呼吸治疗肺保护施丽萍指南课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/9/14,#,呼吸机治疗的肺保护策略,呼吸机治疗的肺保护策略,1,呼吸机相关性肺损伤,acute parenchymal lung injury and an acute inflammatory response,in the lung.,cytokines alveoli,and the systemic circulation multiple,organ dysfunction,mortality,呼吸机相关性肺损伤,2,呼吸机相关性肺损伤ventilator-induced lung injury,容量性损伤,Volutrauma（large gas volumes ）,压力性损伤,Barotrauma（high airway pressure ）,不张性损伤,Atelectotrauma（alveolar collapse and re-expansion）,生物性损伤,Biotrauma（increased inflammation,）,呼吸机相关性肺损伤ventilator-induced l,3,肺 损 伤 病 理,alveolar structural damage,pulmonary edema、 inflammation、 fibrosis,surfactant dysfunction,other organ dysfunction,exacerbate the disturbance of lung development,Semin Neonatol. 2002 Oct;7(5):353-60.,肺 损 伤 病 理alveolar structural d,4,Approaches in the management of acute respiratory failure in children,protective ventilatory and potential protective,ventilatory modes,lower tidal volume and PEEP,permissive hypercapnia,high-frequency oscillatory ventilation,airway pressure release ventilation,partial liquid ventilation,improve oxygenation,recruitment maneuvers,prone positioning,kinetic therapy,reduce FiO,2,and facilitate gas exchange,inhaled nitric oxide and surfactant,Curr Opin Pediatr. 2004 Jun;16(3):293-8.,Approaches in the management,5,Can mechanical ventilation strategies reduce chronic lung disease?,continuous positive airway pressure,permissive hypercapnia,patient-triggered ventilation,volume-targeted ventilation,proportional assist ventilation,high-frequency ventilation,Semin Neonatol. 2003 Dec;8(6):441-8,Can mechanical ventilation str,6,小潮气量和呼气末正压,lower tidal volume and PEEP,小潮气量和呼气末正压,7,Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS,1202 patients,lower tidal volume (7ml/kg),low plateau pressure 30 cm H,2,O versus,tidal volume 10 to 15 ml/kg,Mortality at day 28,long-term mortality was uncertain,low and conventional tidal volume with plateau pressure 31 cm H,2,O was not significantly different,Cochrane Database Syst Rev. 2004;(2):CD003844,Ventilation with lower tidal v,8,Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome,549 patients acute lung injury and ARDS,lower-PEEP group 8.33.2cmH,2,O,higher-PEEP group 13.23.5cmH,2,O (P0.001).,tidal-volume 6ml/kg,end-inspiratory plateau-pressure30cmH,2,O,The rates of death 24.9 % 27.5 % (p=0.48),From day 1 to day 28, breathing was unassisted,14.510.4 days 13.810.6 days (p=0.5),clinical outcomes are similar whether lower or higher PEEP levels are used.,N Engl J Med. 2004 Jul 22;351(4):327-36,.,Higher versus lower positive e,9,Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilation,Sprague-Dawley rats,negative control group,low pressures (PIP = 12 cm H,2,O), rate = 30, iT = 0.5, 1.0, 1.5secs,experimental groups,high pressures (PIP = 45 cm H,2,O), rate = 10, iT = 0.5 , 1.0 , 1.5 secs,lung compliance, PaO,2,/FiO,2,ratio, wet/dry lung weight, and dry lung/body weight,as inspiratory time increased ,static lung compliance (p =.0002) and Pao,2,/Fio,2,(p =.001) decreased. Wet/dry lung weights (p .0001) and dry lung/body weights (p 0.05,0.05,0.05,0.05,0.05,两组胎龄、体重、病情严重程度比较胎龄（周）体重日龄AaDO,14,对照组（NPM,)：,应用人工呼吸机限压定时持续气流型，通气模式为IMV，持续脉搏血氧饱和度监测使其维持在8595%，每8h监测动脉血气一次，要求血气维持在正常范围内，PaO,2,40-70mmHg, PaCO,2,35-45mmHg,对照组（NPM)：,15,观察组（PM组）,：,1、肺力学监测仪(Bicore CP100)每812h 监测一次机械通气时肺力学参数,2、监测时要求患儿与呼吸机完全同步或无自主呼吸状态（必要时通过药物抑制呼吸）,3、肺力学监测仪的传感器置于近端接口,4、气管插管气漏率小于20%,5、每监测一次持续0.51h至数据稳定后记录监测的数据,观察组（PM组）：,16,NPM 组和PM组的评估指标,1. 疾病极期，即生后2448h时呼吸机要求最高值，包括FiO,2,、 PIP、PEEP、Ti、MAP、VR,2. VE、C,20,/C、TC（限于PM组），,3. 记录血pH、PaO,2,、PaCO,2,、氧合指数（OI ）,（OI=FiO,2,MAP/PaO,2,）,和心率、血压,4. 呼吸机应用时间，用氧时间，住院天数，病死率，PDA，IVH和呼吸机相关性肺损伤的发生率。,NPM 组和PM组的评估指标,17,两组呼吸机参数比较,FiO,2,（%）,PIP,（cmH,2,O,),PEEP,（cmH,2,O,),MAP,（cmH,2,O,),Ti,(sec),VR,（次/分）,NPM,6019,30.53.4,5.60.8,14.93.4,0.750.1,399,PM,6218,26.71.7,5.40.6,11.92.0,0.450.1,4210,t,0.184,7.527,1.339,5.818,18.10,1.81,p,0.05,0.05,0.001,0.05,两组呼吸机参数比较FiO2 PIP（cmH2O) PE,18,呼吸治疗肺保护施丽萍指南课件,19,两组血气监测结果比较,PH,PaO,2,(mmHg),PaCO,2,(mmHg),HR,(次/分）,BP,(mmHg),OI,NPM,7.310.1,5717,4010,1448,404.6,1913,PM,7.30.04,5916,486.3,1456,393.6,147.7,t,0.289,0.516,4.663,0.798,0.942,2.011,p,0.05,0.05,0.05,0.05,0.05,两组血气监测结果比较PHPaO2PaCO2 (mmHg)H,20,呼吸治疗肺保护施丽萍指南课件,21,两组呼吸机相关性肺损伤、PDA、IVH、呼吸机应用时间、用氧时间、住院天数、病死率比较,VALI%,PDA,%,IVH,%,IMV,(d),用氧时间(d),住院天数(d),病死率%,NPM,32,36,42,3.91.8,117,1914,14,PM,13.3,33.3,40,4.21.7,137,2211,8.3,t,0.867,1.474,1.22,5.57,0.09,0.05,0.9,p,0.05,0.05,0.05,0.05,0.05,0.05,两组呼吸机相关性肺损伤、PDA、IVH、呼吸机应用时间、用,22,结论,肺力学监测能指导正确应用呼吸机，降低呼吸机相关性肺损伤,从本研究结果推荐RDS呼吸机应用的参数为：PIP 25cmH,2,O左右，短Ti 0.30.5秒，应用适当的PEEP 5-7cmH,2,O治疗RDS，不影响氧合。,PaCO,2,的轻度增高（PaCO,2,45-60），IVH的发生未见增加。,结论肺力学监测能指导正确应用呼吸机，降低呼吸机相关性肺损伤,23,允许性高碳酸血症,Permissive hypercapnia,允许性高碳酸血症,24,Permissive hypercapnia-role in protective lung ventilatory strategies,First, we consider the evidence that protective lung ventilatory strategies improve survival and we explore current paradigms regarding the mechanisms underlying these effects,Second, we examine whether hypercapnic acidosis may have effects that are additive to the effects of protective ventilation,Third, we consider whether direct elevation of CO,2, in the absence of protective ventilation, is beneficial or deleterious,Fourth, we address the current evidence regarding the buffering of hypercapnic acidosis,Permissive hypercapnia-role i,25,Lung-protective ventilation in acute respiratory distress syndrome: protection by reduced lung stress or by therapeutic hypercapnia?,hypercapnic acidosis,lung-protective ventilation,respiratory acidosis protected,the lung,The protective effect,of respiratory acidosis,inhibition of xanthine,oxidase,prevented by buffering the acidosis .,the protection resulted from the acidosis rather,than hypercapnia,Am J Respir Crit Care Med. 2000 Dec;162(6):2021-2,.,Lung-protective ventilation,26,Permissive hypercapnia in ARDS and its effect on tissue oxygenation,The right-shift of the haemoglobin-oxygen dissociation curve,reduce intrapulmonary shunt (Qs/Qt) by potentiating hypoxic pulmonary vasoconstriction,affect the distribution of systemic blood flow both within organs and between organs,Acta Anaesthesiol Scand Suppl. 1995;107:201-8,Permissive hypercapnia in ARDS,27,Hypercapnic acidosis attenuates endotoxin induced acute lung injury,attenuated the decrement in oxygenation,improved lung compliance,reduced alveolar neutrophil infiltration and histologic indices of lung injury,Am J Respir Crit Care Med. 2004 Jan 1;169(1):46-56,Hypercapnic acidosis attenu,28,Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury,12 rabbits ventilator-induced lung injury (VILI),PaCO,2,40 mm Hg n = 6 PaCO,2,80-100 mm Hg n = 6,respiratory mechanics,(plateau pressures) 27.0,2.5 20.9,3.0 p = 0.016,gas exchange (PaO,2,) 165.2,19.4 77.3,87.9 p = 0.02,wet:dry weight 9.7,2.3 6.6,1.8 p = 0.04,bronchoalveolar lavage,fluid protein concentration 1350,228 656,511 p = 0.03,cell count 6.86 x 10,5,2.84 x 10,5,p = 0.021,injury score 7.0,3.3 0.7,0.9 p 60% and MAP,20 cm H,2,O or PEEP15 cm H,2,O,Crit Care Med. 2003 Apr;31(4 Suppl):S317-23,High-frequency oscillatory ve,34,Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants,updated in May 2003 3275 Randomized controlled trials comparing HFOV and CV in preterm or low birth weight infants with pulmonary dysfunction,no evidence of effect on CLD and mortality at 28-30 days,Pre-specified subgroup analyses,Short term neurological morbidity,Grade 3 or 4 IVH and PVL (no using high volume,strategy),Cochrane Database Syst Rev. 2003(4):CD000104,Elective high frequency oscill,35,Open lung ventilation improves gas exchange and attenuates secondary lung injury in a piglet model of meconium aspiration,Prospective, randomized animal study,36 newborn piglets (6 saline controls),PPV(OLC), HFOV(OLC), PPV(CON),ventilated for 5 hrs,bronchoalveolar lavage fluid,myeloperoxidase activity,lung injury score,Alveolar protein influx no different,superior oxygenation and less ventilator-induced lung injury,Crit Care Med. 2004 Feb;32(2):443-9,Open lung ventilation improves,36,Changes in mean airway pressure during HFOV influences cardiac output in neonates and infants,14 patients 1 year weight 10 kg HFOV,study group (n = 9) MAP +5 and -3 cmH2O,control group (n = 5),Cardiac output echocardiography Doppler technique,Cardiac output the study group (P = 0.02),the greatest change at the highest Paw at -11% (range: -19 to -9) compared with baseline.,Acta Anaesthesiol Scand. 2004 Feb;48(2):218-23,Changes in mean airway pressur,37,Randomized trial of high-frequency oscillatory ventilation versus conventional ventilation:,effect on systemic blood flow in very preterm infants,43 infants 29w 8 kg,Vital signs, airway pressures, minute ventilation, Spo(2), and E(T)CO(2) were recorded,APRV provided similar ventilation, oxygenation, mean airway pressure, hemodynamics, and patient comfort as SIMV,APRV significantly lower inspiratory peak and plateau pressures,Pediatr Crit Care Med. 2001 Jul;2(3):243-6,Airway pressure release ventil,40,Airway pressure release ventilation as a primary ventilatory mode in acute respiratory distress syndrome,58 patients randomized APRV or SIMV,PIP at APRV-group (25.9,0.6 vs. 28.6,0.7 cmH,2,O) (P = 0.007).,no different PEEP and physiological variables,(PaO,2,/FiO,2, PaCO,2, pH, minute ventilation, mean arterial pressure, cardiac output),At day 28, the number of ventilator-free days was similar (13.4,1.7 , 12.2,1.5), the mortality (17% and 18%),APRV did not differ from SIMV with PS in clinically relevant outcome,Acta Anaesthesiol Scand. 2004 Jul;48(6):722-31,Airway pressure release ventil,41,APRV,No evidence to indicate that APRV is better than conventional ventilation,APRVNo evidence to indicate th,42,经常,不断地学习,你就什么都知道。你知道得越多,你就越有,力量,Study Constantly, And You Will Know Everything. The More You Know, The More Powerful You Will,Be,写,在最后,经常不断地学习,你就什么都知道。你知道得越多,你就越有力量写,43,谢谢你的到来,学习并没有结束，希望大家继续努力,Learning Is Not Over. I Hope You Will Continue To Work Hard,演讲人：,XXXXXX,时 间：,XX,年,XX,月,XX,日,谢谢你的到来演讲人：XXXXXX,44,