ARDS 柏林新定义告诉了我们什么

ARDS柏林新定义告诉了我们什么？AcuteRespiratoryDistressSyndromeTheBerlinDefinitionJAMA,PublishedonlineMay21,2012内容1.OriginalDefinitionofARDS2.Multipledifferentdefinitions3.AECCDefinition4.AECC？5.TheUpdatedBerlinDefinition6.CommentandconclusionInitialDescriptionTheinitialdescriptionofacuterespiratorydistresssyndrome(ARDS)inadultbyAshbaughetalin1967.Acuterespiratorydistressinadults.Lancet.1967;2(7511):319-323OriginalDefinitionofARDS“Severedyspnea,tachypnea,cyanosisthatisrefractorytooxygentherapy,lossoflungcompliance,anddiffusealveolarinfiltrationseenonchestx-ray.”—AshbaughLancet,1967Aug12;2(7511):319-23.Severedyspnea,tachypneaCyanosisrefractorytooxygentherapyLossoflungcomplianceDiffusealveolarinfiltrationonchestradiographHyperemia,atelectasis,interstitialandalveolarhemorrhageandedema,andhyalinemembranesatautopsy√OriginaldescriptionofARDS×Nospecificcriteria×AutopsynotusuallyperformedARDSin19671967Ashbaugh等N=12(7例创伤，1例胰腺炎，4例肺炎)呼吸衰竭呼吸频速：20-64bpm低氧血症：SaO241%-85%肺顺应性降低：9-19ml/cmH2O胸片：早期斑片状阴影后期浸润扩大吸氧不能纠正低氧，PEEP部分纠正尸检：7例大体：肺重量增加、变硬肺切面与肝类似镜下：肺毛细血管充血、扩张广泛肺泡萎陷大量中性粒细胞浸润肺泡内透明膜形成部分明显间质纤维化Overthefollowing45yearsmultipledifferentdefinitionswereproposedwithvaryingdiagnosticcriteria.DefinitionchangeofARDSOriginalPepeMurrayDelphiConsensusDefinitionDefinitionDefinitionPanelDefinition↓↓↓↓1967→1976→1982→1983→1988→1994→2005→2012→↑↑↑↑↑BoneFowlerAECCOIBerlinDefinitionDefinitionDefinitionDefinitionBonedefinitionin1976PaO2≤70mmHgwithFiO2≥0.5withPEEP（amountofPEEPnotspecified）.√ReasonablethresholdforPaO2/FiO2.×Nospecificsotherthanoxygenation.PepeDefinitionin1982PaO2＜75mmHgwithFiO2≥0.5NewdiffusebilateralchestinfiltrateswithalllungfieldsinvolvedPAWP＜18mmHgNotduetoheartfailure,pleuraleffusion,atelectasisorbacterialpneumonia√Detailedoperationaldefinitionsimilartocurrentdefinitions×PEEPnotincorporated×PAWPoften＞18mmHg×ExcludesbacterialpneumoniaFowlerDefinitionin1983SuddenonsetofbilateralpulmonaryinfiltratesPAWP≤12mmHgCompliance≤50mL/cmH2OPaO2/PAO2≤0.2√Detailedoperationaldefinition×PAWPveryoften＞12mmHg×Compliancenotusuallymeasured×PEEPnotincorporatedMurraydefinitionin1988AcuteorchronicMildtomoderateorsevere(ARDS)lunginjurybasedonLungInjuryScoreCausedbypulmonarydisorderorassociatedwithsystemicdisorder√Lunginjuryscoredescribesseverity√PEEPincorporated√Emphasizescause×Chronicsubtypenolongeraccepted×LungInjuryScorenotprognostic×Compliancenotusuallymeasured×DoesnotexcludeheartfailureMurrayLungInjuryScoreFinalscore=collectivescore/numberofcomponents0:nolunginjury1-2.5:mildtomoderatelunginjuryMorethan2.5:presenceofARDS1.ChestroentgenogramscoreNoalveolarconsolidation0Alveolarconsolidationconfinedto1quadrant1Alveolarconsolidationconfinedto2quadrants2Alveolarconsolidationconfinedto3quadrants3Alveolarconsolidationconfinedinall4quadrants42.HypoxemiascorePaO2/FiO2＞3000PaO2/FiO2225-2991PaO2/FiO2175-2242PaO2/FiO2100-1743PaO2/FiO210043.PEEPscore(whenventilated)(cmH2O)PEEP≤50PEEP6-81PEEP9-112PEEP12-143PEEP≥1544.Respiratorysystemcompliancescore(whenavailable)(ml/cmH2O)Compliance800Compliance60-791Compliance40-592Compliance20-393Compliance194AmRevResporDis1988.138:720-3DelphiConsensuspanelDefinitionin2005DefiningcharacteristicOperationaldefinition1HypoxemiaPaO2/FiO2＜200mmHgwithPEEP≥102AcuteonsetRapidonset72h3RadiographicabnormalitiesBilatcralairspacediseaseinvolving≥2quadrantsonfrontalchestx-ray4NoncardiogenicinoriginNoclinicalevidenceofcongestiveHeartfailure(includinguseofPAcatheterand/orechoifclinicallyindicated)5DecreasedlungcomplianceStaticrespiratorysystemcompliance50ml/cmH2O(Vtof8ml/kg,PEEP≥10)6PredispositionDirectand/orindirectfactorassociatedwithlunginjury.OxygenationIndexMAP×FiO2×100OI=——————————PaO2MAP:meanairwaypressureAECCDefinitionin1994AECC(American-EuropeanConsensusConference).AcuteonsetofhypoxemiaPaO2/FiO2≤200mmHg=ARDSPaO2/FiO2≤300mmHg=ALIBilateralinfiltratesonchestradiographPAWP≤18mmHgwhenmeasuredornoclinicalevidenceofleftatrialhypertension.TheAmerican-EuropeanConsensusConferenceonARDS.Definitions,mechanisms,relevantoutcomes,andclinicaltrialcoordination.AmJRespirCritCareMed.1994AECCdefinitionofALI/ARDSTimingOxygenationChestradiographPulmonaryarterywedgepressureALIAcuteonset≦300(regardlessofPEEP)Bilateralinfiltrates≦18mmHg/noevidenceofleftatrialhypertensionARDSAcuteonset≦200(regardlessofPEEP)Bilateralinfiltrates≦18mmHgornoevidenceofleftatrialhypertensionProsinAECCDifferentiatesARDSwithALI:Anewentity—acutelunginjury(ALI)—beingdescribed,withsimilarcriteriabutlessseverehypoxemia(PaO2/FIO2≤300mmHg).FirstConsensusdefinition.First:Adult→AcuteTheAmerican-EuropeanConsensusConferenceonARDS.Definitions,mechanisms,relevantoutcomes,andclinicaltrialcoordination.AmJRespirCritCareMed.1994修正的AECC定义把急性肺损伤定义为独立的非ARDS的ALI和单独性的ARDS。非ARDS的ALI：200mmHg＜PaO2/FiO2≤300mmHg,不考虑PEEP；ARDS：PaO2/FiO2≤200mmHg,不考虑PEEP。尽管非ARDS的ALI类别这一概念没有被AECC明确地提出，但它一直被很多调查研究者所使用。AECCDefinition靠谱吗？WhatistheaccuracyofcurrentALI/ARDSdefinition？背景18年的AECC定义的临床应用研究，出现了有关ARDS标准的各种问题所有疾病定义都应定期进行回顾ConsinAECC“Acute”notspecificCausenotemphasized