一位重度急性呼吸窘迫症病人應用階梯式肺再擴張術之實證照護

Evidence-Based Care of Staircase Recruitment Maneuver in a Patient with Severe Acute Respiratory Distress Syndrome

急性呼吸窘迫症是致死率很高的急症，嚴重呼吸困難會造成病人有瀕死的危象。筆者於2020 年11月照顧一位67歲男性因急性呼吸衰竭插管治療，對於肺保護通氣策略之效果不佳，甚至使用體外膜氧合維生系統仍嚴重低血氧，引發筆者想解決此醫療困境之動機。運用實證步驟探討階梯式肺再擴張術增加氧合能力之成效，以PICO詮釋臨床問題，P為急性呼吸窘迫症（Acute respiratory distress syndrome, ARDS）、I為階梯式肺再擴張術（Staircase recruitment maneuver, SRM）、C為常規照護（Usual care）、O為氧合能力（PaO2/FiO2 ratio, PFR），檢索Cochrane Library、PubMed、CINAHL和華藝線上圖書館等資料庫，最終納入五篇符合篩選標準之隨機對照試驗研究，經系統性回顧後再進行統合分析，共有1,229 位病人之資料進行統合分析，發現SRM可改善PFR增加氧合，其綜合效量為55.63（95%CI [44.92, 66.33]）。依據研究結果應用於個案，住院第二天在壓力控制模式下執行一次SRM，當驅動壓力15 cmH2O，呼氣末正壓從10 cmH2O開始調升，每40秒增加5 cmH2O，並追蹤個案之動脈血氧，其PFR由174上升至318 mmHg，最終成功脫離呼吸器。因此，建議使用呼吸器之ARDS病人，若肺保護通氣策略下仍有嚴重低血氧時，可以考慮執行SRM來增加病人的氧合，進而讓病人能盡早脫離呼吸器。

 

Acute Respiratory Distress Syndrome is a highly fatal emergency. Severe dyspnea could lead to a re-spiratory crisis. The author provided care for a 67-year-old man who was intubated due to acute respi-ratory failure in November 2020. The ventilation strategies for lung protection strategies (LPS) were not as effective as expected. Even when using the extracorporeal membrane oxygenation (ECMO) life support system, hypoxemia still presented and deteriorated rapidly. This incident gave the author the motivation to solve this medical dilemma. An evidence-based approach was adopted to assess the ef-fectiveness of the staircase recruitment maneuver for oxygenation. The clinical treatment using PICO interpretations are as follows P: Acute respiratory distress syndrome (ARDS), I: Staircase recruitment maneuver (SRM), C: Usual care, O: PaO2/FiO2 ratio (PFR). Databases such as Cochrane Library, PubMed, CINAHL, and Airiti Library were searched. Five randomized controlled trial studies that met the screening criteria were included, and a meta-analysis was conducted after a systematic review. A total of 1,229 patients were analyzed in the meta-analysis, which showed that SRM can improve PFR and increase oxygenation. The effect size was 55.63 (95% CI [44.92, 66.33]). According to the re-search results applied to this case, SRM was performed in pressure control mode on the second day of hospitalization. When the driving pressure was set at 15cmH2O, the positive end-expiratory pressure (PEEP) was titrated from 10cmH2O, increasing by 5cmH2O every 40 seconds. Tracing the patient’s arterial blood oxygenation, the PFR increased from 174 to 318 mmHg, and the patient was successful-ly weaned from the ventilator. Therefore, ventilators are recommended for ARDS patients with severe hypoxemia under LPS. SRM maybe considered to improve the patient’s oxygenation, allowing for ear-ly weaning from the ventilator.