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1、ARDS的治療與循證醫(yī)學(xué)復(fù)興醫(yī)院ICUARDS&EBM1972Cochran提出evidence-basedmedicine(EBM)1EBM的中心思想是-科學(xué)知識(shí)優(yōu)于個(gè)人經(jīng)驗(yàn)1986Sackett首次用于抗血栓藥推薦意見(jiàn)的臨床研究21.CochranAL(1972)NuffieldProvincialHospitalTrust,London2.SackettDL(1986)Chest89:2s-3sARDS&EBMSackett將科學(xué)資料分為5級(jí)Level1:大樣本,隨機(jī)研究課題,結(jié)果清晰;假陽(yáng)性或假陰
2、性的錯(cuò)誤很低Level2:小樣本,隨機(jī)研究課題,結(jié)果不確定;假陽(yáng)性和/或假陰性的錯(cuò)誤較高Level3:非隨機(jī),同期(contemporaneous)控制研究Level4:非隨機(jī),歷史控制和專家意見(jiàn)Level5:病歷,非控制研究和專家意見(jiàn)ARDS&EBM1997肺動(dòng)脈導(dǎo)管共識(shí)會(huì)(ThePulmonaryArteryCatheterConsensusConference)提出將科研結(jié)果分為5級(jí)A:Supportedbyatleasttwolevel1investigationB:Supportedbyonly
3、onelevel1investigationC:Supportedbylevel2investigationonlyD:Supportedbyatleastonelevel3investigationE:Supportedbylevel4orlevel5evidenceCritCareMed199725:910-925ARDS&EBM1995MarinHK提出了ARDS的證據(jù)質(zhì)量和分級(jí)標(biāo)準(zhǔn)(TheQualityoftheEvidenceandtheGradingofRecommendationinARDS
4、)QualityoftheEvidenceLevel1:randomized,prospective,controlledinvestigationLevel2:nonrandomized,concurrent-cohortinvestigation,historical-cohortinvestigation,andcaseseriesofARDSLevel3:randomized,prospective,controlledinvestigationofsepsisorotherrelevantcon
5、ditionswithpotentialapplicationtoARDSLevel4:casereportsofARDSARDS&EBMGradingofrecommendationA:Supportedbyatleasttwolevel1investigationB:Supportedbyonlyonelevel1investigationC:Supportedbylevel2investigationonlyD:Supportedbyatleastonelevel3investigationUngr
6、aded:NoavailableclinicalinvestigationKollefMH1995NEnglJMed332:27-37ARDS&EBM應(yīng)用EBM的原則評(píng)價(jià)ARDS的診斷,發(fā)病和治療發(fā)現(xiàn)了很多問(wèn)題主要是缺乏前瞻性,隨機(jī)的,控制的帶有清晰的轉(zhuǎn)歸結(jié)果的研究病死率住院或ICU天數(shù)無(wú)機(jī)械通氣天數(shù)(ventilator-freedays)ARDS的病理生理PathophysiologyprocessofARDSARDSphysiopathologyARDS的非同一性病變導(dǎo)致有創(chuàng)機(jī)械通氣患者VILI的機(jī)
7、理ARDS&EBM機(jī)械通氣相關(guān)性肺損傷1氣壓傷2容積傷3剪切力4生物學(xué)損傷MechanicalVentilation大量動(dòng)物實(shí)驗(yàn)證明可以損傷正常的肺或加重肺損傷ChiumelloD,MechanicalventilationaffectslocalandsystemiccytokinesinananimalmodelofARDS.AmJRespirCritCareMed1999;157:1721-1725DreyfussD,Mechanicalventilation-inducedpulmonaryede
8、ma.Interactonwithpreviouslungalteratons.AmJRespirCritCareMed1995;151:1568-1575DreyfussD,Roleoftidalvolume,FRC,andend-inspiratoryvolumeinthedevelopmentofpulmonaryedemafollowingmechanicalventilation.AmRevRespirDis1993
