ARDS患者PEEP滴定调节课件

Department of the Intensive Care Unit,the No.4 Hospital Affiliated to Kunming Medical University Xiu Guang-hui Advanced Research Progress of Positive End-Expiratory Pressure Titration after the Alveolar Recruitment Manoeuvre in Patients with Acute Respiratory Distress SyndromeWhat is Acute Respiratory Distress Syndrome(ARDS)?What is Acute Respiratory Distress Syndrome(ARDS)?InjuryInjuryDisruption of AlveolarDisruption of AlveolarCapillary MembraneCapillary MembraneNon-Cardiogenic Pulmonary EdemaNon-Cardiogenic Pulmonary EdemaProtein-rich Plasma FluidProtein-rich Plasma FluidHypoxemiaHypoxemiaDecreased ComplianceDecreased ComplianceMortalityMortalityClinical Risk Factors:Clinical Risk Factors:Direct Lung InjuryDirect Lung InjuryIndirect Lung InjuryIndirect Lung InjuryCommon CausesCommon CausesPneumonia(Bacteria,Viruses,Fungi)Pneumonia(Bacteria,Viruses,Fungi)Aspiration of Gastric ContentsAspiration of Gastric ContentsUncommon CausesUncommon CausesPulmonary ContusionPulmonary ContusionFat EmbolismFat EmbolismAmniotic Fluid EmbolismAmniotic Fluid EmbolismNear-drowningNear-drowningInhalational Injury(Smoke,NHInhalational Injury(Smoke,NH3 3)Reperfusion Injury after TransplantReperfusion Injury after TransplantCommon CausesCommon CausesSepsisSepsisSevere Trauma with ShockSevere Trauma with ShockAcute PancreatitisAcute PancreatitisUncommon CausesUncommon CausesMultiple TransfusionsMultiple TransfusionsDrug OverdoseDrug OverdoseDiffuse Intravascular CoagulationDiffuse Intravascular CoagulationIntact AlveolusIntact AlveolusAEC-IIAEC-IIInfiltration of Inflammatory CellsInfiltration of Inflammatory CellsDenudation of EpitheliumDenudation of EpitheliumDisruption of Alveolar Capillary MembraneDisruption of Alveolar Capillary MembraneLeak of Protein-rich Plasma FluidLeak of Protein-rich Plasma FluidInactivation of SurfactantInactivation of SurfactantAMAMFormation of Provisional MatrixFormation of Provisional MatrixEntrapment of SurfactantEntrapment of SurfactantAccumulation of FibroblastsAccumulation of FibroblastsLoss of Functional AirspaceLoss of Functional AirspacePMNPMNAMAMProvisional MatrixProvisional Matrix(Fibrin,Fibronectin,Proteoglycans)(Fibrin,Fibronectin,Proteoglycans)InsultInsultInfection,Aspiration,TraumaInfection,Aspiration,TraumaDiffuse Alveolar DamageDiffuse Alveolar DamagePathogenesis of ARDSPathogenesis of ARDSReconstitution of EpitheliumReconstitution of EpitheliumRemoval of Provisional MatrixRemoval of Provisional MatrixApoptosis of FibroblastsApoptosis of FibroblastsLimiting Myofibroblast DifferentiatingLimiting Myofibroblast DifferentiatingRepairRepairFibrosisFibrosisImpaired Re-epithelializationImpaired Re-epithelializationFurther Accumulation of FibroblastsFurther Accumulation of FibroblastsMyofibroblast DifferentiationMyofibroblast DifferentiationDeposition and Accumulation of CollagenDeposition and Accumulation of CollagenPathogenesis of ARDSPathogenesis of ARDSDegraded Provisional MatrixDegraded Provisional MatrixChest X-ray:Chest X-ray:Alveolar Injury and Fluid Leak Results in Diffuse Bilateral InfiltratesAlveolar Injury and Fluid Leak Results in Diffuse Bilateral InfiltratesChest CT Scan:Bilateral Infiltrates Are HeterogeneousChest CT Scan:Bilateral Infiltrates Are HeterogeneousEvolution of Pathogenesis:Evolution of Pathogenesis:Exudative PhaseExudative Phase(7 Days)(7 Days)Proliferative PhaseProliferative Phase(14 Days)(14 Days)Fibrotic PhaseFibrotic Phase(21 Days)(21 Days)Alveolar Wall DamageAlveolar Wall DamageWith FloodingWith FloodingType II Alveolar Cell HyperplasiaType II Alveolar Cell HyperplasiaMyofibroblast Infiltration Myofibroblast Infiltration Resolution of EdemaResolution of EdemaExtensive FibrosisExtensive FibrosisWith Loss of Normal LungWith Loss of Normal LungArchitectureArchitecture Pa0Pa02 2 Compliance ComplianceBilateral InfiltratesBilateral Infiltrates Pa0Pa02 2 Compliance ComplianceBilateral InfiltratesBilateral Infiltrates Pa0Pa02 2 Compliance ComplianceInfiltrates BullaeInfiltrates BullaeManagement of ARDS（一）、原发病治疗（一）、原发病治疗（二）、呼吸支持治疗（二）、呼吸支持治疗1、氧疗；、氧疗；2、无创机械通气；、无创机械通气；3、有创机械通气、有创机械通气（1）、机械通气的时机选择）、机械通气的时机选择（2）、肺保护性通气：小潮气量通气（）、肺保护性通气：小潮气量通气（68ml/kg）；限制气道平台压；限制气道平台压 30cmH2O；允许性高碳酸血症；允许性高碳酸血症；（3）、肺复张）、肺复张（4）、）、PEEP的选择：的选择：防止肺泡塌陷的最低防止肺泡塌陷的最低PEEP；（5）、自主呼吸）、自主呼吸（6）、半卧位（）、半卧位（30-45度度）（7）、俯卧位通气）、俯卧位通气（8）、镇静镇痛与肌松）、镇静镇痛与肌松4、高频振荡通气（高频振荡通气（HFOV）5、体外膜氧合技术（、体外膜氧合技术（ECMO）（三）药物治疗（三）药物治疗：保守性液体管理保守性液体管理，糖皮质激素，糖皮质激素，一氧化氮（，一氧化氮（NO）吸入）吸入，泡，泡表面活性物质表面活性物质，前列腺素，前列腺素E1，N-乙酰半胱氨酸和丙半胱氨酸乙酰半胱氨酸和丙半胱氨酸，环氧化酶抑制剂，环氧化酶抑制剂，细胞因子单克隆抗体或拮抗剂，己酮可可碱及其衍化物利索茶碱，重组人活化，细胞因子单克隆抗体或拮抗剂，己酮可可碱及其衍化物利索茶碱，重组人活化蛋白蛋白C，酮康唑，酮康唑，鱼油，鱼油 等等 How to keep the lung open(PEEP Titration)Stepwise incremental PEEPtitration PEEP titration while monitoring compliance looking for maximal complianceStepwise decremental PEEPtitration*PEEP reduction after initial high PEEP(20-25 cm H2O)looking for critical closing pressure that associated with reduction in compliance(alveolar collapse)Stepwise Incremental vs.Decremental PEEP titrationA decremental PEEP trial after full lung recruitment allows for PEEP titration along the deflation limb of the pressure/volume curve while observing changes in both oxygenation and respiratory mechanicsStepwise PEEP according to oxygenation Titrate PEEP to achieve target oxygenation(55 mmHg PaO2 80 mm Hg or 88%SpO2 95%)，then reduce FiO2 Using target scale of FiO2/PEEP from NIH ARDS Network study 2000Setting PEEP at 2 cm H2O above lower inflection point in static pressure volume curvedefined as optimal PEEPpressure control ventilation(PCV)；plateau pressures 30 cm H2O；tidal volumes of less than 6 mls/kg ideal body weight(IBW)with patients；30 degrees head of bed elevation；FIO2 90 to 92%；the high pressure was set to 15 cm H2O above the PEEP；which was increased in a stepwise manner to 20,then 30 and then 40 cm H2O every two minutes,and then reduced to 25,then 22.5,then 20,then 17.5 or then an absolute minimum of 15 cm H2O every three minutes until a decrease in SaO2 1%from maximum SaO2 was observed.This was defined as the derecruitment point.PEEP was then increased to 40 cm H2O for one minute and returned to a PEEP level 2.5 cm H2O above the derecruitment point(which was then defined as optimal PEEP).ConclusionsThis randomized controlled trial showed that a multifaceted open lung strategy that was based on staircase recruitment manoeuvres and decremental PEEP titration improved plasma cytokines(IL-8 and TNF-a),static lung compliance and oxygenation over seven days.There were no differences in duration of mechanical ventilation,ICU stay or hospital stay;however,further investigation in a larger randomized trial is warranted.A global inhomogeneity(GI)index based on EIT wasrecently developed to quantify the tidal volume distribution within the lung。where DI denotes the value of the differential impedance in the tidal images;DIxy is the pixel in the identifiedlung area;DIlung are all pixels in the lung area underobservationThank you for your attention