316.4 📋 章末速記 Summary

316.4.1 🔑 一句話總結

Mechanical ventilation = invasive (intubation) + non-invasive (NIV)；modes：VCV、PCV、PSV、SIMV、APRV、CPAP/BiPAP；lung-protective foundation (ARDSnet 2000)：Vt 6 mL/kg PBW + plateau < 30 + PEEP titrated + driving pressure < 15；sedation strategy：target light sedation + ABCDEF bundle + SAT + SBT daily；weaning：daily SBT；HFNC + NIV preferred over reintubation for post-extubation respiratory failure；common complications：VAP (Pseudomonas, MRSA, Acinetobacter)、VILI、auto-PEEP、dyssynchrony、ICUAW、tracheal stenosis；NIV indications：COPD exacerbation pH < 7.35 (Class I)、cardiogenic edema、immunocompromised hypoxemic RF；HFNC (FLORALI 2015) for hypoxemic RF；tracheostomy for prolonged MV > 14 days；chronic ventilation includes home ventilation + diaphragm pacing；MENDS-2 (2024) confirmed dexmedetomidine = propofol for ARDS sedation but less delirium。

316.4.2 💊 治療精要

• lung-protective ventilation：Vt 6 mL/kg PBW、plateau < 30、PEEP per FiO2 table、driving pressure < 15、permissive hypercapnia (pH > 7.20 OK)
• sedation：light sedation goal；propofol or dexmedetomidine (less delirium - MENDS-2)；fentanyl analgesia；avoid prolonged midazolam
• weaning：daily SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial) paired
• NIV indications：COPD exacerbation pH < 7.35（Class I, reduces intubation + mortality）、acute cardiogenic pulmonary edema、immunocompromised hypoxemic RF、post-extubation high-risk
• HFNC：FLORALI (2015) — comparable to NIV for hypoxemic RF + improved comfort
• VAP：empiric anti-pseudomonal + MRSA → narrow per culture × 7 days
• tracheostomy：prolonged MV > 14 days；TracMan 2013 — no mortality benefit early
• chronic / home ventilation：multidisciplinary care；diaphragm pacing for bilateral paralysis + intact phrenic

316.4.3 🎯 盧醫師的考前提醒

1. lung-protective ventilation 三大要素：Vt 6 mL/kg PBW、plateau < 30、driving pressure < 15 (Amato 2015 — best survival predictor)
2. PEEP titration：依 FiO2 table (ARDSnet)；ALVEOLI + LOVS + ExPress 評估高低 PEEP；individualized
3. ABCDEF bundle：Awakening、Breathing (SBT)、Choice of sedation、Delirium monitoring、Early mobility、Family — 改善 ICU outcomes
4. SAT + SBT paired daily：Spontaneous Awakening Trial (sedation off) + Spontaneous Breathing Trial (PSV trial) — ↓ ventilator days
5. MENDS-2 (2024)：dexmedetomidine = propofol for ARDS sedation outcomes，less delirium — practice consideration
6. NIV in COPD exacerbation pH < 7.35：Class I — ↓ intubation + ↓ mortality；avoid if altered mental status, hemodynamic instability, severe secretions
7. FLORALI (2015) HFNC：vs NIV + face mask O2 — comparable; ↓ reintubation in hypoxemic respiratory failure
8. VAP 在 MV > 48 hr：Pseudomonas + MRSA + Acinetobacter；empiric broad → narrow per culture；7-day course typical (non-MDR)
9. tracheostomy timing：TracMan (2013) — early (within 4 days) vs late (≥ 10 days) — no mortality difference；individualize based on patient + projected length
10. post-extubation respiratory failure：HFNC + NIV preferred over immediate reintubation in select; delayed reintubation worse outcomes — close monitoring critical