特 集 人 工 臓 器 と 救 急 集 中 治 療 ARDS Shingo ICHIBA 1. はじめに acute respirator y distress syndrome, ARDS 2. ARDSの 病 態 について ARDS 1967 Ashbaugh 1) ARDS ARDS 3. 定 義 ARDS 1994 American-European Consensus Conference 2) PaO2 FIO2 P/F ratio 200 mmhg 著 者 連 絡 先 700-0005 1-1 E-mail. sichiba@bme.ous.ac.jp 18 mmhg acute lung injury, ALI P/F ratio 300 mmhg ARDS 4. 疫 学 ARDS 100,000 1.5 75 / 65 Barnard 3) ARDS 9 16 multiple organ failure, MOF 80 90 ICU 4) ALI 121 19.5 ARDS 79 23 MOF ARDS 5. 病 態 生 理 ARDS primar y secondar y Primar y Secondary 2 / / 44 37 1 2008
ARDS 5) 1) 浸 出 期 1 free radical ARDS TNF- IL-1, 6, 8 vasoconstriction 2) 器 質 化 期 Type 3) 線 維 化 期 Type 6. 機 械 的 人 工 呼 吸 (mechanical ventilation, MV)の 功 罪 ARDS ARDS MOF MV MV ventilator induced lung injury VILI VILI biochemical biophysical injur y Biophysical injury barotrauma 6) Tsuno 30 cmh2o barotrauma 7) 150 cmh2o 1 30 ml/kg transpulmonary pressure volutrauma atelectrauma 8) Gattinoni ARDS CT ARDS baby lung model 9) volutrauma 10) atelectrauma MV humoral mediator biotrauma 11) Imai apoptosis 12) ARDS MOF 7. Lung protective ventilation strategy (LPVS) ( 肺 保 護 戦 略 に 基 づく 人 工 呼 吸 管 理 ) ARDS 3 FIO2 1 37 1 2008 45
13) LPVS VILI 1 1990 Amato 14) LPVS RCT ARDS Network ARDSnet 15) 1 6 ml/kg predicted body weight, PBW 12 ml/kg PBW 2008 Surviving Sepsis Campaign Sepsis ALI/ARDS tidal volume of 6 ml/kg PBW Grade 1B moderate quality of evidence, strong recommendation 16) 1 30 cmh2o PEEP VILI LPVS 17),18) open-lung strategy PEEP 19),20) 1 ph 7.2 permissive hypercapnia 21) LPVS CO2 22) 23) CO2 vasoactive Komori PaCO2 PaCO2 150 mmhg 24) hypercapnia ARDS high frequency oscillatory ventilation, HFOV 1 10 HFOV 1 1 3 ml/kg volutrauma 25) 2 RCT ARDS ARDS LPVS 1 6 ml/ kg PBW PEEP 8. 人 工 肺 の 関 与 ARDS? Bernard 3) Roentgen X iron lung Swan-Ganz ARDS 1970 extracorporeal life support ECLS 26) 3 severe ARDS 20 27) ARDS ECLS 表 1 ECLS pre-p/f ratio pre-paco2 3 extracorporeal membrane oxygenation ECMO veno-ar terial bypass VAB veno-venous bypass VVB VVB low frquency positive pressure ventilation with extracorporeal CO2 removal 46 37 1 2008
表 1 Landmark research papers of extracorporeal life support for severe ARDS Author/ country (Reference No) Zapol WM/ USA 26 Gattinoni L/ Italy 31 Morris AH/ USA 32 Lewandowski K/Germany Hemmila MR/ USA 33 Bein T/ Germany Peek GJ/UK Publication year (reference) Method of research 1979 Prospective randomized controlled trial 1986 Uncontrolled study 1994 Prospective randomized controlled trial 1997 Prospective uncontrolled trial 2004 Uncontrolled study 2006 Uncontrolled study Publishing soon Prospective randomized controlled trial Type of ECLS VAB ECMO LFPPV- ECCO2R LFPPV- ECCO2R VVB ECMO VVB or VAB ECMO AVCO2R VVB ECMO Entry criteria Fast entry: At FIO2 1.0 and PEEP 5, PaO2 50 for 2 h Slow entry: At FIO2 0.6 and PEEP 5, PaO2 50, QS/QT 0.3 for 12 h Fast entry: At FIO2 1.0 and PEEP 5, PaO2 50 for 2 h Slow entry: At FIO2 0.6 and PEEP 5, PaO2 50, QS/QT 0.3, CTstat 30 ml/ cmh2o for 12h Fast entry: At FIO2 1.0 and PEEP 5, PaO2 50 for 2 h Slow entry: At FIO2 0.6 and PEEP 5, PaO2 50, QS/QT 0.3 for 12 h Fast entry: At PEEP 10, P/F ratio 50 for 2 h Slow entry: At PEEP 10, P/F ratio 150, Q S/QT 0.3, EVLW 15 ml/kg, CTstat 30 ml/cmh2o for 12 h Failure to algorithm for treatment of severe ARDS: At FIO2 1.0, PaO2 100, A-aDO2 600, or QS/QT 0.3 Failure of advanced treatment: At FIO2 1.0, PaO2 55 and/or hypercapnic acidosis with hemodynamic instability for 2 h, or tendency toward deterioration Severe but potentially reversible respiratory failure, Murray score 2.5 or uncompensated hypercapnea with ph 7.2 Mean Mean ECLS pre-p/f pre-paco2 cases ratio mmhg (survived) 42 4 66.8 48.9 43 21 62.6 50.0 21 7 67.0 65.8 49 27 54.9 46.8 255 132 58.0 60.0 90 37 Survival rate (%) 9.5% 48.8% 33.3% 55.1% 51.8% 41.1% ECMO was favourable PaO2/FIO2 ratio: P/F ratio, A-aDO2: alveolar-arterial gradient, CTstat: thracopulmonary compliance, ECLS: extracorporeal life support, EVLW: extravascular lung water, QS/QT: intrapulmonary right-to-left shunt. Peek, personal communication. LFPPV-ECCO2R ar terio-venous CO2 removal AVCO2R pumpless extracorporeal inter ventional lung assist ila Novalung GmbH, Hechingen, Germany 9. 歴 史 的 な 流 れ 1972 Hill ECMO 28) 24 4 ARDS 75 VAB ECMO Hill ECMO 1974 1977 ECMO randomized controlled trial RCT US National Institute of Health NIH FIO2 50 ECMO fast entr y: FIO2 100 PEEP 5 cmh2o PaO2 50 mmhg 2 slow entry: FIO2 60, PEEP 5 cmh2o PaO2 50 mmhg 12 shunt fraction 30 VAB ECMO 37 1 2008 47
randomize 9 26) VAB Kolobow VAB VVB ARDS 29) ECMO 9 Kolla ECMO 100 ECMO 7 LPVS 30) RCT ECMO Gattinoni CO2 LFPPV-ECCO2R 1970 NIH ECMO 48.8 31) LFPPV-ECCO2R PEEP 15 25 cmh2o, 3 5 /min, peak airway pressure 35 45 cmh2o Tidal volume VT LPVS open lung apneic oxygenation Morris LFPPV-ECCO2R RCT 32) Gattinoni 1970 US ECMO trial 40 3 ECCO2R CO2 1 3.0 ml/kg PBW volutrauma Ppeak 45.4 cmh2o barotrauma 1.76 l/day LFPPV-ECCO2R 21 7 33.3 pressure controlled inverse ratio ventilation PCIRV 20 44 LPVS LFPPV- ECCO2R Gattinoni 31) 2 RCT ECLS Bar tlett ECMO 33) VVB ECMO full support 34) severe ARDS 35) Lewandowski ARDS VVB ECMO ARDS 75 36) Bar tlett 33) 1989 Extracorporeal Life Support Organization ELSO ECMO Center 2007 7 50 図 1 37) ECMO conventional ventilation poly-methyl pentene PMP 38) ECMO ECMO ECMO specialist 48 37 1 2008
図 1 Extracorporeal Life Support Organization International Registry as of July 2007 Cumulative Survival of Adult Respiratory Cases. Hemmila 4 5 30 45 learning curve 33) ECMO GGH National Health Service NHS ECMO RCT conventional ventilator support vs extracorporeal membrane oxygenation for severe adult respiratory failure CESAR trial 39) ECMO 表 1 ARDS randomize ECMO ECMO GGH ECMO conventionai conventional treatment center ECMO was favorable 40) 10. 人 工 肺 の 挑 戦 severe ARDS ECMO 2007 7 ELSO registry report ECMO 1,373 oxygenator failure 19.7 surgical site/cannulation site/gastrointerstinal GI bleeding 40.5 dialysis/hemofiltration/ continuous arteriovenous hemofiltration CAVH required 47.5 Inotropes on ECLS 59.7 cardiac arr ythmia 20 hyper glycemia glucose 240 19.5 culture proven infection 23.1 37) ECMO 40.5 ARDS LPVS 1 PEEP ARDS LPVS ECMO quality of life QOL ila ECMO CO2 LPVS LFPPV-ECCO2R Bein ECMO severe ARDS ila 90 37 1 2008 49
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