PDF(Pubmed)
Abstract：
Prioritizing lung-protective ventilation has produced a clear mortality benefit in neonates with congenital diaphragmatic hernia (CDH). While there is a paucity of CDH-specific evidence to support any particular approach to lung-protective ventilation, a growing body of data in adults is beginning to clarify the mechanisms behind ventilator-induced lung injury and inform safer management of mechanical ventilation in general. This review summarizes the adult data and attempts to relate the findings, conceptually, to the CDH population. Critical lessons from the adult studies are that much of the damage done during conventional mechanical ventilation affects normal lung tissue and that most of this damage occurs at the low-volume and high-volume extremes of the respiratory cycle. Consequently, it is important to prevent atelectasis by using sufficient positive end-expiratory pressure while also avoiding overdistention by scaling tidal volume to the amount of functional lung tissue rather than body weight. Paralysis early in acute respiratory distress syndrome improves outcomes, possibly because consistent respiratory mechanics facilitate avoidance of both atelectasis and overdistention-a mechanism that may also apply to the CDH population. Volume-targeted conventional modes may be advantageous in CDH, but determining optimal tidal volume is challenging. Both high-frequency oscillatory ventilation and high-frequency jet ventilation have been used successfully as \'rescue modes\' to avoid extracorporeal membrane oxygenation, and a prospective trial comparing the two high-frequency modalities as the primary ventilation strategy for CDH is underway.
摘要：
在先天性膈疝（CDH）的新生儿中，优先考虑肺保护性通气已产生明显的死亡率益处。虽然缺乏CDH特异性证据支持任何特定的肺保护性通气方法，越来越多的成人数据开始阐明呼吸机引起的肺损伤背后的机制,并为机械通气的总体安全管理提供依据.这篇综述总结了成人数据，并试图将这些发现联系起来，概念上,CDH人口。成人研究的重要教训是，在常规机械通气过程中造成的许多损伤会影响正常的肺组织，并且大多数损伤发生在呼吸周期的低容量和高容量极端情况。因此,重要的是通过使用足够的呼气末正压来预防肺不张，同时通过将潮气量缩放至功能性肺组织的数量而不是体重来避免过度扩张。急性呼吸窘迫综合征早期麻痹可改善预后，可能是因为一致的呼吸力学有助于避免肺不张和过度扩张-这种机制也可能适用于CDH人群。以音量为目标的传统模式在CDH中可能是有利的，但是确定最佳潮气量是具有挑战性的。高频振荡通气和高频喷射通气都已成功用作避免体外膜氧合的“救援模式”。一项比较两种高频模式作为CDH主要通气策略的前瞻性试验正在进行中.
