respiratory failure

呼吸衰竭
  • 文章类型: English Abstract
    In recent years the number of patients treated in intensive care units by extracorporeal membrane oxygenation (ECMO) due to severe respiratory failure or cardiogenic shock has steadily increased [1]. Consequently, the number of invasive procedures and operations in these patients has also increased. A fundamental understanding of these systems and the clinical indications is therefore helpful for the practicing (non-cardiac) surgeon. This review article focuses on peripheral ECMO procedures: venovenous (V-V) ECMO for patients with respiratory failure and venoarterial (V-A) ECMO for circulatory support in cardiogenic shock.
    UNASSIGNED: In den letzten Jahren haben sich die Zahlen von Patienten, die mit einer extrakorporalen Membranoxygenierung (ECMO) aufgrund einer schweren respiratorischen Insuffizienz oder eines kardiogenen Schocks auf Intensivstationen behandelt werden, stetig erhöht [1]. Damit steigt auch zwangsläufig die Anzahl an invasiven Prozeduren und Operationen bei dieser Patientenklientel. Ein prinzipielles Verständnis der Funktionsweise und der Indikationen für den Einsatz dieser Systeme ist damit auch für den (nicht kardio‑)chirurgisch tätigen Arzt hilfreich. Der Schwerpunkt dieses Übersichtsartikels liegt auf den peripheren ECMO-Verfahren: venovenöse (V-V-)ECMO bei Patienten mit respiratorischer Insuffizienz und venoarterielle (V-A-)ECMO zur Kreislaufunterstützung bei kardiogenem Schock.
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  • 文章类型: Case Reports
    腺病毒肺炎进展迅速,严重肺炎的进展率很高,但早期临床表现缺乏特异性,不易被识别。
    回顾相关文献,我们研究并总结了早期的认识,重症腺病毒肺炎的临床特征和治疗前景病例介绍:1例11岁儿童社区获得性肺炎,胶体金检测甲型流感抗原阳性,住院后进一步发展为急性呼吸窘迫综合征。三天后,咽拭子PCR检测腺病毒阳性,诊断为重症腺病毒肺炎。经过积极的治疗,她的病情好转,出院了。
    临床,腺病毒合并流感病毒感染并不常见,腺病毒感染在青少年中更为罕见。
    UNASSIGNED: Adenovirus pneumonia progresses rapidly, with a high rate of progression to severe pneumonia, but the early clinical manifestations lack specificity and are not easy to be recognized.
    UNASSIGNED: Reviewing the relevant literatures, we studied and summarized the early recognition, clinical features and treatment outlook of severe adenovirus pneumonia Case Presentation: An 11-year-old child with community-acquired pneumonia, with influenza A antigen positive by colloidal gold, which further developed into acute respiratory distress syndrome after hospitalization. Three days later, adenovirus was detected positively by PCR of throat swab and diagnosed as severe adenovirus pneumonia. After aggressive treatment, her condition improved and was discharged from the hospital.
    UNASSIGNED: Clinically, adenovirus combined with influenza virus infection is uncommon, and adenovirus infection is even rarer in adolescent children.
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  • 文章类型: Journal Article
    背景:虽然高流量鼻插管(HFNC)代表了重症监护病房中严重低氧血症患者的护理标准,它在家庭护理设置中的使用是罕见的,尽管它的潜力。与通过鼻低流量治疗的标准长期氧气相比,高流量鼻插管(HFNC)在家庭护理设置中的潜在益处和挑战尚不清楚。方法:我们在呼吸内科进行了一项前瞻性单中心可行性研究,大学医院,法兰克福歌德大学,德国。患有间质性肺病或严重支气管扩张(包括囊性纤维化)的患者被纳入研究。在住院期间引入HFNC。在4-6周的随访中评估患者对家庭使用建议和动脉血气结果的依从性。结果:共分析12例患者。HFNC引发没有导致pO2/fiO2(p/f)比率的显著改善。在最初的住院开始后,12名患者中只有8名(66.6%)在家中使用HFNC。在HFNC发作后3-6周的随访中,总共12名患者中只有7名使用了该疗法。两名患者在观察期间死亡,导致监测死亡率为16.7%。结论:可行性数据显示家庭对HFNC的依从性较低。与ICU中严重呼吸衰竭的患者相比,对p/f比缺乏任何积极影响可能是由于低气流速率和总体轻度低氧血症。
    Background: While high-flow nasal cannulas (HFNCs) represent the standard of care in the intensive care unit for patients with severe hypoxemia, its use in homecare settings is uncommon despite its potential. The potential benefits and challenges of the high-flow nasal cannula (HFNC) in homecare settings compared to standard long-term oxygen via nasal low-flow therapy are unclear. Methods: We conducted a prospective monocentric feasibility study at the Department of Respiratory Medicine, University Hospital, Goethe University Frankfurt, Germany. Patients with interstitial lung disease or severe bronchiectasis (including cystic fibrosis) were enrolled into the study. The HFNC was introduced during hospitalization. The patients\' compliance with home use advice and arterial blood gas results were evaluated at a 4-6-week follow-up. Results: A total of 12 patients were analyzed. HFNC initiation did not result in a significant improvement of the pO2/fiO2 (p/f) ratio. Only 8 out of 12 (66.6%) patients used the HFNC at home after the initial in-hospital initiation. Only 7 of the total 12 patients were using the therapy at a follow-up 3-6 weeks after HFNC onset. Two patients died during the observation, resulting in a surveillance mortality rate of 16.7%. Conclusions: The feasibility data showed low adherence to the HFNC at home. The lack of any positive effect on the p/f ratio may be due to low airflow rates and overall mild hypoxemia compared to patients with severe respiratory failure in the ICU.
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  • 文章类型: Case Reports
    方法:一名62岁的妇女来到我们医院,前一周咳嗽和呼吸困难恶化,在此期间,她因疑似肺炎接受了阿奇霉素和泼尼松治疗。她没有发烧,发冷,或者出汗,但是她的咳嗽在间隔期间变得明显到有血的痰。病史对胰岛素依赖型糖尿病和OSA具有重要意义。她早戒烟44年,没有肺病史。她是居住在明尼苏达州东南部的银行出纳员,没有描述相关的吸入或环境暴露,吸毒,抽吸,或者在她生病之前旅行。
    METHODS: A 62-year-old woman came to our hospital with worsening cough and dyspnea over the preceding week, during which time she had been treated with azithromycin and prednisone for suspected pneumonia. She had no fever, chills, or sweats, but her cough had become productive of clear to blood-tinged phlegm during the interval. Medical history was significant for insulin-dependent diabetes mellitus and OSA. She had quit smoking 44 years earlier and had no history of lung disease. She was a bank teller residing in southeastern Minnesota and described no relevant inhalational or environmental exposures, drug use, aspiration, or travels preceding her illness.
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  • 文章类型: Journal Article
    免疫球蛋白Mu结合蛋白2(IGHMBP2)致病变异导致致命的,神经退行性疾病脊髓性肌萎缩伴呼吸窘迫1型(SMARD1)和轻度,Charcot-Marie-Tooth(CMT)2S型(CMT2S)神经病。在IGHMBP2和SMARD1之间的联系被揭示20多年后,在发现IGHMBP2和CMT2S之间的关联10年后,这些疾病的致病机制仍然不明确。IGHMBP2作为RNA/DNA解旋酶的发现是重要的一步,但没有揭示致病机理。解旋酶是使用ATP水解来催化核酸链分离的酶。它们参与许多细胞过程,包括DNA修复和转录;RNA剪接,运输,编辑和降解;核糖体生物发生;翻译;端粒维持;和同源重组。IGHMBP2似乎是参与调节基因表达的几种细胞过程的多功能因子。很难确定哪些流程,当失调时,导致病理学。这里,我们总结了目前对IGHMBP2相关疾病临床表现的认识.我们还概述了可用的型号,包括酵母,小鼠和细胞,用于研究IGHMBP2的功能和相关疾病的发病机制。Further,我们讨论了IGHMBP2蛋白的结构及其在细胞功能中的作用。最后,我们提出了可能导致在IGHMBP2相关疾病中观察到的神经变性的潜在异常,并强调了最突出的异常.
    Immunoglobulin Mu-binding protein 2 (IGHMBP2) pathogenic variants result in the fatal, neurodegenerative disease spinal muscular atrophy with respiratory distress type 1 (SMARD1) and the milder, Charcot-Marie-Tooth (CMT) type 2S (CMT2S) neuropathy. More than 20 years after the link between IGHMBP2 and SMARD1 was revealed, and 10 years after the discovery of the association between IGHMBP2 and CMT2S, the pathogenic mechanism of these diseases is still not well defined. The discovery that IGHMBP2 functions as an RNA/DNA helicase was an important step, but it did not reveal the pathogenic mechanism. Helicases are enzymes that use ATP hydrolysis to catalyse the separation of nucleic acid strands. They are involved in numerous cellular processes, including DNA repair and transcription; RNA splicing, transport, editing and degradation; ribosome biogenesis; translation; telomere maintenance; and homologous recombination. IGHMBP2 appears to be a multifunctional factor involved in several cellular processes that regulate gene expression. It is difficult to determine which processes, when dysregulated, lead to pathology. Here, we summarise our current knowledge of the clinical presentation of IGHMBP2-related diseases. We also overview the available models, including yeast, mice and cells, which are used to study the function of IGHMBP2 and the pathogenesis of the related diseases. Further, we discuss the structure of the IGHMBP2 protein and its postulated roles in cellular functioning. Finally, we present potential anomalies that may result in the neurodegeneration observed in IGHMBP2-related disease and highlight the most prominent ones.
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  • 文章类型: Journal Article
    这项回顾性研究检查了与重症患者获得性虚弱相关的危险因素和肌电图(EMG)特征,并评估了其对患者预后的影响。
    97名危重病人,通风超过48小时,包括在内。患者数据,包括一般情况,病史,医学研究理事会(MRC)成绩,血清标志物(C反应蛋白,降钙素基因,白蛋白,脑钠肽,尿素氮,肌酐),EMG特征,呼吸治疗方式,和参数,被记录下来。机械通气时间,ICU住院时间,住院时间,并记录患者预后。根据MRC分数,患者分为ICU获得性肌无力(ICU-AW)组(MRC<48分)和非ICU-AW组(MRC≥48分).
    该研究包括47名ICU-AW患者和50名非ICU-AW患者。在年龄上观察到显著差异(p<0.05),MRC得分,白蛋白水平,c反应蛋白,降钙素基因,脑钠肽,尿素氮,肌酐,机械通气持续时间,ICU住院时间,两组之间的住院时间。在ICU-AW组中,神经传导检查显示传导速度慢,降低波振幅,在严重的情况下,完全丧失运动和感觉潜能.多因素logistic分析确定低血清白蛋白水平和MRC评分是潜在的ICU-AW危险因素。
    这项研究表明,低血清白蛋白水平和MRC评分可能导致ICU-AW风险。ICU-AW组在EMG上表现出不同的周围神经损伤和缓慢的传导速度。此外,严重的全身炎症反应,肾功能,脑钠肽水平,长时间机械通气,外周神经损伤可能与ICU-AW有关。后续研究对于进一步理解这些复杂的相互作用至关重要。
    UNASSIGNED: This retrospective study examines risk factors and electromyographic (EMG) characteristics associated with acquired weakness in critically ill patients and assesses their impact on patient prognosis.
    UNASSIGNED: Ninety-seven critically ill patients, ventilated for over 48 hours, were included. Patient data, encompassing general condition, medical history, Medical Research Council (MRC) scores, serum markers (c-reactive protein, calcitonin gene, albumin, brain natriuretic peptide, urea nitrogen, creatinine), EMG characteristics, respiratory treatment modalities, and parameters, were recorded. Mechanical ventilation duration, ICU stay duration, hospitalization duration, and patient prognosis were documented. Based on MRC scores, patients were categorized into the ICU-acquired weakness (ICU-AW) group (MRC <48 points) and the non-ICU-AW group (MRC ≥48 points).
    UNASSIGNED: The study comprised 47 ICU-AW and 50 non-ICU-AW patients. Significant differences (p <0.05) were observed in age, MRC scores, albumin levels, c-reactive protein, calcitonin gene, brain natriuretic peptide, urea nitrogen, creatinine, mechanical ventilation duration, ICU stay duration, and hospitalization duration between groups. In the ICU-AW group, nerve conduction examinations revealed slow conduction velocity, reduced wave amplitude, and in severe cases, a complete loss of motor and sensory potentials. Multivariate logistic analysis identified low serum albumin levels and MRC scores as potential ICU-AW risk factors.
    UNASSIGNED: This study suggests that low serum albumin levels and MRC scores may contribute to ICU-AW risk. The ICU-AW group exhibited varied peripheral nerve damage and slow conduction velocities on EMG. Additionally, severe systemic inflammatory responses, renal function, brain natriuretic peptide levels, prolonged mechanical ventilation, and peripheral nerve damage may be associated with ICU-AW. Follow-up studies are essential for further understanding these complex interactions.
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  • 文章类型: Journal Article
    背景:肺部计算机断层扫描(CT)扫描的自动分析可能有助于表征急性呼吸道疾病的亚表型。我们将通过深度学习测量的肺部CT特征与自主呼吸受试者的临床和实验室数据相结合,以增强对COVID-19亚型的识别。
    方法:这是一项多中心观察性队列研究,在入院7天内暴露于早期肺部CT的COVID-19呼吸衰竭自主呼吸患者中进行。我们使用深度学习方法对肺部CT图像进行定量和定性分析;通过使用临床,实验室和肺部CT变量;3D空间轨迹后,亚表型之间的区域差异。
    结果:559例患者获得了完整的数据集。LCA鉴定了两种亚表型(亚表型1和2)。与亚表型2(n=403)相比,亚表型1患者(n=156)年龄较大,有更高的炎症生物标志物,和更多的低氧血症。与亚表型2相比,亚表型1中的肺具有更高的密度重力梯度,合并肺的比例更高。相比之下,与亚表型1相比,亚表型2具有更高的密度下骨-肺门梯度,毛玻璃混浊的比例更高。亚表型1显示与内皮功能障碍相关的合并症的患病率和90天死亡率高于亚表型2,即使在调整了有临床意义的变量后也是如此。
    结论:在LCA中整合肺CT数据使我们能够识别COVID-19的两种亚型,具有不同的临床轨迹。这些探索性发现表明,机器学习指导的自动成像表征在呼吸衰竭患者的亚表型中的作用。
    背景:ClinicalTrials.gov标识符:NCT04395482。注册日期:2020-05-19。
    BACKGROUND: Automated analysis of lung computed tomography (CT) scans may help characterize subphenotypes of acute respiratory illness. We integrated lung CT features measured via deep learning with clinical and laboratory data in spontaneously breathing subjects to enhance the identification of COVID-19 subphenotypes.
    METHODS: This is a multicenter observational cohort study in spontaneously breathing patients with COVID-19 respiratory failure exposed to early lung CT within 7 days of admission. We explored lung CT images using deep learning approaches to quantitative and qualitative analyses; latent class analysis (LCA) by using clinical, laboratory and lung CT variables; regional differences between subphenotypes following 3D spatial trajectories.
    RESULTS: Complete datasets were available in 559 patients. LCA identified two subphenotypes (subphenotype 1 and 2). As compared with subphenotype 2 (n = 403), subphenotype 1 patients (n = 156) were older, had higher inflammatory biomarkers, and were more hypoxemic. Lungs in subphenotype 1 had a higher density gravitational gradient with a greater proportion of consolidated lungs as compared with subphenotype 2. In contrast, subphenotype 2 had a higher density submantellar-hilar gradient with a greater proportion of ground glass opacities as compared with subphenotype 1. Subphenotype 1 showed higher prevalence of comorbidities associated with endothelial dysfunction and higher 90-day mortality than subphenotype 2, even after adjustment for clinically meaningful variables.
    CONCLUSIONS: Integrating lung-CT data in a LCA allowed us to identify two subphenotypes of COVID-19, with different clinical trajectories. These exploratory findings suggest a role of automated imaging characterization guided by machine learning in subphenotyping patients with respiratory failure.
    BACKGROUND: ClinicalTrials.gov Identifier: NCT04395482. Registration date: 19/05/2020.
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  • 文章类型: Journal Article
    目的:静脉-静脉体外膜肺氧合(VV-ECMO)是循证常规治疗难以治疗的严重呼吸衰竭患者管理算法的组成部分。在VV-ECMO的背景下,与右心室(RV)的尺寸和/或功能异常有关的右心室损伤(RVI)显着影响死亡率。然而,在缺乏普遍接受的RVI定义和基于证据的RVI管理指南的情况下,临床实践中的变化继续存在。
    方法:在对文献进行系统搜索之后,一个国际指导委员会,由8名医疗保健专业人员组成,参与对接受ECMO治疗的患者的管理,确定了与RVI定义和管理相关的领域和知识差距,证据有限或含糊不清.使用Delphi过程,一个由52名专家组成的国际小组编写了这些领域的专家立场声明。该过程还为未来的研究提供了以RV为中心的总体开放问题。共识被定义为当70%或更多的专家同意或不同意李克特量表的声明时,或者当80%或更多的专家同意多项选择题中的特定选项时。
    结果:Delphi过程通过四轮进行,对35种陈述中的31种(89%)达成共识,从中得出24种专家立场陈述。专家立场声明为VV-ECMO设置中的RVI命名法提供了建议,RVI的多模态诊断方法,诊断超声心动图的时间和参数,RVI评估和管理期间的VV-ECMO设置。在RV保护性驱动压力阈值或俯卧位对以患者为中心的结果的影响方面未达成共识。
    结论:在VV-ECMO背景下提出的RVI定义需要通过系统汇总研究数据来验证。在进一步的证据出现之前,专家立场声明可以指导这些患者的管理决策。
    OBJECTIVE: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an integral part of the management algorithm of patients with severe respiratory failure refractory to evidence-based conventional treatments. Right ventricular injury (RVI) pertaining to abnormalities in the dimensions and/or function of the right ventricle (RV) in the context of VV-ECMO significantly influences mortality. However, in the absence of a universally accepted RVI definition and evidence-based guidance for the management of RVI in this very high-risk patient cohort, variations in clinical practice continue to exist.
    METHODS: Following a systematic search of the literature, an international Steering Committee consisting of eight healthcare professionals involved in the management of patients receiving ECMO identified domains and knowledge gaps pertaining to RVI definition and management where the evidence is limited or ambiguous. Using a Delphi process, an international panel of 52 Experts developed Expert position statements in those areas. The process also conferred RV-centric overarching open questions for future research. Consensus was defined as achieved when 70% or more of the Experts agreed or disagreed on a Likert-scale statement or when 80% or more of the Experts agreed on a particular option in multiple-choice questions.
    RESULTS: The Delphi process was conducted through four rounds and consensus was achieved on 31 (89%) of 35 statements from which 24 Expert position statements were derived. Expert position statements provided recommendations for RVI nomenclature in the setting of VV-ECMO, a multi-modal diagnostic approach to RVI, the timing and parameters of diagnostic echocardiography, and VV-ECMO settings during RVI assessment and management. Consensus was not reached on RV-protective driving pressure thresholds or the effect of prone positioning on patient-centric outcomes.
    CONCLUSIONS: The proposed definition of RVI in the context of VV-ECMO needs to be validated through a systematic aggregation of data across studies. Until further evidence emerges, the Expert position statements can guide informed decision-making in the management of these patients.
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  • 文章类型: Case Reports
    背景:病态肥胖患者偶尔会由于通气不足而出现呼吸问题。气道压力释放通气是经常用于急性呼吸窘迫综合征的呼吸管理的通气设置之一。然而,以前的报告表明,气道压力释放通气可能成为一种治疗措施,因为病态肥胖伴呼吸衰竭的呼吸机管理有限.我们报告了一例病态肥胖患者在气道压力释放通气后,氧合明显改善的情况。
    方法:一名50岁的亚裔男子(体重指数41kg/m2)出现呼吸困难。患者出现呼吸衰竭,PaO2/FIO2比值约为100,左肺严重肺不张,并启动呼吸机管理。尽管患者接受了传统的通气模式,氧合没有改善。在第11天,我们将通气设置更改为气道压力释放通气,在PaO2/FIO2比率约为300的情况下,氧合得到了显着改善。我们可以减少镇静药物并进行呼吸康复。患者在第29天从呼吸机上断奶,并在第31天转移到另一家医院进行进一步康复。
    结论:病态肥胖患者的气道压力释放通气呼吸机管理可能有助于改善氧合,并成为重症监护早期的直接治疗措施之一。
    BACKGROUND: Morbidly obese patients occasionally have respiratory problems owing to hypoventilation. Airway pressure release ventilation is one of the ventilation settings often used for respiratory management of acute respiratory distress syndrome. However, previous reports indicating that airway pressure release ventilation may become a therapeutic measure as ventilator management in morbid obesity with respiratory failure is limited. We report a case of markedly improved oxygenation in a morbidly obese patient after airway pressure release ventilation application.
    METHODS: A 50s-year-old Asian man (body mass index 41 kg/m2) presented with breathing difficulties. The patient had respiratory failure with a PaO2/FIO2 ratio of approximately 100 and severe atelectasis in the left lung, and ventilator management was initiated. Although the patient was managed on a conventional ventilate mode, oxygenation did not improve. On day 11, we changed the ventilation setting to airway pressure release ventilation, which showed marked improvement in oxygenation with a PaO2/FIO2 ratio of approximately 300. We could reduce sedative medication and apply respiratory rehabilitation. The patient was weaned from the ventilator on day 29 and transferred to another hospital for further rehabilitation on day 31.
    CONCLUSIONS: Airway pressure release ventilation ventilator management in morbidly obese patients may contribute to improving oxygenation and become one of the direct therapeutic measures in the early stage of critical care.
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  • 文章类型: Journal Article
    在睡眠诊所评估与睡眠有关的呼吸障碍期间,可能会遇到未诊断的慢性高碳酸血症呼吸衰竭。本文回顾了慢性高碳酸血症性呼吸衰竭的机制以及评估临床实践中与夜间通气不足相关的特定睡眠障碍的系统方法。
    Undiagnosed chronic hypercapnic respiratory failure may be encountered during the evaluation of sleep-related breathing disorders at the sleep clinic. This article reviews the mechanism of chronic hypercapnic respiratory failure and the systematic approach to the assessment of specific sleep disorders associated with nocturnal hypoventilation encountered in clinical practice.
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