1.1

重癥流感醫療診治要點WHO:

Upto650000peopledieofrespiratorydiseaseslinkedtoseasonalflueachyearGlobalInfluenzaProgrammeGlobalInfluenzaProgrammeLancet2018;391:1285–300ClinicalInfectiousDiseases2014;58(8):1095–103TwopathwayDirectinjurySIRS:inflammatorystorm病理與病理生理甲型H1N1除在鼻腔復制外在器氣管、支氣管和細支氣管復制Science.2009,325:481-483.病理與病理生理MechanismoftheCytokineStormEvokedbyInfluenzavirusNEnglJMed.

2005

May5;352(18):1839-42.

病理標本來源：2009年4月23日到2009年5月15日，5例確診為甲型H1N1感染的墨西哥居民尸檢結果肺組織大體標本：肺組織重量增加(650-1200gvs450g)；肺實變上呼吸道改變：喉和氣管、細支氣管粘膜水腫、充血、壞死肺組織：毛細血管內皮細胞損傷、毛細血管內液體滲出、血管內纖維血栓形成、肺泡間隔水腫、透明膜形成、II型肺泡上皮細胞增生、肺水腫和實變NEnglJMed2009;361;20病理與病理生理NEnglJMed2009;361:680-9.DiffusealveolardamagewithprominenthyalinemembranesThespecimenhematoxylinandeosin)showsnecrosisofbronchiolarwallsaneutrophilicinfiltrate病理與病理生理重癥流感和早期識別國家衛生健康委辦公廳國家中醫藥局辦公室.流行性感冒診療方案(2018年版修訂版)出現以下情況之一者為重癥病例危重癥流感國家衛生健康委辦公廳國家中醫藥局辦公室.流行性感冒診療方案(2018年版修訂版)出現以下情況之一者為危重病例CritCareMed2015;43:339–345臨床特征Pneumonia/RespiratoryfailurePulmonaryedema/ARDSMyositis/Myocarditis/EncephalitisAKI

and

HepaticdysfunctionCardiopulmonarycollapseSepticshockVentricularfibrillationIncreasedLDHandCK(2)WBC:normalorincreased(3)Lymphopenia:?臨床特征CritCareMed.2015Feb;43(2):339-45.doi:10.1097/CCM.0000000000000695.流感重癥肺炎的影像學特征流感重癥患者的影像學胸片：表現：雙側滲出性改變(70.8%)，雙側上下肺均受累(41.1%)；多病灶實變和胸膜滲出；重癥者可出現輕度纖維化。局限性：靈敏性低，不能早期診斷胸部CT：分辨率高，顯示早期改變NEnglJMed2009;361:1935-44.KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosisAntiviral

therapy：always

delay

CritCareMed.2015Feb;43(2):339-45.doi:10.1097/CCM.0000000000000695.Antiviral

therapy

vs

SheddingTheJournalofInfectiousDiseases?2018;XX00:1–10已經上市的抗流感病毒藥物Dose:

antiviral

drugs/respiratoryPublishedonlineJanuary13,2017/10.1016/S2213-2600(16)30435-0Dose:

antiviral

drugs/respiratoryPublishedonlineJanuary13,2017/10.1016/S2213-2600(16)30435-0viralloadDose:

antiviral

drugs/respiratoryPublishedonlineJanuary13,2017/10.1016/S2213-2600(16)30435-0雙倍劑量(600mg)扎那米韋vs單倍奧司他韋(75mg)或者扎那米韋(300mg)治療住院流感并無優勢Antiviral

therapy

Single

vs

Combination

therapy

TheJournalofInfectiousDiseases?2018;XX00:1–10新型抗流感病毒藥物NEnglJMed2018;379:913-23.

DOI:10.1056/NEJMoa1716197

與安慰劑相比，巴洛沙韋(Baloxavir)可明顯縮短流感癥狀時間與安慰劑和奧司他韋相比，巴洛沙韋(Baloxavir)降低病毒滴度更明顯NEnglJMed2018;379:913-23.

DOI:10.1056/NEJMoa1716197

KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosisOxy

administration:

strategies

Oxy

therapyMVECMO低氧程度吸氧不能糾正的低氧血癥肺泡通氣不足V/Q失調/分流

嚴重的低氧血癥難以糾正的分流和彌散障礙吸氧可糾正的低氧血癥Oxygen

therapy:

Low

flow

sysVt300～700mlRR<25bpm呼吸節律規則而穩定Flow:

Could

NOT

satisfy

the

need

of

pat’s

inspirationOxygen

therapy:

High

flow

sysBMJ,1998,317:798–801.高流量系統提供的氣流能完全滿足患者吸氣的需要患者無需額外吸入空氣

Venturi原理氧射流產生負壓從側孔帶入一定量的空氣，瓣膜孔面積決定吸入氧與空氣混合后的氧濃度High

flow

sys:

High-FlowNasalOxygenAirVO2呼吸濕化治療儀Highconcentration

oxygen:

21~100%High

flow:

~60L/min

(decrease

dead

space)Heatedandhumidifiedair

(100%

RH)CPAP

effect:

lowlevelsofPEEPNewEenglJMed2015,372;2225Classifiedaccordingtowhetherintubationstartedearly(within48h)orlate(atleast48h)

aftercommencingHFNCIntensiveCareMed

2015,DOI10.1007/s00134-015-3693-5HFNC

OR

NIV

Transfer

to

MVMilestone

for

ARDS2000Low

Vt2009EMCO2010NMBA2013Prone

positionVentilation-induced

lung

injury

Low

VT

to

avoidinspiratorystress6ml/kg

IBWUpperlimitgoalforPplat

30cmH2ONEJM

2000,342:13023139.8P=0.00712FiO2PEEP（cmH2O）0.350.45-80.58-100.6100.710-140.8140.914-18NEnglJMed2000;342:1301-8.1.018-24WhatisoptimalPEEP?Clinical

practice

on

PEEP

setting

PEEPsettinga)5-10cmH2Ob)11-15cmH2Oc)>16cmH2OEarlyneuromuscularblockadeinARDS:theACURASYSstudyNEJM,2010,16,363(12):1107Proneposition.BasedoninitialdegreeofseveritySeveremoderate(100-150)andsevereARDSMildmoderateARDS(150-200)PronepositionIFandWHENpossibleContinueTreatmentA,FacialorpelvicfracturesB,BurnsoropenwoundsontheventralbodysurfaceC,Conditionsassociatedwithspinalinstability(eg,rheumatoidarthritis,trauma)D,ConditionsassociatedwithincreasedintracranialpressureE,Life-threateningarrhythmiasMinervaAnestesiol

2014;80(9):1046-57Kaplan-MeiersurvivalestimatesLancet2009;374:1351–63.DOI:10.1016/S0140-6736(09)61069-2CESAR

The

Savior

of

vvECMOECMOReassessseverityVerySevereARDS(<80)withPEEP>15cmH2OModerateARDS(100-200)ContactaReferralCenterforECMOContinueThetreatmentfor48-72hoursandfollowtheevolutionMinervaAnestesiol

2014;80(9):1046-57KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosis我國重癥流感的激素與廣譜抗菌藥物應用廣泛CritCareMed.2015Feb;43(2):339-45.doi:10.1097/CCM.0000000000000695.Corticosteroidswereinitiatedwithin7daysoftheonsetofillnessandthemaximumdoseadministeredwasequivalentto80-mgmethylprednisolone(interquartilerange,40–120mg).CritCareMed2015;43:339–345)IntensiveCareMed2018,

/10.1007/s00134-018-5332-4ReactivityofIVIgagainstseasonalandpandemicstrains.IVIgpreparedin2004(blackdots)or2009priortotheappearanceoftheswineoriginH1N1pandemic(redsquares)EBioMedicine19(2017)119–127Immune

plasma

for

severe

influenza

/respiratoryPublishedonlineMay15,2017/10.1016/S2213-2600(17)30174-1KeypointsforcriticallyillpatientsEarlierdiagnosisandearlyantivirustherapyOxygen

therapy

and

MV

and

ECMOAntibiotics

andglucocorticoidsFluid

management

and

pul

edemaInvasivepulmonaryaspergillosisBothearlyandlatefluidmanagementofsepticshockcomplicatedbyALIcaninfluencepatientoutcomesFluidmanagementinALIsecondarytosepticshockChest