{"id":102534,"date":"2024-10-16T08:31:12","date_gmt":"2024-10-16T01:31:12","guid":{"rendered":"https:\/\/vnras.com\/drug\/?p=102534"},"modified":"2024-11-04T17:36:26","modified_gmt":"2024-11-04T10:36:26","slug":"ap-luc-day-dau-hieu-cua-muc-do-nghiem-trong-gioi-han-an-toan-hay-muc-tieu-cua-tho-may","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/ap-luc-day-dau-hieu-cua-muc-do-nghiem-trong-gioi-han-an-toan-hay-muc-tieu-cua-tho-may\/","title":{"rendered":"\u00c1p l\u1ef1c \u0111\u1ea9y: d\u1ea5u hi\u1ec7u c\u1ee7a m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng, gi\u1edbi h\u1ea1n an to\u00e0n hay m\u1ee5c ti\u00eau c\u1ee7a th\u1edf m\u00e1y?"},"content":{"rendered":"

Driving pressure: a marker of severity, a safety limit, or goal of mechanical ventilation?<\/p>\n

B\u1ea3n d\u1ecbch c\u1ee7a BS. \u0110\u1eb7ng Thanh Tu\u1ea5n<\/p>\n

Xem v\u00e0 t\u1ea3i PDF, T\u1ea0I \u0110\u00c2Y.<\/a><\/p>\n

C\u00e1c h\u01b0\u1edbng d\u1eabn hi\u1ec7n t\u1ea1i v\u1ec1 th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p c\u1ea5p t\u00ednh (acute respiratory distress syndrome – ARDS) g\u1ee3i \u00fd s\u1eed d\u1ee5ng th\u1ec3 t\u00edch kh\u00ed l\u01b0u th\u00f4ng (tidal volume – Vt) th\u1ea5p, \u0111\u01b0\u1ee3c thi\u1ebft l\u1eadp theo c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng (ideal body weight – IBW) c\u1ee7a b\u1ec7nh nh\u00e2n [1] v\u00e0 m\u1ee9c \u00e1p l\u1ef1c d\u01b0\u01a1ng cu\u1ed1i th\u00ec th\u1edf ra (PEEP) cao h\u01a1n \u0111\u1ec3 h\u1ea1n ch\u1ebf t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i g\u00e2y ra do m\u00e1y th\u1edf (ventilator-induced lung injury – VILI) [2, 3]. Tuy nhi\u00ean, c\u00e1c nghi\u00ean c\u1ee9u g\u1ea7n \u0111\u00e2y \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng nh\u1eefng b\u1ec7nh nh\u00e2n ARDS \u0111\u01b0\u1ee3c th\u00f4ng kh\u00ed theo c\u00e1c h\u01b0\u1edbng d\u1eabn n\u00e0y v\u1eabn c\u00f3 th\u1ec3 ph\u1ea3i ch\u1ecbu c\u00e1c l\u1ef1c c\u00f3 th\u1ec3 g\u00e2y ra ho\u1eb7c l\u00e0m tr\u1ea7m tr\u1ecdng th\u00eam t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i [4 \u2013 6].<\/p>\n

\u00c1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf (airway driving pressure) \u0111\u00e3 nh\u1eadn \u0111\u01b0\u1ee3c s\u1ef1 ch\u00fa \u00fd \u0111\u00e1ng k\u1ec3 sau khi Amato v\u00e0 c\u1ed9ng s\u1ef1 [7] c\u00f4ng b\u1ed1 m\u1ed9t ph\u00e2n t\u00edch th\u1ed1ng k\u00ea ph\u1ee9c t\u1ea1p v\u00e0 s\u00e1ng t\u1ea1o v\u1ec1 c\u00e1c th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng ng\u1eabu nhi\u00ean quan tr\u1ecdng \u0111\u00e3 th\u1eed nghi\u1ec7m c\u00e1c thi\u1ebft l\u1eadp th\u00f4ng kh\u00ed \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS. Ph\u00e2n t\u00edch cho th\u1ea5y \u00e1p l\u1ef1c \u0111\u1ea9y, tr\u00e1i ng\u01b0\u1ee3c v\u1edbi Vt v\u00e0 PEEP, l\u00e0 bi\u1ebfn s\u1ed1 c\u00f3 m\u1ed1i t\u01b0\u01a1ng quan t\u1ed1t nh\u1ea5t v\u1edbi kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS [7]. K\u1ec3 t\u1eeb b\u00e0i b\u00e1o n\u00e0y, m\u1ed9t s\u1ed1 t\u00e1c gi\u1ea3 \u0111\u00e3 sao ch\u00e9p gi\u1ea3 thuy\u1ebft n\u00e0y trong c\u00e1c t\u00ecnh hu\u1ed1ng l\u00e2m s\u00e0ng kh\u00e1c nhau, \u0111\u1ebfn m\u1ee9c cho r\u1eb1ng \u00e1p l\u1ef1c \u0111\u1ea9y c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t m\u1ee5c ti\u00eau t\u1ef1 th\u00e2n c\u1ee7a th\u1edf m\u00e1y [8].<\/p>\n

Trong b\u00e0i b\u00e1o n\u00e0y, ch\u00fang t\u00f4i xem x\u00e9t \u00fd ngh\u0129a sinh l\u00fd c\u1ee7a \u00e1p l\u1ef1c \u0111\u1ea9y, xem x\u00e9t b\u1eb1ng ch\u1ee9ng l\u00e2m s\u00e0ng hi\u1ec7n t\u1ea1i v\u00e0 th\u1ea3o lu\u1eadn v\u1ec1 vai tr\u00f2 c\u1ee7a \u00e1p l\u1ef1c \u0111\u1ea9y khi c\u00e0i \u0111\u1eb7t m\u00e1y th\u1edf, coi n\u00f3 nh\u01b0 m\u1ed9t gi\u1edbi h\u1ea1n an to\u00e0n h\u01a1n l\u00e0 m\u1ed9t m\u1ee5c ti\u00eau ri\u00eang l\u1ebb. Th\u1ea3o lu\u1eadn n\u00e0y ch\u1ec9 gi\u1edbi h\u1ea1n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111ang th\u1edf m\u00e1y c\u00f3 ki\u1ec3m so\u00e1t v\u00e0 kh\u00f4ng c\u00f3 n\u1ed7 l\u1ef1c th\u1edf t\u1ef1 nhi\u00ean. Trong qu\u00e1 tr\u00ecnh th\u1edf t\u1ef1 nhi\u00ean, c\u00e1c ph\u00e9p \u0111o \u00e1p l\u1ef1c \u0111\u1ea9y s\u1ebd \u0111\u00e1nh gi\u00e1 th\u1ea5p \u00e1p l\u1ef1c c\u0103ng th\u1ef1c s\u1ef1 c\u1ee7a h\u1ec7 h\u00f4 h\u1ea5p v\u00e0 do \u0111\u00f3, c\u00f3 th\u1ec3 g\u00e2y hi\u1ec3u l\u1ea7m [9].<\/p>\n

Quay l\u1ea1i v\u1ea5n \u0111\u1ec1 c\u01a1 b\u1ea3n: \u00e1p l\u1ef1c \u0111\u1ea9y bi\u1ec3u th\u1ecb \u0111i\u1ec1u g\u00ec?<\/h2>\n
Sau khi m\u00f4 t\u1ea3 kh\u00e1i ni\u1ec7m ph\u1ed5i em b\u00e9 [10], cho th\u1ea5y ph\u1ed5i nh\u1ecf v\u1ec1 m\u1eb7t sinh l\u00fd \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS, m\u1ed9t s\u1ed1 nghi\u00ean c\u1ee9u trong nh\u1eefng n\u0103m 1990 \u0111\u00e3 ki\u1ec3m tra gi\u1ea3 thuy\u1ebft r\u1eb1ng vi\u1ec7c h\u1ea1n ch\u1ebf Vt ho\u1eb7c \u00e1p l\u1ef1c \u0111\u01b0\u1eddng th\u1edf trong qu\u00e1 tr\u00ecnh th\u1edf m\u00e1y c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n k\u1ebft qu\u1ea3 c\u1ee7a nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y. Trong m\u1ed9t nghi\u00ean c\u1ee9u ti\u00ean phong t\u1ea1i m\u1ed9t trung t\u00e2m, Amato v\u00e0 c\u1ed9ng s\u1ef1 l\u00e0 nh\u1eefng ng\u01b0\u1eddi \u0111\u1ea7u ti\u00ean ch\u1ec9 ra r\u1eb1ng t\u1ef7 l\u1ec7 t\u1eed vong gi\u1ea3m trong b\u1ed1i c\u1ea3nh n\u00e0y b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng m\u1ed9t chi\u1ebfn l\u01b0\u1ee3c d\u1ef1a tr\u00ean vi\u1ec7c duy tr\u00ec \u00e1p l\u1ef1c \u0111\u1ea9y h\u00edt v\u00e0o th\u1ea5p (th\u1ea5p h\u01a1n 20 cmH_{2<\/sub>O) c\u00f9ng v\u1edbi m\u1ee9c Vt th\u1ea5p v\u00e0 m\u1ee9c PEEP cao [11]. Ngay sau \u0111\u00f3, th\u1eed nghi\u1ec7m ARDSnet \u0111a trung t\u00e2m l\u1edbn \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng t\u1ef7 l\u1ec7 t\u1eed vong gi\u1ea3m g\u1ea7n 25% \u1edf h\u01a1n 800 b\u1ec7nh nh\u00e2n m\u1eafc ARDS khi s\u1eed d\u1ee5ng 6, thay v\u00ec 12 mL\/kg, IBW, x\u00e1c nh\u1eadn r\u1eb1ng vi\u1ec7c h\u1ea1n ch\u1ebf Vt l\u00e0 m\u1ed9t chi\u1ebfn l\u01b0\u1ee3c c\u01a1 b\u1ea3n \u0111\u1ec3 c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t c\u1ee7a b\u1ec7nh nh\u00e2n m\u1eafc ARDS [1].<\/p>\n}
Tuy nhi\u00ean, m\u1ed9t s\u1ed1 tranh c\u00e3i \u0111\u00e3 n\u1ea3y sinh v\u1ec1 c\u00e1ch t\u1ed1t nh\u1ea5t \u0111\u1ec3 chu\u1ea9n \u0111\u1ed9 Vt: IBW, di\u1ec7n t\u00edch b\u1ec1 m\u1eb7t c\u01a1 th\u1ec3, k\u00edch th\u01b0\u1edbc ph\u1ed5i, \u00e1p l\u1ef1c \u0111\u01b0\u1eddng th\u1edf, v.v. Quay tr\u1edf l\u1ea1i xa h\u01a1n, c\u01a1 s\u1edf h\u1ee3p l\u00fd \u0111\u1ec3 gi\u1edbi h\u1ea1n Vt xu\u1ea5t hi\u1ec7n t\u1eeb m\u00f4 t\u1ea3 v\u1ec1 kh\u00e1i ni\u1ec7m ph\u1ed5i em b\u00e9, cho ch\u00fang ta bi\u1ebft r\u1eb1ng trong ARDS, ch\u00fang ta \u0111ang \u0111\u1ed1i m\u1eb7t v\u1edbi ph\u1ed5i nh\u1ecf v\u1ec1 m\u1eb7t sinh l\u00fd, ch\u1ee9 kh\u00f4ng ph\u1ea3i ph\u1ed5i c\u1ee9ng nh\u01b0 tr\u01b0\u1edbc \u0111\u00e2y v\u1eabn ngh\u0129 [10]. Trong nghi\u00ean c\u1ee9u ban \u0111\u1ea7u c\u1ee7a Gattinoni v\u00e0 c\u1ed9ng s\u1ef1, trong khi oxygen h\u00f3a v\u00e0 t\u1ef7 l\u1ec7 shunt c\u00f3 t\u01b0\u01a1ng quan v\u1edbi m\u00f4 kh\u00f4ng \u0111\u01b0\u1ee3c s\u1ee5c kh\u00ed, th\u00ec \u0111\u1ed9 gi\u00e3n n\u1edf ph\u1ed5i t\u0129nh c\u00f3 t\u01b0\u01a1ng quan m\u1ea1nh v\u1edbi th\u1ec3 t\u00edch ph\u1ed5i \u0111\u01b0\u1ee3c s\u1ee5c kh\u00ed c\u00f2n l\u1ea1i [12], th\u1ec3 t\u00edch c\u1ee7a ph\u1ed5i em b\u00e9.<\/p>\n
V\u1edbi \u0111i\u1ec1u \u0111\u00f3 \u0111\u01b0\u1ee3c n\u00f3i, \u00e1p l\u1ef1c \u0111\u1ea9y (DP) l\u00e0 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa \u00e1p l\u1ef1c \u0111\u01b0\u1eddng th\u1edf \u1edf cu\u1ed1i th\u00ec h\u00edt v\u00e0o (\u00e1p l\u1ef1c \u0111\u1ec9nh, Pplat) v\u00e0 PEEP [7, 13]. \u0110\u1ed5i l\u1ea1i, \u0111\u1ed9 gi\u00e3n n\u1edf t\u0129nh c\u1ee7a h\u1ec7 h\u00f4 h\u1ea5p (C_{RS<\/sub>) l\u00e0 th\u01b0\u01a1ng s\u1ed1 gi\u1eefa Vt v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y. Do \u0111\u00f3, theo ph\u00e9p t\u00ednh s\u1ed1 h\u1ecdc \u0111\u01a1n gi\u1ea3n, \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0 th\u01b0\u01a1ng s\u1ed1 gi\u1eefa Vt v\u00e0 C_{RS<\/sub> c\u1ee7a b\u1ec7nh nh\u00e2n:
\nDP = Pplat \u2212 PEEP<\/p>\n}}
C_{RS<\/sub> =\u00a0 \u00a0Vt\/(Pplat – PEEP) = Vt\/DP<\/p>\n}
DP = Vt\/C_{RS<\/sub><\/p>\n}
Do \u0111\u00f3, \u00e1p l\u1ef1c \u0111\u1ea9y bi\u1ec3u th\u1ecb Vt \u0111\u01b0\u1ee3c hi\u1ec7u ch\u1ec9nh theo CRS c\u1ee7a b\u1ec7nh nh\u00e2n v\u00e0 vi\u1ec7c s\u1eed d\u1ee5ng \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0m gi\u1edbi h\u1ea1n an to\u00e0n c\u00f3 th\u1ec3 l\u00e0 c\u00e1ch t\u1ed1t h\u01a1n \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh Vt nh\u1eb1m gi\u1ea3m bi\u1ebfn d\u1ea1ng (strain) theo chu k\u1ef3 ho\u1eb7c \u0111\u1ed9ng trong qu\u00e1 tr\u00ecnh th\u1edf m\u00e1y.<\/p>\n
M\u1eb7c d\u00f9 th\u1ef1c t\u1ebf l\u00e0 kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o ki\u1ec3m tra ti\u1ec1n c\u1ee9u m\u1ed1i quan h\u1ec7 gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y v\u00e0 Vt, m\u1ed9t s\u1ed1 d\u1eef li\u1ec7u sinh l\u00fd ch\u1ec9 ra r\u1eb1ng n\u00f3 t\u1ed3n t\u1ea1i. \u1ede ch\u00edn b\u1ec7nh nh\u00e2n m\u1eafc ARDS, ch\u00fang t\u00f4i \u0111\u00e3 \u00e1p d\u1ee5ng c\u1ea3 hai chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed t\u1eeb nghi\u00ean c\u1ee9u ARDSnet ban \u0111\u1ea7u, 6 v\u00e0 12 mL\/kg IBW, \u1edf PEEP (9 cmH2O) v\u00e0 th\u00f4ng kh\u00ed ph\u00fat kh\u00f4ng \u0111\u1ed5i. Vi\u1ec7c s\u1eed d\u1ee5ng Vt th\u1ea5p h\u01a1n l\u00e0m gi\u1ea3m \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf (11,6 \u00b1 2,2 so v\u1edbi 22,7 \u00b1 5,4, p \u2009< 0,01) v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i (8,1 \u00b1 2,2 so v\u1edbi 16,8 \u00b1 6,0, p \u2009< 0,01) (H\u00ecnh 1), c\u0169ng nh\u01b0 s\u1ef1 huy \u0111\u1ed9ng-m\u1ea5t huy \u0111\u1ed9ng theo chu k\u1ef3 v\u00e0 si\u00eau b\u01a1m ph\u1ed3ng theo chu k\u1ef3 [14]. Kh\u00f4ng c\u1ea7n ph\u1ea3i n\u00f3i, gi\u1edbi h\u1ea1n Vt \u0111\u00e3 l\u00e0m gi\u1ea3m t\u1ea5t c\u1ea3 c\u00e1c c\u01a1 ch\u1ebf v\u1eadt l\u00fd li\u00ean quan \u0111\u1ebfn s\u1ef1 h\u00ecnh th\u00e0nh VILI.<\/p>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 1 \u00c1p l\u1ef1c \u0111\u01b0\u1eddng th\u1edf (Pao) v\u00e0 th\u1ef1c qu\u1ea3n (Peso) \u1edf b\u1ec7nh nh\u00e2n b\u1ecb vi\u00eam ph\u1ed5i v\u00e0 ARDS trong \u0111i\u1ec1u ki\u1ec7n th\u1edf m\u00e1y ki\u1ec3m so\u00e1t th\u1ec3 t\u00edch v\u1edbi Vt 6 (tr\u00e1i) v\u00e0 Vt 12 (ph\u1ea3i) mL\/kg IBW v\u00e0 PEEP t\u01b0\u01a1ng t\u1ef1. \u00c1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i (hi\u1ec3n th\u1ecb d\u01b0\u1edbi d\u1ea1ng thanh m\u00e0u x\u00e1m) l\u00e0 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf (DP, m\u0169i t\u00ean n\u00e9t li\u1ec1n) v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y th\u1ef1c qu\u1ea3n (DPeso, m\u0169i t\u00ean ch\u1ea5m). C\u1ea3 DP \u0111\u01b0\u1eddng th\u1edf v\u00e0 DP xuy\u00ean ph\u1ed5i \u0111\u1ec1u t\u0103ng khi s\u1eed d\u1ee5ng Vt cao h\u01a1n. \u0110\u00e3 s\u1eeda \u0111\u1ed5i t\u1eeb [11]<\/figcaption><\/figure>\n
$\"H\u00ecnh$ <\/a>
H\u00ecnh 2 \u00c1p l\u1ef1c \u0111\u01b0\u1eddng th\u1edf (\u0111\u01b0\u1eddng m\u00e0u \u0111en) v\u00e0 th\u1ef1c qu\u1ea3n (\u0111\u01b0\u1eddng m\u00e0u x\u00e1m) trong m\u00f4 h\u00ecnh th\u1ef1c nghi\u1ec7m v\u1ec1 t\u0103ng \u00e1p l\u1ef1c \u1ed5 b\u1ee5ng th\u1ee9 ph\u00e1t do tr\u00e0n kh\u00ed m\u00e0ng b\u1ee5ng \u1edf l\u1ee3n (d\u1eef li\u1ec7u ch\u01b0a c\u00f4ng b\u1ed1). Trong qu\u00e1 tr\u00ecnh th\u00f4ng kh\u00ed ki\u1ec3m so\u00e1t th\u1ec3 t\u00edch (Vt 10 mL\/kg v\u00e0 PEEP 5 cmH_{2<\/sub>O), \u00e1p l\u1ef1c trong \u1ed5 b\u1ee5ng (IAP) t\u0103ng t\u1eeb 5 (tr\u00e1i) l\u00ean 15 (gi\u1eefa) v\u00e0 25 cmH_{2<\/sub>O (ph\u1ea3i) g\u00e2y ra s\u1ef1 gia t\u0103ng \u00e1p l\u1ef1c cao nguy\u00ean v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y. Tuy nhi\u00ean, \u00e1p l\u1ef1c xuy\u00ean ph\u1ed5i \u0111\u1ea9y (m\u0169i t\u00ean) v\u1eabn kh\u00f4ng \u0111\u1ed5i<\/figcaption><\/figure>\n\u00c1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i (s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa \u00e1p l\u1ef1c \u0111\u01b0\u1eddng th\u1edf tr\u1eeb \u0111i \u00e1p l\u1ef1c PEEP v\u00e0 \u00e1p l\u1ef1c th\u1ef1c qu\u1ea3n tr\u1eeb \u0111i \u00e1p l\u1ef1c th\u1ef1c qu\u1ea3n cu\u1ed1i th\u00ec th\u1edf ra), khi t\u00ednh \u0111\u1ebfn \u0111\u1ed9 \u0111\u00e0n h\u1ed3i c\u1ee7a th\u00e0nh ng\u1ef1c, c\u00f3 th\u1ec3 ph\u1ea3n \u00e1nh t\u1ed1t h\u01a1n t\u00ecnh tr\u1ea1ng \u1ee9ng su\u1ea5t (stress) c\u1ee7a ph\u1ed5i v\u00e0 l\u00e0 c\u00e1ch an to\u00e0n nh\u1ea5t \u0111\u1ec3 hi\u1ec7u ch\u1ec9nh th\u00f4ng kh\u00ed c\u01a1 h\u1ecdc (H\u00ecnh. 2) [13, 15, 16]. Trong b\u1ed1i c\u1ea3nh n\u00e0y, Chiumello v\u00e0 c\u1ed9ng s\u1ef1 [13] \u0111\u00e3 ti\u1ebfn h\u00e0nh ph\u00e2n t\u00edch h\u1ed3i c\u1ee9u 150 b\u1ec7nh nh\u00e2n ARDS d\u00f9ng thu\u1ed1c gi\u00e3n c\u01a1, \u0111\u01b0\u1ee3c g\u00e2y m\u00ea s\u00e2u \u0111\u00e3 tham gia v\u00e0o c\u00e1c nghi\u00ean c\u1ee9u tr\u01b0\u1edbc \u0111\u00f3, trong \u0111\u00f3 th\u1eed nghi\u1ec7m PEEP \u1edf m\u1ee9c 5 v\u00e0 15 cmH_{2<\/sub>O \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u1edf Vt v\u00e0 nh\u1ecbp th\u1edf kh\u00f4ng \u0111\u1ed5i. \u1ede c\u1ea3 hai m\u1ee9c PEEP, nh\u00f3m \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf cao h\u01a1n c\u00f3 \u1ee9ng su\u1ea5t ph\u1ed5i, \u0111\u1ed9 \u0111\u00e0n h\u1ed3i h\u1ec7 h\u00f4 h\u1ea5p v\u00e0 ph\u1ed5i cao h\u01a1n \u0111\u00e1ng k\u1ec3 so v\u1edbi nh\u00f3m \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf th\u1ea5p h\u01a1n. Quan tr\u1ecdng h\u01a1n, \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf c\u00f3 li\u00ean quan \u0111\u00e1ng k\u1ec3 \u0111\u1ebfn \u1ee9ng su\u1ea5t ph\u1ed5i (\u00e1p l\u1ef1c xuy\u00ean ph\u1ed5i) v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y cao h\u01a1n 15 cmH_{2<\/sub>O v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i cao h\u01a1n 11,7 cmH_{2<\/sub>O, c\u1ea3 hai \u0111\u1ec1u \u0111\u01b0\u1ee3c \u0111o \u1edf PEEP 15 cmH_{2<\/sub>O, \u0111\u1ec1u c\u00f3 li\u00ean quan \u0111\u1ebfn m\u1ee9c \u0111\u1ed9 \u1ee9ng su\u1ea5t nguy hi\u1ec3m.<\/p>\n}}}}
S\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf ch\u1ee7 y\u1ebfu l\u00e0 do s\u1ef1 gia t\u0103ng \u0111\u1ed9 \u0111\u00e0n h\u1ed3i c\u1ee7a th\u00e0nh ng\u1ef1c [15, 17]. \u00c1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf c\u00f3 th\u1ec3 thay \u0111\u1ed5i t\u1eeb s\u1ef1 kh\u00e1c bi\u1ec7t t\u1ed1i thi\u1ec3u (b\u1ec7nh nh\u00e2n g\u1ea7y, vi\u00eam ph\u1ed5i) \u0111\u1ebfn s\u1ef1 \u01b0\u1edbc t\u00ednh qu\u00e1 cao (b\u00e9o ph\u00ec b\u1ec7nh l\u00fd, t\u0103ng \u00e1p l\u1ef1c \u1ed5 b\u1ee5ng) v\u1ec1 \u00e1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i. Tuy nhi\u00ean, \u1edf b\u1ec7nh nh\u00e2n kh\u00f4ng c\u00f3 ho\u1ea1t \u0111\u1ed9ng th\u00f4ng kh\u00ed t\u1ef1 nhi\u00ean, \u00e1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i s\u1ebd lu\u00f4n th\u1ea5p h\u01a1n \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf [13].<\/p>\n
T\u00f3m l\u1ea1i, \u00e1p l\u1ef1c \u0111\u1ea9y trong qu\u00e1 tr\u00ecnh th\u1edf m\u00e1y c\u00f3 li\u00ean quan tr\u1ef1c ti\u1ebfp \u0111\u1ebfn l\u1ef1c \u1ee9ng su\u1ea5t trong ph\u1ed5i. Vi\u1ec7c \u0111\u1ecbnh c\u1ee1 Vt theo t\u1ef7 l\u1ec7 v\u1edbi k\u00edch th\u01b0\u1edbc c\u1ee7a ph\u1ed5i em b\u00e9 b\u1eb1ng c\u00e1ch nh\u1eafm m\u1ee5c ti\u00eau v\u00e0o \u00e1p l\u1ef1c \u0111\u1ea9y, thay v\u00ec v\u00e0o IBW, c\u00f3 th\u1ec3 b\u1ea3o v\u1ec7 ph\u1ed5i t\u1ed1t h\u01a1n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i nghi\u00eam tr\u1ecdng h\u01a1n v\u00e0 th\u1ec3 t\u00edch ph\u1ed5i cu\u1ed1i th\u00ec th\u1edf ra th\u1ea5p [8, 13].<\/p>\n
B\u1eb1ng ch\u1ee9ng l\u00e2m s\u00e0ng hi\u1ec7n t\u1ea1i l\u00e0 g\u00ec?<\/h2>\n
B\u1eb1ng ch\u1ee9ng li\u00ean quan \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u1ebfn k\u1ebft qu\u1ea3<\/h3>\nM\u1ed1i li\u00ean h\u1ec7 gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y v\u00e0 k\u1ebft qu\u1ea3 l\u1ea7n \u0111\u1ea7u ti\u00ean \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 v\u00e0o n\u0103m 2002 [18]. Trong m\u1ed9t nh\u00f3m quan s\u00e1t c\u00f3 ti\u1ec1n c\u1ee9u g\u1ed3m 235 b\u1ec7nh nh\u00e2n m\u1eafc ARDS, Estenssoro v\u00e0 c\u1ed9ng s\u1ef1 \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng \u00e1p l\u1ef1c \u0111\u1ea9y trong tu\u1ea7n \u0111\u1ea7u ti\u00ean lu\u00f4n ph\u00e2n bi\u1ec7t \u0111\u01b0\u1ee3c nh\u1eefng ng\u01b0\u1eddi s\u1ed1ng s\u00f3t v\u00e0 nh\u1eefng ng\u01b0\u1eddi kh\u00f4ng s\u1ed1ng s\u00f3t, c\u00f9ng v\u1edbi c\u00e1c bi\u1ebfn s\u1ed1 kh\u00e1c, ch\u1eb3ng h\u1ea1n nh\u01b0 t\u1ef7 l\u1ec7 PaO_{2<\/sub>:FiO_{2<\/sub> v\u00e0 \u0111i\u1ec3m SOFA.<\/p>\n}}
H\u01a1n m\u1ed9t th\u1eadp k\u1ef7 sau, b\u1eb1ng ch\u1ee9ng t\u1ed1t nh\u1ea5t \u0111\u1ebfn t\u1eeb Amato v\u00e0 c\u1ed9ng s\u1ef1 v\u1edbi ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p ch\u00edn th\u1eed nghi\u1ec7m ti\u1ec1n c\u1ee9u li\u00ean quan \u0111\u1ebfn h\u01a1n 3500 b\u1ec7nh nh\u00e2n cho th\u1ea5y \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0 bi\u1ebfn s\u1ed1 v\u1eadt l\u00fd c\u00f3 m\u1ed1i t\u01b0\u01a1ng quan t\u1ed1t nh\u1ea5t v\u1edbi kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS [7]. Quan tr\u1ecdng h\u01a1n, m\u1ed1i li\u00ean h\u1ec7 n\u00e0y t\u1ed3n t\u1ea1i m\u1eb7c d\u00f9 t\u1ea5t c\u1ea3 c\u00e1c c\u00e0i \u0111\u1eb7t m\u00e1y th\u1edf \u0111\u1ec1u b\u1ea3o v\u1ec7 ph\u1ed5i (\u00e1p l\u1ef1c cao nguy\u00ean \u226430 cmH_{2<\/sub>O v\u00e0 Vt \u22647 mL\/kg IBW).<\/p>\n}
Sau b\u00e1o c\u00e1o c\u1ee7a Amato, m\u1ed9t s\u1ed1 t\u00e1c gi\u1ea3 \u0111\u00e3 x\u00e1c nh\u1eadn m\u1ed1i li\u00ean h\u1ec7 gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y v\u00e0 kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS. Trong s\u1ed1 56 b\u1ec7nh nh\u00e2n m\u1eafc ARDS t\u1eeb th\u1eed nghi\u1ec7m EPVent [16], th\u1eed nghi\u1ec7m vi\u1ec7c s\u1eed d\u1ee5ng ph\u00e9p \u0111o \u00e1p l\u1ef1c th\u1ef1c qu\u1ea3n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS, Baedorf Kassis v\u00e0 c\u1ed9ng s\u1ef1 [19] ph\u00e1t hi\u1ec7n ra r\u1eb1ng vi\u1ec7c s\u1eed d\u1ee5ng chu\u1ea9n \u0111\u1ed9 PEEP \u0111\u1ec3 nh\u1eafm m\u1ee5c ti\u00eau v\u00e0o \u00e1p l\u1ef1c xuy\u00ean ph\u1ed5i d\u01b0\u01a1ng d\u1eabn \u0111\u1ebfn c\u1ea3i thi\u1ec7n c\u1ea3 \u0111\u1ed9 \u0111\u00e0n h\u1ed3i v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y. C\u00e1c t\u00e1c gi\u1ea3 cho r\u1eb1ng c\u00e1c chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed d\u1eabn \u0111\u1ebfn gi\u1ea3m \u00e1p l\u1ef1c \u0111\u1ea9y v\u00e0 \u0111\u1ed9 \u0111\u00e0n h\u1ed3i c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t \u0111\u01b0\u1ee3c c\u1ea3i thi\u1ec7n.<\/p>\n
Trong m\u1ed9t ph\u00e2n t\u00edch th\u1ee9 c\u1ea5p kh\u00e1c v\u1ec1 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ghi danh v\u00e0o hai th\u1eed nghi\u1ec7m c\u00f3 \u0111\u1ed1i ch\u1ee9ng ng\u1eabu nhi\u00ean \u1edf b\u1ec7nh nh\u00e2n ARDS, Acurasys [20] v\u00e0 Proseva [21], \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 nguy c\u01a1 t\u1eed vong, c\u00f9ng v\u1edbi \u00e1p l\u1ef1c cao nguy\u00ean v\u00e0 C_{RS<\/sub> [22]. G\u1ea7n \u0111\u00e2y h\u01a1n, \u1edf g\u1ea7n 800 b\u1ec7nh nh\u00e2n m\u1eafc ARDS t\u1eeb trung b\u00ecnh \u0111\u1ebfn n\u1eb7ng \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i, \u00e1p l\u1ef1c cao nguy\u00ean t\u1ed1t h\u01a1n m\u1ed9t ch\u00fat so v\u1edbi \u00e1p l\u1ef1c \u0111\u1ea9y trong vi\u1ec7c d\u1ef1 \u0111o\u00e1n t\u1eed vong trong b\u1ec7nh vi\u1ec7n [23]. C\u00e1c t\u00e1c gi\u1ea3 \u0111\u00e3 x\u00e1c \u0111\u1ecbnh c\u00e1c gi\u00e1 tr\u1ecb ng\u01b0\u1ee1ng \u00e1p l\u1ef1c cao nguy\u00ean v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y l\u1ea7n l\u01b0\u1ee3t l\u00e0 29 v\u00e0 19 cm H_{2<\/sub>O, tr\u00ean m\u1ee9c \u0111\u00f3 nguy c\u01a1 t\u1eed vong t\u0103ng l\u00ean.<\/p>\n}}
Th\u00f4ng kh\u00ed si\u00eau b\u1ea3o v\u1ec7 v\u1edbi h\u1ed7 tr\u1ee3 ph\u1ed5i ngo\u00e0i c\u01a1 th\u1ec3 c\u00f3 th\u1ec3 gi\u00fap b\u1ea3o v\u1ec7 ph\u1ed5i b\u1eb1ng c\u00e1ch gi\u1ea3m Vt theo \u00e1p l\u1ef1c \u0111\u1ea9y [24]. Trong m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p g\u1ea7n \u0111\u00e2y t\u1eeb ch\u00edn nghi\u00ean c\u1ee9u, bao g\u1ed3m h\u01a1n 500 b\u1ec7nh nh\u00e2n \u0111ang \u0111\u01b0\u1ee3c oxygen h\u00f3a qua m\u00e0ng ngo\u00e0i c\u01a1 th\u1ec3 (ECMO) \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb t\u00ecnh tr\u1ea1ng thi\u1ebfu oxy m\u00e1u kh\u00e1ng tr\u1ecb, Serpa Neto v\u00e0 c\u1ed9ng s\u1ef1 [25] \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng \u00e1p l\u1ef1c \u0111\u1ea9y trong 3 ng\u00e0y \u0111\u1ea7u ti\u00ean trong ECMO c\u00f3 m\u1ed1i li\u00ean h\u1ec7 \u0111\u1ed9c l\u1eadp v\u1edbi t\u1ef7 l\u1ec7 t\u1eed vong trong b\u1ec7nh vi\u1ec7n. M\u1eb7c d\u00f9 h\u1ed7 tr\u1ee3 ECMO cho ph\u00e9p gi\u1ea3m Vt xu\u1ed1ng 4 mL\/kg IBW v\u00e0 \u00e1p l\u1ef1c \u0111\u1ea9y \u1edf g\u1ea7n 4 cmH_{2<\/sub>O, nh\u1eefng ng\u01b0\u1eddi kh\u00f4ng s\u1ed1ng s\u00f3t v\u1eabn cho th\u1ea5y \u00e1p l\u1ef1c \u0111\u1ea9y cao h\u01a1n trong qu\u00e1 tr\u00ecnh ECMO (14,5 \u00b1 6,2 so v\u1edbi 13,3 \u00b1 4,8 cmH_{2<\/sub>O \u1edf nh\u1eefng ng\u01b0\u1eddi s\u1ed1ng s\u00f3t, p \u2009= 0,048).<\/p>\n}}
Trong nghi\u00ean c\u1ee9u quan s\u00e1t l\u1edbn nh\u1ea5t tr\u00ean g\u1ea7n 2400 b\u1ec7nh nh\u00e2n m\u1eafc ARDS, \u00e1p l\u1ef1c \u0111\u1ea9y h\u01a1n 14 cmH_{2<\/sub>O (v\u00e0 kh\u00f4ng ph\u1ea3i Vt) c\u00f3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c t\u0103ng nguy c\u01a1 t\u1eed vong trong b\u1ec7nh vi\u1ec7n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS v\u1eeba v\u00e0 n\u1eb7ng [26]. D\u1eef li\u1ec7u th\u00fa v\u1ecb t\u1eeb nghi\u00ean c\u1ee9u n\u00e0y ch\u1ec9 ra r\u1eb1ng v\u1eabn c\u00f2n ti\u1ec1m n\u0103ng c\u1ea3i thi\u1ec7n \u0111\u00e1ng k\u1ec3 b\u1eb1ng c\u00e1ch \u0111i\u1ec1u ch\u1ec9nh c\u00e1c y\u1ebfu t\u1ed1 c\u00f3 th\u1ec3 thay \u0111\u1ed5i li\u00ean quan \u0111\u1ebfn vi\u1ec7c t\u0103ng t\u1ef7 l\u1ec7 t\u1eed vong, bao g\u1ed3m \u00e1p l\u1ef1c \u0111\u1ea9y [27].<\/p>\n}
B\u1eb1ng ch\u1ee9ng li\u00ean quan \u0111\u1ebfn \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u1ebfn nh\u1eefng thay \u0111\u1ed5i sinh l\u00fd b\u1ec7nh<\/h3>\nM\u1ed9t trong nh\u1eefng v\u1ea5n \u0111\u1ec1 khi thi\u1ebft l\u1eadp th\u00f4ng kh\u00ed \u1edf b\u1ec7nh nh\u00e2n ARDS l\u00e0 t\u00ecnh tr\u1ea1ng qu\u00e1 t\u1ea3i th\u1ea5t ph\u1ea3i (right ventricle – RV), li\u00ean quan \u0111\u1ebfn t\u00ecnh tr\u1ea1ng m\u1ea5t ch\u1ee9c n\u0103ng ph\u1ed5i v\u00e0 c\u0103ng gi\u00e3n qu\u00e1 m\u1ee9c v\u00e0 c\u0169ng \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00e0 c\u00f3 li\u00ean quan \u0111\u1ed9c l\u1eadp v\u1edbi ti\u00ean l\u01b0\u1ee3ng x\u1ea5u [28]. Trong m\u1ed9t nghi\u00ean c\u1ee9u quan s\u00e1t c\u00f3 ti\u1ec1n c\u1ee9u \u1edf 226 b\u1ec7nh nh\u00e2n m\u1eafc ARDS t\u1eeb trung b\u00ecnh \u0111\u1ebfn n\u1eb7ng \u0111\u01b0\u1ee3c th\u00f4ng kh\u00ed v\u1edbi \u00e1p l\u1ef1c cao nguy\u00ean gi\u1edbi h\u1ea1n \u1edf 30 cmH2O v\u00e0 \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 b\u1eb1ng si\u00eau \u00e2m qua th\u1ef1c qu\u1ea3n, t\u00ecnh tr\u1ea1ng t\u00e2m ph\u1ebf m\u1ea1n \u0111\u01b0\u1ee3c ph\u00e1t hi\u1ec7n \u1edf 49 b\u1ec7nh nh\u00e2n (22%); \u00e1p l\u1ef1c \u0111\u1ea9y cao h\u01a1n l\u00e0 m\u1ed9t y\u1ebfu t\u1ed1 \u0111\u1ed9c l\u1eadp li\u00ean quan \u0111\u1ebfn t\u00e2m ph\u1ebf m\u1ea1n [29]. G\u1ea7n \u0111\u00e2y h\u01a1n, \u00e1p l\u1ef1c \u0111\u1ea9y \u226518 cmH_{2<\/sub>O, t\u1ef7 l\u1ec7 PaO_{2<\/sub>:FiO_{2<\/sub> <150 mmHg v\u00e0 PaCO_{2<\/sub> \u2265 48 mmHg \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00e0 th\u00fac \u0111\u1ea9y suy RV \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS do vi\u00eam ph\u1ed5i [30].<\/p>\n}}}}
C\u0169ng c\u00f3 nh\u1eefng b\u00e1o c\u00e1o m\u00f4 t\u1ea3 m\u1ed1i li\u00ean h\u1ec7 gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y v\u1edbi ch\u1ee9c n\u0103ng c\u01a1 ho\u00e0nh. \u1ede 107 b\u1ec7nh nh\u00e2n th\u1edf m\u00e1y, Goligher v\u00e0 c\u1ed9ng s\u1ef1 \u0111\u00e3 t\u00ecm th\u1ea5y m\u1ed1i li\u00ean h\u1ec7 gi\u1eefa \u00e1p l\u1ef1c \u0111\u1ea9y cao h\u01a1n v\u00e0 s\u1ef1 gi\u1ea3m \u0111\u1ed9 d\u00e0y v\u00e0 ho\u1ea1t \u0111\u1ed9ng co b\u00f3p \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng si\u00eau \u00e2m
\n[8].<\/p>\n
B\u1eb1ng ch\u1ee9ng li\u00ean quan \u0111\u1ebfn nh\u1eefng thay \u0111\u1ed5i c\u1ee7a \u00e1p l\u1ef1c \u0111\u1ea9y v\u1edbi k\u1ebft qu\u1ea3<\/h3>\nM\u1eb7c d\u00f9 t\u1ea5t c\u1ea3 c\u00e1c b\u1eb1ng ch\u1ee9ng tr\u00ean li\u00ean k\u1ebft \u00e1p l\u1ef1c \u0111\u1ea9y v\u1edbi k\u1ebft qu\u1ea3 l\u00e2m s\u00e0ng v\u00e0 sinh l\u00fd, cho \u0111\u1ebfn nay ch\u01b0a c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o \u0111\u00e1nh gi\u00e1 \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0 m\u1ee5c ti\u00eau ch\u00ednh trong qu\u00e1 tr\u00ecnh thi\u1ebft l\u1eadp th\u00f4ng kh\u00ed \u1edf b\u1ec7nh nh\u00e2n ARDS. Tuy nhi\u00ean, m\u1ed9t s\u1ed1 nghi\u00ean c\u1ee9u \u0111\u00e3 ph\u00e2n t\u00edch t\u00e1c \u0111\u1ed9ng ri\u00eang l\u1ebb c\u1ee7a c\u00e1c can thi\u1ec7p c\u1ee5 th\u1ec3 \u0111\u1ed1i v\u1edbi \u00e1p l\u1ef1c \u0111\u1ea9y v\u00e0 li\u00ean h\u1ec7 nh\u1eefng thay \u0111\u1ed5i n\u00e0y v\u1edbi k\u1ebft qu\u1ea3.<\/p>\n
Trong m\u1ed9t nghi\u00ean c\u1ee9u ti\u1ec1n c\u1ee9u g\u1ea7n \u0111\u00e2y tr\u00ean 200 b\u1ec7nh nh\u00e2n m\u1eafc ARDS, Kacmarek v\u00e0 c\u1ed9ng s\u1ef1 [3] \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng chi\u1ebfn l\u01b0\u1ee3c ti\u1ebfp c\u1eadn ph\u1ed5i m\u1edf (th\u1ee7 thu\u1eadt huy \u0111\u1ed9ng ti\u1ebfp theo l\u00e0 gi\u1ea3m PEEP), so v\u1edbi chi\u1ebfn l\u01b0\u1ee3c PEEP b\u1ea3o th\u1ee7 h\u01a1n, \u0111\u00e3 c\u1ea3i thi\u1ec7n oxygen h\u00f3a v\u00e0 gi\u1ea3m \u00e1p l\u1ef1c \u0111\u1ea9y, nh\u01b0ng kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t \u0111\u00e1ng k\u1ec3 v\u1ec1 kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t.<\/p>\n
Trong b\u1ed1i c\u1ea3nh ph\u1eabu thu\u1eadt, m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p g\u1ea7n \u0111\u00e2y li\u00ean quan \u0111\u1ebfn 17 nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng v\u00e0 2250 b\u1ec7nh nh\u00e2n cho th\u1ea5y nh\u1eefng thay \u0111\u1ed5i v\u1ec1 m\u1ee9c PEEP d\u1eabn \u0111\u1ebfn t\u0103ng \u00e1p l\u1ef1c \u0111\u1ea9y c\u00f3 li\u00ean quan \u0111\u1ebfn nhi\u1ec1u bi\u1ebfn ch\u1ee9ng ph\u1ed5i sau ph\u1eabu thu\u1eadt h\u01a1n [31].<\/p>\n
Trong ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p c\u1ee7a Amato v\u00e0 c\u1ed9ng s\u1ef1 [7], khi ph\u00e2n t\u00edch nh\u1eefng thay \u0111\u1ed5i v\u1ec1 \u00e1p l\u1ef1c \u0111\u1ea9y x\u1ea3y ra do nh\u1eefng thay \u0111\u1ed5i c\u1ee5 th\u1ec3 v\u1ec1 th\u1ec3 t\u00edch kh\u00ed l\u01b0u th\u00f4ng ho\u1eb7c PEEP \u0111\u01b0\u1ee3c \u00e1p d\u1ee5ng sau khi ph\u00e2n b\u1ed5 ng\u1eabu nhi\u00ean, nh\u1eefng thay \u0111\u1ed5i d\u1eabn \u0111\u1ebfn gi\u1ea3m \u00e1p l\u1ef1c \u0111\u1ea9y c\u00f3 li\u00ean quan \u0111\u1ebfn kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t cao h\u01a1n.<\/p>\n
M\u1eb7c d\u00f9 b\u1eb1ng ch\u1ee9ng n\u00e0y kh\u00e1 y\u1ebfu \u0111\u1ec3 h\u1ed7 tr\u1ee3 khuy\u1ebfn ngh\u1ecb ch\u1eafc ch\u1eafn v\u1ec1 vi\u1ec7c nh\u1eafm m\u1ee5c ti\u00eau \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0 m\u1ee5c ti\u00eau ch\u00ednh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n th\u1edf m\u00e1y, ch\u00fang t\u00f4i tin r\u1eb1ng ch\u00fang t\u1ea1o th\u00e0nh c\u01a1 s\u1edf \u0111\u1ea7y h\u1ee9a h\u1eb9n cho m\u1ed9t th\u1eed nghi\u1ec7m trong t\u01b0\u01a1ng lai. Ngo\u00e0i ra, ch\u00fang cung c\u1ea5p manh m\u1ed1i cho c\u00e1c b\u00e1c s\u0129 l\u00e2m s\u00e0ng v\u1ec1 c\u00e1ch h\u1ecd c\u00f3 th\u1ec3 \u00e1p d\u1ee5ng kh\u00e1i ni\u1ec7m m\u1edbi n\u00e0y v\u00e0o th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng, trong khi ch\u00fang t\u00f4i ch\u1edd \u0111\u1ee3i th\u00eam b\u1eb1ng ch\u1ee9ng.<\/p>\n
S\u1eed d\u1ee5ng l\u00e2m s\u00e0ng \u00e1p l\u1ef1c \u0111\u1ea9y<\/h2>\nCh\u00fang ta h\u00e3y so s\u00e1nh v\u1ec1 m\u1eb7t l\u00fd thuy\u1ebft hai b\u1ec7nh nh\u00e2n c\u00f3 c\u00f9ng \u0111\u1ed9 tu\u1ed5i v\u00e0 ki\u1ec3u h\u00ecnh m\u1eafc b\u1ec7nh vi\u00eam ph\u1ed5i m\u1eafc ph\u1ea3i trong c\u1ed9ng \u0111\u1ed3ng v\u00e0 t\u00ecnh tr\u1ea1ng thi\u1ebfu oxy m\u00e1u n\u1eb7ng \u0111\u01b0\u1ee3c th\u1edf m\u00e1y v\u1edbi c\u00f9ng m\u1ee9c Vt (6 mL\/kg IBW) v\u00e0 PEEP (10 cmH_{2<\/sub>O). Sau thao t\u00e1c t\u1eafc ngh\u1ebdn cu\u1ed1i th\u00ec h\u00edt v\u00e0o, m\u1ed9t b\u1ec7nh nh\u00e2n c\u00f3 \u00e1p l\u1ef1c cao nguy\u00ean l\u00e0 22 cmH_{2<\/sub>O (\u00e1p l\u1ef1c \u0111\u1ea9y 12 cmH_{2<\/sub>O), trong khi b\u1ec7nh nh\u00e2n kia c\u00f3 30 cmH_{2<\/sub>O (\u00e1p l\u1ef1c \u0111\u1ea9y 20 cmH_{2<\/sub>O). R\u00f5 r\u00e0ng, b\u1ec7nh nh\u00e2n th\u1ee9 hai c\u00f3 C_{RS<\/sub> th\u1ea5p h\u01a1n v\u00e0 c\u00f3 th\u1ec3 c\u00f3 ti\u00ean l\u01b0\u1ee3ng x\u1ea5u h\u01a1n. \u1ede b\u1ec7nh nh\u00e2n n\u00e0y, sau khi gi\u1ea3m Vt xu\u1ed1ng 5 mL\/kg v\u00e0 chu\u1ea9n \u0111\u1ed9 PEEP l\u00ean 14 cmH2O, \u00e1p l\u1ef1c cao nguy\u00ean gi\u1ea3m xu\u1ed1ng c\u00f2n 26 cmH_{2<\/sub>O. Li\u1ec7u hai b\u1ec7nh nh\u00e2n n\u00e0y hi\u1ec7n t\u1ea1i, sau khi \u0111\u1ea1t \u0111\u01b0\u1ee3c c\u00f9ng \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0 12 cmH2O, c\u00f3 c\u00f9ng ti\u00ean l\u01b0\u1ee3ng kh\u00f4ng? Logic c\u00f3 xu h\u01b0\u1edbng cho r\u1eb1ng \u0111\u00e2y kh\u00f4ng ph\u1ea3i l\u00e0 t\u01b0\u01a1ng \u0111\u1ed3ng, v\u00ec b\u1ec7nh nh\u00e2n c\u00f3 m\u1ee9c \u0111\u1ed9 b\u1ec7nh n\u1eb7ng h\u01a1n s\u1ebd c\u1ea7n nhi\u1ec1u li\u1ec7u ph\u00e1p h\u1ed7 tr\u1ee3 h\u01a1n, ch\u1eb3ng h\u1ea1n nh\u01b0 n\u1eb1m s\u1ea5p v\u00e0 phong b\u1ebf th\u1ea7n kinh c\u01a1, nh\u01b0ng v\u1eabn c\u00f3 th\u1ec3 c\u00f3 k\u1ebft qu\u1ea3 t\u1ed3i t\u1ec7 h\u01a1n.<\/p>\n}}}}}}}
Nh\u01b0 \u0111\u00e3 th\u1ea3o lu\u1eadn, \u00e1p l\u1ef1c \u0111\u1ea9y cao c\u00f3 li\u00ean quan ch\u1eb7t ch\u1ebd v\u1edbi t\u1ef7 l\u1ec7 t\u1eed vong cao h\u01a1n. Tuy nhi\u00ean, gi\u1edbi h\u1ea1n an to\u00e0n c\u1ee7a \u00e1p l\u1ef1c \u0111\u1ea9y ch\u01b0a \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh v\u00e0 ng\u01b0\u1ee1ng c\u1eaft \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t thay \u0111\u1ed5i t\u1eeb 14 \u0111\u1ebfn 18 cmH_{2<\/sub>O [26, 30]. Trong c\u00e1c nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng so s\u00e1nh th\u00f4ng kh\u00ed Vt cao so v\u1edbi th\u1ea5p \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS, c\u00e1c chi\u1ebfn l\u01b0\u1ee3c kh\u00f4ng b\u1ea3o v\u1ec7 th\u00f4ng th\u01b0\u1eddng d\u1eabn \u0111\u1ebfn \u00e1p l\u1ef1c \u0111\u1ea9y l\u1edbn h\u01a1n 20 cmH_{2<\/sub>O, trong khi c\u00e1c chi\u1ebfn l\u01b0\u1ee3c b\u1ea3o v\u1ec7 th\u01b0\u1eddng d\u01b0\u1edbi 15\u201316 cmH_{2<\/sub>O. Ng\u01b0\u1ee3c l\u1ea1i, trong c\u00e1c nghi\u00ean c\u1ee9u so s\u00e1nh PEEP cao so v\u1edbi th\u1ea5p, trong \u0111\u00f3 t\u1ea5t c\u1ea3 c\u00e1c nh\u00f3m \u0111\u1ec1u gi\u1edbi h\u1ea1n Vt, \u00e1p l\u1ef1c \u0111\u1ea9y trung b\u00ecnh th\u1ea5p h\u01a1n nhi\u1ec1u so v\u1edbi 15 cmH_{2<\/sub>O (B\u1ea3ng 1).<\/p>\n}}}}
Trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng c\u00f3 nghi\u00ean c\u1ee9u ti\u1ec1n c\u1ee9u n\u00e0o s\u1eed d\u1ee5ng \u00e1p l\u1ef1c \u0111\u1ea9y l\u00e0m m\u1ee5c ti\u00eau khi thi\u1ebft l\u1eadp m\u00e1y th\u1edf, ch\u00fang t\u00f4i \u0111\u1ec1 xu\u1ea5t r\u1eb1ng \u00e1p l\u1ef1c \u0111\u1ea9y n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nh\u01b0 m\u1ed9t s\u1ef1 b\u1ed5 sung cho, ch\u1ee9 kh\u00f4ng ph\u1ea3i l\u00e0 thay th\u1ebf cho, Vt. Theo \u0111\u00f3, ch\u00fang ta n\u00ean duy tr\u00ec m\u1ee5c ti\u00eau Vt t\u1eeb 6 \u0111\u1ebfn 8 mL\/kg IBW, sau \u0111\u00f3 ki\u1ec3m so\u00e1t \u0111\u1ed9 an to\u00e0n c\u1ee7a n\u00f3 theo \u00e1p l\u1ef1c \u0111\u1ea9y (H\u00ecnh 3). M\u1eb7c d\u00f9 kh\u00f4ng c\u00f3 \u0111\u1ee7 b\u1eb1ng ch\u1ee9ng \u0111\u1ec3 g\u1ee3i \u00fd gi\u00e1 tr\u1ecb ng\u01b0\u1ee1ng c\u1ee5 th\u1ec3 cho \u00e1p l\u1ef1c \u0111\u1ea9y, ch\u00fang t\u00f4i \u0111\u1ec1 xu\u1ea5t 15 cmH_{2<\/sub>O, kh\u00f4ng ph\u1ea3i l\u00e0 m\u1ee5c ti\u00eau, m\u00e0 l\u00e0 gi\u1edbi h\u1ea1n an to\u00e0n. C\u00f3 l\u1ebd h\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n kh\u00f4ng m\u1eafc ARDS s\u1ebd c\u00f3 \u00e1p l\u1ef1c \u0111\u1ea9y d\u01b0\u1edbi 10 cmH_{2<\/sub>O, ph\u1ea3n \u00e1nh C_{RS<\/sub> b\u00ecnh th\u01b0\u1eddng ho\u1eb7c g\u1ea7n b\u00ecnh th\u01b0\u1eddng [31]. Ng\u01b0\u1ee3c l\u1ea1i, \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS t\u1eeb trung b\u00ecnh \u0111\u1ebfn n\u1eb7ng ho\u1eb7c c\u00e1c b\u1ec7nh h\u1ea1n ch\u1ebf kh\u00e1c (ph\u00f9 ph\u1ed5i, tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i l\u01b0\u1ee3ng l\u1edbn, b\u1ec7nh k\u1ebd, x\u01a1 h\u00f3a, v.v.), \u00e1p l\u1ef1c \u0111\u1ea9y tr\u00ean 10 s\u1ebd ph\u1ed5 bi\u1ebfn v\u00e0 c\u00f3 th\u1ec3 ph\u1ea3n \u00e1nh C_{RS<\/sub> gi\u1ea3m ho\u1eb7c c\u00e0i \u0111\u1eb7t Vt\/PEEP kh\u00f4ng ph\u00f9 h\u1ee3p.<\/p>\n}}}}
\u00c1p l\u1ef1c \u0111\u1ea9y c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t c\u00f4ng c\u1ee5 c\u00f3 gi\u00e1 tr\u1ecb \u0111\u1ec3 thi\u1ebft l\u1eadp PEEP. Kh\u00f4ng ph\u1ee5 thu\u1ed9c v\u00e0o chi\u1ebfn l\u01b0\u1ee3c \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 chu\u1ea9n \u0111\u1ed9 PEEP, nh\u1eefng thay \u0111\u1ed5i v\u1ec1 m\u1ee9c PEEP n\u00ean xem x\u00e9t t\u00e1c \u0111\u1ed9ng \u0111\u1ebfn \u00e1p l\u1ef1c \u0111\u1ea9y, b\u00ean c\u1ea1nh c\u00e1c bi\u1ebfn s\u1ed1 kh\u00e1c nh\u01b0 trao \u0111\u1ed5i kh\u00ed v\u00e0 huy\u1ebft \u0111\u1ed9ng h\u1ecdc [3, 32, 33]. Vi\u1ec7c gi\u1ea3m \u00e1p l\u1ef1c \u0111\u1ea9y sau khi t\u0103ng PEEP ch\u1eafc ch\u1eafn s\u1ebd ph\u1ea3n \u00e1nh s\u1ef1 huy \u0111\u1ed9ng v\u00e0 gi\u1ea3m bi\u1ebfn d\u1ea1ng theo chu k\u1ef3. Ng\u01b0\u1ee3c l\u1ea1i, vi\u1ec7c t\u0103ng \u00e1p l\u1ef1c \u0111\u1ea9y s\u1ebd g\u1ee3i \u00fd m\u1ed9t ph\u1ed5i kh\u00f4ng th\u1ec3 huy \u0111\u1ed9ng, trong \u0111\u00f3 t\u00ecnh tr\u1ea1ng c\u0103ng gi\u00e3n qu\u00e1 m\u1ee9c chi\u1ebfm \u01b0u th\u1ebf h\u01a1n s\u1ef1 huy \u0111\u1ed9ng [34]. N\u1ebfu sau khi t\u1ed1i \u01b0u h\u00f3a PEEP, \u00e1p l\u1ef1c \u0111\u1ea9y v\u1eabn tr\u00ean 15 cmH_{2<\/sub>O, ch\u00fang t\u00f4i \u0111\u1ec1 xu\u1ea5t gi\u1ea3m th\u00eam Vt xu\u1ed1ng d\u01b0\u1edbi 6 mL\/kg IBW (H\u00ecnh 3) [24]. Ngo\u00e0i ra, c\u00f3 th\u1ec3 c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng \u1ed1ng th\u00f4ng th\u1ef1c qu\u1ea3n \u0111\u1ec3 \u0111o \u00e1p l\u1ef1c \u0111\u1ea9y xuy\u00ean ph\u1ed5i.<\/p>\n}
B\u1ea3ng 1 C\u00e1c th\u00f4ng s\u1ed1 th\u00f4ng kh\u00ed sau 24 gi\u1edd v\u00e0 t\u1ef7 l\u1ec7 t\u1eed vong trong c\u00e1c nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng so s\u00e1nh chi\u1ebfn l\u01b0\u1ee3c b\u1ea3o v\u1ec7 (gi\u1edbi h\u1ea1n Vt) v\u1edbi nh\u00f3m \u0111\u1ed1i ch\u1ee9ng (b\u1ea3ng tr\u00ean c\u00f9ng) v\u00e0 chi\u1ebfn l\u01b0\u1ee3c PEEP cao so v\u1edbi PEEP th\u1ea5p ho\u1eb7c gi\u00e3n n\u1edf t\u1ed1i thi\u1ec3u (b\u1ea3ng d\u01b0\u1edbi c\u00f9ng) \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nT\u00e1c gi\u1ea3<\/strong><\/td>\n N\u0103m<\/strong><\/td>\n N<\/strong><\/td>\n Vt<\/strong><\/td>\n P,…<\/strong><\/td>\n P\u00c9P<\/strong><\/td>\n DP<\/strong><\/td>\n Ch\u1ebft<\/strong><\/td>\n Vt<\/strong><\/td>\n P,…<\/strong><\/td>\n P\u00c9P<\/strong><\/td>\n DP<\/strong><\/td>\n Ch\u1ebft<\/strong><\/td>\n \u2206DP<\/strong><\/td>\n p^{b<\/sup><\/strong><\/td>\n<\/tr>\n}
Chi\u1ebfn l\u01b0\u1ee3c b\u1ea3o v\u1ec7 <\/strong><\/td>\n Nh\u00f3m ki\u1ec3m so\u00e1t <\/strong><\/td>\n<\/tr>\n
Brochard<\/td>\n 1998<\/td>\n 108<\/td>\n 7.1<\/td>\n 25,7<\/td>\n 10.7<\/td>\n 15<\/td>\n 46,6%<\/td>\n 10.3<\/td>\n 31,7<\/td>\n 10.7<\/td>\n 21<\/td>\n 37,9%<\/td>\n 6<\/td>\n Kh\u00f4ng<\/td>\n<\/tr>\n
Stewart<\/td>\n 1998<\/td>\n 120<\/td>\n 7.2<\/td>\n 22.3<\/td>\n 8.6<\/td>\n 13,7<\/td>\n 48,0%<\/td>\n 10.8<\/td>\n 26,8<\/td>\n 7.2<\/td>\n 19,6<\/td>\n 46,0%<\/td>\n 5.9<\/td>\n Kh\u00f4ng<\/td>\n<\/tr>\n
Ranieri^{a<\/sup><\/td>\n} 1999<\/td>\n 44<\/td>\n 7.6<\/td>\n 24,6<\/td>\n 14,8^{a<\/sup><\/td>\n} 9.8<\/td>\n 38,0%<\/td>\n 11.1<\/td>\n 31<\/td>\n 6,5<\/td>\n 24,5<\/td>\n 58,0%<\/td>\n 14,7<\/td>\n 0,19<\/td>\n<\/tr>\n
Brower<\/td>\n 1999<\/td>\n 52<\/td>\n 7.3<\/td>\n 27<\/td>\n 9.3<\/td>\n 17,7<\/td>\n 50,0%<\/td>\n 10.2<\/td>\n 30<\/td>\n 8.2<\/td>\n 21,8<\/td>\n 46,0%<\/td>\n 4.1<\/td>\n Kh\u00f4ng<\/td>\n<\/tr>\n
Amato^{a<\/sup><\/td>\n} 1998<\/td>\n 53<\/td>\n 6<\/td>\n 31,8<\/td>\n 16,3^{a<\/sup><\/td>\n} 15,5<\/td>\n 38,0%<\/td>\n 12<\/td>\n 34,4<\/td>\n 6.9<\/td>\n 27,5<\/td>\n 71,0%<\/td>\n 12<\/td>\n <0,001<\/td>\n<\/tr>\n
ARDSnet<\/td>\n 2000<\/td>\n 861<\/td>\n 6.1<\/td>\n 25<\/td>\n 9.4<\/td>\n 15,6<\/td>\n 31,0%<\/td>\n 11.9<\/td>\n 33<\/td>\n 8.6<\/td>\n 24,4<\/td>\n 39,8%<\/td>\n 8.8<\/td>\n 0,007<\/td>\n<\/tr>\n
PEEP cao <\/strong><\/td>\n PEEP th\u1ea5p<\/strong><\/td>\n<\/tr>\n
ALVEOLI<\/td>\n 2004<\/td>\n 549<\/td>\n 6.1<\/td>\n 27<\/td>\n 14,7<\/td>\n 12.3<\/td>\n 27,5%<\/td>\n 6.0<\/td>\n 24<\/td>\n 9.1<\/td>\n 14,9<\/td>\n 24,9%<\/td>\n 2.6<\/td>\n Kh\u00f4ng<\/td>\n<\/tr>\n
Mercat<\/td>\n 2008<\/td>\n 767<\/td>\n 6.1<\/td>\n 27,5<\/td>\n 15.8<\/td>\n 11.7<\/td>\n 35,4%<\/td>\n 6.1<\/td>\n 21.1<\/td>\n 8.4<\/td>\n 12,7<\/td>\n 39,0%<\/td>\n 1.0<\/td>\n Kh\u00f4ng<\/td>\n<\/tr>\n
Meade<\/td>\n 2008<\/td>\n 963<\/td>\n 6.8<\/td>\n 30,2<\/td>\n 15,6<\/td>\n 14,6<\/td>\n 36,4%<\/td>\n 6.8<\/td>\n 24,9<\/td>\n 10.1<\/td>\n 14.8<\/td>\n 40,4%<\/td>\n 0,2<\/td>\n Kh\u00f4ng<\/td>\n<\/tr>\n
Talmor ^{c<\/sup><\/td>\n} 2008<\/td>\n 61<\/td>\n 7.1<\/td>\n 28<\/td>\n 17<\/td>\n 11<\/td>\n 17%<\/td>\n 6.8<\/td>\n 25<\/td>\n 10<\/td>\n 15<\/td>\n 39%<\/td>\n 4.0<\/td>\n 0,055<\/td>\n<\/tr>\n
Kacmarek<\/td>\n 2016<\/td>\n 200<\/td>\n 5.6<\/td>\n 27,9<\/td>\n 15.8<\/td>\n 11.8<\/td>\n 22%<\/td>\n 6.2<\/td>\n 25.2<\/td>\n 11.6<\/td>\n 13.8<\/td>\n 27%<\/td>\n 2.0<\/td>\n 0,18<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\u00c1p l\u1ef1c \u0111\u1ea9y c\u1ee7a h\u1ec7 h\u00f4 h\u1ea5p (DP) \u0111\u01b0\u1ee3c t\u00ednh l\u00e0 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa \u00e1p l\u1ef1c cao nguy\u00ean (Pplat) v\u00e0 PEEP. L\u01b0u \u00fd r\u1eb1ng s\u1ef1 kh\u00e1c bi\u1ec7t l\u1edbn h\u01a1n v\u1ec1 DP gi\u1eefa c\u00e1c nh\u00f3m (Dif DP) c\u00f3 li\u00ean quan \u0111\u1ebfn s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u1ef7 l\u1ec7 t\u1eed vong<\/p>\n
^{a<\/sup> nghi\u00ean c\u1ee9u c\u1ee7a Ranieri [37] v\u00e0 Amato [11] c\u0169ng s\u1eed d\u1ee5ng PEEP cao trong chi\u1ebfn l\u01b0\u1ee3c b\u1ea3o v\u1ec7<\/p>\n}
^{b<\/sup> Gi\u00e1 tr\u1ecb p \u0111\u1ec1 c\u1eadp \u0111\u1ebfn s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u1ef7 l\u1ec7 t\u1eed vong (Mort) gi\u1eefa c\u00e1c nh\u00f3m<\/p>\n}
^{c<\/sup> C\u00e1c th\u00f4ng s\u1ed1 th\u00f4ng kh\u00ed \u1edf th\u1eddi \u0111i\u1ec3m 72 gi\u1edd<\/p>\n}
K\u1ebft lu\u1eadn<\/h2>\n\u00c1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf l\u00e0 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa \u00e1p l\u1ef1c cao nguy\u00ean v\u00e0 PEEP v\u00e0 bi\u1ec3u th\u1ecb cho bi\u1ebfn d\u1ea1ng theo chu k\u1ef3 m\u00e0 nhu m\u00f4 ph\u1ed5i ph\u1ea3i ch\u1ecbu trong m\u1ed7i chu k\u1ef3 th\u00f4ng kh\u00ed. \u0110\u00e2y l\u00e0 m\u1ed9t c\u00e1ch sinh l\u00fd \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh Vt theo k\u00edch th\u01b0\u1edbc ph\u1ed5i c\u00f2n l\u1ea1i (\u0111\u1ed9 gi\u00e3n n\u1edf c\u1ee7a h\u1ec7 th\u1ed1ng h\u00f4 h\u1ea5p) c\u1ee7a b\u1ec7nh nh\u00e2n, t\u01b0\u01a1ng quan tr\u1ef1c ti\u1ebfp v\u1edbi \u00e1p l\u1ef1c xuy\u00ean ph\u1ed5i v\u00e0 li\u00ean quan \u0111\u1ebfn s\u1ef1 s\u1ed1ng c\u00f2n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc ARDS [7]. Do \u0111\u00f3, vi\u1ec7c thi\u1ebft l\u1eadp c\u00e1c th\u00f4ng s\u1ed1 th\u00f4ng kh\u00ed \u0111\u1ec3 gi\u1ea3m \u00e1p l\u1ef1c \u0111\u1ea9y c\u00f3 th\u1ec3 c\u00f3 vai tr\u00f2 trong vi\u1ec7c c\u1ea3i thi\u1ec7n k\u1ebft qu\u1ea3 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u1ea7n th\u1edf m\u00e1y.<\/p>\n
Tuy nhi\u00ean, \u00e1p l\u1ef1c \u0111\u1ea9y ch\u1ec9 l\u00e0 m\u1ed9t trong nhi\u1ec1u bi\u1ebfn s\u1ed1 li\u00ean quan \u0111\u1ebfn c\u00f4ng su\u1ea5t c\u01a1 h\u1ecdc ho\u1eb7c n\u0103ng l\u01b0\u1ee3ng \u0111\u01b0\u1ee3c \u00e1p d\u1ee5ng cho nhu m\u00f4 ph\u1ed5i. Vt, l\u01b0u l\u01b0\u1ee3ng v\u00e0 nh\u1ecbp th\u1edf c\u0169ng \u0111\u00e3 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y ra VILI [35, 36]. Nghi\u00ean c\u1ee9u s\u00e2u h\u01a1n s\u1ebd c\u1ea7n ph\u1ea3i kh\u00e1m ph\u00e1 c\u00e1ch t\u1ea5t c\u1ea3 c\u00e1c y\u1ebfu t\u1ed1 n\u00e0y ho\u1ea1t \u0111\u1ed9ng \u1edf m\u1ed9t b\u1ec7nh nh\u00e2n c\u1ee5 th\u1ec3.<\/p>\n
Trong khi \u0111\u00f3, ch\u00fang t\u00f4i \u0111\u1ec1 xu\u1ea5t \u0111i\u1ec1u ch\u1ec9nh h\u1ed7 tr\u1ee3 th\u00f4ng kh\u00ed b\u1eb1ng c\u00e1c th\u00f4ng s\u1ed1 b\u1ea3o v\u1ec7 truy\u1ec1n th\u1ed1ng, Vt 6\u20138 mL\/kg IBW v\u00e0 m\u1ee9c PEEP v\u1eeba ph\u1ea3i, v\u00e0 \u0111i\u1ec1u ch\u1ec9nh ch\u00fang theo \u00e1p l\u1ef1c \u0111\u1ea9y, l\u00fd t\u01b0\u1edfng nh\u1ea5t l\u00e0 d\u01b0\u1edbi 15 cmH2O, m\u1eb7c d\u00f9 gi\u1edbi h\u1ea1n n\u00e0y c\u1ea7n \u0111\u01b0\u1ee3c th\u1eed nghi\u1ec7m trong c\u00e1c th\u1eed nghi\u1ec7m trong t\u01b0\u01a1ng lai.<\/p>\n
<\/a>H\u00ecnh 3 S\u01a1 \u0111\u1ed3 lu\u1ed3ng \u0111\u1ec1 xu\u1ea5t \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh c\u00e1c th\u00f4ng s\u1ed1 th\u00f4ng kh\u00ed theo \u00e1p l\u1ef1c \u0111\u1ea9y \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u1ea7n th\u1edf m\u00e1y x\u00e2m l\u1ea5n. *Gi\u1edbi h\u1ea1n 15 cmH_{2<\/sub>O ch\u1ec9 mang t\u00ednh suy \u0111o\u00e1n v\u00ec ch\u01b0a x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c gi\u1edbi h\u1ea1n an to\u00e0n n\u00e0o cho \u00e1p l\u1ef1c \u0111\u1ea9y (xem v\u0103n b\u1ea3n). T\u1eeb vi\u1ebft t\u1eaft: Vt th\u1ec3 t\u00edch kh\u00ed l\u01b0u th\u00f4ng, IBW tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 l\u00fd t\u01b0\u1edfng, DP \u00e1p l\u1ef1c \u0111\u1ea9y \u0111\u01b0\u1eddng th\u1edf, CRS \u0111\u1ed9 gi\u00e3n n\u1edf t\u0129nh c\u1ee7a h\u1ec7 h\u00f4 h\u1ea5p, NM th\u1ea7n kinh c\u01a1, T\u1ef7 l\u1ec7 PaO_{2<\/sub>:FiO_{2<\/sub> t\u1ef7 l\u1ec7 \u00e1p l\u1ef1c ri\u00eang ph\u1ea7n c\u1ee7a oxy \u0111\u1ed9ng m\u1ea1ch v\u1edbi n\u1ed3ng \u0111\u1ed9 oxy h\u00edt v\u00e0o<\/figcaption><\/figure>\nReferences<\/h2>\n1. Acute Respiratory Distress Syndrome Network. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301\u20138. doi: 10.1056\/NEJM200005043421801.<\/p>\n
2. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, Slutsky AS, Pullenayegum E, Zhou Q, Cook D, v\u00e0 c\u1ed9ng s\u1ef1 Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865\u201373. doi: 10.1001\/jama.2010.218.<\/p>\n
3. Kacmarek RM, Villar J, Sulemanji D, Montiel R, Ferrando C, Blanco J, Koh Y, Soler JA, Martinez D, Hernandez M, v\u00e0 c\u1ed9ng s\u1ef1 Open lung approach for the acute respiratory distress syndrome: a pilot, randomized controlled trial. Crit Care Med. 2016;44(1):32\u201342. doi: 10.1097\/CCM.0000000000001383.<\/p>\n
4. Bellani G, Guerra L, Musch G, Zanella A, Patroniti N, Mauri T, Messa C, Pesenti A. Lung regional metabolic activity and gas volume changes induced by tidal ventilation in patients with acute lung injury. Am J Respir Crit Care Med. 2011;183(9):1193\u20139. doi: 10.1164\/rccm.201008-1318OC.<\/p>\n
5. Terragni PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, v\u00e0 c\u1ed9ng s\u1ef1 Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2007;175(2):160\u20136. doi: 10.1164\/rccm.200607-915OC.<\/p>\n
6. Grasso S, Stripoli T, De Michele M, Bruno F, Moschetta M, Angelelli G, Munno I, Ruggiero V, Anaclerio R, Cafarelli A, v\u00e0 c\u1ed9ng s\u1ef1 ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive endexpiratory pressure. Am J Respir Crit Care Med. 2007;176(8):761\u20137. doi: 10.1164\/rccm.200702-193OC.<\/p>\n
7. Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, v\u00e0 c\u1ed9ng s\u1ef1 Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747\u201355. doi: 10.1056\/NEJMsa1410639.<\/p>\n
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18. Estenssoro E, Dubin A, Laffaire E, Canales H, Saenz G, Moseinco M, Pozo M, Gomez A, Baredes N, Jannello G, v\u00e0 c\u1ed9ng s\u1ef1 Incidence, clinical course, and outcome in 217 patients with acute respiratory distress syndrome. Crit Care Med. 2002;30(11):2450\u20136. doi: 10.1097\/00003246-200211000-00008.<\/p>\n
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20. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, v\u00e0 c\u1ed9ng s\u1ef1 Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107\u201316. doi: 10.1056\/NEJMoa1005372.
\n21. Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, v\u00e0 c\u1ed9ng s\u1ef1 Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159\u201368. doi: 10.1056\/NEJMoa1214103.<\/p>\n
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35. Serpa Neto A, Amato M, Schultz M. Dissipated energy is a key mediator of VILI: rationale for using low driving pressures. In: Vincent J-L, editor. Annual update in intensive care and emergency medicine, 1st edition. Switzerland: Springer International Publishing; 2016. p. 311\u201321.<\/p>\n
36. Gattinoni L, Tonetti T, Cressoni M, Cadringher P, Herrmann P, Moerer O, Protti A, Gotti M, Chiurazzi C, Carlesso E, v\u00e0 c\u1ed9ng s\u1ef1 Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med. 2016;42(10):1567\u201375. doi: 10.1007\/s00134-016-4505-2.
\n37. Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, Bruno F, Slutsky AS: Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. Jama 1999;282(1):54\u201361.<\/p>\n","protected":false},"excerpt":{"rendered":"
Driving pressure: a marker of severity, a safety limit, or goal of mechanical ventilation? B\u1ea3n d\u1ecbch c\u1ee7a BS. \u0110\u1eb7ng Thanh Tu\u1ea5n Xem v\u00e0 t\u1ea3i PDF, T\u1ea0I \u0110\u00c2Y. C\u00e1c h\u01b0\u1edbng d\u1eabn hi\u1ec7n t\u1ea1i v\u1ec1 th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n m\u1eafc h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p c\u1ea5p t\u00ednh (acute respiratory distress syndrome […]\n","protected":false},"author":1,"featured_media":102537,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-102534","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-y-te-suc-khoe"],"acf":[],"_links":{"self":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/102534","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/comments?post=102534"}],"version-history":[{"count":7,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/102534\/revisions"}],"predecessor-version":[{"id":102637,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/102534\/revisions\/102637"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media\/102537"}],"wp:attachment":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media?parent=102534"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/categories?post=102534"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/tags?post=102534"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}}}}}}