肺部超声在急性呼吸窘迫综合征表型中的应用进展

doi:10.3877/cma.j.issn.1674-0785.2024.12.013

急性呼吸窘迫综合征（ARDS）是目前重症医学领域关键性疾病，在人群中具有较高的发病率及病死率。在新型冠状病毒感染暴发后，有关ARDS的研究广泛开展，尽管对于该疾病的认知得到了更进一步的发展，然而，在ARDS的治疗方面，大量的临床研究并未获得预想中的成功，这是因为ARDS存在多方面的异质性，即不同的表型，使得单一、固定化的治疗并不能对患者都能起到有效改善预后的作用。因此，快速、准确鉴别ARDS表型，将患者依据不同表型细分为更同质化的亚组，再予以精准的个性化治疗，对于患者的治疗至关重要。肺部超声（LUS）在ARDS患者的诊疗过程中已得到广泛应用，也为ARDS表型鉴别提供了一个有力的工具。本文旨在通过论述LUS在ARDS患者表型鉴别中的应用进展，辅助临床医生制定个性化治疗方案，进而改善患者预后。

关键词: 急性呼吸窘迫综合征, 表型, 肺部超声, 临床应用

Acute respiratory distress syndrome (ARDS) represents a crucial disease within the domain of critical care medicine, featuring a relatively high incidence and mortality rate among the population.Subsequent to the outbreak of the Coronavirus Disease 2019 epidemic, extensive research on ARDS has been carried out. Despite the advancement in the understanding of this disease, numerous clinical studies on the treatment of ARDS have failed to achieve the anticipated success. This is due to the heterogeneity of ARDS in multiple aspects, this is, it has different phenotypes, which renders single, standardized treatments ineffective in improving the prognosis for all patients. Therefore, if the phenotypes of ARDS can be identified rapidly and accurately, and patients are subdivided into more homogeneous subgroups based on the different phenotypes followed by precise and individualized treatment, favorable feedback should be achievable. Lung ultrasound(LUS) has been widely applied in the diagnosis and treatment of ARDS patients, providing a potent tool for the identification of ARDS phenotypes. This paper aims to expound on the application progress of pulmonary ultrasound in the identification of ARDS phenotypes, assisting clinicians in formulating individualized treatment plans and enhancing patient prognosis.

Key words: Acute respiratory distress syndrome, Phenotype, Lung ultrasound, Clinical application

表1 ARDS表型

表型	分类依据	差异
病因表型	发病诱因：直接肺损伤：肺炎、肺挫伤、误吸等；间接肺损伤：输血、非肺脓毒症、非胸部创伤等	肺泡塌陷程度、细胞损伤部位等
严重程度表型	柏林定义中ARDS 患者病情严重程度：轻度：200 mmHg＜PaO₂/FiO₂≤300 mmHg；中度：100 mmHg＜PaO₂/FiO₂≤200 mmHg重度：PaO₂/FiO₂≤100 mmHg	缺氧及肺泡损伤程度
炎症表型	炎症反应严重程度	血浆炎症生物标志物浓度
影像学表型	肺部CT 影像学特征	病变累及部位的肺内分布

表1 ARDS表型

表型	分类依据	差异
病因表型	发病诱因：直接肺损伤：肺炎、肺挫伤、误吸等；间接肺损伤：输血、非肺脓毒症、非胸部创伤等	肺泡塌陷程度、细胞损伤部位等
严重程度表型	柏林定义中ARDS 患者病情严重程度：轻度：200 mmHg＜PaO₂/FiO₂≤300 mmHg；中度：100 mmHg＜PaO₂/FiO₂≤200 mmHg重度：PaO₂/FiO₂≤100 mmHg	缺氧及肺泡损伤程度
炎症表型	炎症反应严重程度	血浆炎症生物标志物浓度
影像学表型	肺部CT 影像学特征	病变累及部位的肺内分布

表2 ARDS全球新定义与2012柏林定义的差别

指标	柏林定义	全球新定义
发病时间	一周内新发或已知的呼吸道症状加重	未作明确改变，但纳入了无需插管的HFNO 患者
病情严重程度	轻度：200 mmHg＜PaO₂/FiO₂≤300 mmHg；中度：100 mmHg＜PaO₂/FiO₂≤200 mmHg；重度：PaO₂/FiO₂≤100 mmHg	轻度：200 mmHg＜PaO₂/FiO₂≤300 mmHg 或235＜SpO₂/FiO₂≤315（SpO₂≤97%）；中度：100 mmHg＜PaO₂/FiO₂≤200 mmHg 或148＜SpO₂/FiO₂≤235（SpO₂≤97%）；重度：PaO₂/FiO₂≤100 mmHg 或SpO₂/FiO₂≤148（SpO₂≤97%）
影像学	胸片和（或）胸部CT 提示双侧肺浸润	胸片、胸部CT 或超声提示双侧肺浸润

表2 ARDS全球新定义与2012柏林定义的差别

指标	柏林定义	全球新定义
发病时间	一周内新发或已知的呼吸道症状加重	未作明确改变，但纳入了无需插管的HFNO 患者
病情严重程度	轻度：200 mmHg＜PaO₂/FiO₂≤300 mmHg；中度：100 mmHg＜PaO₂/FiO₂≤200 mmHg；重度：PaO₂/FiO₂≤100 mmHg	轻度：200 mmHg＜PaO₂/FiO₂≤300 mmHg 或235＜SpO₂/FiO₂≤315（SpO₂≤97%）；中度：100 mmHg＜PaO₂/FiO₂≤200 mmHg 或148＜SpO₂/FiO₂≤235（SpO₂≤97%）；重度：PaO₂/FiO₂≤100 mmHg 或SpO₂/FiO₂≤148（SpO₂≤97%）
影像学	胸片和（或）胸部CT 提示双侧肺浸润	胸片、胸部CT 或超声提示双侧肺浸润

表3 LUS评分标准

分数	超声征象
0 分	有A 线或＜ 3 个孤立B 线
1 分	多条边界清楚（≥ 3 条）的B 线
2 分	有互相融合的多发B 线
3 分	出现肺实变和（或）胸腔积液

表3 LUS评分标准

分数	超声征象
0 分	有A 线或＜ 3 个孤立B 线
1 分	多条边界清楚（≥ 3 条）的B 线
2 分	有互相融合的多发B 线
3 分	出现肺实变和（或）胸腔积液

1	Matthay MA, Arabi Y, Arroliga AC, et al. A new global definition of acute respiratory distress syndrome [J]. Am J Respir Crit Care Med,2024, 209(1): 37-47.
2	Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care,and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries [J]. JAMA, 2016, 315(8): 788-800.
3	张磊, 陶洋, 姚丽娜, 等. 肺部超声评分在急性呼吸窘迫综合征患者早期病情评估中应用 [J]. 中国现代医生, 2019, 57(1): 28-32.
4	王吉, 张颖, 顾雪, 等. 间充质干细胞微泡对ARDS肺纤维化影响的实验研究[J/OL]. 中华临床医师杂志(电子版), 2024,18(1):72-78.
5	Bos L, Ware LB. Acute respiratory distress syndrome: causes,pathophysiology, and phenotypes [J]. Lancet, 2022, 400(10358): 1145-1156.
6	Reilly JP, Calfee CS, Christie JD. Acute respiratory distress syndrome phenotypes [J]. Semin Respir Crit Care Med, 2019, 40(1): 19-30.
7	王玉妹, 张琳琳, 周建新. 《ESICM急性呼吸窘迫综合征指南：定义、表型和呼吸支持策略》解读 [J].中国急救医学, 2023,43(11): 855-861.
8	Chang X, Li S, Fu Y, et al. Safety and efficacy of corticosteroids in ARDS patients: a systematic review and meta-analysis of RCT data [J].Respir Res, 2022, 23(1): 301.
9	Matthay MA, Arabi YM, Siegel ER, et al. Phenotypes and personalized medicine in the acute respiratory distress syndrome [J]. Intensive Care Med, 2020, 46(12): 2136-2152.
10	Toya S, Struyf S, Huerta L, et al. A narrative review of chemokine receptors CXCR1 and CXCR2 and their role in acute respiratory distress syndrome [J]. Eur Respir Rev, 2024, 33(173): 230172.
11	Xu H, Sheng S, Luo W, et al. Acute respiratory distress syndrome heterogeneity and the septic ARDS subgroup [J]. Front Immunol,2023, 14: 1277161.
12	何梦菲, 赵玉杰, 任佳佳, 等. 急性呼吸窘迫综合症表型研究的现状与未来 [J]. 实用医院临床杂志, 2024, 21(4): 44-47.
13	Zhang S, Huang W, Wu X, et al. IBR1, a novel endogenous IFIH1-binding dsRNA, governs IFIH1 activation and M1 macrophage polarisation in ARDS [J]. Clin Transl Med, 2024, 14(9): e70027.
14	Jones TK, Feng R, Kerchberger VE, et al. Plasma sRAGE acts as a genetically regulated causal intermediate in sepsis-associated acute respiratory distress syndrome [J]. Am J Respir Crit Care Med, 2020,201(1): 47-56.
15	Sweet DG, Carnielli VP, Greisen G, et al. European consensus guidelines on the management of respiratory distress syndrome: 2022 update [J]. Neonatology, 2023, 120(1): 3-23.
16	Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies [J]. Intensive Care Med, 2023, 49(7):727-759.
17	Famous KR, Delucchi K, Ware LB, et al. Acute respiratory distress syndrome subphenotypes respond differently to randomized fluid management strategy [J]. Am J Respir Crit Care Med, 2017, 195(3):331-338.
18	Baedorf-Kassis E, Murn M, Dzierba AL, et al. Respiratory drive heterogeneity associated with systemic inflammation and vascular permeability in acute respiratory distress syndrome [J]. Crit Care,2024, 28(1): 136.
19	Constantin JM, Jabaudon M, Lefrant JY, et al. Personalised mechanical ventilation tailored to lung morphology versus low positive endexpiratory pressure for patients with acute respiratory distress syndrome in France (the LIVE study): a multicentre, single-blind,randomised controlled trial [J]. Lancet Respir Med, 2019, 7(10): 870-880.
20	Lichtenstein D, Mézière G, Biderman P, et al. The comet-tail artifact.An ultrasound sign of alveolar-interstitial syndrome [J]. Am J Respir Crit Care Med, 1997, 156(5): 1640-1646.
21	Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding [J]. Chest, 1995,108(5): 1345-1348.
22	Riviello ED, Kiviri W, Twagirumugabe T, et al. Hospital incidence and outcomes of the acute respiratory distress syndrome using the Kigali modification of the Berlin definition [J]. Am J Respir Crit Care Med,2016, 193(1): 52-59.
23	See KC, Ong V, Tan YL, et al. Chest radiography versus lung ultrasound for identification of acute respiratory distress syndrome: a retrospective observational study [J]. Crit Care, 2018, 22(1): 203.
24	Lichtenstein D. Novel approaches to ultrasonography of the lung and pleural space: where are we now? [J]. Breathe (Sheff), 2017, 13(2):100-111.
25	Bitker L, Talmor D, Richard JC. Imaging the acute respiratory distress syndrome: past, present and future [J]. Intensive Care Med, 2022,48(8): 995-1008.
26	Chiumello D, Arnal JM, Umbrello M, et al. Hysteresis and lung recruitment in acute respiratory distress syndrome patients: a CT scan study [J]. Crit Care Med, 2020, 48(10): 1494-1502.
27	Boumans M, Aerts W, Pisani L, et al. Diagnostic accuracy of lung ultrasound in diagnosis of ARDS and identification of focal or nonfocal ARDS subphenotypes: a systematic review and meta-analysis [J].Crit Care, 2024, 28(1): 224.
28	Pierrakos C, Smit MR, Pisani L, et al. Lung ultrasound assessment of focal and non-focal lung morphology in patients with acute respiratory distress syndrome [J]. Front Physiol, 2021, 12: 730857.
29	Sanjan A, Krishnan SV, Abraham SV, et al. Utility of Point-of-Care Lung Ultrasound for Initial Assessment of Acute Respiratory Distress Syndrome Patients in the Emergency Department [J]. J Emerg Trauma Shock, 2019, 12(4): 248-253.
30	Huang D, Ma H, Xiao Z, et al. Diagnostic value of cardiopulmonary ultrasound in elderly patients with acute respiratory distress syndrome[J]. BMC Pulm Med, 2018, 18(1): 136.
31	吕茂华, 曹励琪, 李香祥, 等. 肺部超声评分评估急性呼吸窘迫综合征严重程度的Meta分析 [J]. 中国超声医学杂志, 2022, 38(10):1191-1194.
32	Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with the acute respiratory distress syndrome [J]. N Engl J Med, 2006,354(17): 1775-1786.
33	Banavasi H, Nguyen P, Osman H, et al. Management of ARDS - what works and what does not [J]. Am J Med Sci, 2021, 362(1): 13-23.
34	谢芳清, 杨培, 刘娟, 等. 基于超声指标对脓毒症合并急性呼吸窘迫综合征机械通气患者撤机结局的预测价值 [J]. 哈尔滨医药,2024, 44(5): 67-69.
35	熊厚仁, 朱明华, 方明, 等. 肺部超声引导肺康复训练在ICU机械通气患者中的应用 [J]. 中国呼吸与危重监护杂志, 2024, 23(9):634-639.
36	Sinnige JS, Smit MR, Ghose A, et al. Personalized mechanical ventilation guided by ultrasound in patients with acute respiratory distress syndrome (PEGASUS): study protocol for an international randomized clinical trial [J]. Trials, 2024, 25(1): 308.
37	Tusman G, Acosta CM, Nicola M, et al. Real-time images of tidal recruitment using lung ultrasound [J]. Crit Ultrasound J, 2015, 7(1):19.
38	林文婷. 肺部超声评分法与氧合法指导滴定呼气末正压治疗急性呼吸窘迫综合征患者的效果对比 [J]. 大医生, 2024, 9(21): 36-40.
39	Corsini I, Rodriguez-Fanjul J, Raimondi F, et al. Lung UltrasouNd Guided surfactant therapy in preterm infants: an international multicenter randomized control trial (LUNG study) [J]. Trials, 2023,24(1): 706.
40	Haddam M, Zieleskiewicz L, Perbet S, et al. Lung ultrasonography for assessment of oxygenation response to prone position ventilation in ARDS [J]. Intensive Care Med, 2016, 42(10): 1546-1556.
41	Puskarz-Gąsowska J, Hożejowski R, Błaż W, et al. Prognostic relevance of the lung ultrasound score: a multioutcome study in infants with respiratory distress syndrome [J]. Am J Perinatol, 2024, 41(S 01):e2862-e2869.

[1]	叶晨雨, 王臻, 牟珂, 袁鸣, 程雨欣, 杨勇. 肺部超声在儿童支原体肺炎中的应用价值初步研究[J/OL]. 中华医学超声杂志（电子版）, 2024, 21(12): 1118-1123.
[2]	江雅婷, 刘林峰, 沈辰曦, 陈奔, 刘婷, 龚裕强. 组织相关巨噬素3 保护肺血管内皮糖萼治疗急性呼吸窘迫综合征的机制研究[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(05): 353-362.
[3]	王淑君, 张楚晗, 唐一阳, 赵雨桐, 李佳伦, 付佳乐. 自粘接树脂水门汀的临床应用及展望[J/OL]. 中华口腔医学研究杂志(电子版), 2024, 18(04): 276-286.
[4]	胡思平, 熊性宇, 徐航, 杨璐. 衰老相关分泌表型因子在前列腺癌发生发展中的作用机制[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(05): 425-434.
[5]	杨柯佳, 孙琦, 瞿伟丰, 翁鸢, 崔启辰, 李金友. Flex-3D 胸腔镜肺叶切除术在非小细胞肺癌中的临床应用[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(01): 62-67.
[6]	张铭杰, 李梦娜, 程明瑶, 王宇亮, 粘永健, 赵瑞臣, 杨宇, 刘慕源, 廖元, 唐超. 高原肺水肿肺超声筛查深度学习模型构建与优化[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(01): 68-73.
[7]	袁丽, 钱际银, 张云, 张晶, 高霏. 急性呼吸窘迫综合征患者体外膜氧合救治的临床分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(06): 1013-1016.
[8]	梁波, 张春雨, 郑永财, 徐冰, 蒋敏娜, 赵学刚, 刘晓敏. 结缔组织疾病相关间质性肺病肺部超声与疾病严重程度的相关性[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(06): 875-881.
[9]	陈丽, 郭俊氚, 马红梅, 刘遵季. 死腔分数对急性呼吸窘迫综合征预后预测意义[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(06): 942-947.
[10]	李智, 冯芸. NF-κB 与MAPK 信号通路及其潜在治疗靶点在急性呼吸窘迫综合征中的研究进展[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(05): 840-843.
[11]	沈琪乐, 赵勤华, 宫素岗, 刘锦铭, 王岚, 邱宏玲. COPD 稳定期患者血清CC16 蛋白表达与肺功能、肺气肿表型的关系分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(05): 690-695.
[12]	燕红玲, 王岩岩, 陈树斌. PCT、NLR联合LUBS预测ICU CRKP致呼吸机相关肺炎撤机及预后分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(04): 617-620.
[13]	周楚仪, 王乐今. 先天性眼球震颤相关致病基因及分子遗传学的研究进展[J/OL]. 中华眼科医学杂志(电子版), 2024, 14(06): 363-367.
[14]	王晓霞, 乌丹, 张江英, 乌雅罕, 郝颖楠, 斯日古楞. 《2023 年美国胸科学会关于成人急性呼吸窘迫综合征患者管理的临床实践指南更新》解读[J/OL]. 中华重症医学电子杂志, 2024, 10(04): 338-343.
[15]	唐瑶瑶, 郭莹, 秦红霄, 于晶晶, 张义璇, 方明星, 孟稳利. HVHF联合CHVHF对脓毒症相关ARDS患者炎症反应和呼吸功能的影响[J/OL]. 中华临床医师杂志(电子版), 2024, 18(12): 1097-1103.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Progress in application of pulmonary ultrasound in phenotype identification of acute respiratory distress syndrome

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Progress in application of pulmonary ultrasound in phenotype identification of acute respiratory distress syndrome