背景COVID-19发生急性呼吸窘迫综合征(ARDS)“CARDS”的患者与经典形式的ARDS患者的行为不同。最近已经描述了2张卡片的表型,L型和H型大多数患者稳定在较温和的形式,L型,当未知子集进入H型时,类似于成熟的ARDS。如果未更正,表型转换可以诱导向进行性肺损伤的快速下降,血管停搏,和肺收缩,冒着呼吸机诱发的肺损伤(VILI)的风险,被称为“VILI涡流”。没有报告院内表型转换的病例,而这些患者的通气策略不同于经典ARDS的肺保护方法。病例报告一名29岁男性因COVID-19肺炎并发严重ARDS入院,多器官衰竭,细胞因子释放综合征,和他入院时的凝血病。他最初类似于CARDSL型案件,虽然难治性低氧血症,发烧,高病毒负荷促使在8天内转化为H型。尽管有通风策略,神经肌肉阻滞,吸入疗法,和维生素C,他与呼吸机保持异步,容量和压力超过可接受的阈值,最终发展为致命的张力性气胸。结论转换为H型的患者可以迅速进入低氧血症的螺旋,分流,和朝向全功能ARDS的死空间通风。了解其细微差别对于中断表型转换和进入VILI涡流至关重要。张力性气胸代表CARDS患者的不良预后。监测肺动力学的进一步研究,修改通风策略,并且需要了解CARDS对各种通气模式的反应,以减轻这些不良后果。
BACKGROUND COVID-19 patients that develop acute respiratory distress syndrome (ARDS) \"CARDS\" behave differently compared to patients with classic forms of ARDS. Recently 2 CARDS phenotypes have been described, Type L and Type H. Most patients stabilize at the milder form, Type L, while an unknown subset progress to Type H, resembling full-blown ARDS. If uncorrected, phenotypic conversion can induce a rapid downward spiral towards progressive lung injury, vasoplegia, and pulmonary shrinkage, risking ventilator-induced lung injury (VILI) known as the \"VILI vortex\". No cases of in-hospital phenotypic conversion have been reported, while ventilation strategies in these patients differ from the lung-protective approaches seen in classic ARDS.
CASE REPORT A 29-year old male was admitted with COVID-19 pneumonia complicated by severe ARDS, multi-organ failure, cytokine release syndrome, and coagulopathy during his admission. He initially resembled CARDS Type L
case, although refractory hypoxemia, fevers, and a high viral burden prompted conversion to Type H within 8 days. Despite ventilation strategies, neuromuscular blockade, inhalation therapy, and vitamin C, he remained asynchronous to the ventilator with volumes and pressures beyond accepted thresholds, eventually developing a fatal tension pneumothorax. CONCLUSIONS Patients that convert to Type H can quickly enter a spiral of hypoxemia, shunting, and dead-space ventilation towards full-blown ARDS. Understanding its nuances is vital to interrupting phenotypic conversion and entry into VILI vortex. Tension pneumothorax represents a poor outcome in patients with CARDS. Further research into monitoring lung dynamics, modifying ventilation strategies, and understanding response to various modes of ventilation in CARDS are required to mitigate these adverse outcomes.