急性呼吸窘迫症候群診斷定義的新變革— 從AECC到柏林定義

1 2013 24 79-84.. aecc . 1 1,2 1,2. 1.. 2.. (ARDS) 1967 . ARDS 1994 . ARDS ( aecc ) aecc . ARDS . aecc 2011 . ARDS ARDS aecc . ARDS -- . (Acute respiratory distress syndrome). (Berlin definition). (Adult respiratory distress syndrome) (ARDS)2 Chest . 1967 Ashbaugh 12 ARDS . X. 1.. X .. (Positive ARDS . end-expiratory pressure--PEEP) .. (widespread pulmonary inflamma- ARDS . tion) (hyaline membranes) 1988 3 Murray . 1971 Petty (parenchymal lung injury) ( ) . 2 201 . 079-084_1140 79 2013/5/8 02:08:39. 80 . 1. 2. ( mmHg . lung injury score ) 3. -- (acute lung injury, lung injury score ( ) ALI).

2 X (PaO2/FiO2 ratio) (PaO2/FiO2 300 mmHg) IV.. PEEP 0-4 . > ARDS . ARDS . 1994 . (The American-European Consensus . Conference, aecc ) ARDS ( . aecc ) aecc ( ). 4,5 I. ARDS A ARDS . acute adult ARDS Acute aecc . respiratory distress syndrome II. ARDS ARDS aecc . 6,7 . 1. aecc . III. ARDS . ( ) (1) (2) 2. aecc ARDS . X (3) 18mmHg X . (4) PaO2/FiO2 200 X Ferguson (Parenchymal lung injury) 3. 1 . 2 (Lung injury score) (ARDS) .. 3 . disseminated intravascular coagulation . (Lung injury score) 3.. 0 1 2 3 4. X (consolidation). 1 2 3 4.. (P/F ratio) 300 225-299 175-224 100-174 100.

3 PEEP, cmH2O 5 6-8 9-11 12-14 15. , ml/cmH2O 80 60-79 40-59 20-39 19. P/F ratio = PaO2/FiO2. = . 0 .. > (ARDS). 079-084_1140 80 2013/5/8 02:08:40. 81. aecc (ALI)/ (ARDS) (criteria)4. X . ALI PaO2/FiO2 300 mmHg 18mmHg . ARDS PaO2/FiO2 200 mmHg 18mmHg . aecc . aecc aecc .. X . 18mmHg ARDS . ALI: PaO2/FiO2 300 mmHg ALI/ARDS . ARDS: PaO2/FiO2 200 mmHg PaO2/FiO2 300 mmHg PEEP FiO2 .. 8 X ARDS. aecc (Berlin definition)20 . 84% 51% . 3. aecc ARDS ARDS -- (Berlin 18mmHg ARDS Definition) ( ). ARDS aecc . ARDS . 9,10. > 18mmHg 4. - . aecc ALI ARDS PaO2/ (alveolar capillary membrane).

4 FiO2 300 mmHg 200 mmHg . ALI ARDS X (opacity) . Scandinavian aecc . ALI ARDS 90 ALI ARDS . 11. ARDS ALI ARDS . 8,12,13. PaO2/FiO2 FiO2 . PEEP 14-19 (acute) . aecc ARDS 5. aecc ARDS . ARDS 7 . 2011 ARDS 7 21 . 72 . ARDS ARDS . ARDS 2012 7 . 079-084_1140 81 2013/5/8 02:08:40. 82 . ARDS (Berlin definition)20. ARDS. / . (opacity).. ARDS . (hydrostatic edema).. 200 mmHg < PaO2/FiO2 300 mmHg + PEEP CPAP 5 cm H2O. 100 mmHg < PaO2/FiO2 200 mmHg + PEEP 5 cm H2O. PaO2/FiO2 100 mmHg + PEEP 5 cm H2O. CPAP: Continuous Positive Airway Pressure . X . aecc ARDS . X (opacity) (hydrostatic edema).

5 aecc ARDS . (oxygenation) . PaO2/FiO2 300 aecc . mmHg 200 mmHg 100 mmHg . ARDS . 22,23. PaO2/FiO2 . (ALI) ( .. PEEP . PEEP . PEEP ) . PEEP (time- dependent) aecc . PEEP PaO2/ aecc . FiO2 PEEP 5 cm . H2O (atelectasis) ARDS .. ARDS .. ARDS . ARDS ARDS . 079-084_1140 82 2013/5/8 02:08:40. 83. 12. Kalhan R, Mikkelsen M, Dedhiya P, et al. Underuse of lung protective ventilation: analysis of potential factors to explain ARDS physician behavior. Crit Care Med 2006; 34: 300-6. 13. Rubenfeld GD, Cooper C, Carter G, Thompson BT, Hudson LD. Barriers to providing lung-protective ventilation to patients with acute lung injury.

6 Crit Care Med 2004; 32: 1. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute 1289-93. respiratory distress in adults. Lancet 1967; 2: 319-23. 14. Villar J, Perez-Mendez L, Kacmarek RM. Current definitions 2. Petty TL, Ashbaugh DG. The adult respiratory distress of acute lung injury and the acute respiratory distress syndrome. Clinical features, factors influencing prognosis syndrome do not reflect their true severity and outcome. and principles of management. Chest 1971; 60: 233-9. Intensive Care Med 1999; 25: 930-5. 3. Murray JF, Matthay MA, Luce JM, Flick MR.

7 An expanded 15. Gowda MS, Klocke RA. Variability of indices of hypoxemia definition of the adult respiratory distress syndrome. Am in adult respiratory distress syndrome. Crit Care Med 1997;. Rev Respir Dis 1988; 138: 720-3. 25: 41-5. 4. Bernard GR, Artigas A, Brigham KL, et al. The American- 16. Ferguson ND, Kacmarek RM, Chiche JD, et al. Screening European Consensus Conference on ARDS. Definitions, of ARDS patients using standardized ventilator settings: mechanisms, relevant outcomes, and clinical trial influence on enrollment in a clinical trial. Intensive Care coordination.

8 Am J Respir Crit Care Med 1994; 149: 818-24. Med 2004; 30: 1111-6. 5. Artigas A, Bernard GR, Carlet J, et al. The American- 17. Villar J, Perez-Mendez L, Lopez J, et al. An early PEEP/. European Consensus Conference on ARDS, part 2: FIO2 trial identifies different degrees of lung injury in Ventilatory, pharmacologic, supportive therapy, study design patients with acute respiratory distress syndrome. Am J. strategies, and issues related to recovery and remodeling. Respir Crit Care Med 2007; 176: 795-804. Acute respiratory distress syndrome. Am J Respir Crit Care 18.

9 Aboab J, Louis B, Jonson B, Brochard L. Relation between Med 1998; 157: 1332-47. PaO2/FIO2 ratio and FIO2: a mathematical description. 6. Phua J, Badia JR, Adhikari NK, et al. Has mortality from Intensive Care Med 2006; 32: 1494-7. acute respiratory distress syndrome decreased over time?: A. 19. Britos M, Smoot E, Liu KD, Thompson BT, Checkley W, systematic review. Am J Respir Crit Care Med 2009; 179: Brower RG. The value of positive end-expiratory pressure 220-7. and Fio(2) criteria in the definition of the acute respiratory 7. Levy MM. PEEP in ARDS--how much is enough?

10 N Engl J. distress syndrome. Crit Care Med 2011; 39: 2025-30. Med 2004; 351: 389-91. 20. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute 8. Ferguson ND, Frutos-Vivar F, Esteban A, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. respiratory distress syndrome: underrecognition by clinicians 2012; 307: 2526-33. and diagnostic accuracy of three clinical definitions. Crit 21. Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical Care Med 2005; 33: 2228-34. risks for development of the acute respiratory distress 9. Ferguson ND, Meade MO, Hallett DC, Stewart TE.