EELV监测对ARDS机械通气治疗的指导意义课件

,*,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,*,EELV,监测对,ARDS,机械通气治疗的指导意义,EELV监测对ARDS机械通气治疗的指导意义,ARDS,病死率居高不下,Crude 60-day Mortality Among ARDS Network Patients, 1996-2005,Crit Care Med. 2009; 37(5): 15741579.,ARDS 病死率居高不下Crude 60-day Morta,ARDS,病理生理改变,大量肺泡塌陷,肺容积减小,肺顺应性降低,HEART,SP,小潮气量,-,限制平台压力,RM,PEEP,ARDS病理生理改变大量肺泡塌陷HEARTSP小潮气量-限制,内容提要,FRC,监测重要性,FRC,测定与评估方法,FRC,对,ARDS,机械通气治疗的指导意义,FRC,测定的准确性及对的疗效评估,指导,RM,指导,PEEP,选择,指导撤机,内容提要FRC监测重要性,Static Lung Volumes,功能残气量,(FRC),：平静呼气后，肺脏所含的气量,Static Lung Volumes功能残气量(FRC)：,功能残气量的生理意义,容量 “储备库”,防止肺泡和气道萎陷,避免分流,降低呼吸做功,预计值,120%,为增高, 预计值120%为增高,Factors Affecting FRC,Increased FRC,肺弹性回缩力下降,肺气肿或衰老,部分气道阻塞,气道狭窄或受挤压,Decreased FRC,肺顺应性下降,肺纤维化、表面活性物质缺乏,胸廓变形,Factors Affecting FRCIncreased,ARDS,肺泡塌陷,In ARDS patients, FRC decrease significantly,healthy subject (- - -); patients with ARDS (),Eur Respir J.2003;,22: 22s26s.,ARDS肺泡塌陷In ARDS patients, FRC,FRC,and EELV,FRC,：,appears to be a very promising tool for monitoring lung recruitment,FRC and EELVFRC：appears to be,内容提要,FRC,监测重要性,FRC,测定与评估方法,FRC,对,ARDS,机械通气治疗的指导意义,FRC,测定的准确性及对的疗效评估,指导,RM,指导,PEEP,选择,指导撤机,内容提要FRC监测重要性,FRC,测定方法,体积描记法,影像法,气体分析法,氦气稀释法,氮气洗出法,重复呼吸氮气洗出法,FRC测定方法体积描记法,体积描记法,坐入密闭体积描记仪,测平静呼气末肺泡压（,P1,）,和肺容积（,FRC,）,阻断咬口器,测吸气时肺泡压变化,(P),和肺容积变化,(V),波义耳定律,(,一定量气体,V*P=k),P1 * FRC = P2 *,（,FRC + V,）,体积描记法 坐入密闭体积描记仪波义耳定律(一定量气体V*P=,CT,影像法,-,金标准,Overly,aerated,1000,900,HU,Nnderaerated,500,100 HU,N,onaerated,100,+100 HU,N Engl J Med.2006;354:1775-1786.,N,ormally aerated,900,500 HU,CT影像法-金标准Overly aerated Nnder,EIT,影像法,Before RM,After RM,Pats ventilated with same tidal volumes before and after RM,max.,min.,EIT影像法 Before RM After RMPats,CT and EIT,EIT,床旁实时监测 需要特殊设备,肺横断面截面容积相对变化,与全肺容积的变化不呈线性关系,30 %,35 %,15 %,20 %,CT and EITEIT30 %35 %15 %20 %,氦气稀释法,质量守恒定律,C,1, V,1,= C,2, ( V,1,+ FRC),平静呼气末吸入已知浓度和体积的氦气,重复呼吸直到氦气达到平衡,测定氦气浓度,氦气稀释法质量守恒定律平静呼气末吸入已知浓度和体积的氦气,氮气洗出法,质量守恒定律,C,1, FRC= C,2, V,2,经过三通单向吸入纯氧,呼出气经过单向阀收集到,密闭容器内,测定收集气内,N,2,浓度和容积,氮气洗出法质量守恒定律 经过三通单向吸入纯氧,ETN,2,(1),is the last recorded value after the step change,改变,FiO,2,0.10,机械通气,20,次左右，直至呼出气,N,2,浓度稳定,测定每次呼出气浓度和容积,计算每次呼吸,N,2,量的变化,FRC ?,O,2,FRC,N,2,?,O,2,?,FRC ?,N,2,?,O,2,?,FRC,O,2,F,I,O,2,=,N,2,washin,F,I,O,2,=,N,2,washout,FRC ?,O,2,FRC,N,2,?,O,2,?,N,2,?,O,2,?,O,2,F,I,O,2,=,N,2,washin,F,I,O,2,=,N,2,FRC ?,重复呼吸,N,2,洗出法,ETN2(1) is the last recorded v,EELV监测对ARDS机械通气治疗的指导意义课件,重复呼吸,N,2,洗出法影响因素,呼吸节律不规则,潮气量变异度大,激动,应用条件,:,VCO,2,EtO,2,EtCO,2,稳定, Fi,O,2,40 65%,重复呼吸N2洗出法影响因素 呼吸节律不规则应用条件: VC,内容提要,FRC,监测重要性,FRC,测定与评估方法,FRC,对,ARDS,机械通气治疗的指导意义,FRC,测定的准确性及对的疗效评估,指导,RM,指导,PEEP,选择,指导撤机,内容提要FRC监测重要性,改良氮气洗入,/,洗出方法测定,EELV,的准确性,Respir Care 2010;55(11):1464 1468.,6,只健康家猪,单侧胸水模型（,13 ml/kg,；,26 ml/kg,）,改良的氮气洗入,/,洗出方法,vs. CT,扫描,改良氮气洗入/洗出方法测定EELV的准确性Respir Ca,Respir Care 2010;55(11):1464 1468.,改良氮气洗入,/,洗出方法测定,EELV,的准确性,Respir Care 2010;55(11):1464 ,肺泡死腔对于改良的氮气洗入,/,洗出方法的影响,10,只健康家猪,肺泡灌洗复制急性肺损伤模型,全肺复张后,PEEP,递减（,20 4cmH2O,）,CT,扫描和 改良的氮气洗入,/,洗出方法测定,EELV,容积二氧化碳图测定肺泡死腔,依据最低,VDalv/VTalv,将测量数据分为高,PEEP,组和低,PEEP,组,肺泡死腔对于改良的氮气洗入/洗出方法的影响10只健康家猪,肺泡死腔对于改良的氮气洗入,/,洗出方法的影响,低,PEEP,组,测量误差均值,:,11.2 97.2 ml,测量误差的,95%,可信区间,:,-179.4201.8 ml.,肺泡死腔对于改良的氮气洗入/洗出方法的影响低PEEP组,高,PEEP,组,(,死腔增加,)-CT,法与改良的氮气洗入,/,洗出方法测定的相关性降低,高,PEEP,组,测量误差均值,:,-168.1 171.5 ml,测量误差的,95%,可信区间,:,-502.4168.0 ml.,低估,高PEEP组(死腔增加)-CT法与改良的氮气洗入/洗出方法测,肺泡死腔对于改良的氮气洗入,/,洗出方法的影响,高,PEEP,组,测量误差与肺泡死腔、过度膨胀肺组织呈相关性,肺泡死腔对于改良的氮气洗入/洗出方法的影响高PEEP组,FRC,可评估,PEEP,所致肺容积改变,Crit Care Med 2010; 38:1300 1307.,10 sedated MV ARDS pats,FRC is affected by PEEP,FRC可评估PEEP所致肺容积改变Crit Care Med,FRC,测定评估治疗效果,Pediatr Pulmonol.2004; 38:5563.,62 very low birth weight infants,FRC measured by the nitrogen washout method,Randomized to two dose of dexamethasone,high dose(2.35 mg/kg tapered over 7 days),low dose(1 mg/kg tapered over 7 days),The lower total dose effective as the higher in increasing FRC,FRC测定评估治疗效果Pediatr Pulmonol.20,内容提要,FRC,监测重要性,FRC,测定与评估方法,FRC,对,ARDS,机械通气治疗的指导意义,FRC,测定的准确性及对的疗效评估,指导,RM,指导,PEEP,选择,指导撤机,内容提要FRC监测重要性,Lung recruitablity in ALI/ARDS,To most ALI pts, lung recruitability was low,To ARDS pts, lung recruitability varied largely from pt to pt,N Engl J Med, 2006,354: 1775-1786.,Lung recruitablity in ALI/ARDS,肺的可复张性的评估,64 ARDS pats,高可复张,(,可复张的肺组织,9%),氧合及顺应性差，病死率高,N Engl J Med, 2006,354: 1775-1786.,肺的可复张性的评估64 ARDS pats高可复张(可复,EELV,测定评价肺可复张性,30,名,ARDS,患者分别给予,2,个,PEEP,水平：,低,PEEP5-9cmH2O,高,PEEPExpress,研究（,Pplat 28-30cmH2O,）,改良的氮气洗入,/,洗出方法测定,EELV,，流速法测定,FRC,（,at ZEEP),依据肺复张容积（,Recestim,）是否高于中位值将患者分为,high recruiter,和,low recruiter,EELV/FRC,评价患者肺可复张性（应用,ROC,曲线）,Intensive Care Med, 2011,37(10):1595-1604.,Low recruiters 55% 2370,High recruiters 110% 76135,EELV测定评价肺可复张性30名ARDS患者分别给予2个PE,FRC,评估肺复张的效果,RM and PEEP were needed to increase and maintain the increased lung volume,Acta Anaesthesiol Scand.2004;,48: 187197,30 MV pats after cardiac surgery,SI 45cmH,2,O for 10-s for RM,Measure EELV, RM followed with ZEEP, RM followed with PEEP of 12cmH2O, PEEP of 12cmH2O without RM,FRC评估肺复张的效果RM and PEEP were ne,FRC,可评估吸痰后肺泡塌陷,Applied Cardiopulmonary Pathophysiology. 2008;12: 27-32,20 postoperative ventilated cardiac surgery pats,FRC可评估吸痰后肺泡塌陷Applied Cardiopul,FRC is reduced after suctioning, regardless of which method is used,routine estimation of FRC could be used to find who would benefit from a RM after suction,Anesth Analg. 2008; 107: 941944.,评估去复张后肺复张时机,CS-PCV, closed suctioning with PCV,CS-VCV, closed suctioning with VCV,OS, open suctioning,Negative pressure of 200 cm H,2,O,was applied for 20 s,postoperative cardiac surgery patients (,n=20),FRC is reduced after suctionin,EELV,测定指导吸痰后肺复张,59,名心脏外科术后患者,非密闭式吸痰,氧气洗入,/,洗出方法测定,EELV,（,T1,吸痰前，,T2,，吸痰后,15,，,T3,，吸痰后,30,，,T4,，吸痰后,45,，,T5,，吸痰后,60),依据吸痰后,EELV,是否低于基础值,94%,将患者分为：,Group A,：,FRC 94% + RM,Group A: FRC 94% + no RM,Group B: FRC 94% + RM,Group B: FRC 94% + no RM,Crit Care Med 2011; 39:10421049,EELV,测量可以识别吸痰后需要实施肺复张的患者,EELV测定指导吸痰后肺复张59名心脏外科术后患者Crit,FRC,指导吸痰后,RM,PEEP=0 cmH,2,O,PEEP=5 cmH,2,O,Suction,PEEP=5 cmH,2,O,Suction,SI 30cmH,2,O*30s,PEEP=5 cmH,2,O,Suction,SI 30cmH,2,O*30s,PEEP=10 cmH,2,O,东南大学附属中大医院重症医学科,1 pneumonia , ARDS patient,FRC指导吸痰后RMPEEP=0 cmH2OPEEP=5 c,动态监测,FRC,指导,RM,注：,吸痰后与吸痰前相比,p,0.05,，,肺复张后与吸痰后相比,p, 0.05,吸痰和肺复张后肺呼吸力学，氧合和,FRC,的变化,东南大学附属中大医院重症医学科,8,例机械通气患者,动态监测FRC指导RM注：吸痰后与吸痰前相比, p0.0,FRC,动态监测指导,RM,吸痰和吸痰后肺复张对,FRC,的影响,(n=8),注：,吸痰后与吸痰前基础状态相比,p,0.05,，,*,肺复张后与吸痰后相比,p,5 cm H,2,O,PEEP increased from ZEEP to 150% of PEEPi,FRC measured by inductive plethysmography,Crit Care Med. 2005;33:1519 1528.,PEEP can be used in pts with paradoxic response under CMV,A, paradoxic response,VT 6 mL/kg RR 9 breaths/min,B, biphasic response ,VT 9 mL/kg RR 6 breaths/min,C, classic overinflation response,VT 9 mL/kg RR 9 breaths/min,COPD/哮喘患者PEEP 的选择4 Asthma and,FRC,指导,ARDS,的,PEEP,选择,Combined FRC and Crs measurements may help to identify the optimal level of PEEP,Critical Care.,2008, 12:R91.,6 pigs,Oleic acid,Measure FRC,Change of PEEP from 20 cm H,2,O to 0 cm H,2,O by steps of 5 cm H,2,O,FRC指导ARDS的PEEP选择Combined FRC a,Eur J Anaesthesiol 2010;27:508513,FRC,用于指导麻醉患者,PEEP,的选择,After anaesthesia, EELV markedly reduced,PEEP led to significant improvements in EELV and respiratory mechanics,Preoperative FRC:,nonobese 2861682 ml,the obese 2173403 ml,Eur J Anaesthesiol 2010;27:508,FRC,用于指导选择,PEEP,1 pneumonia patient,东南大学附属中大医院重症医学科,SI 30cmH,2,O, 30s,PEEP INview,NICO,同步测定,VD/VT,、,Cst,FRC用于指导选择PEEP1 pneumonia patie,FRC,用于指导选择,PEEP,1 pneumonia patient,SI 30cmH,2,O, 30s,PEEP INview,NICO,同步测定,VD/VT,、,Cst,东南大学附属中大医院重症医学科,FRC用于指导选择PEEP1 pneumonia patie,内容提要,FRC,监测重要性,FRC,测定与评估方法,FRC,对,ARDS,机械通气治疗的指导意义,FRC,测定的准确性及对的疗效评估,指导,RM,指导,PEEP,选择,指导撤机,内容提要FRC监测重要性,FRC,指导撤机,Premature Infants with IRDS (n=20),FRC,：,helium gas dilution,Extubation failed in 7 Succeeded in 13,Pediatr Pulmonol.1996;,21: 250-254.,FRC指导撤机Premature Infants with,撤机过程中,FRC,的变化,10 postoperative cardiac,surgery patients,Ventilatory protocol,BIPAP10 (PEEP 10cmH,2,O),BIPAP 7 (PEEP 7cmH,2,O),CPAP7-1 (PEEP 7cmH,2,O),CPAP7-2 (PEEP 7cmH,2,O),FRC measured by oxygen washout,Anesth Analg.2009;108: 911915.,Relative change of FRC,Decreasing FRC during the weaning process, this variable could help guide a weaning protocol has to be studied further,撤机过程中FRC的变化10 postoperative ca,小结,重复呼吸,N,2,洗出法可准确的在床旁监测,EELV,EELV,的变化是反应肺复张的良好指标,床旁,EELV,的监测，可用于,评估治疗效果,指导,RM,实施,指导,PEEP,选择,撤机？,小结重复呼吸N2洗出法可准确的在床旁监测EELV,Thank you for your attention!,Thank you for your attention!,