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1、ARDS的治疗与循证医学复兴医院ICUARDS&EBM1972Cochran提出evidence-basedmedicine(EBM)1EBM的中心思想是-科学知识优于个人经验1986Sackett首次用于抗血栓药推荐意见的临床研究21.CochranAL(1972)NuffieldProvincialHospitalTrust,London2.SackettDL(1986)Chest89:2s-3sARDS&EBMSackett将科学资料分为5级Level1:大样本,随机研究课题,结果清晰;假阳性或假阴
2、性的错误很低Level2:小样本,随机研究课题,结果不确定;假阳性和/或假阴性的错误较高Level3:非随机,同期(contemporaneous)控制研究Level4:非随机,历史控制和专家意见Level5:病历,非控制研究和专家意见ARDS&EBM1997肺动脉导管共识会(ThePulmonaryArteryCatheterConsensusConference)提出将科研结果分为5级A:Supportedbyatleasttwolevel1investigationB:Supportedbyonly
3、onelevel1investigationC:Supportedbylevel2investigationonlyD:Supportedbyatleastonelevel3investigationE:Supportedbylevel4orlevel5evidenceCritCareMed199725:910-925ARDS&EBM1995MarinHK提出了ARDS的证据质量和分级标准(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应用EBM的原则评价ARDS的诊断,发病和治疗发现了很多问题主要是缺乏前瞻性,随机的,控制的带有清晰的转归结果的研究病死率住院或ICU天数无机械通气天数(ventilator-freedays)ARDS的病理生理PathophysiologyprocessofARDSARDSphysiopathologyARDS的非同一性病变导致有创机械通气患者VILI的机
7、理ARDS&EBM机械通气相关性肺损伤1气压伤2容积伤3剪切力4生物学损伤MechanicalVentilation大量动物实验证明可以损伤正常的肺或加重肺损伤ChiumelloD,MechanicalventilationaffectslocalandsystemiccytokinesinananimalmodelofARDS.AmJRespirCritCareMed1999;157:1721-1725DreyfussD,Mechanicalventilation-inducedpulmonaryede
8、ma.Interactonwithpreviouslungalteratons.AmJRespirCritCareMed1995;151:1568-1575DreyfussD,Roleoftidalvolume,FRC,andend-inspiratoryvolumeinthedevelopmentofpulmonaryedemafollowingmechanicalventilation.AmRevRespirDis1993
