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酸素化の目標値をどこに設定するか
中川 聡
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ARDS
国立成育医療研究センター
3,207
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概要
小児ARDS（PARDS）の人工呼吸管理を、最新国際ガイドラインPALICC-2に基づき解説します。肺保護換気の要となる1回換気量、プラトー圧、ドライビングプレッシャーの目標値を整理。腹臥位療法などの治療もエビデンスと共に考察します。
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研修医／専攻医／専門医
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このスライドと同じ診療科のスライド
テキスト全文
小児ARDSにおける機械換気戦略の考慮点
#1.
Pediatric ARDS; Special Consideration on Mechanical Ventilation Strategies Satoshi Nakagawa, MD National Center for Child Health and Development Tokyo, Japan
#2.
目次 • PALICC-2 • 1回換気量 • 気道内圧 • PEEP • 気管挿管チューブ • 腹臥位
#3.
PICUで必要な知識や⼿技、 対応のポイントをスライド形式でまとめています ✓ 系統別に学ぶ⼩児集中治療の知識 ✓ ⼿技（挿管‧エコー等）の習得 ✓ ショック‧外傷など緊急対応の理解 スライドで詳しく学ぶ https://slide.antaa.jp/special/pediatric-intensive-care
PALICC-2ガイドラインの概要と治療法
PARDS患者における換気モードと推奨事項
PEEPの調整と酸素化の重要性
肺保護換気バンドルの使用と推奨
許容的高二酸化炭素血症とその影響
体位管理とコルチコステロイドの使用に関する考察
肺への血流と体位の影響
小児におけるARDSの要約と今後の展望
#4.
Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)
#5.
Invasive mechanical ventilation • 3.1. ventilation modes • 3.2. tidal volumes • 3.3. airway pressure • 3.4. PEEP • 3.5. lung protection ventilation bundle • 3.6. recruitment maneuver • 3.7. mechanical power calculation • 3.8. HFOV • 3.9. oxygenation targets • 3.10. hypercapnia and pH target • 3.11. endotracheal tube
#6.
Pulmonary specific ancillary treatment • 4.3. prone positioning • 4.6. corticosteroids
#7.
• Research Statement 3.1. We cannot make a recommendation on the specific ventilator mode preferred for PARDS patients. Future clinical studies should be conducted to assess controlled and assisted modes of ventilation on outcomes. • Recommendation 3.2. We suggest the use of physiologic tidal volumes of 6-8 mL/kg in patients with PARDS as compared to supraphysiologic tidal volumes (VT > 8 mL/kg). (Conditional recommendation, very low certainty of evidence, 98% agreement). • Remarks: Tidal volume below 6 mL/kg should be used in patients, if needed, to remain below suggested plateau pressure (PPlat) and driving pressure limits. Tidal volume below 4 mL/kg should be used with caution.
#8.
ARDS Network. Ventilation with lower tidal volumes compared with traditional tidal volumes for ARDS. N Engl J Med 2000, 342: 1301-1308. an adult study 30% died no matter how small the tidal volume is. 60 % survived no matter how big the tidal volume is. Tidal volumes: 6 ml/kg vs. 12 ml/kg
#9.
10 ml/kg
#10.
#11.
• Recommendation 3.3.1. In the absence of transpulmonary pressure measurements, we suggest an inspiratory PPlat ≤ 28 cm H2O. • (Conditional recommendation, very low certainty of evidence, 92% agreement). • Remarks: The PPlat may be higher (29-32 cm H2O) for patients with reduced chest wall compliance. • Recommendation 3.3.2. We suggest limiting DP to 15 cm H2O (as measured under static conditions) for patients with PARDS. • (Conditional recommendation, very low certainty of evidence, 82% agreement).
#12.
#13.
#14.
This is an observational study, not an RCT C=Vt/ΔP If Vt=6 mL/kg and ΔP=15, C=0.4 mL/cmH2O/kg
#15.
• Recommendation 3.4.1 We suggest that PEEP should be titrated to oxygenation/oxygen delivery, hemodynamics, and compliance measured under static conditions as compared to other clinical parameters or any of these parameters in isolation in patients with PARDS. • (Conditional recommendation, very low certainty of evidence, 96% agreement). • Recommendation 3.4.2 We recommend that PEEP levels should typically be maintained at or above the lower PEEP/higher FIO2 table from the ARDS Network 22 protocol ( ) (Supplemental Table 17, https://links.lww.com/PCC/C304) as compared to PEEP levels lower than the lower PEEP/ higher FIO2 table. • (Strong recommendation, moderate certainty of evidence, 96% agreement). • Good Practice Statement 3.4.3. When adjusting PEEP levels to achieve the proposed oxygen target range for PARDS, attention to avoid exceeding plateau pressure and/or DP limits is warranted. • (Ungraded good practice statement, 100% agreement)
#16.
#17.
Will we apply the same PEEP level?
#18.
• Recommendation 3.5. We suggest that a lung protective ventilation bundle should be used as compared to no bundle when caring for ventilated patients with PARDS. • (Conditional recommendation, low certainty of evidence, 83% agreement). • Remarks: Lung protective bundles prioritize maintaining multiple ventilator settings (VT, PPlat, DP, PEEP) within the suggested limits as well as using detection algorithms and educational programs.
#19.
• Recommendation 3.6. We cannot suggest for or against the use of recruitment maneuvers in patients with PARDS. • (Conditional Recommendation, low certainty of evidence, 94% agreement). • Remarks: Careful recruitment maneuvers may be applied in the attempt to improve oxygenation by slow incremental and decremental PEEP steps. Sustained inflation maneuvers cannot be recommended. • Research Statement 3.7. There is insufficient evidence to suggest the use of mechanical power calculations to guide pediatric mechanical ventilation. Future research is needed with regard to mechanical power calculations in children before clinical use. • (Ungraded research statement, 90% agreement).
#20.
• Recommendation 3.8.1. We cannot make a recommendation as to whether high frequency oscillatory ventilation (HFOV) should be used instead of conventional ventilation in patients with PARDS. • (Conditional recommendation, low certainty of evidence, 90% agreement). • Remarks. HFOV may be considered in patients with PARDS in whom the ventilatory goals are not achieved with a lung protective strategy on conventional mechanical ventilation. • Good Practice Statement 3.8.2. When using HFOV, the optimal lung volume should be achieved by exploration of the potential for lung recruitment with a stepwise increase and decrease of the mean airway pressure under continuous monitoring of the oxygen and CO2 response and hemodynamic parameters. • (Ungraded good practice statement, 90% agreement).
#21.
• Recommendation 3.9.1. We suggest that for mild/moderate PARDS, SpO2 be maintained between 92–97%. • (Conditional recommendation, low certainty of evidence, 98% agreement). • Recommendation 3.9.2. We suggest that for severe PARDS, after optimizing PEEP, SpO2 less than 92% can be accepted to reduce FIO2 exposure. • (Conditional recommendation, low certainty of evidence, 88% agreement). • Good Practice Statement 3.9.3. Prolonged exposure to hypoxemic (<88%) or “high” (>97%) SpO2 targets should be avoided while on oxygen supplementation. • (Ungraded good practice statement, 88% agreement). • Good Practice Statement 3.9.4. When SpO2 is < 92%, central venous saturation and markers of oxygen delivery/utilization should be monitored. • (Ungraded good practice statement, 94% agreement).
#22.
#23.
#24.
• Recommendation 3.10.1. We suggest allowing permissive hypercapnia (to a lower limit pH of 7.20) in patients with PARDS to remain within previously recommended pressure and tidal volume ranges. • (Conditional recommendation, very low certainty of evidence, 100% agreement). • Remarks: Exceptions to permissive hypercapnia include, but are not limited to, intracranial hypertension, severe pulmonary hypertension, select congenital heart disease lesions, hemodynamic instability, and significant ventricular dysfunction. • Recommendation 3.10.2. We suggest against the routine use of bicarbonate supplementation as compared to selective use of bicarbonate in PARDS. • (Conditional recommendation, low certainty of evidence, 96% agreement). • Remarks: Bicarbonate supplementation can be considered in situations where severe metabolic acidosis or pulmonary hypertension are adversely affecting cardiac function or hemodynamic stability.
#25.
• Good practice statement 3.11. Cuffed endotracheal tubes should be used when ventilating a patient with PARDS. • (Ungraded good practice statement, 100% agreement).
#26.
#27.
#28.
#29.
• Recommendation 4.3. There are insufficient definitive data to support or refute the use of prone positioning in patients with PARDS. • (Conditional recommendation, low certainty of evidence, 94% agreement). • Remarks: The use of prone positioning may be considered in patients with PARDS and hypoxemia not responding to other interventions. If used, improvement in oxygenation while in the prone position should be assessed. We cannot make recommendations on the duration of prone positioning. • Recommendation 4.6. We suggest against the routine use of corticosteroids in patients with PARDS as compared to selective use of steroids. • (Conditional Recommendation, low certainty of evidence, 96% agreement). • Remarks: There may be some benefit in patients with PARDS caused by SARS-CoV-2, however we cannot make recommendations regarding other specific populations for use.
#30.
Dorsal atelectasis
#31.
#32.
#33.
Blood flow to the lungs: Dorsal part receives more in both supine and prone position
#34.
#35.
#36.
Prone positioning • If you want to apply prone positioning • Earlier the better, probably • Longer than 16 hours a day may be better
#37.
Refractory hypoxemia Key question is whether lungs are recruitable or not. If recruitable, apply higher PEEP or try recruitment maneuver If not recruitable, consider prone positioning
#38.
Summary • Tidal volumes: 6 to 8 mL/kg is recommended, but there is no evidence in pediatrics • Plat≦28 cmH2O may not be practical in some patients, especially who require higher PEEP • There are no RCTs on driving pressure. This comes from an observational study. • PEEP FIO2 table is not physiology-based. Individualized PEEP setting is recommended. • Currently available cuffed endotracheal tubes have some problems. • There is no evidence of prone positioning in pediatrics, however, it is recommended personally.
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