背景:本文件更新了先前发布的急性呼吸窘迫综合征(ARDS)患者管理的临床实践指南,结合新的证据来解决皮质类固醇的使用,静脉-体外膜氧合,神经肌肉阻断剂,呼气末正压(PEEP)。
方法:我们总结了解决四个“PICO问题”的证据(患者,干预,比较,和结果)。具有ARDS专业知识的多学科小组使用了建议分级,评估,发展,和评估框架,以制定临床建议。
结果:我们建议:1)对ARDS患者使用皮质类固醇(有条件的推荐,证据的适度确定性),2)重症ARDS患者的静脉-静脉体外膜氧合(有条件推荐,证据确定性低),3)早期严重ARDS患者的神经肌肉阻滞剂(有条件推荐,证据确定性低),和4)与中度至重度ARDS患者的较低PEEP相比,较高的PEEP无肺复张动作(有条件的推荐,低到中等的确定性),和5)我们建议不要在中度至重度ARDS患者中使用延长的肺部募集策略(强烈建议,适度的确定性)。
结论:我们为ARDS的管理提供了最新的循证建议。在临床决策和实施这些建议时应考虑个体患者和疾病特征,同时从急需的临床试验中产生更多证据。
Background: This document updates previously published Clinical Practice
Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four \"PICO questions\" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.