醫(yī)院培訓課件：《重癥流感醫(yī)療診治要點》

1.1

重癥流感醫(yī)療診治要點WHO:

Upto650000peopledieofrespiratorydiseaseslinkedtoseasonalflueachyearGlobalInfluenzaProgrammeGlobalInfluenzaProgrammeLancet2018;391:1285–300ClinicalInfectiousDiseases2014;58(8):1095–103TwopathwayDirectinjurySIRS:inflammatorystorm病理與病理生理甲型H1N1除在鼻腔復制外在器氣管、支氣管和細支氣管復制Science.2009,325:481-483.病理與病理生理MechanismoftheCytokineStormEvokedbyInfluenzavirusNEnglJMed.

2005

May5;352(18):1839-42.

病理標本來源：2009年4月23日到2009年5月15日，5例確診為甲型H1N1感染的墨西哥居民尸檢結果肺組織大體標本：肺組織重量增加(650-1200gvs450g)；肺實變上呼吸道改變：喉和氣管、細支氣管粘膜水腫、充血、壞死肺組織：毛細血管內皮細胞損傷、毛細血管內液體滲出、血管內纖維血栓形成、肺泡間隔水腫、透明膜形成、II型肺泡上皮細胞增生、肺水腫和實變NEnglJMed2009;361;20病理與病理生理NEnglJMed2009;361:680-9.DiffusealveolardamagewithprominenthyalinemembranesThespecimenhematoxylinandeosin)showsnecrosisofbronchiolarwallsaneutrophilicinfiltrate病理與病理生理重癥流感和早期識別國家衛(wèi)生健康委辦公廳國家中醫(yī)藥局辦公室.流行性感冒診療方案(2018年版修訂版)出現(xiàn)以下情況之一者為重癥病例危重癥流感國家衛(wèi)生健康委辦公廳國家中醫(yī)藥局辦公室.流行性感冒診療方案(2018年版修訂版)出現(xiàn)以下情況之一者為危重病例CritCareMed2015;43:339–345臨床特征Pneumonia/RespiratoryfailurePulmonaryedema/ARDSMyositis/Myocarditis/EncephalitisAKI

and

HepaticdysfunctionCardiopulmonarycollapseSepticshockVentricularfibrillationIncreasedLDHandCK(2)WBC:normalorincreased(3)Lymphopenia:?臨床特征CritCareMed.2015Feb;43(2):339-45.doi:10.1097/CCM.0000000000000695.流感重癥肺炎的影像學特征流感重癥患者的影像學胸片：表現(xiàn)：雙側滲出性改變(70.8%)，雙側上下肺均受累(41.1%)；多病灶實變和胸膜滲出；重癥者可出現(xiàn)輕度纖維化。局限性：靈敏性低，不能早期診斷胸部CT：分辨率高，顯示早期改變NEnglJMed2009;361:1935-44.KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosisAntiviral

therapy：always

delay

CritCareMed.2015Feb;43(2):339-45.doi:10.1097/CCM.0000000000000695.Antiviral

therapy

vs

SheddingTheJournalofInfectiousDiseases?2018;XX00:1–10已經(jīng)上市的抗流感病毒藥物Dose:

antiviral

drugs/respiratoryPublishedonlineJanuary13,2017/10.1016/S2213-2600(16)30435-0Dose:

antiviral

drugs/respiratoryPublishedonlineJanuary13,2017/10.1016/S2213-2600(16)30435-0viralloadDose:

antiviral

drugs/respiratoryPublishedonlineJanuary13,2017/10.1016/S2213-2600(16)30435-0雙倍劑量(600mg)扎那米韋vs單倍奧司他韋(75mg)或者扎那米韋(300mg)治療住院流感并無優(yōu)勢Antiviral

therapy

Single

vs

Combination

therapy

TheJournalofInfectiousDiseases?2018;XX00:1–10新型抗流感病毒藥物NEnglJMed2018;379:913-23.

DOI:10.1056/NEJMoa1716197

與安慰劑相比，巴洛沙韋(Baloxavir)可明顯縮短流感癥狀時間與安慰劑和奧司他韋相比，巴洛沙韋(Baloxavir)降低病毒滴度更明顯NEnglJMed2018;379:913-23.

DOI:10.1056/NEJMoa1716197

KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosisOxy

administration:

strategies

Oxy

therapyMVECMO低氧程度吸氧不能糾正的低氧血癥肺泡通氣不足V/Q失調/分流

嚴重的低氧血癥難以糾正的分流和彌散障礙吸氧可糾正的低氧血癥Oxygen

therapy:

Low

flow

sysVt300～700mlRR<25bpm呼吸節(jié)律規(guī)則而穩(wěn)定Flow:

Could

NOT

satisfy

the

need

of

pat’s

inspirationOxygen

therapy:

High

flow

sysBMJ,1998,317:798–801.高流量系統(tǒng)提供的氣流能完全滿足患者吸氣的需要患者無需額外吸入空氣

Venturi原理氧射流產(chǎn)生負壓從側孔帶入一定量的空氣，瓣膜孔面積決定吸入氧與空氣混合后的氧濃度High

flow

sys:

High-FlowNasalOxygenAirVO2呼吸濕化治療儀Highconcentration

oxygen:

21~100%High

flow:

~60L/min

(decrease

dead

space)Heatedandhumidifiedair

(100%

RH)CPAP

effect:

lowlevelsofPEEPNewEenglJMed2015,372;2225Classifiedaccordingtowhetherintubationstartedearly(within48h)orlate(atleast48h)

aftercommencingHFNCIntensiveCareMed

2015,DOI10.1007/s00134-015-3693-5HFNC

OR

NIV

Transfer

to

MVMilestone

for

ARDS2000Low

Vt2009EMCO2010NMBA2013Prone

positionVentilation-induced

lung

injury

Low

VT

to

avoidinspiratorystress6ml/kg

IBWUpperlimitgoalforPplat

30cmH2ONEJM

2000,342:13023139.8P=0.00712FiO2PEEP（cmH2O）0.350.45-80.58-100.6100.710-140.8140.914-18NEnglJMed2000;342:1301-8.1.018-24WhatisoptimalPEEP?Clinical

practice

on

PEEP

setting

PEEPsettinga)5-10cmH2Ob)11-15cmH2Oc)>16cmH2OEarlyneuromuscularblockadeinARDS:theACURASYSstudyNEJM,2010,16,363(12):1107Proneposition.BasedoninitialdegreeofseveritySeveremoderate(100-150)andsevereARDSMildmoderateARDS(150-200)PronepositionIFandWHENpossibleContinueTreatmentA,FacialorpelvicfracturesB,BurnsoropenwoundsontheventralbodysurfaceC,Conditionsassociatedwithspinalinstability(eg,rheumatoidarthritis,trauma)D,ConditionsassociatedwithincreasedintracranialpressureE,Life-threateningarrhythmiasMinervaAnestesiol

2014;80(9):1046-57Kaplan-MeiersurvivalestimatesLancet2009;374:1351–63.DOI:10.1016/S0140-6736(09)61069-2CESAR

The

Savior

of

vvECMOECMOReassessseverityVerySevereARDS(<80)withPEEP>15cmH2OModerateARDS(100-200)ContactaReferralCenterforECMOContinueThetreatmentfor48-72hoursandfollowtheevolutionMinervaAnestesiol

2014;80(9):1046-57KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosis我國重癥流感的激素與廣譜抗菌藥物應用廣泛CritCareMed.2015Feb;43(2):339-45.doi:10.1097/CCM.0000000000000695.Corticosteroidswereinitiatedwithin7daysoftheonsetofillnessandthemaximumdoseadministeredwasequivalentto80-mgmethylprednisolone(interquartilerange,40–120mg).CritCareMed2015;43:339–345)IntensiveCareMed2018,

/10.1007/s00134-018-5332-4ReactivityofIVIgagainstseasonalandpandemicstrains.IVIgpreparedin2004(blackdots)or2009priortotheappearanceoftheswineoriginH1N1pandemic(redsquares)EBioMedicine19(2017)119–127Immune

plasma

for

severe

influenza

/respiratoryPublishedonlineMay15,2017/10.1016/S2213-2600(17)30174-1KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosisBothearlyandlatefluidmanagementofsepticshockcomplicatedbyALIcaninfluencepatientoutcomesFluidmanagementinALIsecondarytosepticshockChest