溺水

约 40％的接近淹溺患者会出现 ARDS，ARDS 是指 PaO2/FiO2 低于 200 mmHg，并且非心源性肺水肿导致两肺浸润。机械通气的肺保护策略包括呼气末正压通气和低潮气量，可充实肺不张，减轻 V/Q 失衡和分流的程度。[32]The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308.http://www.nejm.org/doi/full/10.1056/NEJM200005043421801#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/10793162?tool=bestpractice.com[33]Amato M, Barbas C, Medeiros D, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347-354.http://www.ncbi.nlm.nih.gov/pubmed/9449727?tool=bestpractice.com已证明此方法可降低死亡率，减少呼吸机使用的天数。[32]The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308.http://www.nejm.org/doi/full/10.1056/NEJM200005043421801#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/10793162?tool=bestpractice.com[33]Amato M, Barbas C, Medeiros D, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347-354.http://www.ncbi.nlm.nih.gov/pubmed/9449727?tool=bestpractice.com证据 BARDS（急性呼吸窘迫综合征）的小潮气量通气：有中等质量的证据表明，与传统通气相比，ARDS时的小潮气量通气能提高存活率，减少呼吸机的使用天数。[32]The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308.http://www.nejm.org/doi/full/10.1056/NEJM200005043421801#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/10793162?tool=bestpractice.com[33]Amato M, Barbas C, Medeiros D, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347-354.http://www.ncbi.nlm.nih.gov/pubmed/9449727?tool=bestpractice.com受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。

急性呼吸窘迫综合征

颈椎损伤的发生率比较小 (0.5%)。常规固定颈椎不仅仅针对有接近淹溺史的患者；相反，它还适用于高冲击性溺水的患者（比如飞机坠毁、机动车辆碰撞或从高处坠落）。[39]Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658-662.http://www.ncbi.nlm.nih.gov/pubmed/11586155?tool=bestpractice.com

急性颈椎创伤

约 15％需要住院治疗的接近淹溺者会发生肺炎。[37]Van Berkel M, Bierens JJ, Lie RL et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intensive Care Med. 1996;22:101-107.http://www.ncbi.nlm.nih.gov/pubmed/8857116?tool=bestpractice.com机械通气、胃内容物误吸、被污染的浸泡介质和低体温是肺炎发展的常见危险因素。患者可能出现：发热；新的、持续性或加重的肺部浸润；脓痰或脓毒症。[33]Amato M, Barbas C, Medeiros D, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347-354.http://www.ncbi.nlm.nih.gov/pubmed/9449727?tool=bestpractice.com

肺炎可能在溺水数天至数月后出现。经验疗法应包括一种广谱青霉素/ β-内酰胺酶抑制剂。如患者中度不适，可添加使用氨基糖苷类药物。不必进行抗真菌治疗，除非患者对抗生素治疗无效或出现脑脓肿/脑膜炎。支气管肺泡灌洗和培养对指导治疗有所帮助。[38]Ender PT, Dolan MJ. Pneumonia associated with near-drowning. Clin Infect Dis. 1997;25:896-907.http://www.ncbi.nlm.nih.gov/pubmed/9356805?tool=bestpractice.com

肺炎概述