ブックタイトル第43回日本集中治療医学会学術集会プログラム・抄録集

概要

第43回日本集中治療医学会学術集会プログラム・抄録集

－363－LS11Department of Intensive Care Medicine, University of Barcelona, SpainJosep MasipNoninvasive ventilation（NIV）refers to the application of positive intrathoracic pressure without endotracheal intubation（EI）. The positive intrathoracic pressure improves oxygenation through the recruitment of collapsed alveolar units and theincrease of functional residual capacity among others. Main hemodynamic effects include a decrease in intrapulmonaryshunt and a reduction of venous return（preload）and systolic wall stress（afterload）. In patients with normal cardiacfunction, this may decrease blood pressure and cardiac output. Conversely, in some patients with elevated preload as those withAHF, it may decrease pulmonary congestion and increase cardiac output. There are two main modalities of NIV. One is“continuous positive airway pressure”（CPAP）, which is a simple technique that can be applied without a ventilator beingappropriate in low-equipped areas. The other is “pressure support ventilation with positive end expiratory pressure”（NIPSV）that needs a ventilator and some expertise in tuning it.Since 1985, numerous studies have demonstrated the superiority of NIV over conventional oxygen therapy（COT）in improvinggas-exchange and symptoms in patients with acute cardiogenic pulmonary edema（ACPE）. Furthermore, several meta-analyseswere consistent in showing that CPAP and NIPSV reduce nearly to half the risk of EI when compared with COT. In addition,both techniques tended to reduce mortality, which was statistically significant for CPAP. However, in 2008, the 3 CPO-Trial waspublished. This was, to date, the largest randomized NIV trial, including more than 1000 acidotic ACPE patients attended in ERin the UK. The study showed a faster improvement of respiratory failure with NIV compared to COT, but failed to demonstratea reduction in mortality. Several reasons might be argued to explain this discrepancy between this trial and the meta-analyses,such as differences in the population, a high crossover rate or a very low EI rate（<3%）in the trial, among others. Although asubsequent meta-analysis including this trial still showed a significant reduction of mortality with CPAP, predominantly inpatients with acute coronary syndromes, it is difficult to formulate a clear conclusion on this issue.Several randomized studies have shown benefit with the use of CPAP in the pre-hospital setting. There is no evidence for thesuperiority of one technique over the other. However, NIPSV provides a ventilatory support that would seem more appropriatefor patients with hypercapnia or fatigue. In patients treated with NIPSV, high FiO2 up to 100% should be used to rapidlyachieve SpO2- guided normal blood oxygenation, avoiding hyperoxia. The use of mild sedation, particularly opiates, isrecommended in anxious or poorly-adapted patients.ランチョンセミナー 11 2月12日（金）　12：20～13：20　第12会場Noninvasive Ventilation in Acute Cardiogenic Pulmonary EdemaLS12順天堂大学大学院医学研究科　救急・災害医学射場 敏明　まず臨床面における抗凝固療法に関する最近の動向としては、システマティックレビューやメタアナリシス、DiagnosisProcedure Combination（DPC）データを用いたプロペンシティーアナリシスなどの、新しい解析方法をもちいた有効性の再評価がある。このような動きは、とりもなおさず新しいrandomized controlled trial（RCT）がこの領域で行なわれていないことを反映したものであるが、昨今はRCT の実施がきわめて厳しい状況であり、このような環境下では既報のデータを統合したり、ビックデータを用いて後ろ向き検討を行なったりするなどして、治療効果を評価せざるを得ないであろう。他方、基礎研究に目を向けると、pathogen-associated molecular pattern（PAMPs）, damage-associated molecular patterns（DAMPs）の病態形成への関与、白血球や血小板、あるいは血管内皮細胞をはじめとする細胞系の形態、機能変化が新しいテーマとして挙げられる。本セミナーにおいては、これらの概略を俯瞰的に解説する。ランチョンセミナー 12 2月12日（金）　12：20～13：20　第13会場DICの研究における最近の動向