315.4 📋 章末速記 Summary

315.4.1 🔑 一句話總結

Respiratory failure 分 type I (hypoxemic, PaO2 < 60) + type II (hypercapnic, PaCO2 > 45)；ARDS = acute diffuse lung injury 造成的 type I；Berlin Definition 2012：onset within 1 wk + bilateral opacities + not solely cardiac + PaO2/FiO2 < 300 with PEEP ≥ 5；severity = mild (200-300) / moderate (100-200) / severe (≤ 100)；core management：(1) lung-protective ventilation (ARMA 2000) — Vt 6 mL/kg PBW + plateau < 30 + driving pressure < 15；(2) PROSEVA 2013 prone for severe ARDS ↓ mortality 16%；(3) conservative fluid (FACTT)；(4) NMB for refractory dyssynchrony (ACURASYS positive, ROSE neutral)；(5) ECMO for refractory (CESAR, EOLIA)；(6) steroids for non-COVID ARDS (DEXA-ARDS) + COVID-ARDS (RECOVERY dexamethasone)；(7) COVID-ARDS adds tocilizumab/baricitinib (REMAP-CAP)；ARDS subphenotypes (Calfee)：hyperinflammatory vs hypoinflammatory；type II RF：NIV for COPD exacerbation (pH < 7.35) + OHS。

315.4.2 💊 治療精要

• lung-protective ventilation (ARMA / ARDSnet)：tidal volume 6 mL/kg PBW、plateau pressure < 30、PEEP titrated by FiO2 table、driving pressure < 15 cm H2O (Amato 2015)
• prone positioning (PROSEVA)：severe ARDS (PaO2/FiO2 < 150)，16+ hours/day，↓ mortality 16%
• fluid management (FACTT)：conservative if hemodynamically stable，diurese to euvolemia
• NMB (cisatracurium) for refractory dyssynchrony：ACURASYS positive；ROSE 認為一般 ARDS 不必 routinely 用
• steroids：non-COVID ARDS (methylprednisolone 1 mg/kg or dexamethasone — DEXA-ARDS)；COVID-ARDS dexamethasone 6 mg × 10 d (RECOVERY)；COVID + tocilizumab/baricitinib (REMAP-CAP)
• ECMO (VV-ECMO)：refractory (PaO2/FiO2 < 80, pH < 7.20, plateau > 30)；CESAR + EOLIA support；refer early to ECMO center
• HFNC + awake prone for non-intubated hypoxemic RF (COVID era)

315.4.3 🎯 盧醫師的考前提醒

1. ARDS Berlin Definition 2012 四要素：onset within 1 wk + bilateral opacities + not solely cardiac + PaO2/FiO2 < 300 with PEEP ≥ 5；2023 Global update 包含 HFNC + ultrasound
2. severity 三級：mild 200-300、moderate 100-200、severe ≤ 100；嚴重度決定 prone + ECMO 適應症
3. ARMA / ARDSnet (2000)：tidal volume 6 mL/kg PBW vs 12 mL/kg → ↓ mortality 9% — foundation of modern ARDS care
4. plateau pressure < 30 cm H2O + driving pressure (Plateau - PEEP) < 15 cm H2O (Amato 2015) — strongest survival predictor
5. PROSEVA 2013：prone positioning ≥ 16 hr/d in severe ARDS (PaO2/FiO2 < 150) → ↓ mortality 16% — standard of care
6. NMB：ACURASYS (2010) cisatracurium ↑ survival；ROSE (2019) with light sedation neutral；現用 for refractory dyssynchrony
7. FACTT (2006)：conservative fluid management ↑ ventilator-free days；no mortality difference — practice once hemodynamically stable
8. ECMO：CESAR (2009) + EOLIA (2018) support；refer early to ECMO center for refractory (PaO2/FiO2 < 80, pH < 7.20)
9. COVID-ARDS lessons：dexamethasone 6 mg × 10 d (RECOVERY) + tocilizumab / baricitinib (REMAP-CAP) + awake prone + early HFNC + standard ARDS care
10. TRALI is iatrogenic ARDS（within 6 hr of transfusion）— donor antibodies；female donor predominantly restricted; supportive care