ARDS肺复张的实施课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,ARDS,肺复张的实施,科学与艺术的困惑,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,RM,ARDSnet:,小潮气量通气,Low Tidal Volumes,Traditional Tidal Volumes,P-,value,Death before discharge home and breathing without assistant (%),31.0,39.8,0.007,Breathing without assistance by days (%),65.7,55.0,0.001,NO of ventilator free days,Day1-28,12,11,10,11,0.007,Boratrauma, Day1-28(%),10,11,0.43,NO of days without failure of,nonpulmonary,organs or systems Day1-28,15,11,12,11,0.006,ARDS,Net.,N,Engl,J Med. 2000 May 4;342(18):1301-8,.,Low tidal volume: more,alv,collapse,小,V,t,不能复张塌陷肺泡，加重低氧血症,实施肺保护性通气策略,至少1525%患者需提高,FiO2,邱海波, 刘大为, 陈德昌等. 中华麻醉学杂志, 1998, 18: 202-205,Collapsed,airway,V1,V2,Pressure,Volume,V1,V1 + V2,Opening,pressure,Normal,ARDS,PEEP,adjustment,LIP：,塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力,PEEP not enough: more,alv,keep collapse,30,kg Pig,Post,Lavage,PCV,Paw 13 cmH,2,O PEEP 5 cmH,2,O,Experimental study-Pig with ARDS,许红阳，邱海波,. ARDS,绵羊肺复张容积测定方法的比较,.,中国危重病急救医学，,2004, 16: 413.,邱海波,. PEEP,对,ARDS,肺复张容积及氧合影响的临床研究,.,中国危重病急救医学，,2004, 16: 399.,Clinical Trial,11 ARDS pats,A.,Hypoxamia,B. Shear forces,C. Surfactants inactivate,D.,Biotrauma,and MODS,Pathophysiology,Consolidation,and,alv,collapse,A .,低氧血症,肺泡塌陷：,ARDS,重力依赖区,炎症或不张区,生理性低氧缩血管反应：障碍,How,Does Excessive Mechanical,Stress Inflame the Lung?,“,Shear”,Verbrugge,et al.,Crit,Care Med 1999;27：779,Ventilator-associated lung injury,Purine,: a marker of,ATP breakdown,and VILI,42 SD rats,PCV 6min,PCV Pre/PEEP,BALF,purine,and,protein,Lachmann,. ICM, 1994; 20:6-11,Intra-alveolar proteins inactivate,alv,surfactant in a dose-dependent way,1mg surfactant,=,inhibitory effect of 1mg plasma protein,C. Surfactant,灭活,Surfactant move away,When lung regions collapse at end expiration, surfactant molecules move away from the,alv,surface toward terminal bronchioles,and,cannot be reused during next inflation,Rouby,JJ. Am J,Respir,Crit,Care Med, 2001, 165: 1182,D.,预防,Biotrauma,和,MODS,Marini,JJ,Gattinoni,L.,Ventilatory,management,of,acute,respiratory,distress,syndrome,: a,consensus,of,two,Crit,Care,Med. 2004 Jan;32(1):250-5.,“,Stretch”,“,Shear”,Airway Trauma,俯卧位通气的病理生理特征,改善通气过程, 胸膜腔压力梯度, 顺应性,胸壁,促进分泌物的清除,Closing,pressure,Closing,pressure,Time course of Prone on PaO2/FiO2,between,ARDSp,vs,ARDSexp,Time response of Prone position on PaO2/FiO2 between,ARDSp,vs,ARDSexp,黄英姿,邱海波,.,肺内外源性,ARDS,实施俯卧位通气时间的选择,.,中华内科杂志,2004, 43(12):883-887,保留自主呼吸的优点,Paw cmH,2,O,%,Opening and Closing Pressures,0,5,10,15,20,25,30,35,40,45,50,0,10,20,30,40,50,Opening,pressure,Closing,pressure,5 patients,ALI / ARDS,From Crotti et al,AJRCCM 2001.,Some units cant,be kept open by,any reasonable PEEP!,Amato: CT + PV Curve,Heart,Sp,P,V,LIP,UIP,Insp recruit,Larger,Vt,/Sigh: Pressure must be high enough,Even up to UIP,许红阳，邱海波,. ARDS,绵羊肺复张容积测定方法的比较,.,中国危重病急救医学，,2004, 16: 413.,邱海波,. PEEP,对,ARDS,肺复张容积及氧合影响的临床研究,.,中国危重病急救医学，,2004, 16: 399.,Clinical Trial,11 ARDS pats,Recruitment is Time-Dependent, 40 SECONDS,Recruitment,mannuvers,Basic Principles,Methods for Recruitment,Experimental Studies and Clinical Trials,Efficacy,Hazards,1.,控制性肺膨胀,(SI),法,2. PEEP,递增法,3.,压力控制,(PCV),法,Methods for Recruitment,CPAP,模式,: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold:,将吸气保持键按住，持续,20- 40s,控制性肺膨胀,(SI),法,Multiple,Maneuvers May Be Needed For Optimum RM Effect,Fujino,et al,Crit,Care Med,2001; 29(8):1579-1586,Post-RM PEEP Determines PaO,2,Averaged data from three models,RM,S-C Lim, CCM 2004,Transient Benefit,Post-RM-PEEP,肺开放效应持续时间的决定因素,CCM, 2004, 32: 2371-2377,28 mixed-breed pigs,Models of ARDS:,OA,VILI,Pneumonia(PNM,),RM,SI,Increased PEEP,PCV,肺开放后的,PEEP,选择,-PaO,2,/FiO,2,1. RM,后,PEEP: 20cmH,2,O,2. PEEP,递减,: 2cmH,2,O/5min,3. PEEP,阈值,:,PaO,2,/FiO,2,5%,4. PEEP:,PEEP,阈值,+2cmH,2,O,BASELINE VENTILATION,Tidal volume=6ml/kg,PEEP=5cmH,2,O,Modify PEEP to get a,1.1,0.9,recruiting maneuver,Measure,1.1,0.9,Leave PEEP unchanged,stress index,0.9,1.1,Decrease PEEP until 1.1,stress index,0.9,Crit,Care Med, 2004, 32: 1018-1027,肺开放后的,PEEP,选择,- Stress index,Implications,RM,的有效性,ALI,的病因,(direct,vs,in direct),Post RM PEEP,Method in certain settings,RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury,PCV may be better tolerated than SI,Recommendations,Use PCV in preference to SI,Safer, “multiple”, effective, maintains ventilation, simple,Monitor hemodynamics during recruiting interval.,以下情况需重复作,RM:,体位改变,管路断开,呼吸力学特征或,PaO2,明显恶化,对于顽固性难治性,ARDS,患者,可考虑反复,RM,和更高的压力,Employ Prone Position and/or PEEP to consolidate RM benefit.,