ARDS患者的肺复张课件

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,*,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,*,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,*,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,*,*,ARDS患者的肺复张,ARDS患者的肺复张ARDS患者的肺复张内容小潮气量通气的问题,肺复张的理论与实践,肺复张与PEEP,肺复张后的PEEP,不同复张方法的差异,肺复张的临床适应症,肺复张的副作用,肺复张存在的问题2,书籍能培养我们的道德情操，给我们巨大的精神力量，鼓舞我们前进,内容,小潮气量通气的问题,肺复张的理论与实践,肺复张与,PEEP,肺复张后的,PEEP,不同复张方法的差异,肺复张的临床适应症,肺复张的副作用,肺复张存在的问题,2,内容,小潮气量通气的问题,肺复张的理论与实践,肺复张与,PEEP,肺复张后的,PEEP,不同复张方法的差异,肺复张的临床适应症,肺复张的副作用,肺复张存在的问题,3,ARDS,的肺保护性通气策略,患者数,潮气量,病死率,作者,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,Villar,50,45,7.3, 0.9,10.2, 1.2,34,55,0.041,4,ARDS,的肺保护性通气策略,小潮气量,(6 ml/kg IBW),避免过度膨胀造成的容积伤,(volutrauma),足够的,PEEP,防止肺泡复张造成的剪切力损伤,(atelectrauma),5,肺泡塌陷与复张造成的剪切力,F = P,L,x (V,0,/V),2/3,F:,剪切力,P,L,:,跨肺压,V,0,:,最初容积,V:,复张后容积,如果,:P,L,= 30 cmH,2,O, V,0,/V = 1/10,则,:,F = 140 cmH,2,O,Mead J, Takishima T, Leith D. Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 1970; 28(5): 596-608,6,小潮气量通气的问题,LVt,(n = 15),CVt,(n = 15),P value,Vt, ml,411, 55,664, 84, 0.01,Vt, ml/kg,6, 1,10, 1, 0.01,setPEEP, cmH,2,O,10, 4,10, 4,n.s.,PEEPtot, cmH,2,O,11, 4,11, 4,n.s.,Pplat, cmH,2,O,23, 8,30, 10, 0.01,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613,7,小潮气量通气的问题,LVt,(n = 15),CVt,(n = 15),P value,PaO,2, mmHg,136, 80,156, 82,n.s.,PaO,2,/FiO,2, mmHg,165, 84,183, 83,n.s.,SaO,2, %,94.8, 5.0,97.6, 2.1, 0.05,PaCO,2, mmHg,60, 35,38, 21, 0.001,pH,7.21, 0.1,7.36, 0.1, 0.001,SBP, mmHg,125, 25,121, 20,n.s.,DBP, mmHg,60, 9,60, 10,n.s.,HR, bpm,101, 15,93, 15,n.s.,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613,8,小潮气量通气的问题,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613,9,受损的肺组织如何复张,俯卧位,足够的,PEEP,足够的潮气量,和,(,或,),叹气,?,肺复张手法,减少水肿,(?),最低可接受的,FiO,2,(?),自主呼吸,(?),10,内容,小潮气量通气的问题,肺复张的理论与实践,肺复张与,PEEP,肺复张后的,PEEP,不同复张方法的差异,肺复张的临床适应症,肺复张的副作用,肺复张存在的问题,11,肺泡的开放压与闭合压,12,PEEP,不能使肺复张,13,LIP:,仅仅是肺复张的开始,Hickling KG. The pressure-volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998: 158: 194-202.,14,Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. PressureVolume Curves and Compliance in Acute Lung Injury: Evidence of Recruitment Above the Lower Inflection Point. Am J Respir Crit Care Med 1999; 159: 1172-1178,低位转折点之上仍有肺组织复张,15,肺泡的开放压与闭合压,16,肺泡开放压与闭合压,0,10,20,30,40,50,0,5,10,15,20,25,30,35,40,45,50,Opening pressure,Paw (cmH,2,O),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.,Closing pressure,17,ARDS,的肺开放,Editorial,Open up the lung and keep the lung open,B. Lachmann,Dept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands,(1992) 18:319-321,18,RM,能够使肺开放,RM: PIP 45 cmH,2,O, PEEP 35 cmH,2,O x 1 min,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,19,肺复张能够改善,ARDS,氧合,Lapinsky SE, Aubin M, Mehta S, Boiteau P, Slutsky AS: Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.,Intensive Care Med,1999, 25: 1297-1301.,20,肺复张的各种方法,CPAP (SI),incremental PEEP,PCV,Sigh (modified),HFOV,俯卧位,21,SI,改善氧合,Tugrul S, Akinci O, Ozcan PE, Ince, S, Esen F, Telci L, Akpir K, Cakar N. Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome: Focusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744,Sustained Inflation:,45 cmH,2,O x 30 s,22,SI,改善氧合,Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Care Med 2005; 33: 181-188,Sustained Inflation:,30 cmH,2,O x 30 s,Twice with 1 min interval,23,叹气的设置,Lim CM, Koh Y, Park W, Chin JY, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD: Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260,充气阶段,每,30,秒,PEEP,增加,5 cmH,2,O,Vt,减少,2 ml/kg,前,2,次呼吸除外,直至,Vt 2 ml/kg, PEEP 25 cmH,2,O,暂停阶段,CPAP 30 cmH,2,O,for 30 s,放气阶段,24,叹气改善氧合,Lim CM, Koh Y, Park W, Chin JY, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD: Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260,25,叹气对氧合,与,呼吸力学的影响,Pelosi P, Cadringher P, Bottino N, Panigada M, Carrieri F, Riva E, Lissoni A, Gattinoni L. Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159: 872-880,Sigh: 3 consecutive sighs/min at Pplat 45 cmH,2,O,26,叹气的设置,Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-94,Baseline:,PSV,Sigh:,BIPAP,PEEPhigh =,1.2 x PIPpsv or,35 cmH,2,O,Ti,s = 3 5 s,f = 1 bpm,27,叹气改善呼吸力学,与,氧合,Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-94,28,ARDS,对,RM,的反应,Villagra A, Ochagavia A, Vatus S, Murias G, Fernandez MF, Aguilar JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2002; 165: 165-170,29,肺复张, CT,的提示,Henzler D, Mahnken AH, Wildberger JE, Rossaint R, Gnther RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006; 16: 1351-1359,30,肺复张, CT,的提示,Henzler D, Mahnken AH, Wildberger JE, Rossaint R, Gnther RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006; 16: 1351-1359,31,内容,小潮气量通气的问题,肺复张的理论与实践,肺复张与,PEEP,肺复张后的,PEEP,不同复张方法的差异,肺复张的临床适应症,肺复张的副作用,肺复张存在的问题,32,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,33,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,34,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,35,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,36,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,37,内容,小潮气量通气的问题,肺复张的理论与实践,肺复张与,PEEP,肺复张后的,PEEP,不同复张方法的差异,肺复张的临床适应症,肺复张的副作用,肺复张存在的问题,38,为什么肺复张作用不能持久,?,baseline,3 min post-RM,30 min post-RM,PaO,2,/FiO,2,(mmHg),139, 46,246, 111,138, 39,PaCO,2,(mmHg),48.6, 12.1,47.6, 13,46.4, 12,SvO,2,(%),70.4, 6.1,72.4, 5.6,70, 6.2,Qs/Qt (%),30.8, 5.8,21.5, 9.7,29.2, 7.4,Crs (ml/cmH,2,O),34.1, 12.6,36.9, 15.1,35.7, 13.5,Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5,39,为什么肺复张作用不能持久,?,肺复张的方法,?,SI: 50 cmH,2,O x 30 s,作者认为,Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5,40,RM + PEEP vs. RM vs. PEEP,Lim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418,41,RM + PEEP vs. RM vs. PEEP,Lim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418,RM + PEEP,RM only,42,RM,后的,PEEP,43,RM,后的,PEEP,能够稳定肺泡,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,44,RM,后的,PEEP,能够稳定肺泡,RM: PIP 45 cmH,2,O, PEEP 35 cmH,2,O x 1 min,PEEP 5 cmH,2,O,PEEP 10 cmH,2,O,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,45,肺泡稳定能够改善,PaO,2,McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic ulmonary vasoconstriction. Crit Care med 2002; 30: 1315-1321,46,RM,后的,PEEP,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,47,RM + PEEP vs. PEEP only,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,RM + PEEP,PEEP only,48,PEEP,的设置,RM,之后通常将,PEEP,设置在能够维持,PaO,2,(,防止塌陷,),的水平,最初将,PEEP,设置为,20 cmH,2,O,然后将,FiO,2,减小到最低水平,维持,SpO,2,90 95%,每,20 30,分钟降低,PEEP 2 cmH,2,O,直至患者,SpO,2,下降,49,PEEP,的设置,氧合下降前的,PEEP,水平,防止大部分肺泡塌陷的,PEEP,一旦确认,则需重复肺复张操作,然后把,PEEP,和,FiO2,重新设置在上述水平,对于多数,ARDS,患者, PEEP,介于,15 20 cmH,2,O,之间,某些患者, 20 cmH,2,O,50,PEEP,的设置,如果将,PEEP,设置于,20 cmH,2,O,后,仍发现,PaO,2,/FiO,2,显著下降,按照最初的,PEEP,设置,25 cmH,2,O,重复肺复张,然后按照上述方法调节,FiO,2,和,PEEP,51,PEEP,的设置,将,PEEP,从不必要的高水平逐渐降低,不要将,PEEP,由低水平增加到高水平,如同,P-V,曲线所示,根据设置方法不同,同样水平的,PEEP,所维持的肺容积不同,如果在肺泡塌陷后设置,PEEP (,增加,PEEP),则所设置的,PEEP,水平可以使肺容积减少, PaO,2,降低,52,PEEP/FiO,2,的调整,推荐意见,降低,PEEP,之前应当首先降低,FiO,2,以避免肺泡塌陷,一般情况下,FiO,2,应当减低到, 5 min),时,如果没有观察到氧合下降,则需要每日进行一次或两次肺复张,未知,85,总结,肺复张是肺保护性通气策略的重要组成,开放肺并维持肺开放是其理论基础,应用气道高压使塌陷肺泡开放,应用足够的,PEEP,维持肺泡开放,肺复张对循环的影响,肺复张尚未解决的问题,压力,时间,频率,适应症,86,87,PEEP,能否使肺复张,?,PEEP,能够防止肺泡塌陷,(derecruitment),低水平的,PEEP,只能使很少的肺复张,对于,ARDS,将压力持续维持在常用的,PEEP,水平,( 20 cmH,2,O),只能使小部分肺组织复张,88,PEEP,能否使肺复张,?,ARDS,患者的肺复张贯穿于整个吸气过程,by Hickling AJRCCM 1998,Tidal recruitment occurs below optimal PEEP,