【医学课件】ARDS患者的肺复张-协和(杜斌)

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,北京协和医院,杜斌,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,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,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,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),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,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,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,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,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(?),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,肺泡的开放压与闭合压,PEEP不能使肺复张,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.,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,肺泡的开放压与闭合压,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,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,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,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.,肺复张的各种方法,CPAP (SI),incremental PEEP,PCV,Sigh (modified),HFOV,俯卧位,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,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,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,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,叹气对氧合及呼吸力学的影响,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,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,叹气改善呼吸力学及氧合,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,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,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,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,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,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,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,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,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,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,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,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,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,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 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,RM后的PEEP,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,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,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,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,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,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,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,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,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,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,如果降低PEEP导致氧合下降,应当重新设定PEEP,肺泡塌陷时不应增加FiO,2,肺复张后氧合稳定所需时间,Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, T Akpir. Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 2005; 33: 995-1000,= LIP + 2,肺复张后氧合稳定所需时间,Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, T Akpir. Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 2005; 33: 995-1000,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,不同RM方法的比较,基础通气方式,VCV: Vt 10 ml/kg, f 20 bpm, I:E 1:2, FiO,2,肺复张:,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,Mode,f,Vt/PC,PEEP,I:E,Time,Rpt,ViCM,CPAP,40,30”,3,PCRM,PCV,20,20,20,1:1,30”,3,SLRM,VCV,20,10,15,1:2,15,每分钟2次将吸气末暂停延长至7 s,不同RM方法的比较,Odenstedt H, Lindgren S, Olegard C, et al. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,SLRM,PCRM,ViCM,不同RM方法的比较,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,不同RM方法的比较,对于灌洗造成的急性肺损伤模型,缓慢低压复张操作可以,促进肺泡复张,减少对循环系统的抑制,避免对呼吸力学的不良影响,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,不同RM方法的比较,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,Sustained inflation,45 for 40 s,Incremental PEEP,PIP 35, PEEP 8 - 35,PCV,PIP 45, PEEP 16,I:E 1:2, 2 min,对于,VILI,模型,PCV,是,最佳的,RM,方法,其他模型结果相似,PEEP 8,PEEP 12,PEEP 16,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,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,RM保护肺内皮而非肺泡上皮,试验动物: 大鼠,模型制备: 酸(pH 1.5)吸入,机械通气:,Vt6 ml/kg,PEEP5 cmH,2,O,FiO,2,F60 70 bpm,复张操作:,30 cmH,2,O x 30 s x 2,间隔1分钟,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,RM保护肺内皮而非肺泡上皮,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,RM: ARDS早期 vs. 晚期,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,原发性ARDS对RM反应不佳,Saline lavage,Oleic acid injury,Pneumonia,Van der Kloot TE, Blanch L, Youngblood AM, Weinert C, Adams AB, Marini JJ, Shapiro RS, Nahum A. Recruitment Maneuvers in Three Experimental: Models of Acute Lung Injury Effect on Lung Volume and Gas Exchange. Am J Respir Crit Care Med 2000; 161: 1485-1494,Sustained inflation,CPAP 40/30,CPAP 60/30,CPAP 60/30,油酸损伤模型RM作用短暂,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,PEEP 8,PEEP 12,PEEP 16,不同病因对RM的反应,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,RM: ARDSp与ARDSexp,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,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,叹气: ARDSp与ARDSexp,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,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,RM不增加肺泡过度膨胀,Bugedo G, Bruhn A, Hernandez G, et al. Lung computed tomography during a lung recruitment maneuver in patients with acute lung injury. Intensive Care Med 2003; 29: 218-225,肺复张对内脏血流的影响,Nunes S, Rothen HU, Brander L, Takala J, Jakob SM. Changes in Splanchnic Circulation During an Alveolar Recruitment Maneuver in Healthy Porcine Lungs. Anesth Analg 2004; 98: 1432-8,肺复张对胃肠道血流的影响,Claesson J, Lehtipalo S, Winso D. Do lung recruitment maneuvers decrease gastric mucosal perfusion? Intensive Care Med 2003: 29: 1314-1321,肺复张对脑氧代谢的影响,Bein T, Kuhr LP, Bele S, Ploner F, Keyl C, Taeger K. Lung recruitment maneuver in patients with cerebral injury: effects on intracranial pressure and cerebral metabolism. Intensive Care Med 2002; 28: 554-558,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,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,即使使用足够的PEEP也不能使所有肺单位开放,RM对哪些患者疗效好?,尚不清楚肺复张对哪类患者疗效更好,肺复张对早期ARDS/ALI患者的效果更显著,随着ARDS的进展, 肺进入纤维增殖期,肺复张就无法有效改善氧合,气压伤的危险反而增加,RM对哪些患者疗效好?,ARDS的病因,继发性ARDS (全身性感染, 创伤等)比原发性ARDS (肺炎)更容易复张,目前的推荐意见,在ARDS/ALI病程早期进行肺复张,无论ARDS的病因如何,肺复张操作的频率,尚不清楚对某一患者进行肺复张操作的适宜频率,以下情况应进行肺复张操作,病程早期,当肺泡塌陷时,例如呼吸机脱开,肺复张操作的频率,对于ARDS患者,脱离呼吸机能够导致肺泡迅速塌陷, 从而发生严重的低氧血症,为避免呼吸机脱开, 建议采用,密闭吸痰装置,特殊雾化装置,肺复张操作的频率,肺复张操作,当观察到SpO,2,持续降低( 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,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,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,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, PEEP at the optimal level generally results in a decreased quasi-static compliance when measured on the ventilator,by Jonson et al AJRCCM 1999,肺复张所需的压力,正常潮气量通气也能使肺组织复张,但是, 大部分肺组织可能仍未充分复张,在有限的吸气时间内,在目标气道峰压水平,由于,塌陷肺泡表面液体的粘滞性,这些肺单位较高的表面张力,间质组织的限制,塌陷的肺组织需要较高的气道压力和较长的时间才能复张,How high a pressure?How long a time? - healthy lung,transpulmonary pressure of 30 cmH,2,O to recruit atelectatic healthy lungs,Greaves et al JAP 1990,peak alveolar pressures of 40 cmH,2,O for 7 to 15 seconds to recruit lungs of previously healthy normal patients following 20 minutes of general anesthesia,by Rothen et al Br J Anaesth 1993, 1998,resolution of atelectasis during a 40 cmH,2,O RM has a time constant of 2.6 sec,Rothen et al Br J Anaesth 1999,How high a pressure?How long a time? - healthy lung,As a result,in previously healthy individuals,the vast majority of atelectasis would be recruited within about 7-8 sec,How high a pressure?How long a time? - anima