ARDS机械通气治疗策略课件

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,诊断困惑与治疗策略,空军总医院呼吸科,张波,ARDS,诊断难以判断之处,急性起病,脓毒症者约一半以上患者在24小时内出新浸润,肺外创伤患者可以在数天到1周内出现浸润,80%以上的患者1周内发生肺部浸润,双肺浸润影,肺梗塞,肺不张,肺水肿,胸腔积液,肺泡出血等,无左心功能受累的证据难以掌握,ARDS,诊断的困惑,现行诊断标准的敏感性和特异性？,382例外科,ICU,中,死亡的患者进行了尸体解剖,127例,达到,ARDS,的临床诊断标准,临床标准诊断,ARDS,中度敏感(75%)和特异(84%),重症患者,ARDS,的临床标准和病理诊断存在差异,Esteban A,etal,. Ann Intern Med2004,141:440-445,临床、影像和病理学诊断的差异,ARDS,病因的异质性决定诊断的困难性,感染性（细菌、病毒、真菌,）,非感染（药物中毒、免疫损伤等）,肺外与肺内因素,The Role of Open-Lung Biopsy in ARDS?,Sanjay R. Patel,Chest.,2004;125:197-202,57例,ARDS,开胸肺活检患者资料,Age, yr,53 18,PaO,2,/FIO,2, mm Hg,145 61,Positive end-expiratory pressure, cm H,2,O 10.3 4.1,Male gender 36 (63.2),Immunosuppressed,17 (29.8),BAL prior to biopsy 44 (77.2),Days from admission to biopsy 7 (148),Days from,intubation,to biopsy 3 (025),病理诊断,DAD 23,Acute phase 5,Fibroproliferative,phase 18,Specific infection 8,Diffuse alveolar hemorrhage 5,BOOP 5,Bronchiolitis,3,Culture-negative purulent pneumonia 2,Drug reaction 2,Pulmonary lymphoma 2,Lymphangitic,tumor 1,Organizing pneumonia 1,Desquamative,interstitial pneumonia 1,Hypersensitivity,pneumonitis,1,Chronic,eosinophilic,pneumonia 1,Allergic,bronchopulmonary aspergillosis,1,Pulmonary edema 1,主要并发症,Com,plications N（%）,Major 4 (7.0),Death 1 (1.8),Hemothora,2 (3.5),New dialysis 1 (1.8),Minor 18 (31.6),Acute renal failure 6 (10.5),Persistent air leak 12 (21.1),Any 22(38.6),41例开胸肺活检,ARDS,患者特征,主要提示,ARDS,的临床诊断标准无法准确反映导致疾病的诱因,ARDS,是一组,异质性疾病的统称,没有病理诊断往往导致错误治疗或不必要的过度治疗,对,ARDS,患者选择性进行开胸肺活检是可以接受的一项检查,关于诊断的总结,现有的诊断标准有缺陷但尚在沿用,病因的复杂性决定了临床表现的多样性,ARDS,的病因诊断水平有限,病因的异质性决定了对治疗反应的不同,早期病因诊断决定治疗成败,一、,ARDS,病理生理,PEEP15cmH2O,A:over stretched,B:excessive stress,C:repeated opened and closed,ARDS,机械通气目标,Maintain adequate O,2,delivery,Maintain normal CO,2,Avoid,Atelectasis,Avoid ventilator-induced lung injury,barotrauma,MODS,Atelectasis,Hemodynamic,impairment,Patient-ventilator asynchrony,Support ventilation,Reduce mortality、hospital day、,ventliator,free day and cost,肺保护性通气策略的应用,PEEP in ARDS-how much is enough?,Brower RG,et al.N,Engl,J Med2004,351:389,549,ARDS patients,Keep VT6ml/kg,Pplat,30cmh2O,High PEEP group 13.2+/-3.5cmH2O,Low PEEP group8.3+/-3.2cmH2O,Mortality before discharge,High PEEP group 27.5%,Low PEEP group 24.9%,1-28days MV free time,High PEEP group 14.5 +/-10.4d,Low PEEP group 13.8 +/-10.6d,合适,PEEP,水平的确定方法,气流阻断法,静态顺应性法,HEART,SP,Pulmonary Parenchymal Injury,1,.,Overdistention,Injury,-,Pplat,15 cmH,2,0),3. Prolonged Collapse Injury,- Recruitment, Prone, Liquid,实变区延迟开放,需要实施肺开放策略,RM,的应用现状,对,多种新的通气模式的评价,VAPSV,PRVCV,VSV,Permissive,Hypercapnia,IRV,High frequency ventilation,Inhaled nitric oxide,Prone positioning,PLV,TGI,ARPV,理论上具有先进性,患者临床情况的复杂性、多变性，决定了监测指标的多变性,目前尚没有比传统模式优越的客观证据,需进一步进行深入临床研究,对多种新的通气模式目前尚不能作为常规推荐应用,Synchronized Transitions,Spontaneous Breath,P,T,PEEP,H,PEEP,L,Spontaneous Breathing and Aeration,CMV,BIPAP,ARCMVDS, 24 hours on each mode. P. Neumann (Gttingen),Putensen,C et al.: AJRCCM2001 Jul 1;164(1):43-9,PCV,APRV,权衡利弊、个体化、紧急优先原则,氧合状态（,SpO210个有意义),预防治疗策略,IV,Ig,-CMV,Advantages:Few side effects,Disadvantages:Low efficacy,High-dose,acyclovir,Advantages: Few side effects,Disadvantages: High cost,Ganciclovir,Advantages:,Highly effective,Disadvantages: High risk of,neutropenia,(especially in BMT*); late CMV disease possible,谢谢！,