{"id":3224,"date":"2023-04-12T18:11:45","date_gmt":"2023-04-12T11:11:45","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=3224"},"modified":"2023-04-13T19:13:27","modified_gmt":"2023-04-13T12:13:27","slug":"chien-luoc-thong-khi-bao-ve-phoi-trong-dieu-tri-hoi-chung-nguy-kich-ho-hap","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/12\/chien-luoc-thong-khi-bao-ve-phoi-trong-dieu-tri-hoi-chung-nguy-kich-ho-hap\/","title":{"rendered":"Chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i trong h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p"},"content":{"rendered":"<p><strong>Chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i (lung-protective ventilation) \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh nhi\u1ec1u nh\u1ea5t l\u00e0 cho b\u1ec7nh nh\u00e2n m\u1eafc h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p c\u1ea5p (ARDS) ho\u1eb7c c\u00e1c b\u1ec7nh l\u00fd kh\u00e1c \u0111\u00f2i h\u1ecfi m\u00e1y th\u00f4ng kh\u00ed nh\u00e2n t\u1ea1o trong ph\u00f2ng ch\u0103m s\u00f3c \u0111\u1eb7c bi\u1ec7t (ICU). Chi\u1ebfn l\u01b0\u1ee3c n\u00e0y \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o cho b\u1ec7nh nh\u00e2n m\u1eafc ARDS v\u00ec th\u1ec3 t\u00edch l\u01b0u th\u00f4ng v\u00e0 \u00e1p su\u1ea5t \u0111\u01b0\u1eddng th\u1edf cao trong qu\u00e1 tr\u00ecnh th\u00f4ng kh\u00ed \u0111\u01b0\u1ee3c ch\u1ee9ng t\u1ecf c\u00f3 th\u1ec3 l\u00e0m x\u1ea5u \u0111i nh\u1eefng t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i hi\u1ec7n c\u00f3 ho\u1eb7c g\u00e2y ra nh\u1eefng th\u01b0\u01a1ng t\u1ed5n m\u1edbi trong ph\u1ed5i, l\u00e0m \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn ch\u1ee9c n\u0103ng h\u00f4 h\u1ea5p n\u00f3i chung v\u00e0 s\u1ee9c kh\u1ecfe b\u1ec7nh nh\u00e2n n\u00f3i ri\u00eang.<\/strong><\/p>\n<p>Chi\u1ebfn l\u01b0\u1ee3c n\u00e0y gi\u00fap gi\u1ea3m nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng ph\u1ed5i do m\u00e1y th\u1edf (VILI), n\u00ean c\u00f2n \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh \u1edf c\u00e1c b\u1ec7nh nh\u00e2n nghi ng\u1edd hay ch\u1ea9n \u0111o\u00e1n t\u00ecnh tr\u1ea1ng VILI. B\u1ed1i c\u1ea3nh l\u00e2m s\u00e0ng th\u01b0\u1eddng g\u1eb7p l\u00e0 c\u00e1c b\u1ec7nh nh\u00e2n th\u1edf m\u00e1y ti\u1ebfn tri\u1ec3n x\u1ea5u ho\u1eb7c xu\u1ea5t hi\u1ec7n m\u1edbi nh\u1eefng tri\u1ec7u ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p nh\u01b0 t\u0103ng nh\u1ecbp th\u1edf, nh\u1ecbp tim, c\u1ea7n t\u1ef7 l\u1ec7 oxy trong kh\u00ed h\u00edt v\u00e0o cao h\u01a1n \u0111\u1ec3 duy tr\u00ec oxy trong m\u00e1u. VILI v\u00e0 ARDS c\u00f3 nh\u1eefng \u0111\u1eb7c \u0111i\u1ec3m r\u1ea5t gi\u1ed1ng nhau v\u1ec1 c\u1ea3 b\u1ec7nh h\u1ecdc v\u00e0 tri\u1ec7u ch\u1ee9ng, n\u00ean vi\u1ec7c s\u1eed d\u1ee5ng chi\u1ebfn l\u01b0\u1ee3t n\u00e0y \u1edf c\u00e1c b\u1ec7nh nh\u00e2n nghi ng\u1edd hay ch\u1ea9n \u0111o\u00e1n VILI \u0111\u01b0\u1ee3c xem l\u00e0 \u0111i\u1ec1u tr\u1ecb \u0111\u1ea7u tay.<\/p>\n<p>&nbsp;<\/p>\n<p><img decoding=\"async\" loading=\"lazy\" src=\"https:\/\/pneumoniaresearchnews.com\/wp-content\/uploads\/2017\/03\/shutterstock_158642774-760x475@2x.jpeg\" alt=\"minh-hoa-chien-luot-thong-khi-bao-ve-phoi\" width=\"406\" height=\"271\" \/><\/p>\n<h2>1. Kh\u1edfi \u0111\u1ed9ng chi\u1ebfn l\u01b0\u1ee3t th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i<\/h2>\n<p>Th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i s\u1eed d\u1ee5ng th\u1ec3 t\u00edch l\u01b0u th\u00f4ng th\u1ea5p (th\u01b0\u1eddng l\u00e0 6 mL\/kg) \u0111\u1ec3 gi\u1edbi h\u1ea1n nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng ph\u1ebf nang do qu\u00e1 tr\u00ecnh gi\u00e3n n\u1edf qu\u00e1 m\u1ee9c, \u0111\u1ed3ng th\u1eddi c\u0169ng l\u00e0m gi\u1ea3m c\u00e1c t\u1ed5n th\u01b0\u01a1ng do sinh h\u1ecdc. Chi\u1ebfn l\u01b0\u1ee3t n\u1ea7y c\u0169ng s\u1eed d\u1ee5ng c\u00e1c m\u1ee9c \u00e1p l\u1ef1c d\u01b0\u01a1ng \u0111\u01b0\u1eddng th\u1edf cu\u1ed1i th\u00ec th\u1edf ra (PEEP) \u0111\u1ec3 gi\u1edbi h\u1ea1n nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng do s\u1ef1 \u0111\u00f3ng x\u1eb9p l\u1eadp \u0111i l\u1eadp l\u1ea1i c\u1ee7a c\u00e1c ph\u1ebf nang. Th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 c\u1ea3i thi\u1ec7n t\u1ef7 l\u1ec7 s\u1ed1ng s\u00f3t \u1edf b\u1ec7nh nh\u00e2n m\u1eafc h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p c\u1ea5p (ARDS). Giao th\u1ee9c \u0111\u01b0\u1ee3c gi\u1edbi thi\u1ec7u b\u00ean d\u01b0\u1edbi \u0111\u01b0\u1ee3c tham kh\u1ea3o d\u1ef1a tr\u00ean giao th\u1ee9c ph\u00e1t tri\u1ec3n b\u1edfi M\u1ea1ng l\u01b0\u1edbi L\u00e2m s\u00e0ng ARDS (ARDS Clinical Network &#8211; m\u1ed9t m\u1ea1ng l\u01b0\u1edbi \u0111\u01b0\u1ee3c t\u1ea1o ra b\u1edfi c\u00e1c c\u01a1 quan ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe ch\u00ednh ph\u1ee7 Hoa K\u1ef3 \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 c\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb ti\u1ec1m n\u0103ng cho ARDS) v\u00e0 c\u00f3 s\u1eb5n t\u1ea1i \u0111\u1ecba ch\u1ec9 www.ardsnet.org.<\/p>\n<h3><strong>1.1 L\u1ef1u ch\u1ecdn th\u00f4ng s\u1ed1 ban \u0111\u1ea7u<\/strong><\/h3>\n<ul>\n<li>Ch\u1ebf \u0111\u1ed9 th\u1edf: l\u1ef1a ch\u1ecdn ch\u1ebf \u0111\u1ed9 th\u00f4ng kh\u00ed h\u1ed7 tr\u1edf &#8211; ki\u1ec3m so\u00e1t (assist-control mode) c\u00f3 gi\u1edbi h\u1ea1n th\u1ec3 t\u00edch (volume-limited)<\/li>\n<li>T\u00ednh to\u00e1n c\u00e2n n\u1eb7ng \u01b0\u1edbc t\u00ednh (predicted body weight &#8211; PBW) c\u1ee7a b\u1ec7nh nh\u00e2n theo c\u00f4ng th\u1ee9c:\n<ul>\n<li>N\u1eef: PBW (kg) = 45.5 + 0.91 * (chi\u1ec1u cao [cm] &#8211; 152.4)<\/li>\n<li>Nam: PBW (kg) = 50 + 0.91 * (chi\u1ec1u cao [cm] &#8211; 152.4)<\/li>\n<\/ul>\n<\/li>\n<li>C\u00e0i \u0111\u1eb7t th\u1ec3 t\u00edch l\u01b0u th\u00f4ng (VT) ban \u0111\u1ea7u \u1edf m\u1ee9c 8 (mL\/kg) x PBW.<\/li>\n<li>Th\u00eam \u00e1p l\u1ef1c d\u01b0\u01a1ng \u0111\u01b0\u1eddng th\u1edf cu\u1ed1i th\u00ec th\u1edf ra (PEEP) \u1edf m\u1ee9c 5 cm H2O.<\/li>\n<li>Ch\u1ecdn n\u1ed3ng \u0111\u1ed9 oxy trong kh\u00ed h\u00edt v\u00e0o (FIO2) th\u1ea5p nh\u1ea5t c\u00f3 th\u1ec3 \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c v\u00e0 duy tr\u00ec m\u1ee9c SpO2 t\u1eeb 88 \u0111\u1ebfn 95%.\n<div class=\"page\" title=\"Page 4\">\n<div class=\"section\"><\/div>\n<\/div>\n<\/li>\n<li>Gi\u1ea3m VT \u0111i 1 mL\/kg sau m\u1ed7i 2 gi\u1edd cho \u0111\u1ebfn khi VT = 6 mL\/kg.<\/li>\n<\/ul>\n<h3><strong>1.2 Hi\u1ec7u ch\u1ec9nh VT v\u00e0 t\u1ea7n s\u1ed1 th\u1edf.<\/strong><\/h3>\n<ul>\n<li>Khi VT = 6 mL\/kg, \u0111o \u00e1p su\u1ea5t b\u00ecnh nguy\u00ean (Ppl) b\u1eb1ng nghi\u1ec7m ph\u00e1p t\u1ea1m ng\u01b0ng h\u00edt v\u00e0o (inspiratory hold maneuver)<\/li>\n<li>N\u1ebfu Ppl &gt; 30 cm H2O, gi\u1ea3m VT \u0111i 1 mL\/kg cho \u0111\u1ebfn khi Ppl &lt;30 cm H2O ho\u1eb7c VT = 4 mL\/kg.<\/li>\n<li>Th\u1ef1c hi\u1ec7n kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch \u0111\u1ec3 ph\u00e1t hi\u1ec7n toan h\u00f3a m\u00e1u do h\u00f4 h\u1ea5p,\n<ul>\n<li>N\u1ebfu pH = 7,15 &#8211; 7,30, t\u0103ng t\u1ea7n s\u1ed1 th\u1edf (RR) cho \u0111\u1ebfn khi pH &gt; 7,30 ho\u1eb7c RR = 35 l\u1ea7n\/ph\u00fat.<\/li>\n<li>N\u1ebfu pH &lt; 7,15, t\u0103ng RR l\u00ean 35 l\u1ea7n\/ph\u00fat. N\u1ebfu pH v\u1eabn &lt; 7,15, t\u0103ng VT t\u1eebng 1 mL\/kg cho \u0111\u1ebfn khi pH &gt; 7,15<\/li>\n<\/ul>\n<\/li>\n<li>Th\u00f4ng s\u1ed1 l\u00fd t\u01b0\u1edfng: VT = 6 mL\/kg, Ppl \u2264 30 cm H2O, SpO2 = 88\u201395%, pH = 7.30 \u2013 7.45<\/li>\n<\/ul>\n<h3><strong>1.3 Hi\u1ec7u ch\u1ec9nh FIO2 v\u00e0 PEEP<\/strong><\/h3>\n<ul>\n<li>N\u1ebfu oxy h\u00f3a m\u00e1u ch\u01b0a \u0111\u1ea1t, c\u00f3 th\u1ec3 hi\u1ec7u ch\u1ec9nh t\u0103ng FiO2 v\u00e0 PEEP<\/li>\n<li>FIO2 t\u1ed1i \u0111a l\u00e0 100% v\u00e0 m\u1ee9c PEEP t\u1ed1i \u0111a \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o l\u00e0 18-24cmH2O<\/li>\n<\/ul>\n<p>M\u1ee5c ti\u00eau c\u1ee7a vi\u1ec7c \u00e1p d\u1ee5ng PEEP cho b\u1ec7nh nh\u00e2n m\u1eafc ARDS l\u00e0 t\u1ed1i \u0111a h\u00f3a v\u00e0 duy tr\u00ec s\u1ef1 huy \u0111\u1ed9ng c\u00e1c ph\u1ebf nang, t\u1eeb \u0111\u00f3 c\u1ea3i thi\u1ec7n oxy h\u00f3a v\u00e0 gi\u1edbi h\u1ea1n \u0111\u1ed9c t\u00ednh oxy. Trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p c\u1ea7n m\u1ed9t m\u1ee9c n\u1ed3ng \u0111\u1ed9 oxy trong kh\u00ed h\u00edt v\u00e0o qu\u00e1 cao &#8211; \u1edf ng\u01b0\u1ee1ng c\u00f3 th\u1ec3 g\u00e2y h\u1ea1i (FIO2&gt;50%) \u0111\u1ec3 duy tr\u00ec m\u1ee9c SpO2 m\u1ee5c ti\u00eau t\u1eeb 88 \u0111\u1ebfn 95%, c\u00e1c m\u1ee9c PEEP cao h\u01a1n 5 cm H2O c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 c\u1ea3i thi\u1ec7n oxy h\u00f3a \u0111\u1ed9ng m\u1ea1ch v\u00e0 gi\u1ea3m FIO2 xu\u1ed1ng m\u1ee9c an to\u00e0n h\u01a1n. Tuy nhi\u00ean, \u0111i\u1ec1u quan tr\u1ecdng c\u1ea7n nh\u1ea5n m\u1ea1nh l\u00e0 t\u0103ng PEEP c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m cung l\u01b0\u1ee3ng tim. N\u1ebfu m\u1ee5c ti\u00eau c\u1ee7a vi\u1ec7c t\u0103ng PEEP l\u00e0 \u0111\u1ec3 duy tr\u00ec c\u00f9ng m\u1ee9c SpO2 v\u1edbi m\u1ee9c FIO2 th\u1ea5p h\u01a1n, cung l\u01b0\u1ee3ng tim gi\u1ea3m s\u1ebd l\u00e0m gi\u1ea3m l\u01b0\u1ee3ng O2 cung c\u1ea5p h\u1ec7 th\u1ed1ng.<\/p>\n<h2>2. Hi\u1ec7u qu\u1ea3 c\u1ee7a chi\u1ebfn l\u01b0\u1ee3t th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i<\/h2>\n<ul>\n<li>Nghi\u00ean c\u1ee9u v\u1ec1 chi\u1ebfn l\u01b0\u1ee3t n\u00e0y tr\u00ean b\u1ec7nh nh\u00e2n ARDS, th\u1ef1c hi\u1ec7n \u0111a trung t\u00e2m, ng\u1eabu nhi\u00ean tr\u00ean 861 b\u1ec7nh nh\u00e2n \u0111ang th\u1edf m\u00e1y do ARDS th\u1ef1c hi\u1ec7n chi\u1ebfn l\u01b0\u1ee3t th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i (VT ban \u0111\u1ea7u l\u00e0 6 mL\/kg PBW) cho th\u1ea5y nh\u00f3m \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n chi\u1ebfn l\u01b0\u1ee3t n\u00e0y c\u00f3 t\u1ef7 l\u1ec7 t\u1eed vong th\u1ea5p h\u01a1n (31% so v\u1edbi 40%) v\u00e0 s\u1ed1 ng\u00e0y kh\u00f4ng c\u1ea7n th\u1edf m\u00e1y nhi\u1ec1u h\u01a1n (12 ng\u00e0y so v\u1edbi 10 ng\u00e0y)<\/li>\n<li>Hai nghi\u00ean c\u1ee9u \u0111o\u00e0n h\u1ec7 ti\u1ebfn c\u1ee9u tr\u00ean 485 b\u1ec7nh nh\u00e2n th\u1ef1c hi\u1ec7n chi\u1ebfn l\u01b0\u1ee3t b\u1ea3o v\u1ec7 ph\u1ed5i, cho th\u1ea5y s\u1ef1 t\u01b0\u01a1ng quan gi\u1eefa kh\u00f4ng tu\u00e2n th\u1ee7 chi\u1ebfn l\u01b0\u1ee3t n\u00e0y v\u00e0 m\u1ee9c t\u1eed xu\u1ea5t cao h\u01a1n. Trong m\u1ed9t ph\u00e2n t\u00edch, khi tu\u00e2n th\u1ee7 \u00a0gi\u1ea3m t\u1eeb 100% xu\u1ed1ng c\u00f2n 50% ho\u1eb7c 0%, t\u1ef7 l\u1ec7 t\u1eed vong sau hai n\u0103m t\u0103ng l\u00ean l\u1ea7n l\u01b0\u1ee3t l\u00e0 4% v\u00e0 8%.<\/li>\n<\/ul>\n<p>Khi s\u1eed d\u1ee5ng m\u00e1y th\u1edf nh\u00e2n t\u1ea1o, c\u00e1c chuy\u00ean gia y t\u1ebf t\u1ea1i <a href=\"https:\/\/vinmec.com\/vi\/dangkykham\/\">Vinmec<\/a> lu\u00f4n c\u1eadp nh\u1eadt ki\u1ebfn th\u1ee9c v\u00e0 k\u1ef9 n\u0103ng \u0111\u1ec3 \u00e1p d\u1ee5ng c\u00e1c k\u1ef9 thu\u1eadt ti\u1ebfn b\u1ed9 v\u00e0 cung c\u1ea5p ch\u0103m s\u00f3c t\u1ed1t nh\u1ea5t cho b\u1ec7nh nh\u00e2n.<\/p>\n<p>Ngu\u1ed3n tham kh\u1ea3o:<\/p>\n<p>Acute Respiratory Distress Syndrome Network; 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 May 4;342(18):1301-8. doi: 10.1056\/NEJM200005043421801.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i (lung-protective ventilation) \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh nhi\u1ec1u nh\u1ea5t l\u00e0 cho b\u1ec7nh nh\u00e2n m\u1eafc h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p c\u1ea5p (ARDS) ho\u1eb7c c\u00e1c b\u1ec7nh l\u00fd kh\u00e1c \u0111\u00f2i h\u1ecfi m\u00e1y th\u00f4ng kh\u00ed nh\u00e2n t\u1ea1o trong ph\u00f2ng ch\u0103m s\u00f3c \u0111\u1eb7c bi\u1ec7t (ICU). Chi\u1ebfn l\u01b0\u1ee3c n\u00e0y \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o cho b\u1ec7nh nh\u00e2n [&hellip;]<\/p>\n","protected":false},"author":37,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[23,33],"tags":[3],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v20.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 ph\u1ed5i trong h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p<\/title>\n<meta name=\"description\" content=\"Chi\u1ebfn l\u01b0\u1ee3c th\u00f4ng kh\u00ed b\u1ea3o v\u1ec7 (lung-protective ventilation) ph\u1ed5i \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh nhi\u1ec1u nh\u1ea5t cho b\u1ec7nh nh\u00e2n m\u1eafc h\u1ed9i ch\u1ee9ng nguy k\u1ecbch h\u00f4 h\u1ea5p c\u1ea5p.\" \/>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" 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