摘要目的：探讨在急性呼吸窘迫综合征（ARDS）治疗时是应该保留自主呼吸还是使用肌松剂消除自主呼吸？方法采用前瞻性单盲随机对照研究设计方法，选择云南省个旧市人民医院重症医学科2013年7月1日至2015年12月31日收治的所有ARDS患者，均符合ARDS柏林定义诊断标准，排除年龄＜15岁、孕妇及终末期疾病患者。按随机数字表法分为保留自主呼吸组和肌松组。保留自主呼吸组仅行联合镇静镇痛治疗，维持Ramsay镇静评分2～4分，若出现人-机协调性差或氧合难以维持则转入肌松组。肌松组患者在联合镇静镇痛治疗基础上给予维库溴铵维持肌松，若使用大剂量血管活性药物仍难以维持血压，则转入保留自主呼吸组。记录患者呼吸机支持治疗后5d内机械通气指标、血气分析指标及预后指标。结果共入选50例ARDS患者，其中2例未行气管插管、1例重度颅脑损伤、1例后续确诊为急性心肌梗死、5例因经济原因自动出院被排除，最终纳入保留自主呼吸组17例，肌松组24例（其中6例由保留自主呼吸组转入）。与保留自主呼吸组比较，肌松组患者年龄更小（岁：35±16比50±16，P＜0.01），需要更高的呼气末正压〔PEEP（cmH2O，1cmH2O＝0.098kPa）：8±3比6±2，P＜0.05〕，肺复张比例更高（58.3%比23.5%，P＜0.05）；而两组患者性别、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、ARDS的病因和分级以及其他呼吸机参数比较差异均无统计学意义。保留自主呼吸组转入肌松组的6例患者均为重症ARDS，均进行了肺复张，且PEEP水平均较高；而肌松组则无一例转入保留自主呼吸组。保留自主呼吸组和肌松组呼吸机相关性肺炎（VAP）发生率（0比4.2%）、重症加强治疗病房（ICU）未用镇静药时间（d：4.4±4.0比3.7±2.9）、ICU未用升压药时间（d：7.5±5.9比8.1±5.4）、28d内非机械通气时间（d：17.1±8.2比17.9±7.4）、28d内非ICU住院时间（d：15.9±7.6比17.2±6.3）、28d和90d病死率（11.8%比4.2%，17.6%比4.2%）比较差异均无统计学意义（均P＞0.05）。结论 ARDS机械通气患者使用肌松剂是安全的，不会增加病死率、机械通气时间及ICU住院时间；尤其对于重症ARDS患者，使用肌松剂有利于改善氧合。

abstractsObjective To investigate whether patients should retain spontaneous breath or eliminate breathing with neuromuscular blocking agent during ventilation treatment for patients with acute respiratory distress syndrome (ARDS). Methods A prospective single-blind randomized controlled trial was conducted. All patients with ARDS admitted to Department of Critical Care Medicine of Gejiu People's Hospital from July 1st, 2013 to December 31st, 2015 were enrolled. All cases met the criterion of Berlin definition, and patients with age lower than 15 years, in pregnancy or with end-stage disease were excluded. The subjects were randomly divided into retaining spontaneous breathing group and muscle paralysis group. The patients in retaining spontaneous breathing group were only sedated and analgesia to persist Ramsay sedation score from 2 to 4. Some patients would be transferred to muscle paralysis group who could not cooperate with ventilator or maintain the oxygenation. Spontaneous breathing of patients in muscle paralysis group was eliminated with vecuronium on the basis of sedation and analgesia. If high dose of vasopressor is still difficult to maintain blood pressure in muscle paralysis group, the patients would be transferred to the retaining spontaneous breathing group. The parameters of mechanical ventilation, indexes of arterial blood gas samples analysis and prognostic indexes were collected prospectively from the first day to the fifth day after mechanical ventilation. Results Totally 50 ARDS patients were enrolled in this study, 9 patients were excluded (2 patients not intubated, 1 patient with severe traumatic brain injury, 1 patient with confirmed diagnosis of acute myocardial infarction, 5 patients discharged by themselves owing to the short of money). Finally, there were 17 patients in the retaining spontaneous breathing group and 24 in the muscle paralysis group (6 patients were transferred from the retaining spontaneous breathing group). Patients in muscle paralysis group were significantly younger than those in the retaining spontaneous breathing group (age: 35±16 vs. 50±16, P < 0.01), need higher positive end expiratory pressure [PEEP (cmH2O, 1 cmH2O = 0.098 kPa): 8±3 vs. 6±2, P < 0.05] and have a higher percent age of pulmonary rehabilitation (58.3% vs. 23.5%, P < 0.05). There was no significant difference in gender, acute physiology and chronic healthy evaluation Ⅱ (APACHE Ⅱ) score, cause of disease and classifications of ARDS, parameters of mechanical ventilation between two groups. Six patients transferred from the retaining spontaneous breathing group were all severe ARDS, who were all treated with a higher PEEP pulmonary rehabilitation therapy. None of patient in the muscle paralysis group was transferred to the retaining spontaneous breathing group. There were no significant differences in the incidence rate of ventilator-associated pneumonia (VAP, 0 vs. 4.2%), sedative-free days in intensive care unit (ICU, days: 4.4±4.0 vs. 3.7±2.9), vasopressor-free days in ICU (days: 7.5±5.9 vs. 8.1±5.4), ventilator-free days within 28 days (days: 17.1±8.2 vs. 17.9±7.4), days out of ICU within 28 days (days: 15.9±7.6 vs. 17.2±6.3), 28-day and 90-day mortality (11.8% vs. 4.2%, 17.6% vs. 4.2%) between the retaining spontaneous breathing group and muscle paralysis group (all P > 0.05). Conclusions A neuromuscular blocking agent administrated to the ARDS patients on mechanical ventilation was safe, which will not increase mortality, ventilator days and ICU days. Especially, in patients with severe ARDS, administration of a neuromuscular blocking agent improved the oxygenation.