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摘要: 2022年6月26日，连云港市第一人民医院收治1例吸入性损伤致重度急性呼吸窘迫综合征的54岁男性患者。患者入院后即接受了有创机械通气（驱动压导向的呼吸机参数设置）联合俯卧位治疗，但其病情持续恶化。入院5 h后，患者接受了静脉-静脉体外膜氧合（VV-ECMO）支持治疗、基于肺超保护性通气策略的治疗联合每日>12 h的俯卧位通气治疗，同时经脉搏轮廓心输出量监测技术监测心脏指数及血管外肺水指数等情况以指导容量管理，并行多次纤维支气管镜肺泡灌洗治疗，后成功撤离VV-ECMO及呼吸机并顺利康复出院。伤后随访1年，患者无明显呼吸道症状，肺功能基本正常。Abstract: A 54-year-old male patient with severe acute respiratory distress syndrome caused by inhalation injury was admitted to the First People's Hospital of Lianyungang City on June 26 th, 2022. After admission, the patient received invasive mechanical ventilation (driving pressure-guided ventilator parameter setting) combined with prone position treatment immediately, but his condition continued to deteriorate. Five hours after admission, the patient received veno-venous extracorporeal membrane oxygenation (VV-ECMO) supporting treatment, treatment based on ultra-protective lung ventilation strategy combined with prone position ventilation for more than 12 hours per day. At the same time, pulse contour cardiac output monitoring technology was used to monitor cardiac index and extravascular lung water index to guide volume management, and fiberoptic bronchoalveolar lavage was performed for several times. After that, the patient was successfully weaned from VV-ECMO and ventilator, and then discharged from hospital successfully. During follow-up of one year after the injury, the patient showed no obvious respiratory symptoms, and his lung function was basically normal.
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参考文献
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1 吸入性损伤致重度急性呼吸窘迫综合征患者入院初及行VV-ECMO支持治疗及肺超保护通气期间胸部X线片变化及肺部灌洗时吸出物。1A.入院初，双肺弥漫性病变，左肺更重；1B.行VV-ECMO支持治疗第4天，从肺内吸出焦痂样坏死黏膜且部分呈支气管树影状；1C.行VV-ECMO支持治疗第5天，右侧气胸，双肺弥漫性病变好转；1D.行VV-ECMO支持治疗第8天，双肺纹理增多，无明显肺不张或感染
注：VV-ECMO为静脉-静脉体外膜氧合
表1 1例吸入性损伤致重度ARDS患者行肺超保护性通气期间PiCCO监测数据变化
通气时间 心脏指数 （L·min -1·m -2） 每搏量变异率（%） 血管外肺水指数（mL/kg） 中心静脉压（cmH 2O） 全心舒张末期容积 指数（mL/m 2） 外周血管阻力指数 （dyn·s·cm -5·m 2） 平均动脉压（mmHg） 第1天 8.1 10 17 4 1 026 818 85 第2天 8.4 10 26 13 1 021 832 84 第3天 4.0 10 25 10 796 1 294 80 第4天 3.1 5 26 15 667 1 599 75 第5天 4.2 11 17 12 909 1 503 91 第6天 3.7 16 11 10 736 1 256 75 注：表中数据为监测当天均值；ARDS为急性呼吸窘迫综合征，PiCCO为脉搏轮廓心输出量；1 cmH 2O=0.098 kPa，1 mmHg=0.133 kPa 
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表2 1例吸入性损伤致重度ARDS患者行肺超保护性通气期间呼吸力学指标变化
通气时间 潮气量 （mL/kg） 呼气末正压 （cmH 2O） 气道阻力 （cmH 2O·L -1·s -1） 驱动压 （cmH 2O） 呼吸机设置呼吸 频率（次/min） 肺顺应性 （L/cmH 2O） 平台压 （cmH 2O） 第1天 3.3 14 33 14 12 24 28 第2天 3.3 14 27 13 12 33 27 第3天 3.3 14 28 9 12 32 23 第4天 3.7 10 32 11 12 24 21 第5天 3.7 5 23 8 12 35 13 第6天 4.7 5 24 8 12 53 13 第7天 4.7 5 18 7 12 49 12 第8天 6.0 5 10 7 12 62 12 注：表中数据为监测当天均值；ARDS为急性呼吸窘迫综合征；1 cmH 2O=0.098 kPa
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