ARDSの人工呼吸管理とその方向性について考える
ARDSにおける肺傷害のメカニズムには，①人工呼吸器を使用すること自体が肺傷害を悪化させる人工呼吸器関連肺傷害（ventilator-associated lung injury, VALI）や，②強い吸気努力が肺傷害を悪化させる自発呼吸誘発性肺傷害がある。VALIを防ぐために，低1回換気量と低いプラトー圧，PEEP付加を柱とする肺保護換気戦略が行われてきた。しかし，患者ごとに病態が不均一であるにもかかわらず画一的な治療を行ってきたため，過去20年間にわたりARDSの院内死亡率が改善しなかった可能性がある。ARDSの死亡率を低下させるためには，治療介入に効果のあるサブグループ/表現型を検出する...
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| Published in | 日本集中治療医学会雑誌 Vol. 31; no. 5; pp. 469 - 476 |
|---|---|
| Main Authors | , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本集中治療医学会
01.09.2024
|
| Online Access | Get full text |
| ISSN | 1340-7988 1882-966X |
| DOI | 10.3918/jsicm.31_469 |
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| Abstract | ARDSにおける肺傷害のメカニズムには，①人工呼吸器を使用すること自体が肺傷害を悪化させる人工呼吸器関連肺傷害（ventilator-associated lung injury, VALI）や，②強い吸気努力が肺傷害を悪化させる自発呼吸誘発性肺傷害がある。VALIを防ぐために，低1回換気量と低いプラトー圧，PEEP付加を柱とする肺保護換気戦略が行われてきた。しかし，患者ごとに病態が不均一であるにもかかわらず画一的な治療を行ってきたため，過去20年間にわたりARDSの院内死亡率が改善しなかった可能性がある。ARDSの死亡率を低下させるためには，治療介入に効果のあるサブグループ/表現型を検出することにより，人工呼吸理戦略を「画一的治療」から「個別化治療」へと発展させる必要がある。 |
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| AbstractList | ARDSにおける肺傷害のメカニズムには，①人工呼吸器を使用すること自体が肺傷害を悪化させる人工呼吸器関連肺傷害（ventilator-associated lung injury, VALI）や，②強い吸気努力が肺傷害を悪化させる自発呼吸誘発性肺傷害がある。VALIを防ぐために，低1回換気量と低いプラトー圧，PEEP付加を柱とする肺保護換気戦略が行われてきた。しかし，患者ごとに病態が不均一であるにもかかわらず画一的な治療を行ってきたため，過去20年間にわたりARDSの院内死亡率が改善しなかった可能性がある。ARDSの死亡率を低下させるためには，治療介入に効果のあるサブグループ/表現型を検出することにより，人工呼吸理戦略を「画一的治療」から「個別化治療」へと発展させる必要がある。 |
| Author | 吉田, 健史 星野, 太希 |
| Author_xml | – sequence: 1 fullname: 吉田, 健史 organization: 大阪大学大学院医学系研究科生体統御医学講座麻酔集中治療医学教室 – sequence: 1 fullname: 星野, 太希 organization: 大阪大学大学院医学系研究科生体統御医学講座麻酔集中治療医学教室 |
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| Copyright | 2024 日本集中治療医学会 |
| Copyright_xml | – notice: 2024 日本集中治療医学会 |
| DOI | 10.3918/jsicm.31_469 |
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N Engl J Med 2001;345:568-73. 48) Mauri T, Yoshida T, Bellani G, et al; PLeUral pressure working Group (PLUG–Acute Respiratory Failure section of the European Society of Intensive Care Medicine). Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 2016;42:1360-73. 5) Gattinoni L, Marini JJ, Pesenti A, et al. The “baby lung” became an adult. Intensive Care Med 2016;42:663-73. 15) Hashimoto H, Yoshida T, Firstiogusran AMF, et al. Asynchrony Injures Lung and Diaphragm in Acute Respiratory Distress Syndrome. Crit Care Med 2023;51:e234-2. 18) Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010;363:1107-16. 36) Sinha P, Churpek MM, Calfee CS. Machine Learning Classifier Models Can Identify Acute Respiratory Distress Syndrome Phenotypes Using Readily Available Clinical Data. Am J Respir Crit Care Med 2020;202:996-1004. 53) Sarge T, Baedorf-Kassis E, Banner-Goodspeed V, et al; EPVent-2 Study Group. Effect of Esophageal Pressure-guided Positive End-Expiratory Pressure on Survival from Acute Respiratory Distress Syndrome: A Risk-based and Mechanistic Reanalysis of the EPVent-2 Trial. Am J Respir Crit Care Med 2021;204:1153-63. 16) Blanch L, Villagra A, Sales B, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med 2015;41:633-41. 12) Oswalt CE, Gates GA, Holmstrom MG. Pulmonary edema as a complication of acute airway obstruction. JAMA 1977;238:1833-5. 59) Yoshida T, Piraino T, Lima CAS, et al. Regional Ventilation Displayed by Electrical Impedance Tomography as an Incentive to Decrease Positive End-Expiratory Pressure. Am J Respir Crit Care Med 2019;200:933-7. 8) Yoshida T, Uchiyama A, Matsuura N, et al. 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Acute respiratory distress syndrome subphenotypes and differential response to simvastatin: secondary analysis of a randomised controlled trial. Lancet Respir Med 2018;6:691-8. 22) Yoshida T, Grieco DL, Brochard L, et al. Patient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing. Curr Opin Crit Care 2020;26:59-65. 46) Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 2010;303:865-73. 28) Laffey JG, Kavanagh BP. Negative trials in critical care: why most research is probably wrong. Lancet Respir Med 2018;6:659-60. 58) Pereira SM, Tucci MR, Morais CCA, et al. Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis. Anesthesiology 2018;129:1070-81. 17) Vaporidi K, Babalis D, Chytas A, et al. 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Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis. Minerva Anestesiol. 2010;76:448-54. 23) Spinelli E, Pesenti A, Slobod D, et al. Clinical risk factors for increased respiratory drive in intubated hypoxemic patients. Crit Care 2023;27:138. 34) Taccone P, Pesenti A, Latini R, et al; Prone-Supine II Study Group. Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial. JAMA 2009;302:1977-84. 7) Putensen C, Zech S, Wrigge H, et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 2001;164:43-9. 11) Cornejo RA, Arellano DH, Ruiz-Rudolph P, et al. Inflammatory biomarkers and pendelluft magnitude in ards patients transitioning from controlled to partial support ventilation. Sci Rep 2022;12:20233. 1) Gattinoni L, Pesenti A. The concept of “baby lung”. 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Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials. Lancet Respir Med 2014;2:611-20. 47) Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006;354:1775-86. 6) Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8. 27) Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med 2005;353:1685-93. 41) Chen L, Grieco DL, Beloncle F, et al. Partition of respiratory mechanics in patient |
| References_xml | – reference: 1) Gattinoni L, Pesenti A. The concept of “baby lung”. Intensive Care Med 2005;31:776-84. – reference: 15) Hashimoto H, Yoshida T, Firstiogusran AMF, et al. Asynchrony Injures Lung and Diaphragm in Acute Respiratory Distress Syndrome. Crit Care Med 2023;51:e234-2. – reference: 47) Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006;354:1775-86. – reference: 32) Guerin C, Gaillard S, Lemasson S, et al. Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA 2004;292:2379-87. – reference: 25) Spinelli E, Mauri T, Beitler JR, et al. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med 2020;46:606-18. – reference: 18) Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010;363:1107-16. – reference: 38) Famous KR, Delucchi K, Ware LB, et al; ARDS Network. Acute Respiratory Distress Syndrome Subphenotypes Respond Differently to Randomized Fluid Management Strategy. Am J Respir Crit Care Med 2017;195:331-8. – reference: 58) Pereira SM, Tucci MR, Morais CCA, et al. Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis. Anesthesiology 2018;129:1070-81. – reference: 42) Laffey JG, Bellani G, Pham T, et al; LUNG SAFE Investigators and the ESICM Trials Group. Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study. Intensive Care Med 2016;42:1865-76. – reference: 29) Matthay MA, McAuley DF, Ware LB. Clinical trials in acute respiratory distress syndrome: challenges and opportunities. Lancet Respir Med 2017;5:524-34. – reference: 40) Amato MB, Meade MO, Slutsky AS, et al. 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Spontaneous effort causes occult pendelluft during mechanical ventilation. Am J Respir Crit Care Med 2013;188:1420-7. – reference: 36) Sinha P, Churpek MM, Calfee CS. Machine Learning Classifier Models Can Identify Acute Respiratory Distress Syndrome Phenotypes Using Readily Available Clinical Data. Am J Respir Crit Care Med 2020;202:996-1004. – reference: 39) Calfee CS, Delucchi KL, Sinha P, et al; Irish Critical Care Trials Group. Acute respiratory distress syndrome subphenotypes and differential response to simvastatin: secondary analysis of a randomised controlled trial. Lancet Respir Med 2018;6:691-8. – reference: 5) Gattinoni L, Marini JJ, Pesenti A, et al. The “baby lung” became an adult. Intensive Care Med 2016;42:663-73. – reference: 14) Dreyfuss D, Soler P, Basset G, et al. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988;137:1159-64. – reference: 48) Mauri T, Yoshida T, Bellani G, et al; PLeUral pressure working Group (PLUG–Acute Respiratory Failure section of the European Society of Intensive Care Medicine). Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 2016;42:1360-73. – reference: 19) Qadir N, Sahetya S, Munshi L, et al. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024;209:24-36. – reference: 16) Blanch L, Villagra A, Sales B, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med 2015;41:633-41. – reference: 51) Beitler JR, Sarge T, Banner-Goodspeed VM, et al; EPVent-2 Study Group. Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure-Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2019;321:846-57. – reference: 44) Goligher EC, Costa ELV, Yarnell CJ, et al. Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance. Am J Respir Crit Care Med 2021;203:1378-85. – reference: 55) Zerbib Y, Lambour A, Maizel J, et al. Respiratory effects of lung recruitment maneuvers depend on the recruitment-to-inflation ratio in patients with COVID-19-related acute respiratory distress syndrome. Crit Care 2022;26:12. – reference: 24) Dianti J, Fard S, Wong J, et al. Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial. Crit Care 2022;26:259. – reference: 2) Slutsky AS, Ranieri VM. 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Prone Position Reduces Spontaneous Inspiratory Effort in Patients with Acute Respiratory Distress Syndrome: A Bicenter Study. Am J Respir Crit Care Med 2021;203:1437-40. – reference: 30) Guérin C, Reignier J, Richard JC, et al; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68. – reference: 45) Richard JC, Rabilloud M, Chorfa F, et al. Discussions on VT4COVID-Authors’ reply. Lancet Respir Med 2023;11:e91-2. – reference: 21) Katira BH, Osada K, Engelberts D, et al. Positive End-Expiratory Pressure, Pleural Pressure, and Regional Compliance during Pronation: An Experimental Study. Am J Respir Crit Care Med 2021;203:1266-74. – reference: 33) Mancebo J, Fernández R, Blanch L, et al. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 2006;173:1233-9. – reference: 28) Laffey JG, Kavanagh BP. 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| Snippet | ARDSにおける肺傷害のメカニズムには，①人工呼吸器を使用すること自体が肺傷害を悪化させる人工呼吸器関連肺傷害（ventilator-associated lung injury, VALI）や，②強い吸... |
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| Title | ARDSの人工呼吸管理とその方向性について考える |
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