ARDS机械通气策略的评估课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,ARDS,机械通气策略的评估,北京协和医院,杜斌,ARDS,的回顾,1967年,Ashbaugh,提出,1985,年病理生理研究,1990年肺保护性通气策略,1998年,Amato,2000,年,NHBLI,的,ARDSnet,多中心研究,1995年首次报道,ARDS,病死率降低,内容,什么是,ARDS,1,如何选择潮气量,2,如何设定,PEEP,3,4,是否需要肺复张,内容,如何选择潮气量,2,如何设定,PEEP,3,4,是否需要肺复张,什么是,ARDS,1,什么是,ALI / ARDS,ALI,急性起病,PaO,2,/FiO,2, 300,CXR:,双侧浸润影,PAWP 18 mmHg,ARDS,急性起病,PaO,2,/FiO,2, 200,CXR:,双侧浸润影,PAWP 18 mmHg,什么是,ARDS,ARF,发病率(1994),137.1例/100,000人口/年,ALI,发病率(1996 1999),22.4 64.2例/100,000人口/年,Behrendt,CE. Acute respiratory failure in the United States incidence and 31-day survival. Chest 2000; 118: 1100-5,Goss CH, Brower RG, Hudson LD, et al. Incidence of Acute Lung Injury in the United States,.,Crit,Care Med 31(6):1607-1611, 2003,ARDS,在中国,上海12所大学医院15个,ICU,2001 2002,年间5320名患者收入,ICU,108,名(2%)发生,ARDS,PaO,2,/FiO,2,111.3, 40.3,APACHE II,17.3, 8.0,肺源性38% (41), 肺外源性62% (67),肺炎34.3%, 其他部位感染30.6%,住院病死率68.5%,Lu Y, Song Z,Zhou,X, Huang S, Zhu D, Yang C,Bai,X, Sun B,Spragg,R; Shanghai ARDS Study Group. A 12-month clinical survey of incidence and outcome of acute respiratory distress syndrome in Shanghai intensive care units. Intensive Care Med. 2004 Dec; 30(12):2197-203,什么是,ARDS,Moss M,Mannino,DM.,Race and gender differences in acute respiratory distress syndrome deaths in the United States: an analysis of multiple-cause mortality data (1979-1996).,Crit,Care Med 2002; 30(8): 1679-1685,什么是,ARDS,Moss M,Mannino,DM.,Race and gender differences in acute respiratory distress syndrome deaths in the United States: an analysis of multiple-cause mortality data (1979-1996).,Crit,Care Med 2002; 30(8): 1679-1685,什么是,ARDS,Herridge,M, Cheung AM,Tansey,CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N,Engl,J Med 2003; 348: 683-93.,什么是,ARDS,3个月,6个月,12个月,DLCO (%,预期值),63 (54 77),70 (58 82),72 (61 82),6,分钟行走距离(,m),281 (55 454),396 (244 500),422 (277 510),6,分钟行走时,SaO,2, 88%,的比例(%),10,8,6,SF-36,中的,physical role,0 (0 0),0 (0 50),25 (0 100),Herridge,M, Cheung AM,Tansey,CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N,Engl,J Med 2003; 348: 683-93.,什么是,ARDS,ARDS,病死率40 60%,病因学未知,治疗支持性,机械通气肺损伤,如何对,ARDS,患者进行机械通气, 而不导致或加重肺损伤?,内容,什么是,ARDS,1,如何选择潮气量,2,如何设定,PEEP,3,4,是否需要肺复张,如何选择潮气量,充分的气体交换,减少呼吸机相关性肺损伤的危险,低容量: 周期性肺泡塌陷和复张,高容量: 牵张/过度膨胀,VALI ,动物试验证据,Dreyfuss,DP. AJRCCM 1988; 137:1159,肺,过度膨胀与肺炎克氏菌菌血症,目的: 检验,PIP,和,PEEP,对菌血症发生的影响,方法: 80只大鼠, 气道内植入肺炎克氏菌,植入细菌22小时后进行机械通气3小时,4,种,通气策略,(13/3; 13/0;30/10;30/0),血,培养,Verbrugge, ,Lachmann,Intens,Care Med,1998;24:172-7,VALI ,临床试验证据,ARDS,潮气量的选择 临床试验,作者,患者数,潮气量,病死率,小潮气量,对照,小潮气量,对照,小潮气量,对照,P,值,Amato,29,24,6.1, 0.2,11.9, 0.5,38,71, 0.001,Stewart,60,60,7.2, 0.8,10.6, 0.2,50,47,0.72,Brochard,58,58,7.2, 0.2,10.4, 0.2,47,38,0.38,Brower,26,26,7.3, 0.1,10.2, 0.1,50,46,0.60,ARDSnet,432,429,6.3, 0.1,11.7, 0.1,31,40,0.007,measured body weight; ideal body weight = 25 x (height in meters),2,;, Dry weight measured weight minus estimated weight gain from salt and water retention;, Predicted body weight 50 (for males) or 45.5 (for females) + 2.3 (height in inches) - 60,ARDS,潮气量的选择 临床试验,组间,潮气量差异大,ARDSnet,: 6.2,vs,11.8; Steward: 7.2,vs,10.8;,Brochard,: 7.1,vs,10.3,大样本量,(n= 861),足以检测组间的差异,酸中毒的治疗,与其他临床试验相比, 采用增加,RR,以及输注碳酸氢钠的方法纠正轻至中度酸中毒, 因此组间,PaCO,2,和,pH,值,差异较小,ARDSnet,: PaCO,2,: 41.5,vs,35.5; pH: 7.38,vs,7.41 (,目标,: 7.3, 7.45); Steward: 54.4,vs,45.7; 7.29,vs,7.34 (,下限,: 7.0);,Brochard,: 59.5,vs,41.3; 7.28,vs,7.4 (,下限,: 7.05),ARDS,小潮气量临床试验的差异,还有其他的原因吗?,临床试验的差异性,平台压的改变,荟粹分析的提示,2项,阳性试验的对照组潮气量与临床情况存在差异, 因而不能确定试验组是否优于临床治疗,大潮气量,(12,ml/kg),组气道压高,(,34,cm H,2,O),患者预后差,荟粹分析的提示,3项,阴性试验的对照组与临床情况非常接近,只要气道压力介于,28 32,cmH,2,O,进一步降低潮气量,(6 7,ml/kg),患者不会额外受益,荟粹分析的提示,气道平台压力作为主要指标,一致的治疗指标,与,VALI,密切相关,Amato,的研究还有哪些提示,Study (reference),Died/Total (%),Died/Total (%),Low,Vt,/Open Lung Group,Conventional Group,Amato, et al (1995),5/15 (33%),7/13 (54%),Amato, et al (1998),11/29 (38%),17/24 (71%),Interval (between 1995 1998),6/14 (43%),10/11 (91%)*,*P = 0.078 (7/13 vs. 10/11), Fishers exact test,Parshuram,C and,Kavanagh,B. Meta-analysis of tidal volumes in ARDS. Am J,Respir Crit,Care Med 2003; 167: 798,ARDSNet,研究中最初的潮气量,ARDSNet,研究中符合入选标准但未参与试验患者的生存率,P = 0.002,Krishnan JA, Hayden D,Schoenfeld,D, Bernard G, Brower R. (for the NHLBI,ARDSNetwork,Investigators). Outcome of participants vs. eligible,nonparticipants,in a clinical trial of critically ill patients Abstract.,Am J,Respir Crit,Care Med,2000;161:A210,有关机械通气的世界性调查结果,1992,年的情况,超过,1,000,名受调查者,45%,表明会将潮气量限制在,5 9,ml/kg(,实际体重),96%,表明潮气量的选择受到气道压力的影响,Carmichael LC,Dorinsky,PM, Higgins SB, Bernard GR, Dupont WD,Swindell,B, Wheeler AP. Diagnosis and therapy of acute respiratory distress syndrome in adults: an international survey.,J,Crit,Care,1996; 11: 918,1994,年的教科书,Assuming that inflating the lungs to volumes above TLC is unsafe, it has become common practice to reduce VT to,no more than 7 cm,3,/kg,actual body weight in the management of ARDS,Hubmayr,RD. Setting the ventilator. In: Tobin MJ, editor. Principles and practice of mechanical ventilation. New York: McGraw-Hill; 1994, p. 191206.,NIH,研究中6,ml/kg,和,12,ml/kg,潮气量组患者病死率与第1天平台压的关系,1.0,0.8,0.6,0.4,0.2,0,Lowess,smoother, bandwidth = .8,12 ml/kg group. Proportion discharge dead,0,20,26,31,37.3,60,Mean,Pplat,on day 1,1.0,0.8,0.6,0.4,0.2,0,Lowess,smoother, bandwidth = .8,6 ml/kg group. Proportion discharge dead,0,20,25,32,60,Mean,Pplat,on day 1,NIH,研究中6,ml/kg,和12,ml/kg,潮气量组患者病死率与第1天平台压的关系,1.0,0.8,0.6,0.4,0.2,0,0,20,26,31,37.3,60,Mean,Pplat,on day 1,Petrucci,Lacovelli,. Meta-analysis Small,Vt Cochrane,Database 2003: 3,所有5项研究, 共,1,202,名患者,小潮气量组病死率降低,216/605 (35.7%),vs. 249/597 (41.7%) p 0.05,RR0.85 (CI 0.74 0.98),然而, 如果平台压, 31,cmH,2,O,小,潮气量与大潮气量组患者间并无显著差异,RR1.13 (CI 0.88 1.45),对,ARDS,病死率的影响,Pplat, 30 cmH,2,O,无论潮气量如何, 病死率均降低,Pplat,越低, 预后越好,与10 12,ml/kg,相比, 5 8,ml/kg,潮气量降低病死率?,调整呼吸频率以纠正,PaCO,2,(,只要没有内源性,PEEP, 88%,1,可,接受,FiO,2,FiO,2, 0.60,2,Brower RG,Lanken,PN,MacIntyre,N, et al. Higher versus lower positive,endexpiratory,pressures in patients with the acute respiratory distress syndrome. N,Engl,J Med 2004; 351:327336.,Amato MBP,Barbas,CSV, Medeiros DM,Magaldi,RB,Schettino,G,Lorenzi,-,Fihlo,G,Kairalla,RA,Deheinzelin,D, Munoz C, Oliveira R,Takagaki,TY,Carvalho,CRR. Effect of protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N,Engl,J Med 1998; 338: 347-354,最佳,PEEP,保证氧输送,(,DO,2,),达到最大值的,PEEP,水平,Peter M,Suter, et al. N,Engl,J Med 1975; 284,超高PEEP: Qs/Qt 0.20,PEEP up to 25 cmH,2,O well tolerated in healthy rhesus monkeys with,Intermittent mandatory ventilation,Intravascular,volume expansion,Careful cardiovascular monitoring,Kirby RR, Perry JC,Calderwood,HW, Ruiz BC,Lederman,DS.,Cardiorespiratory,effects of high positive end-expiratory pressure. Anesthesiology. 1975 Nov; 43(5):533-9.,如何选择,PEEP,ARDS,肺形态学,重力依赖区域的肺不张,重力依赖区域的肺不张,重力依赖区域的肺不张,Control:,V,T,7; PEEP 3,MVHP:,V,T,15; PEEP 10,MVZP:,V,T,15; PEEP 0,HVZP:,V,T,40; PEEP 0,Tremblay L. J,Clin,Invest 1997; 99:944,PEEP ,动物试验证据,病死率的比较,临床试验,通气策略,28天病死率,PLV-Trial,CMV,治疗组,年龄 65岁,(,n = 107),VT,9 ml/kg IBW,PEEP, 14 cmH,2,O,EIP 28 cmH,2,O,15.0%,ARDSnet,小,潮气量组,年龄 65岁,(,n = 350),VT,6 ml/kg IBW,PEEP, 9 cmH,2,O,EIP 28 cmH,2,O,19.7%,Villar,(,待发表),RCT,严重,ARDS P/F 200 mmHg,高,PEEP,小,潮气量,vs.,低,PEEP,中等潮气量,对照组:,Vt,9 11 ml/kg PBW, PEEP, 5 cmH,2,O,治疗组:,Vt,5 8 ml/kg PBW,PEEP,Pflex,+ 2 cmH,2,O,目标:,PCO,2,35 50 mmHg, PO,2,70 100 mmHg,通过调整呼吸频率纠正,PCO,2,治疗:,氧合恶化 增加,PEEP,氧合改善 降低,FiO,2,Villar,(,待发表) 第1天,对照组,治疗组,P value,Vt,(ml/kg),10.2,1.2,7.3,0.9, 0.001,PEEP,9.0,2.7,14.1,2.8, 0.001,Resp,rate,15.0,3.0,20.6,4.0, 0.01,Pplat,32.6,6.2,30.6,6.0,FiO,2,0.70,0.20,0.60,0.15, 0.05,P/F,124,54,139,43,PCO,2,46.0,11.1,42.7,9.6,pH,7.35,0.07,7.35,0.09,Villar,(,待,发表,),Day 3,Day 6,Vt,(ml/kg),对照,10.0,1.0*,9.9,1.2*,治疗,7.1,0.9,7.1,0.9,PEEP,对照,8.7,2.8*,8.3,3.7,治疗,11.2,3.1,8.2,3.5,FiO,2,对照,0.67,0.19#,0.61,0.22#,治疗,0.55,0.17,0.48,0.15,Pplat,对照,32.5,7.5#,32.4,8.0*,治疗,28.4,5.4,25.7,7.2,PaO,2,/FiO,2,对照,134,57#,163,93*,治疗,174,61,208,72,#,p 0.01, * p 0.001,Villar,(,待发表),对照组治疗组,N = 50N = 53,病死率54%病死率30%,在最终的数据分析期间发现, 一个研究中心的随机分组存在问题, 因而需要删除该中心入选患者的相关数据,N = 45,N = 50,病死率53.3%病死率32%,P = 0.04 (0.017),Villar,(,待发表),次要预后指标,对照组,治疗组,P,值,住院病死率,55.5% (25),34% (17),0.04,脱离呼吸机天数,6.02,7.95,10.9,9.45,0.008,随机分组后器官衰竭数目,1.71,1.34,1.10,1.13,0.019,高,PEEP,能否改善,ARDS,患者的预后?,Amato NEJM 1998; 338: 347 (n = 53),Absolute mortality difference,33%,NNT3.03,Villar,Kacmarek,(,待发表) (,n = 95),Absolute mortality difference21.3%,NNT4.7,ARDSnet,NEJM 2000; 342: 1305 (n = 861),Absolute mortality difference8.9%,NNT11.2,ALVEOLI,试验 假设,对于接受限制容量和压力的,ALI/ARDS,患者,更高的,PEEP,可能改善临床预后,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,ALVEOLI,试验设计,动脉氧合:,SpO,2,= 88 - 95% PaO,2,= 55 - 80 mmHg,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,Lower PEEP/ Higher FiO,2,PEEP,5,5,8,8,10,12,14,16 18,20 24,FiO,2,.3,.4,.4,.5,.,5 .7,.7,.,7 .9,.9,1.0,Higher PEEP/ Lower FiO,2,PEEP,12,14,14,16,16,18,20,22,24,FiO,2,.3,.3,.4,.4,.5,.5,.,5 .8,.,8 .9,1.0,ALVEOLI,试验结果 ,PEEP,*,*,*,*,*,Low PEEP,High PEEP,PEEP,cm H,2,O,Study Day,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,ALVEOLI,试验 平台压,*,*,*,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,ALVEOLI,试验 ,住院病死率,P=0.56,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,ALVEOLI,试验 总结,550名,患者,试验中期结束,无,显著差异,:,病死率,脱离呼吸机天数,ICU,以外住院日,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,高,PEEP,对,病死率的影响,10% 0% 10%,Favors Lower PEEP,Favors Higher PEEP,Mortality Difference,Adjusted,Unadjusted,(95% Confidence Intervals),NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,ALVEOLI,试验 高,PEEP,为何无效,?,高,PEEP,的,有益作用被副作用抵消,?,需要进行肺复张,?,“低,PEEP”,足以防止低呼气末容积通气所导致的肺损伤,?,低潮气量和气道平台压力减少了低呼气末容积通气所导致的肺损伤,?,NHLBI ARDS Clinical Trial Network. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N,Engl,J Med 2004; 351: 327-36.,为什么评价,PEEP,对,ARDS,患者预后影响的研究存在差异,?,设定,PEEP,的方法,ARDSnet,采用,PEEP/FiO,2,表,Alveoli ,采用,PEEP/FiO,2,表,Ranieri, PV,曲线,Amato PV,曲线,Villar, PV,曲线,Kacmarek,至少13,cmH,2,O,内容,什么是,ARDS,1,如何选择潮气量,2,如何设定,PEEP,3,4,是否需要肺复张,有关呼吸力学的假设和现实,假设,PEEP,可以使塌陷的肺泡复张,现实,PEEP,并不能使肺泡复张,PEEP,能够防止已经复张的肺泡再次塌陷,PV,曲线: 吸气支和呼气支,呼气相,肺泡塌陷与吸气相肺泡塌陷密切相关,Crotti,S,Mascheroni,D,Caironi,P,Pelosi,P,Ronzoni,G,Mondino,M,Marini,JJ,Gattinoni,L. Recruitment and,derecruitment,during acute respiratory failure: a clinical study. Am J,Respir Crit,Care Med 2001: 164: 131-140.,Decremental,PEEP Associated With Best Compliance,Hickling,KG. Best compliance during a,decremental, but not incremental, positive end- expiratory pressure trial is related to open-lung positive end- expiratory pressure. A mathematical model of acute respiratory distress syndrome lungs. Am J,Respir Crit,Care Med 2001: 163: 69-78.,0,20,40,60,80,100,0,5,10,15,20,25,30,35,PEEP (cmH,2,O),Mean tidal PV slope (ml/cmH,2,O),Maximum PV slope,at PEEP 16,Maximum PV slope,at PEEP 20,Incremental PEEP,Decremental,PEEP,Hickling,的数学模型,The Pressure-Volume Curve Is Greatly Modified by Recruitment,A Mathematical Model of ARDS Lungs,KEITH G. HICKLING,Intensive Care Unit and Department of,Anaesthesia, Queen Elizabeth Hospital,Kowloon,; and Department of Anesthesia and Intensive Care, Chinese University of Hong Kong, Hong Kong,Am. J.,Respir,.,Crit,. Care Med., Volume 158, Number 1, July 1998, 194-202,肺,复张 ,Hickling,的数学模型,肺复,张 动物试验的结果,Gattinoni, et al. Am J,Respir Crit,Care Med 2001; 164: 1701-11,肺,复张 临床研究结果,Crotti,S,Mascheroni,D,Caironi,P, et al. Recruitment and,derecruitment,during acute respiratory failure a clinical study. Am J,Respir Crit,Care Med 2001; 164; 131-40,肺,复张 临床研究结果,肺复张 临床研究结果,Crotti,S,Mascheroni,D,Caironi,P, et al. Recruitment and,derecruitment,during acute respiratory failure a clinical study. Am J,Respir Crit,Care Med 2001; 164; 131-40,ARDS,的,机械通气 总结,潮气量的选择,12,ml/kg:,过高,6,ml/kg:,过低?,6 10,ml/kg:OK ?,或者首先应当考虑平台压力?,PEEP,的选择,改善氧合的效果肯定,如何选择: 呼吸力学,vs.,经验性,肺复张,The Unknown,As we know,There are known,knowns,.,There are things we know we know.,We also know,There are known unknowns.,That is to say,We know there are some things We do not know.,But there are also unknown unknowns,The ones we dont know We dont know.,Feb. 12, 2002, Department of Defense news briefing,Photograph of Donald,Rumsfeld,by Kevin,Lamarque,/Reuters,