Ventilatory Strategy in Management of ARDS

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Ventilatory Strategy in Management of
ARDS
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∏’√™—¬ ©—π∑‚√®π廑√‘
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°“√„™â‡§√◊ËÕߙ૬À“¬„®„πºŸâªÉ«¬∑’ˇªìπ ARDS
°“√ªÑÕß°—π‰¡à„À⇰‘¥ Ventilator-induced lung injury (VILI)
Pressure À√◊Õ volume limited ventilation
Positive end expiratory pressure (PEEP)
Inspiratory time
Prone position ventilation
√ÿª
Ventilatory Strategy in Management of ARDS, ∏’√™—¬ ©—π∑‚√®π廑√‘
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°“√„™â‡§√◊ËÕߙ૬À“¬„®„πºŸâªÉ«¬∑’ˇªìπ ARDS
°“√„™â‡§√◊ËÕߙ૬À“¬„®‡æ◊ËÕ∑’Ë®–™à«¬„Àâ‡π◊ÈÕ‡¬◊ËÕ
¢Õß√à“ß°“¬‰¥â√—∫ÕÕ°´‘‡®π∑’ˇ撬ßæÕ‡ªìπÀ—«„® ”§—≠
Õ—πÀπ÷ßË ¢Õß°“√√—°…“ºŸªâ «É ¬∑’‡Ë ªìπ ARDS ·≈–‡ªìπ∑’∑Ë √“∫
°—π¥’«“à °“√‡ª≈’¬Ë π·ª≈ß∑“ß欓∏‘ √’√«‘∑¬“∑’ Ë ”§—≠¢Õß
ARDS §◊Õ hypoxemia ·≈–°“√∑’˺ŸâªÉ«¬¡’ lung compliance ≈¥≈ß
°“√§«∫§ÿ¡‡æ◊ËÕ„À⇰‘¥°“√·≈°‡ª≈’ˬπ°ä“´∑’Ë¥’
®–µâÕßæ‘®“√≥“∂÷ß à«πª√–°Õ∫µà“ßÊ ¥—ßµàÕ‰ªπ’È
1. Oxygen ®“°æ¬“∏‘ ¿“æ¢Õß‚√§ oxygenation „πºŸâªÉ«¬∑’ˇªìπ ARDS ®– “¡“√∂‡æ‘Ë¡¢÷Èπ‰¥â¥â«¬
°“√∑”„Àâ alveoli ∑’·Ë ø∫Õ¬Ÿ‡à ªî¥¡“°∑’ Ë ¥ÿ (recruitment)
‚¥¬°“√„™â airway pressure ∑’Ë Ÿß °“√„™â PEEP À√◊Õ
°“√‡æ‘¡Ë inspiratory : expiratory ratio ‡æ◊ÕË „Àâ inspiratory time π“π¢÷Èπ Õ¬à“߉√°Áµ“¡®–µâÕߧլ√–«—߉¡à„Àâ
‡°‘¥º≈‡ ’¬®“° positive pressure µàÕ√–∫∫µà“ßÊ ¢Õß
√à“ß°“¬‡™àπ √–∫∫À¡ÿπ‡«’¬π‚≈À‘µ ‡ªìπµâπ πÕ°®“°π’È
®–µâÕß欓¬“¡À≈’°‡≈’ˬ߰“√„™âÕÕ°´‘‡®π∑’Ë¡’§«“¡‡¢â¡
¢âπ ŸßÊ ‡æ◊ÕË ªÑÕß°—π‰¡à„À⇰‘¥¿“«–¢ÕßÕÕ°´‘‡®π toxicity
·≈–°“√‡°‘¥ reabsorptive atelectasis ´÷Ëß„π°“√¥Ÿ·≈
ºŸªâ «É ¬∑’¡Ë ¿’ “«–¥—ß°≈à“«®–„™â§“à ¢Õß oxygen saturation
∑’¡Ë “°°«à“ 90% ‡ªìπ‡ªÑ“À¡“¬∑’ Ë ”§—≠¡“°°«à“°“√„™â§“à
¢Õß PaO2 ‚¥¬‡™◊ËÕ«à“∑’Ë oxygen saturation ¡“°°«à“
90% ∂â“ cardiac output ª°µ‘ ®–¡’ oxygen delivery
‰¥â‡æ’¬ßæÕ°—∫§«“¡µâÕß°“√¢Õß√à“ß°“¬·≈–®“°≈—°…≥–
¢Õß Hb-oxygen dissociation curve ®–æ∫«à“∂â“
oxygen saturation µË”°«à“ 88% oxygen delivery ®–
≈¥µË”≈ßÕ¬à“ß√«¥‡√Á« ”À√—∫„π∫“ß°√≥’∂“â 欓∏‘ ¿“æ
„πªÕ¥¢ÕߺŸªâ «É ¬‡ªìπ¡“° ·≈–°“√ª√—∫‡§√◊ÕË ß™à«¬À“¬„®
‡æ◊ÕË „À≥â oxygen saturation µ“¡µâÕß°“√ (> 90%) ®–
∑”„À⇰‘¥º≈‡ ’¬µàÕ°“√∑”ß“π¢Õß√–∫∫À¡ÿπ‡«’¬π‚≈À‘µ
¡“° À√◊ÕÕ“®‡°‘¥Õ—πµ√“¬µàÕ‡π◊ÈÕªÕ¥‡Õß ·æ∑¬åºŸâ¥Ÿ·≈
°ÁÕ“®®–¬Õ¡√—∫ oxygen saturation ∑’˵˔°«à“ 90% ‰¥â
”À√—∫§«“¡‡¢â¡¢âπ¢ÕßÕÕ°´‘‡®π∑’§Ë «√„™â¬ß—
‰¡à¡°’ “√»÷°…“™—¥‡®π«à“§«√®–Õ¬Ÿ√à –¥—∫‡∑à“‰√ ·µà‡ªìπ∑’Ë
¬Õ¡√—∫°—π∑—Ë«‰ª«à“ §«√®–ª√—∫≈¥ FiO2 „ÀâµË”°«à“ 0.6
„Àâ‡√Á«∑’Ë ÿ¥‡∑à“∑’Ë®–‡ªìπ‰ª‰¥â
2. Carbon dioxide °“√„™â‡§√◊ÕË ß™à«¬À“¬„®‚¥¬
∑’√Ë –¡—¥√–«—߉¡à„À⇰‘¥ lung injury π—πÈ Õ“®®–¡’º≈∑”„Àâ
‰¡à “¡“√∂¢—∫ carbon dioxide ‰¥âµ“¡ª°µ‘ ´÷Ëß«‘∏’°“√
™à«¬À“¬„®∑’¬Ë Õ¡√—∫§à“ PaCO2 ´÷ßË Ÿß°«à“ª°µ‘π‡È’ √’¬°«à“
permissive hypercapnia1 ®“°√“¬ß“π‡∫◊ÕÈ ßµâπ· ¥ß„Àâ
‡ÀÁπ«à“°“√„™â permissive hypercapnia ¡’º≈∑”„ÀâÕµ— √“
µ“¬¢ÕߺŸªâ «É ¬∑’‡Ë ªìπ ARDS ≈¥≈ߵ˔°«à“∑’‡Ë §¬¡’√“¬ß“π
‰«â º≈¢Õß hypercapnia ®–∑”„À⇰‘¥°“√‡ª≈’¬Ë π·ª≈ß„π
√–∫∫µà“ßÊ ¢Õß√à“ß°“¬ ‡™àπ respiratory acidosis,
pulmonary hypertension, increase cerebral blood
flow, cerebral edema µ≈Õ¥®π cerebral hemorrhage
‰¥â Õ¬à“߉√°Áµ“¡¬—߉¡à¡°’ “√»÷°…“∑’·Ë πà™¥— «à“ respiratory
acidosis ¢π“¥‡∑à“„¥ ∂÷ß®–ª≈Õ¥¿—¬‚¥¬∑’‰Ë ¡à‡°‘¥º≈‡ ’¬
µ“¡¡“ ®÷ß¡’°“√欓¬“¡À“«‘∏’°“√¢—∫§“√å∫Õπ‰¥ÕÕ°‰´¥å¥â«¬°“√„™â«‘∏’∑’ˇ√’¬°«à“ Tracheal gas insufflation
‚¥¬„Àâ°ä“´‡ √‘¡‡¢â“‰ª„πµ≈Õ¥¢Õß™à«ß¢Õß°“√À“¬„®
À√◊Õ‡©æ“–™à«ßÀ“¬„®ÕÕ° ‡æ◊ÕË ™à«¬„Àâ°“√¢—∫§“√å∫Õπ‰¥ÕÕ°‰´¥åÕÕ°®“°√à“ß°“¬‰¥â¥’¢÷Èπ ´÷Ëß°ä“´∑’Ë„ à‡¢â“‰ª
„πÀ≈Õ¥≈¡®–∑”„À⢗∫§“√å∫Õπ‰¥ÕÕ°‰´¥å®“° dead
space „π trachea ÕÕ° ·≈–ªÑÕß°—π°“√‡°‘¥ rebreathing2
„πªí®®ÿ∫—π«‘∏’°“√π’È°Á¬—߉¡à‰¥â„™â·æ√àÀ≈“¬·≈–¬—߉¡à¡’
‡§√◊ËÕß¡◊ÕÕÕ°®”Àπà“¬„π‡™‘ßæ“≥‘™¬å ºŸâ∑’Ë®–„™â«‘∏’°“√π’È
®–µâÕß®–µâÕ߇ªìπºŸâ∑’Ë¡’§«“¡™”π“≠·≈–µâÕߧ”π÷ß∂÷ß
º≈‡ ’¬∑’ËÕ“®®–‡°‘¥¢÷Èπµ≈Õ¥®π¿“«–·∑√°´âÕπ®“°
°“√‡æ‘Ë¡¢÷Èπ¢Õß intrinsic PEEP, tidal volume ·≈–
peak airway pressure ‰¥â „πÀ≈—°ªØ‘∫—µ‘ permissive
hypercapnia “¡“√∂∑’Ë®–¬Õ¡„Àâ PaCO2 ‡æ‘Ë¡¢÷Èπ 2-3
‡∑à“¢Õß§à“ª°µ‘ ‚¥¬∑’Ë¡—°‰¡à‡°‘¥§«“¡º‘¥ª°µ‘¢Õß
√–∫∫Õ◊πË Ê „π√à“ß°“¬√à«¡¥â«¬ πÕ°®“°π’®È –µâÕß欓¬“¡
20 New Insight in Pediatric Critical Care 2003
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∑’Ë®–„Àâ§à“¢Õß pH „π‡≈◊Õ¥ Ÿß°«à“ 7.20 ¥â«¬°“√„Àâ
NaHCO3 ‡¢â“‰ª∑“ßÀ≈Õ¥‡≈◊Õ¥¥”Õ¬à“ß™â“Ê 3 °Á®–‡ªìπ
Õ’°«‘∏’Àπ÷Ëß∑’˙૬„Àâ‰¡à‡°‘¥§«“¡º‘¥ª°µ‘¢Õß√–∫∫Õ◊ËπÊ
µ“¡¡“‰¥â
°“√ªÑÕß°—π‰¡à„À⇰‘¥ Ventilator-induced lung
injury (VILI)
VILI ‡ªì𠓇Àµÿ ”§—≠∑’ Ë ¥ÿ ∑’∑Ë ”„ÀâÕµ— √“µ“¬¢Õß
ºŸâªÉ«¬∑’ˇªìπ ARDS Ÿß¢÷Èπ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß barotrauma „πªí®®ÿ∫—π‰¥â¡’§«“¡æ¬“¬“¡„π°“√»÷°…“À“
«‘∏°’ “√µà“ßÊ „π°“√„™â‡§√◊ÕË ß™à«¬À“¬„® ‡æ◊ÕË „À⇰‘¥ VILI
πâÕ¬∑’ Ë ¥ÿ ®“°°“√»÷°…“‡ª√’¬∫‡∑’¬∫«‘∏°’ “√„™â‡§√◊ÕË ß™à«¬
À“¬„®‚¥¬ lung protective strategies ∑’Ë√“¬ß“π‰«â
(µ“√“ß∑’Ë 1) æ∫«à“∑’Ë lower tidal volume < 6 ml/kg3
·≈– lower peak inspiratory pressure (PIP < 30
cmH2O) ¡’Õ—µ√“µ“¬µË”°«à“„π°≈ÿà¡∑’Ë„™â higher tidal
volume (TV > 10 ml/kg) ·≈– higher peak inspiratory pressure (PIP > 50 cmH2O) Õ¬à“ß¡’π—¬ ”§—≠
∑“ß ∂‘µ‘ (µ“√“ß∑’Ë 1, 2)
Amato ·≈–§≥–4 ‰¥â»÷°…“°“√„™â«‘∏’°“√™à«¬
À“¬„®·∫∫ traditional ventilation strategy („™â volume cycle ª√—∫ tidal volume 12 ml/kg, minimum
PEEP ‚¥¬æ‘®“√≥“°“√ª√—∫ PEEP ®“°°“√„™â FiO2
∑’‰Ë ¡à ߟ ‡°‘π‰ª·≈– PaCO2 ∑’ÕË ¬Ÿ„à π‡°≥±åª°µ‘) ·≈–‡ª√’¬∫
‡∑’¬∫°—∫«‘∏’°“√∑’ˇ√’¬°«à“ lung protective strategy
‚¥¬„™â Pressure volume curve ‡ªìπµ—« monitor („™â
pressure limited mode ª√—∫ PEEP „ÀâÕ¬Ÿ à ߟ °«à“ lower
inflection point, tidal volume < 6 ml/kg, permissive
hypercapnia, PIP < 40 cmH2O) (¿“æ∑’Ë 1) ®“°°“√
»÷°…“π’Èæ∫«à“„π°≈ÿà¡ protective lung strategy ¡’
oxygenation index, lung compliance ·≈–Õ—µ√“°“√
weaning ¥’¢π÷È Õ—µ√“µ“¬∑’Ë 28 «—π¢Õß°“√Õ¬Ÿ‚à √ß欓∫“≈
„π°≈ÿ¡à ¢Õß traditional ventilation strategy Ÿß°«à“°≈ÿ¡à
protective Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (71% °—∫ 45%;
P < 0.001) ∂÷ß·¡â«à“Õ—µ√“°“√®”Àπà“¬ºŸâªÉ«¬ÕÕ°®“°
‚√ß欓∫“≈¢Õß∑—Èß 2 °≈ÿà¡¥—ß°≈à“«®–‰¡à·µ°µà“ß°—π
™—¥‡®π (71% °—∫ 45%; P > 0.37) «‘∏’°“√µà“ßÊ ‡À≈à“
π’Ȭ—ßµâÕß°“√°“√»÷°…“‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ„Àâ “¡“√∂„™â‡ªìπ
µ“√“ß∑’Ë 1 Randomised prospective studies of ventilatory strategies to limit lung overdistension in patients
with ARDS
Mortality
Reference
n
çProtectiveé
Control
Stewart (1998)
120 ë Vt < 8 ml/kg
ë Vt 10-15 ml/kg No difference
ë PIP < 30 cmH2O
ë PIP < 50 cmH2O
ë PEEP levels similar
in both groups
No difference
Brochard (1998) 116 ë Vt < 10 ml/kg
ë Vt > 10 ml/kg
ë Pplat < 25 cmH2O
ë Normocapnia
ë PEEP levels similar
in both groups
Brower (1999)
52 ë Vt 5-8 ml/kg
ë Vt 10-12 ml/kg No difference
ë Pplat < 30 cmH2O
ë Pplat < 45-55
cmH2O
Lower in çprotectiveé
ARDSNet (2000) 861 ë Vt 6 ml/kg
ë Vt 12 ml/kg
ë PIP < 30 cmH2O
ë PIP < 50 cmH2O group (31% v 40%)
Vt=tidal volume; PIP=peak inspiratory pressure; Pplat=end inspiratory plateau pressure; PEEP=positive end expiratory pressure
Ventilatory Strategy in Management of ARDS, ∏’√™—¬ ©—π∑‚√®π廑√‘
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µ“√“ß∑’Ë 2 Protective lung ventilation protocol from the ARDS Net study
Setting
Variable
Volume assist-control
Ventilator mode
6 (adjusted according to plateau pressure)
Tidal volume (initial) (ml/kg)
< 30
Plateau pressure (cmH2O))
6-35
Rate (breaths/min)
1:1-1:3
I:E ratio
Oxygenation target
7.3-10.7
PaO2 (kPa)
88-95
SpO2 (%)
Set according to predetermined combinations (PEEP range
PEEP and FiO2
5-24 cmH2O)
¿“æ∑’Ë 1 Pressure-volume curve derived from a patient
with ARDS
(LIP = Lower inflection point, UIP = Upper inflection point)
·π«∑“ß„π°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‡æ◊ËÕ„ÀâÕ—µ√“µ“¬≈¥≈ß
·≈–Õ—µ√“°“√‡°‘¥§«“¡æ‘°“√πâÕ¬≈ß
Pressure À√◊Õ volume limited ventilation
‡π◊ËÕß®“° lung pathology ¢ÕߺŸâªÉ«¬∑’ˇªìπ
ARDS ®–‡ªìπªÕ¥∑’Ë¡’ compliance µË”¡“°Ê ®”‡ªìπ
µâÕß„™â‡§√◊ÕË ß™à«¬À“¬„®∑’®Ë – “¡“√∂™à«¬„Àâ ventilation
‰ª®π∂÷ß alveoli ‰¥âÕ¬à“ßæՇ撬߷≈– ¡Ë”‡ ¡Õ ¥—ßπ—πÈ
‡§√◊ËÕߙ૬À“¬„®∑’Ëπ‘¬¡„™â°—π‰¥â·°à ‡§√◊ËÕߙ૬À“¬„®∑’Ë
§«∫§ÿ¡ª√‘¡“µ√¢Õß≈¡À“¬„®‡¢â“ÕÕ° (volume limited
ventilator) À√◊Õ‡§√◊ÕË ß™à«¬À“¬„®∑’§Ë «∫§ÿ¡¥â«¬§«“¡¥—π
(pressure limited ventilator)
¢âÕ·µ°µà“ß∑’ Ë ”§—≠¢Õß pressure ·≈– volume
limited ventilation (µ“√“ß∑’Ë 3) °Á§Õ◊ „π pressure controlled mode ®–∑”„Àâ “¡“√∂®”°—¥§à“ PIP ‰¡à„Àâ Ÿß
‡°‘π‰ª®πÕ“®®–‡°‘¥ barotrama ‰¥âßà“¬ ´÷Ëß¡’¢âÕ‡ ’¬§◊Õ
‰¡à “¡“√∂„Àâ minute ventilation ∑’§Ë ß∑’‰Ë ¥â à«π volume
controlled mode “¡“√∂„Àâ minute volume ∑’˧ß∑’Ë
·µà PIP ®–‡ª≈’¬Ë π‰ªµ“¡ compliance ·≈– resistance
¢ÕߺŸâªÉ«¬ ´÷Ëß®“°°“√»÷°…“¬—߉¡à “¡“√∂ √ÿª‰¥â«à“«‘∏’
°“√„™â‡§√◊ËÕߙ૬À“¬„®·∫∫ volume controlled À√◊Õ
pressure controlled ®–¡’Õ—µ√“µ“¬∑’Ë·µ°µà“ß°—πÕ¬à“ß
™—¥‡®π5-7 Õ¬à“߉√°Áµ“¡®“°√“¬ß“π¢Õß ARDS Net3
æÕ®– √ÿª‰¥â«à“‰¡à«à“®–„™â«‘∏’°“√™à«¬À“¬„®·∫∫„¥ ®–
µâÕß„™â tidal volume ª√–¡“≥ 6 ml/kg ¡“°°«à“∑’®Ë –„™â
traditional tidal volume (10-12 ml/kg) ·≈–欓¬“¡
ª√—∫‡§√◊ËÕߙ૬À“¬„®„Àâ peak inspiratory pressure
Õ¬Ÿ√à –À«à“ß 30-35 cmH2O ‡æ◊ÕË ªÑÕß°—π over distension
·≈– inspiratory phase §«√®–À¬ÿ¥°àÕπ∑’®Ë –∂÷ß®ÿ¥∑’‡Ë ªìπ
upper inflection point (¿“æ∑’Ë 1) ®“°°“√»÷°…“‡ª√’¬∫
‡∑’¬∫¢Õß°“√™à«¬À“¬„®∑—ßÈ 2 «‘∏¥’ ß— °≈à“« æ∫«à“ PIP
„π pressure controlled ®–µË”°«à“„π volume controlled Õ¬à“ß™—¥‡®π (µ“√“ß∑’Ë 4)
22 New Insight in Pediatric Critical Care 2003
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µ“√“ß∑’Ë 3 Volume-Targeted versus Pressure-Targeted Ventilation
Volume Control
Rate
Set or variable
VT
Set
Peak pressure
Variable
Peak flow
Set
Flow wave
Set but Variable
A/C
Yes
Control
Yes
Inspiratory time
Variable
I/E ratio
Variable
Pressure Control
Set or variable
Variable
Set
Variable
Set
Yes
Yes
Variable
Variable
A/C, assist/control; I/E, inspiration/expiration
Inspiratory time
µ“√“ß∑’Ë 4 Gas Mixing Benefits of pressure-cycling
Held constant: VT, Rate, Expiratory time,
PEEP
Volume
Pressure
80 + 9
92 + 8
PaO2, mmHg
44 + 3
41 + 3
PaCO2, mmHg
93 + 1
95 + 1
SaO2, %
62 + 5
45 + 3
PIP, cmH2O
20 + 1
21 + 1
Paw, cmH2O
Abraham, et al. Chest 98:1445:1990.
Positive end expiratory pressure (PEEP)
°“√„™â PEEP „π°“√µ—ßÈ ‡§√◊ÕË ß™à«¬À“¬„® ”À√—∫
ºŸâªÉ«¬∑’ˇªìπ ARDS ‡™◊ËÕ«à“®–∑”„Àâ oxygenation ¢Õß
ºŸâªÉ«¬¥’¢÷Èπ ‚¥¬°“√∑”„Àâ fluid ∑—Èß„π interstitial ·≈–
alveoli ≈¥≈ß À≈Õ¥≈¡ΩÕ¬·≈–∂ÿß≈¡ªÕ¥ à«π∑’Ë·ø∫
Õ¬Ÿà°Á®–¢¬“¬µ—«‰¥â¡“°¢÷Èπ8 ·≈– functional residual
capacity (FRC) ‡æ‘Ë¡¢÷Èπ ªí≠À“¢Õß°“√„™â PEEP „π
ºŸâªÉ«¬°≈ÿà¡π’ȧ◊Õ ®–„™âÕ–‰√‡ªìπµ—«æ‘®“√≥“«à“‡∑à“„¥∂÷ß
®–‡À¡“– ¡ ∂Ⓡªìπ‡§√◊ÕË ß™à«¬À“¬„®∑’¡Ë ’ graphic analysis °“√¥Ÿ®“° pressure volume curve ¥â«¬°“√ª√—∫
PEEP „ÀâÕ¬Ÿà Ÿß°«à“ lower inflection point ª√–¡“≥
2 cmH2O ‡™◊ËÕ«à“®–∑”„Àâ¡’ lung recruitment ‰¥â¥’¢÷Èπ
‚Õ°“ ‡°‘¥ air trapping °Á®–πâÕ¬≈ߥ⫬
°“√„™â inspiratory time ∑’ˬ“«¢÷ÈπÀ√◊Õ‡æ‘Ë¡ I:E
ratio „Àâ¡“°¢÷Èπ °Á‡ªìπÕ’°«‘∏’Àπ÷Ëß„π°“√∑’Ë®–™à«¬‡ªî¥
ªÕ¥∑’·Ë ø∫Õ¬Ÿ„à Àâ “¡“√∂∑”ß“π‰¥â¥¢’ πÈ÷ ¡—°®–„™â√«à ¡°—∫
pressure controlled mode Õ¬à“߉√°Áµ“¡°“√„™â
reverse I:E ratio À√◊Õ prolong inspiratory time Õ“®
®–∑”„Àâ cardiac output ≈¥≈ß ‡°‘¥ hyperinflation ·≈–
intrinsic PEEP ‡æ‘Ë¡¢÷Èπµ≈Õ¥®π¡’§“√å∫Õπ‰¥ÕÕ°‰´¥å
§—Ë߉¥â ´÷Ë߇«≈“„™â reverse I:E ratio ®–µâÕߧլ‡ΩÑ“
√–«—ß°“√‡ª≈’¬Ë π·ª≈ߢÕß≈—°…≥–∑“ߧ≈‘π°‘ Õ¬à“ß„°≈♥‘
®–‡ÀÁπ‰¥â«à“‡¡◊ËÕ‡√‘Ë¡„™â reverse I:E ratio ®–∑”„Àâ„™â
peak airway pressure ≈¥≈ß·≈– oxygenation ¥’¢÷Èπ
(¿“æ∑’Ë 2)
Prone position ventilation
°“√®—¥∑à“ºŸªâ «É ¬„ÀâπÕπ§«Ë”„π¢≥–∑’„Ë ™â‡§√◊ÕË ß™à«¬
À“¬„®°Á‡ªìπÕ’°«‘∏À’ π÷ßË ∑’‡Ë ™◊ÕË «à“ “¡“√∂‡æ‘¡Ë oxygenation
„πºŸâªÉ«¬∑’ˇªìπ severe ARDS ‰¥â9 ´÷Ëß°≈‰°¢Õß°“√
‡ª≈’¬Ë π·ª≈ß∑“ߥâ“π √’√«‘∑¬“À√◊Õ欓∏‘ √’√«‘∑¬“¬—߉¡à
“¡“√∂Õ∏‘∫“¬‰¥âÕ¬à“ß™—¥‡®π·≈–º≈°“√»÷°…“‡ª√’¬∫
‡∑’¬∫°Á‰¡à¡’§«“¡·µ°µà“ß°—πÕ¬à“ß ”§—≠„π¥â“π¢Õß
outcome ¢ÕߺŸâªÉ«¬∑’ˇªìπ ARDS10 ·≈–°“√„À⺟âªÉ«¬
Õ¬Ÿà„π∑à“ prone position ¢≥–„™â‡§√◊ËÕߙ૬À“¬„®°Á
®–µâÕß√–«—ß¿“«–·∑√°´âÕπµà“ßÊ ‡™àπ venous con-
Ventilatory Strategy in Management of ARDS, ∏’√™—¬ ©—π∑‚√®π廑√‘
23
...................................................................................
2:1
1.5:1
4:1
1.5:1
100
80
60
40
20
PaO2
FIO2
Pressure (cm H2O)
PCO2
Trial of IMV
mm Hg or % FIO2
I:E Ratios:
Placed on IRV
60
40
20
Peak Press
1
2
3
4
PEEP
5 6
Days
7
8
9 10
¿“æ∑’Ë 2 · ¥ß∂÷ß clinical course ¢ÕߺŸâªÉ«¬∑’Ë„™â pressure-controlled IRV mode
gestion ∑’Ë∫√‘‡«≥„∫ÀπⓇ°‘¥¡’ facial edema, ¡’‚Õ°“ ‡°‘¥Õ—πµ√“¬µàÕµ“µ—ßÈ ·µà corneal abrasion, retinal and
optic nerve ischemia11 endotracheal tube ·≈– central venous catheter À≈ÿ¥ßà“¬¢÷πÈ ·≈– intraabdominal
pressure ‡æ‘Ë¡¢÷Èπ ∑”„Àâ°“√™à«¬À“¬„®≈”∫“°¬‘Ëߢ÷Èπ‰¥â
√ÿª
°“√„™â‡§√◊ÕË ß™à«¬À“¬„®„πºŸªâ «É ¬∑’‡Ë ªìπ ARDS „π
ªí®®ÿ∫—ππ’È·π–π”„Àℙ⫑∏’°“√∑’ˇ√’¬°«à“ protective lung
strategy §◊Õ„™â tidal volume πâÕ¬ (6 ml/kg) ®”°—¥
plateau pressure „ÀâµË”°«à“ 30 cmH2O µ≈Õ¥®π°“√
¬Õ¡√—∫§“√å∫Õπ‰¥ÕÕ°‰´¥å„π‡≈◊Õ¥∑’¢Ë π“¥ Ÿß¢÷πÈ √à«¡°—∫
°“√¥Ÿ·≈Õ¬à“ßÕ◊πË ‡™◊ÕË «à“∑”„ÀâÕµ— √“µ“¬¢ÕߺŸªâ «É ¬∑’‡Ë ªìπ
ARDS ≈¥≈߉¥â ”À√—∫«‘∏’°“√Õ◊ËπÊ ‡™àπ °“√„™â high
frequency ventilation À√◊Õ liquid ventilation À√◊Õ
nitric oxide °Á§ß¬—ßµâÕß√Õº≈°“√»÷°…“‡æ‘Ë¡‡µ‘¡µàÕ‰ª
24 New Insight in Pediatric Critical Care 2003
....................................................................................
‡Õ° “√Õâ“ßÕ‘ß
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hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med 1990; 16: 372-7.
2. Nahum A, Ravenscraft SA, Nakos G, et al. Tracheal gas insufflation during pressure-control ventilation. Effect of catheter
position, diameter, and flow rate. Am Rev Respir Dis 1992; 146: 965-73.
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