俯卧位通气

单击此处编辑母版标题样式,Page,#,单击此处编辑母版文本样式,第二级,第三级,第四级,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,Page,#,单击此处编辑母版文本样式,第二级,第三级,第四级,俯卧位通气的实践,细节,时机,？疗程？操作流程？风险,？,四川大学华西医院,重,症医学科,王 波,提纲,俯卧位通气的生理学机制,俯卧位通气适应症与禁忌症,俯卧位通气的实施,俯卧位通气的平安性,小结,ARDS,柏林定义,轻度,中度,重度,起病,急性起病，一周内因已知病因导致的新发,/,恶化的呼吸综合征,低氧血症,使用,PEEP/CPAP5,PaO2/FiO2 201300,使用,PEEP/CPAP5,PaO2/FiO2 200,使用,PEEP/CPAP10,PaO2/FiO2 100 with,水肿原因,不能完全用心衰或液体过负荷解释的呼吸衰竭,影像学改变,双肺斑片影,双肺斑片影,斑片影累及,3/4,肺区,其他生理学,紊乱,N/A,N/A,VEcorret 10 L/min or Crs 40 ml/cmH2O,*,Not fully explained by effusions, nodules, masses, or lobar/lung collapse; use training set of CXRs,*Need objective assessment if no risk factor present (see table),VEcorr = VE x PaCO2 / 40 (corrected for Body Surface Area),ARDS,的病理生理,肺容积明显降低,肺泡水肿,肺泡外表活性物质的消耗或缺乏,肺间质水肿压迫远端细支气管,肺顺应性明显降低,通气/血流比例失调,肺内分流和死腔样通气,Mild ARDS,Moderate ARDS,Severe ARDS,PaO2/FiO2,Increasing Severity of Lung Injury,Low Tidal Volume Ventilation,300,250,200,150,100,50,Increasing Intensity of Intervention,Higher PEEP,NIV,Low-Moderate PEEP,Prone Positioning,ECCO2-R,NMB,iNO,HFOV,ECMO,小潮气量不能解决所有问题,小潮气量,(n = 15),常规潮气量,(n = 15),P value,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,PaCO,2, mmHg,60, 35,38, 21, 0.001,pH,7.21, 0.1,7.36, 0.1,5,FIO2 0.6,平均,PaO2/FIO2,127,152,105,113,100,实际,PEEP,10,8,7,10,10,开始时间,未设定,12-24,48,72,12-24h,俯卧位通气禁忌症,绝对禁忌症,脊柱不稳定,未监测的颅内压升高,相对禁忌症,开放性腹部伤,多发,创伤伴不稳定骨折,妊娠,严重血流动力学不稳定,气道与血管通路高依赖,俯卧位,通气临床操作,俯卧,位通气临床操作,肥胖患者,CHEST 2021; 143(6):15541561,俯卧位,通气实施,PS I,2001,Guerin,2004,Mancebo,2006,PS,II,2009,PROSEVA,2013,设计俯卧时间,6 h/d,8 h/d,20 h/d,20 h/d,16 h/d,实际俯卧时间,7h,9h,17,18h,17h,设计俯卧疗程,10 d,直至撤机,直至撤机,直至撤机,至,PaO2/FIO2,150,PEEP5,FIO2 0.6,设计俯卧疗程,5d,4d,10d,8d,4d,Rivalet al. Critical Care2021,15:R125,俯卧位通气的联合治疗,气体,交换明显改善,不良反响,俯卧位操作有关,气道阻塞,氧饱和度一过性降低,低血压、心率失常、血管活性药物需求增加,静脉通路脱落,气管插管移位,气管切开移位,不良反响,俯卧位疗程有关,压,疮,增加镇静,/,肌,松,呕吐,神经与视网膜血管压迫,不良反响,压疮,Intensive Care Med (2021) 40:397403,压疮,心跳骤停,俯卧位通气与预后,目的：评价早期使用俯卧位通气治疗重症,ARDS,的治疗效果。,多中心前瞻随机对照研究,纳入,466,例重度,ARDS,患者,主要终点指标：,28d,全因病死率,次要终点指标：,90d,病死率，拔管成功率，拔管时间,N Engl J Med 2021;368:2159-68,纳入标准,ARDS (AECC,标准,);,气管插管机械通气时间,36h;,PaO2/FiO2 150 mmHg (Fio2 0.6, PEEP 5 cmH2O Vt,6 ml/kg PBW).,干预措施,俯卧位通气,俯卧通气次数,44 per patient,每次俯卧通气时间,173 hours,俯卧通气时间比例,73%,辅助治疗措施,ECMO 2.6% vs. 0.8%,NO 15.7% vs. 9.7%,研究结果,病死率,P,P,研究结果,时间指标,Supine Group(N = 229),Prone Group (N = 237),P,值,住,ICU,时间,(90,天评价,),存活组,2627,2422,0.05,死亡组,1815,2120,无机械通气时间,28,天,1010,149,0.001,90,天,4338,5734,0.001,研究结果,拔管率,Supine Group(N = 229),Prone Group (N = 237),P,值,90,天成功拔管率,145/223,(65.0 58.771.3),186/231,(80.5 75.485.6),0.001,成功拔管时间,存活组,1921,1716,0.87,死亡组,1611,1814,大型研究结果,PS I,2001,Guerin,2004,Mancebo,2006,PS,II,2009,PROSEVA,2013,随访时间,6mo,90d,出院,6mo,90d,死亡率,俯卧,vs,仰卧,62.5% vs. 58.6%,43.3% vs. 42.2%,50.0% vs. 60.0%,47.0% vs. 52.3%,23.6% vs. 41.0%,P,值,0.50,0.74,0.22,0.33,0.001,同途疏归？,Crit Care Med2021;42:12521262,大型研究结果,PS I,2001,Guerin,2004,Mancebo,2006,PS,II,2009,PROSEVA,2013,随访时间,6mo,90d,出院,6mo,90d,死亡率,俯卧,vs,仰卧,62.5% vs. 58.6%,43.3% vs. 42.2%,50.0% vs. 60.0%,47.0% vs. 52.3%,23.6% vs. 41.0%,P,值,0.50,0.74,0.22,0.33,0.001,肺保护通气,否,否,是,Vt,10 ml/kg,是,Vt,8ml/kg,是,Vt=6 ml/kg,俯卧位时间大于,10,小时,否,否,是,是,是,严重,ARDS,部分,部分,部分,部分,是,小结,如何做好俯卧位通气？,俯卧位团队,医生、护士、呼吸治疗师和伤口治疗师,严格选择适宜的病人,PaO2/FiO2150mmHg,及早开始俯卧位,联合保护性通气策略,谢谢,