血管外肺水的定量评估课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,血管外肺水的定量评估,血管外肺水的定量评估,1,血管外肺水的定义,Pulmonary edema is,characterized by,excess accumulation of fluid in the extravascular space of the lungs, namely,extravascular lung,water (EVLW),.,肺水肿是指过多的液体聚集,于,肺血管外，也就是血管外肺水,血管外肺水的定义 Pulmonary edema is ch,2,The pathological condition of pulmonary edema develops by two,mechanisms: An,increase in the pulmonary capillary hydrostatic pressure (hydrostatic or,cardiogenic pulmonary,edema) and an increase in pulmonary capillary,permeability (,acute respiratory distress syndrome ARDS,).,However, it is often difficult,to discriminate,between edema caused by increased hydrostatic pressure in the,course of,cardiac disease, or by increased permeability associated with,ARDS,肺水肿的发生机制有两种,：1.肺毛细血管的静水压增高（静水压或者心源性肺水肿）。2.毛细血管通透性增高（ARDS）,。然而临床上有时很难区别这两种病因。前者进入肺间质和肺泡的主要是,水分，而后者除了水分外还有大量蛋白等组织成分,The pathological condition of,3,AECC,和柏林标准诊断,ARDS,存在的问题,对影像学的评估主要是主观的，缺少客观指标,基础有慢性心脏疾病的患者，在罹患,ARDS,时会合并心脏功能不全，即使既往五心脏疾病，脓毒症本身等因素本身也会导致心脏功能受损,对病理与临床关系的研究显示，临床诊断为,ARDS,是患者，仅有一半左右表现为,ARDS,的特征病理学变化：弥漫性肺泡损伤,AECC和柏林标准诊断ARDS存在的问题 对影像学的评估主要,4,Am J Respir Crit Care Med. 2013,187,(7):761-7.,Am J Respir Crit Care Med. 201,5,If we are to require positive,pressure,ventilation,in our,definition, why not consider,lung,water, is it not time to move,forward,？,If not EVLW,then,perhaps,deadspace fraction, or the distribution of,injury,and,/or lung weight by Cat Scan, or a direct measure,of,permeability, some more direct measure of,injury,specifi,c to ARDS.,If we are to require positive,6,Conclusions,: A definite correlation exists between EVLW measured by the single-indicator transpulmonary,thermodilution technique and post-mortem lung weight in humans,Tagami et al. Critical Care 2010, 14:R162,Conclusions: A definite correl,7,Crit Care Med. 2013 Sep;41(9):2144-50.,Crit Care Med. 2013 Sep;41(9):,8,EVLWI,与,ARDS,发病前状态及,ARDS,的关系,Annual,update,in,intensive,care,and,emergenct,medicine,2014,p,258,EVLWI与ARDS发病前状态及ARDS的关系Annual,9,弹丸注射,肺,PiCCO,导管,如：股动脉,经肺热稀释技术需要在中心静脉注射冷盐水,( 8C),或室温盐水,( 24C),A.,热稀释参数,左心,右心,RA,PBV,EVLW,LA,LV,EVLW,RV,弹丸注射 肺PiCCO 导管 经肺热稀释技术需要在中心静,10,11,全心舒张末期容积,（,Global Enddiastolic Volume,，,GEDV,）是舒张末时心脏,4,个腔室的容积之和,全心舒张末期容积,PTV,RAEDV,LAEDV,LVEDV,RVEDV,GEDV,GEDV = ITTV - PTV,ITTV,GEDV,是,ITTV,与,PTV,之差,11全心舒张末期容积（Global Enddiastolic,11,12,血管外肺水,EVLW,EVLW,RAED,V,RVEDV,LAEDV,LVEDV,PTV,EVLW,ITBV,ITTV,RAEDV,RVEDV,LAEDV,LVEDV,PBV,血管外肺水（,Extravascular Lung Water,，,EVLW,）反映肺间质内含有的水量，通过,ITTV,与,ITBV,之差得到,12血管外肺水EVLWEVLWRAEDVRVEDVLAEDV,12,血管外肺水与血管外肺水指数,单纯讨论血管外肺水无意义，必须评估血管外肺水指数,血管外肺水指数的计算方法为：血管外肺水,/,体重,此体重为哪种体重？实际体重？预计体重？,血管外肺水与血管外肺水指数单纯讨论血管外肺水无意义，必须评估,13,Crit Care Med. 2008 June ; 36(6): 18031809,Crit Care Med. 2008 June ; 36(,14,Crit Care Med. 2008 Jan;36(1):69-73.,Crit Care Med. 2008 Jan;36(1):,15,Crit Care Med. 2008 Jan;36(1):69-73.,Crit Care Med. 2008 Jan;36(1):,16,预计体重的计算公式,The PBW is calculated as follows: men, PBW (kg) = 50 + 0.91 (,height,in,centimeters,-152.4,),;,women, PBW (kg) = 45.5 + 0.91 (height in,centimeters-,152.4,.,预计体重的计算公式 The PBW is calculate,17,Crit Care Med. 2012 March ; 40(3): 847854,Crit Care Med. 2012 March ; 40,18,Crit Care Med. 2012 March ; 40(3): 847854,Crit Care Med. 2012 March ; 40,19,问题,In,the Berlin definition, the measurement of EVLW was considered but not,included,in,the current,criteria.,The authors stated that “EVLW does,not,distinguish,between hydrostatic and inflammatory pulmonary edema”, and for,this,reason,it was not included,问题In the Berlin definition, th,20,21,肺血管通透性指数,肺,血管通透性指数（,Pulmonary Vascular Permeability Index,，,PVPI,）是血管外肺水（,EVLW,）与肺血容积（,PBV,），反映了肺水肿的类型,P,ulmonarv,B,lood,V,olume,静水压,肺水肿,通透性,肺水肿,PVPI,=,PBV,EVLW,正常,升高,升高,PVPI =,PBV,EVLW,升高,升高,正常,PVPI,=,PBV,EVLW,正常,正常,正常,PBV,EVLW,PBV,EVLW,PBV,EVLW,正常,E,xtra,V,ascular,L,ung,W,ater,21肺血管通透性指数肺血管通透性指数（Pulmonary V,21,Annual,update,in,intensive,care,and,emergenct,medicine,2014,p,259,Annual update in intensive car,22,Kushimoto et al. Critical Care 2012, 16:R232,Kushimoto et al. Critical Care,23,Annual,update,in,intensive,care,and,emergenct,medicine,2014,p,263,Annual update in intensive car,24,Examples: Interpretation of,EVLW,and,PVPI Values,A patient admitted 2 days earlier with bacterial pneumonia and bilateral,consolidations,on,a CT scan was ventilated with an FiO2 of 60%, a PEEP of 10 cmH2 O,the,Po2,is,70mmHg,Diagnoses,:,Severe,pneumonia,？,Moderate,to,severe,ARDS,？,He,had an EVLW of 17ml/kg, and a PVPI of 1.5,Examples: Interpretation of EV,25,Examples: Interpretation of EVLW,and PVPI Values,Early,aggressive,intervention,in,addition to lung-protective ventilation, may be required. On the,other,hand, despite a 2-day history of sepsis with fluid overload, white lungs on,portable,radiograph, and ventilation with an FiO2 of 60% and a PEEP level of 10 cmH2 O,an,EVLW of 8ml/kg and a PVPI of,1.0,could indicate clinical conditions,other,than,pulmonary edema,Examples: Interpretation of EV,26,Examples: Interpretation of EVLW,and PVPI Values,He,accepted,lung,CT,scan,the,result,revealed,atelectasis,Bronchoscopy,was,prescribed,for,him.,2,days,late,his,symptom,released,and,weaned,from,ventilation,Examples: Interpretation of EV,27,总结,目前,ARDS,诊断标准存在问题，如果要提高诊断的准确率需要评估,血管外肺水指数及肺血管通透性,血管外肺水指数应该根据预测体重来计算，而不应该根据实际值计算,对于罹患,ARDS,的高危患者，根据血管外肺水指数提前,2,天左右干预能改善患者预后,PVPI,大于,3,能诊断,ARDS,，而小于,1.7,可排除,ARDS,的诊断,总结目前ARDS诊断标准存在问题，如果要提高诊断的准确率需要,28,谢谢各位老师的聆听,谢谢各位老师的聆听,29,