ATS/A 成人重症患者脱机指南之康复锻炼、气囊漏气
这是危通社发布的2017年第一稿。
最新一期的蓝皮书（AJRCCM）刊登了两篇指南，分别是：
Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults（ATS/A临床实践指南：成人重症患者的脱机）
An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests（ATS/A临床实践指南：成人重症患者的脱机，康复、脱机规程与气囊漏气试验）
两个指南都由ATS/A的委员会制定（ATS/CHEST Ad Hoc Committee on Liberation from Mechanical Ventilation in Adults）。其中，第一个脱机指南2016年10月20日在线发表。危通社已经进行过报道。
（补充：指南一共提出成人重症患者脱机的6个问题，都按照PICO（Population,Intervention, Comparator 和 Outcomes）的格式提出，然后就问题进行完整的文献复习，依照GRADE原则提出证据。随后工作组按照证据-决策的工作框架制定每个问题的推荐意见，其中必然包括对问题的重要性、证据的可信性、对不同预后的权衡、治疗措施的来源、成本、接受度及可行性......等多因素的考量）。
以下就对第二个指南的内容进行扼要介绍。
An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests（ATS/A临床实践指南：成人重症患者的脱机，康复、脱机规程与气囊漏气试验
根据摘要，指南就成人重症患者脱机中的康复锻炼、脱机以及漏气试验提出4个问题，然后就问题进行完整的文献复习，依照GRADE原则提出证据。随后工作组仍然是依据与上述第一个指南类似的过程制定出推荐意见。
问题1：机械通气＞24h的成人住院患者需否实施以早期活动为目标的程序化康复，亦或以早期活动为目标，但无需规程？
ATS/Chest推荐意见：推荐实施以早期活动为目标的程序化康复（有条件推荐，证据等级：低确定性）
评价：没有充分证据提示何种康复规程更优
Question 1: Should Acutely Hospitalized Adults Who Have Been Mechanically Ventilated For >24 Hours Be Subjected to Protocolized Rehabilitation Directed toward Early Mobilization Or no Protocolized Attempts at Early Mobilization?
ATS/CHEST recommendation：For acutely hospitalized adults who have been mechanically ventilated for >24 hours, we suggest protocolized rehabilitation directed toward early mobilization (conditional recommendation, low certainty in the evidence).
Remarks：There is insufficient evidence to recommend any rehabilitation protocol over another.
问题2：机械通气＞24h的成人住院患者应该按照脱机规程治疗还是无需规程？
ATS/Chest推荐意见： 此类患者推荐按照脱机规程治疗（有条件推荐，证据等级：低确定性）
评价：脱机规程即可个体也可计算机管理，但没有充分证据提示何种脱机规程更优
Question 2: Should Acutely Hospitalized Adults Who Have Been Mechanically Ventilated For >24 Hours Be Managed with a Ventilator Liberation Protocol Or no Protocol?
ATS/CHEST recommendation：We suggest managing acutely hospitalized adults who have been mechanically ventilated for >24 hours with a ventilator liberation protocol (conditional recommendation, low certainty in the evidence).
Remarks： The ventilator liberation protocol may be either personnel-driven or computer-driven. There is insufficient evidence to recommend any ventilator liberation protocol over another.
问题3a：机械通气拔管前是否需要气囊漏气试验？（危通社注：漏气试验是为了考察是否存在上呼吸道梗阻，如试验阴性，提示梗阻，拔管后容易出现啸鸣，往往需提前使用激素，如下问）。
问题3b:拔管前若气囊漏气试验阴性是否需要注射皮质激素？
对符合拔管标准并很可能存在拔管后啸鸣的高危患者推荐实施气囊漏气试验（有条件推荐，证据等级：确定性极低）。
对已准备好拔管，但未能通过气囊漏气试验者，建议至少在拔管前4小时静推激素（有条件推荐，证据等级：中级确定）。
评价：拔管后啸鸣的危险因素包括：拔管损伤、插管时间大于6天，气管插管口径过大，女性、非计划性拔管的再次插管。注射激素后不需要重复进行气囊漏气试验。
Question 3a: Should a Cuff Leak Test Be Performed Prior to Extubation of Mechanically Ventilated Adults?
Question 3b: Should Systemic Steroids Be Administered to Adults Who Fail a Cuff Leak Test Prior to Extubation?
ATS/CHEST recommendations
We suggest performing a cuff leak test in mechanically ventilated adults who meet extubation criteria and are deemed high risk for post-extubation stridor (conditional recommendation, very low certainty in the evidence).
For adults who have failed a cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation, (conditional recommendation, moderate certainty in the evidence).
Remarks: Risk factors for post-extubation stridor include traumatic intubation, intubation > 6 days, large endotracheal tube, female sex, and reintubation after unplanned extubation. A repeat cuff leak test is not required following the administration of systemic steroids.