、休克、肾功能衰竭及坏死性脑病为患儿入住PICU的常见原因。尸体解剖发现从上气道到肺泡均有病毒定植,所有标本均可见弥漫性肺泡损害,部分可见肺泡出血、肺泡内水肿、血管周围炎、微血栓形成和(或)肺栓塞。肺泡细胞如Ⅰ型和Ⅱ型肺泡上皮细胞是最主要的感染肺泡。尤其值得注意的是,将近25%的患者合并有细菌感染。该病治疗除呼吸支持外,奥司他韦为首选抗病毒药,耐药者用扎那米韦或帕那米韦。
(3) influenza A H1N1 influenza caused by H1N1, 2009 the first place in the American state of California, triggered a global epidemic, the incidence of children in our country is very high, almost every PICU in many children were admitted during the epidemic period. The onset symptoms of respiratory tract symptoms, progression of viral pneumonia, mostly benign, severe progression of ARDS. In 2009, severe influenza A was found in infants less than 1 years old, pregnant women, chronic cardiovascular disease, chronic lung disease, pathological obesity, chronic kidney disease, hemoglobin disease, sclerosis, etc.. But in the hospital or death of the children, half of the children with no such complications. Viral pneumonia with hypoxemia, ARDS, shock, renal failure and necrotizing encephalopathy are the common causes of PICU in children. The autopsy found from the upper airway to the alveoli were viral colonization, all specimens showed diffuse alveolar damage, visible alveolar hemorrhage and alveolar edema, perivascular inflammation, micro thrombosis and pulmonary embolism (or). Alveolar cells, such as type I and type II alveolar epithelial cells, are the most important alveolar cells. Of particular note is that nearly 25% of patients with bacterial infection. The disease in the treatment of respiratory support, oseltamivir is the preferred antiviral drugs, drug resistant patients with zanamivir or Pana Mi Vee.
(4)麻疹麻疹病毒最近在我国许多地区流行,多见于未予预防接种的患儿及小于8个月患儿。许多患儿并发麻疹肺炎合并ARDS,其主要症状为高热、咳嗽、肺部浸润影、低氧血症。治疗主要保持液体负平衡、合并感染者及时给予抗生素治疗、大剂量维生素A治疗、呼吸支持等。二、诊断
(4) measles virus recently popular in many areas of our country, not found in the vaccination of children and infants less than 8 months. Many children with measles pneumonia complicated with ARDS, the main symptoms of high fever, cough, pulmonary infiltrates, hypoxemia. Treatment mainly to maintain a negative balance of the liquid, the combination of infection in a timely manner to antibiotic treatment, high-dose vitamin A therapy, respiratory support, etc.. Two, diagnosis
ARDS诊断目前主要依据两个标准,分别为2012年ARDS柏林标准及2015年美国小儿急性肺损伤协作网的“小儿ARDS共识”。两个标准无太大差异,前者易掌握,较直观;后者更贴近49L实际,但有些标准难以掌握。无论如何,两个标准只要符合任一标准即可诊断为ARDS。诊断标准见表1和表2。
ARDS diagnosis is currently based on two criteria, namely the 2012 ARDS Berlin standard and the United States children’s acute lung injury in collaboration with the children’s ARDS consensus in 2015. There is no big difference between the two standards, the former easy to grasp, more intuitive; the latter closer to the actual 49L, but some difficult to grasp the standard. In any case, the two criteria can be diagnosed as ARDS. Diagnostic criteria see Table 1 and table 2.
三、临床特征

Three, clinical features
经过近十年的临床救治,结合相关文献,我们总结病毒性ARDS的临床特征如下。
几乎所有跨国公司都认为给新入职员工提供培训是非常有必要的,且多数已经将信息安全纳入到新员工的培训当中。
After nearly ten years of clinical treatment, combined with the relevant literature, we summarize the clinical features of viral ARDS are as follows.
1.起病急骤患儿从肺炎到转变为ARDS时间短,有些患儿在1~2d之内,多在3~5d之内,很少有超过1周才发生ARDS,尤以禽流感肺炎相关性ARDS起病最为急骤,甲型流感肺炎相关性ARDS起病次之,麻疹肺炎相对较缓。
1 children with sudden onset from pneumonia to ARDS into a short time, some children in the 1 ~ 2D, in 3 ~ 5D, with little more than 1 weeks before the occurrence of ARDS, especially in the relationship between the onset of ARDS avian influenza pneumonia most quickly, influenza associated pneumonia ARDS onset of measles pneumonia is relatively slow.
2.低氧血症明显此类患儿多迅速进展为重症ARDS,且有进行性加重趋势。其血PaO2多很低,常有低达20mmHg~40mmHg的情形,易被误诊为静脉血气,此时只要核对一下患儿紫绀情形及脉氧饱和度即能断定。从另一方面讲,若在临床中遇到血气特差、发展极快的,应疑及重症病毒性肺炎,应仔细询问病史,注意当地流行病学史及禽类接触史,并常规行各种病毒学检测。值得注意的是,在询问禽类接触史时,应仔细询问自家、邻居、本村或社区有无接触活禽史,有无异常死禽包括飞鸟死亡现象及有无实质接触等。
2 hypoxemia was significantly more rapid progression of such children with severe ARDS, and there was a progressive trend. The blood PaO2 is very low, often as low as 20mmHg ~ 40mmHg, were easily misdiagnosed as venous blood gas, this time as long as check with cyanosis and pulse oxygen saturation can be determined. On the other hand, if the blood in the clinical encounter in poor, fast development, and should be suspected of severe viral pneumonia, should pay attention to careful history, history and local poultry epidemiological contact history, and a variety of routine virological testing. It is worth noting that, in asking the history of exposure to poultry, should be careful to ask their neighbors, the village or community, have no history of contact with live poultry, there is no abnormal dead bird birds including death phenomenon and has no substantive contact etc..
3.肺顺应性差病毒性肺炎患儿多数肺部顺应性很差,但部分患儿存在顽固性低氧血症但肺部顺应性尚好的情形,尤以甲型流感患儿和腺病毒肺炎患儿为突出。这类患儿其影像学检查提示肺部病变很重,但呼吸机压力参数不高,潮气量却非常高,远超过肺保护性通气所要求的潮气量,应变力(strain)显著上升,极易导致呼吸机相关性肺损伤,加重本以存在的ARDS。这多与此类患儿神经冲动强烈有关,需要强镇静及肌松剂,否则无法进行肺保护性通气策略。
3 poor lung compliance in children with viral pneumonia most lung compliance is poor, but some patients had refractory hypoxemia but pulmonary compliance is still good, especially in children with influenza and adenovirus pneumonia is prominent. These children with the imaging revealed pulmonary lesions is very heavy, but the pressure parameter is not high, the tidal volume is very high, far more than the tidal volume lung protective ventilation requirements, strain (strain) increased significantly, can easily lead to ventilator induced lung injury, the increase in the presence of ARDS. This is more strongly associated with this type of nerve impulses, the need for strong sedation and muscle relaxants, or can not be lung protective ventilation strategy.
4.自发性气胸 病毒性肺炎另一个重要的临床特征是自发性气胸,可能病毒性肺炎合并ARDS患儿多存在坏死细支气管炎相关。即在患儿未接受任何正压通气的情形下出现气胸、纵隔气肿,给ARDS的机械通气治疗带来极大困难。此类患儿一方面会出现自发性气胸,另一方面机械通气后比其他儿童更易发生气胸。探讨其机制,从病理解剖上可以看出,一些病毒性肺炎除了肺实质病变外,尚易出现坏死性细支气管炎。这样必然导致气体逸出,沿支气管鞘漏至纵隔,引起纵隔气肿及气胸。
4 another important clinical feature of spontaneous pneumothorax viral pneumonia is spontaneous pneumothorax, which may be related to the presence of necrotizing bronchiolitis in children with viral pneumonia complicated with ARDS. The children did not receive any positive pressure ventilation under pneumothorax, mediastinal emphysema, brought great difficulties to the mechanical ventilation in the treatment of ARDS. On the one hand, this kind of children will appear spontaneous pneumothorax, on the other hand, mechanical ventilation is more prone to pneumothorax than other children. To explore the mechanism, we can see from the pathological anatomy, some viral pneumonia in addition to the lung parenchyma lesions, still prone to necrotizing bronchiolitis. This will inevitably lead to gas leakage, along the bronchial sheath into the mediastinum caused by mediastinal emphysema and pneumothorax.
ARDS肺部实变CT影像
ARDS lung real change CT image
四、管理
Four, management
病毒性肺炎所致ARDS是PICU中最大的挑战,其治疗极为困难,需要集中整个团队的力量,应用可能应用的所有技术手段,尽最大可能的救治患儿。本文只针对特殊治疗手段作阐述。
Viral pneumonia caused by ARDS is the biggest challenge in PICU, its treatment is extremely difficult, the need to focus on the strength of the whole team, the application of all possible technical means, to the best possible treatment of children. This article is only for special treatment means.
1.肺保护性机械通气策略肺保护性通气策略的精髓是小潮气量、高PEEP及限制平台压。将Pa02维持在55~80mmHg,PaC02维持在35~45mmHg,Sa02维持在88%~92%。
1 lung protective mechanical ventilation strategy of lung protective ventilation strategy is the essence of low tidal volume, high pressure PEEP and restricted platform. Pa02 will be maintained at 55 ~ 80mmHg, PaC02 maintained at 35 ~ 45mmHg, Sa02 maintained at between 88% ~ 92%.
(1)小潮气量小潮气量目前已成为业界共识,但是否能坚持每一天都应用小潮气量是重要问题。我国PICU的ARDS治疗临床医师多采用压力控制通气模式,其重要特征是潮气量不稳定,如果不能每天密切监测潮气量,会出现两种结果:一是患儿肺顺应性越来越差,潮气量远小于6ml/kg,此时若PaC02正常,氧合在可接受范围,恰是理想状态,是“歪打正着”。更多是患儿通气严重不足,PaC02过高,氧合受影响,患儿病情恶化,此时若不调高压力将潮气量维持在6ml/kg左右,会产生恶性结局;二是患儿顺应性转好,潮气量远大于6ml/kg,此时必然会导致ARDS肺的应变力(strain)显著上升,导致呼吸机相关性肺损伤。
(1) the low tidal volume and low tidal volume at present has become the industry consensus, but whether it can be used every day low tidal volume is an important problem to. ARDS treatment of PICU in China by clinicians pressure control ventilation mode, its important characteristics is the tidal volume is not stable, if not daily close monitoring of tidal volume, there will be two results: one is the children with lung compliance is getting worse, the tidal volume is far less than 6ml \/ kg, if the PaC02 is normal, oxygenation range in May, it is the ideal state, is a. More children is a serious shortage of ventilation, high PaC02, oxygenation affected, with disease progression, if not adjusted high pressure tidal volume remained at 6ml \/ kg, will produce a vicious outcome; two patients compliance improved, tidal volume is far greater than 6ml \/ kg, this will inevitably lead to the strain ARDS of the lung (strain) increased significantly, leading to ventilator induced lung injury.
这里存在一个误区,有医师认为肺顺应性转好,潮气量上升点没有关系,理论上讲似乎正确,但若以应力(stress)应变(strain)理论来评估ARDS患儿潮气量,尤其是病毒性肺炎所致ARDS潮气量,大多小儿潮气量应远小于6ml/kg,临床实际应用时综合通气功能才设定为6ml/kg,故当肺顺应性好转后仍将潮气量设定为6ml/kg应恰好符合了ARDS肺生理需求。今年美国一项多中心研究亦证实了这样的观点,他们研究发现:①初始参数中,潮气量每增高1ml/kg,ARDS病死率增加23%;在初始参数设定之后,后续参数中,潮气量每增加1ml/kg,病死率增加15%。②刚上呼吸机后连续8d应用潮气量8ml/kg,与连续应用8d潮气量6ml/kg相比,初始8d病死率分别为7.2%和2.7%。
Here there is a misunderstanding, some doctors think lung compliance improved, tidal volume rising point Never mind theory, seems to be correct, but if the stress (stress) strain (strain) theory to evaluate with ARDS tidal volume, especially viral pneumonia caused by ARDS tidal volume, large tidal volume should be far less than many children 6ml \/ kg, the clinical application of comprehensive ventilation function is set to 6ml \/ kg before, so when the lung compliance improved will still set tidal volume is 6ml \/ kg should be exactly in line with the ARDS pulmonary physiological needs. The United States this year, a multicenter study also confirmed this point of view, they discovered that the initial parameters, each tidal volume increased 1ml \/ kg, the mortality rate of ARDS increased by 23%; after the initial parameter setting, follow-up parameters, each increase in tidal volume of 1ml \/ kg, the mortality rate increased by 15%. The first 8D application after continuous ventilator tidal volume of 8ml \/ kg, compared with the continuous application of 8D \/ kg tidal volume 6ml, initial 8D mortality rates were 7.2% and 2.7%.
(2)相对高PEEP临床医师在ARDS患儿氧合不好时,多首先调节氧浓度,而不是去调节PEEP。将PEEP调节到较理想状态是最佳选择,因为维持肺泡适度开放是患儿获得较好氧合的最重要条件之一。我们提倡应根据美国ARDS协作网提供的Fi02/PEEP捆绑法来设定PEEP,PEEP维持在8~16cmH2O是最常见的选择,不能太低。
(2) compared with the high PEEP clinicians, when children with ARDS were not well oxygenated, they first adjusted the oxygen concentration, rather than the PEEP. It is the best choice to adjust the PEEP to the ideal state, because the maintenance of alveolar opening is one of the most important conditions for children to get better oxygenation. We advocate the United States should be provided by the ARDS collaboration Fi02 \/ PEEP bundle method to set PEEP, PEEP maintained at 8 ~ 16cmH2O is the most common choice, not too low.
2.俯卧位通气病毒性肺炎所致ARDS,一旦符合重度ARDS,建议试行俯卧位通气,若有效,应坚持每天应用16h以上。若无效,可24h后再试用。俯卧位通气是继小潮气量后ARDS治疗的又一重大进展,可显著降低严重ARDS病死率,但应密切注意并发症,避免血流动力学不稳定及脱管等意外发生。同时若本来有血流动力学不稳定、颈髓外伤等情形不宜使用该方法。具体可见参考文献。
2 prone ventilation viral pneumonia caused by ARDS, once with severe ARDS, suggestions for prone position ventilation, if effective, should adhere to the above application 16h every day. If it is not valid, it can be tried again after 24h. Prone ventilation is another major progress after ARDS treatment of low tidal volume, and can decrease the mortality rate of ARDS, but should pay close attention to avoid complications, hemodynamic instability and tube off accident. At the same time, if there is hemodynamic instability, cervical spinal cord injury and other circumstances should not use this method. Specific visible reference.
3.保守补液ARDS本质上是肺泡毛细血管屏障破坏引起的蛋白渗出性肺水肿。由于肺泡毛细血管屏障破坏,若我们临床上不注意液体平衡,形成液体入量大于出量,其每日多余的液量必然顺着压力梯度进入肺泡,加重业已存在的肺水肿。既往有观察性研究证实,ARDS患者若头3d的累积液体出量大于入量,与更好的预后相关。一项观察性研究说明预后好的ARDS患者头3d会出现自发性利尿现象,以减轻肺水肿。这项研究给我们的启示是我们应当人为制造液体负平衡,以减轻ARDS患儿肺水肿。故在临床上,应每日核计出入量,确保出量大于或等于入量,维持患儿在轻度脱水状态。
3 conservative fluid replacement ARDS is essentially a pulmonary edema caused by damage to the alveolar capillary barrier. Because of the alveolar capillary barrier damage, if we do not pay attention to the clinical fluid balance, the formation of liquid intake is greater than the amount of the daily excess the amount of fluid into the alveolar pressure gradient along the inevitable, aggravate the existing pulmonary edema. Previous observational studies have shown that the cumulative fluid volume of 3D in patients with ARDS is greater than that in the patients, and is associated with a better prognosis. An observational study has shown that spontaneous diuresis may occur in patients with ARDS, who have a good prognosis, to alleviate pulmonary edema (3D). The implication of this study is that we should artificially create a negative balance of fluid to relieve pulmonary edema in children with ARDS. Therefore, in clinical practice, should assess the daily intake, ensure that the volume is greater than or equal to the amount, in the maintenance of children with mild dehydration state.
4.镇痛镇静肌松几乎所有的机械通气患儿均需给予镇痛镇静,将Ramsay评分维持在2~5分左右,这已成为共识。对于病毒性ARDS患儿来说,这可能还不够。前面临床特征中我们提到,有些病毒性ARDS患儿,其肺部病变极重,氧饱和度极差,可是其顺应性却很好,我们潮气量目标设定在6ml/kg,可根本无法达到,其潮气量往往在10ml/kg以上,这样势必会引起呼吸机相关性肺损伤。此类患儿应给予深度镇静镇痛加肌松,打掉患儿自主呼吸,确保小潮气量方案的实施。值得注意的是肌松剂的合理时间是不超过48h,肌松剂禁与激素合用。
4 analgesia sedation muscle relaxation almost all of the children with mechanical ventilation are required to give analgesia sedation, the Ramsay score in 2 ~ 5 minutes or so, this has become a consensus. This may not be enough for children with viral ARDS. In front of the clinical features we mentioned, some children with viral ARDS, the lung lesions in extremely poor oxygen saturation, but its adaptability is very good, our tidal volume target set at 6ml \/ kg, which cannot be achieved, the tidal volume in 10ml \/ kg or more often, it is bound to cause ventilator induced lung injury. The children should be given the depth of sedation and analgesia and muscle relaxation were destroyed, spontaneous breathing, to ensure the implementation of the scheme of low tidal volume. It is worth noting that the reasonable time of muscle relaxant is not more than 48h, the combination of muscle relaxant and hormone.
5.体外膜肺体外膜肺氧合在甲型流感所致重度ARDS相关临床研究中,发现可以显著降低ARDS病死率。体外膜肺氧合是病毒性ARDS的终极救治手段,但由于其投入高,适合病例少,目前在我国开展不多,相信随着国家经济实力的日益增加,体外膜肺氧合会逐步得到普及。

5 extracorporeal membrane oxygenation (ARDS) in patients with severe influenza A (ARDS) was associated with a significant reduction in mortality. Extracorporeal membrane oxygenation is the ultimate means of treatment of viral ARDS, but because of its high investment, suitable for the small number of cases, at present in our country is not much, I believe that with the country’s economic strength is increasing, extracorporeal membrane oxygenation will gradually gain popularity.
6.对症处理自发性气胸及机械通气后患儿出现的压力性气胸是病毒性ARDS最为常见的并发症,亦是稍有不慎即可致命的并发症。病毒性肺炎所致ARDS患儿应密切监测有无自发性纵隔气肿和气胸,上机后若发现患儿突然急剧加重应首先排除气胸,若是气胸,应首先降低呼吸机参数,及时作胸腔闭式引流,此类患儿多数呼吸机参数较高,不能等不要观察,及时胸腔闭式引流是最重要的方法。胸腔闭式引流成功后可将参数调回原先数值即可,注意只要胸腔闭式引流有效,呼吸机参数几乎完全可以自由调节。有些患儿只有纵隔气肿皮下气肿,这类患儿较难处置。有条件的医院可作胸骨上凹或剑突下皮瓣引流,无条件者可用注射针头刺到皮下放气,其呼吸机参数可置相对低水平,若后来出现气胸,即可行胸腔闭式引流,纵隔内积气会一同排出,此时呼吸机参数可自由调节。
6 symptomatic treatment of spontaneous pneumothorax and mechanical ventilation in children after the emergence of pressure pneumothorax is the most common complications of viral ARDS, but also a little can be fatal complications. Children with viral pneumonia caused by ARDS should be closely monitored with spontaneous pneumomediastinum and pneumothorax, if found on children with sudden exacerbation should first exclude pneumothorax, if pneumothorax, should reduce ventilator parameters first, timely closed thoracic drainage, the children most breathing machine parameters is higher, can not observe, timely closed thoracic drainage is the most important method. Closed thoracic drainage after the success of the parameter can be transferred back to the original value, as long as the attention of closed thoracic drainage, ventilator parameters can be adjusted freely almost completely. Some children only mediastinal emphysema and subcutaneous emphysema, these children are difficult to dispose of. The conditions of the hospital as the suprasternal fossa or epigastric flap drainage, no condition available injection needle into the subcutaneous bleeding, the ventilator parameters can be arranged at relatively low levels, if later pneumothorax can be closed thoracic drainage, mediastinal pneumatosis will be discharged, the breathing machine parameters can be adjusted freely.
资料来源:
Sources of data:
喻文亮,葛许华.病毒所致急性呼吸窘迫综合征.中国小儿急救医学,2015,22(12):818-821,825.
Yu Wenliang, Ge Xu Hua. Acute respiratory distress syndrome caused by virus. Chinese pediatric emergency medicine, 2015, 22 (): 818-821825.
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