Yoğun Bakımda COVID-19 İlişkili ARDS’de Optimal PEEP ve İnvaziv Mekanik Ventilasyon Modları
Özet
Bu çalışma, COVID-19 ilişkili Akut Solunum Sıkıntısı Sendromu (ARDS) olgularında yoğun bakımda uygulanan optimal pozitif ekspirasyon sonu basınç (PEEP) titrasyon yöntemleri ile invaziv mekanik ventilasyon modlarını incelemektedir. SARS-CoV-2 enfeksiyonunun neden olduğu ARDS, pulmoner perfüzyonda bozulma, mikrotrombüsler ve non-kardiyojenik ödemle karakterize olup temel ölüm nedenidir. Çalışmada klasik ARDS'den farklı olarak normal akciğer kompliyansına sahip "Tip L" ve klasik ARDS özellikleri taşıyan "Tip H" şeklinde iki farklı COVID-19 ARDS fenotipi tanımlanmış ve bunlara yönelik farklı PEEP stratejileri önerilmiştir. Optimal PEEP seviyesinin belirlenmesinde ARDSnet tabloları, azalan PEEP titrasyonu, basınç-volüm eğrisi, transpulmoner basınç, sürüş basıncı (Pdrive) ve elektrik empedans tomografisi gibi yöntemler değerlendirilmiş ancak sağkalım üzerinde kesin üstünlüğü kanıtlanmış tek bir yöntem olmadığı vurgulanmıştır. Mekanik ventilasyon uygulamalarında ise AC/VC, APRV ve PSV gibi modların kullanımı tartışılmış; bir modun diğerine üstünlüğü gösterilemediğinden, mod seçiminden ziyade akciğer koruyucu ventilasyon sınırlarına (tidal volüm 4-8 ml/kg, plato basıncı <30 cm H2O, Pdrive <15 cm H2O) bağlı kalınması gerektiği belirtilmiştir. Sonuç olarak, COVID-19 ARDS'li hastaların heterojen akciğer tutulumları sebebiyle, genel şablonlar yerine hekim tecrübesine dayanan, hemodinamik parametreleri bozmayan ve hasta bazında özelleştirilmiş ventilasyon stratejilerinin oluşturulması önerilmektedir.
This study examines the optimal positive end-expiratory pressure (PEEP) titration methods and invasive mechanical ventilation modes applied in the intensive care unit for COVID-19-associated Acute Respiratory Distress Syndrome (ARDS) cases. ARDS caused by SARS-CoV-2 infection is characterized by impaired pulmonary perfusion, microthrombi, and non-cardiogenic edema, serving as the leading cause of death. Unlike classic ARDS, the study identifies two distinct COVID-19 ARDS phenotypes: "Type L," characterized by normal lung compliance, and "Type H," which shares features with classic ARDS, proposing different PEEP strategies for each. Methods such as ARDSnet tables, decremental PEEP titration, pressure-volume curves, transpulmoner pressure, driving pressure (Pdrive), and electrical impedance tomography were evaluated for determining optimal PEEP; however, it is emphasized that no single method has proven survival superiority. In mechanical ventilation, the use of modes like AC/VC, APRV, and PSV was discussed, and since no mode has demonstrated superiority over another, adhering to lung-protective ventilation limits (tidal volume 4-8 ml/kg, plateau pressure <30 cm H2O, Pdrive <15 cm H2O) is deemed more critical than mode selection. Consequently, due to the heterogeneous lung involvement in COVID-19 ARDS patients, the study suggests establishing patient-specific ventilation strategies based on physician experience that do not compromise hemodynamic functions, rather than relying on generic templates.
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