ARDS肺复张的实施知识

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,邱海波,东南大学附属中大医院,ICU,东南大学急诊与危重病医学研究所,ARDS,肺复张的实施,科学与艺术的困惑,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,RM,ARDSnet:,小潮气量通气,Low Tidal Volumes,Traditional Tidal Volumes,P-,value,Death before discharge home and breathing without assistant(%),31.0,39.8,0.007,Breathing without assistance by days(%),65.7,55.0,0.001,NO of ventilator free days,Day1-28,12,11,10,11,0.007,Boratrauma,Day1-28(%),10,11,0.43,NO of days without failure of nonpulmonary organs or systems Day1-28,15,11,12,11,0.006,ARDS,Net.,N Engl J Med.2000 May 4;342(18):1301-8,.,Low tidal volume:more alv collapse,小,V,t,不能复张塌陷肺泡，加重低氧血症,实施肺保护性通气策略,至少1525%患者需提高,FiO2,邱海波,刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205,Collapsed,airway,V1,V2,Pressure,Volume,V1,V1+V2,Opening,pressure,Normal,ARDS,PEEP,adjustment,LIP：,塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力,PEEP not enough:more alv keep collapse,30,kg Pig,Post Lavage,PCV,Paw 13 cmH,2,O PEEP 5 cmH,2,O,Experimental study-Pig with ARDS,许红阳，邱海波,.ARDS,绵羊肺复张容积测定方法的比较,.,中国危重病急救医学，,2004,16:413.,邱海波,.PEEP,对,ARDS,肺复张容积及氧合影响的临床研究,.,中国危重病急救医学，,2004,16:399.,Clinical Trial,11 ARDS pats,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,RM,A.Hypoxamia,B.Shear forces,C.Surfactants inactivate,D.Biotrauma and MODS,Pathophysiology,Consolidation,and alv collapse,A.,低氧血症,肺泡塌陷：,ARDS,重力依赖区,炎症或不张区,生理性低氧缩血管反应：障碍,How,Does Excessive Mechanical,Stress Inflame the Lung?,“,Shear”,Verbrugge,et al.,Crit Care Med 1999;27：779,Ventilator-associated lung injury,Purine,:a marker of,ATP breakdown,and VILI,42 SD rats,PCV 6min,PCV Pre/PEEP,BALF,purine,and,protein,Lachmann.ICM,1994;20:6-11,Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way,1mg surfactant,=,inhibitory effect of 1mg plasma protein,C.Surfactant,灭活,Surfactant move away,When lung regions collapse at end expiration,surfactant molecules move away from the alv surface toward terminal bronchioles,and,cannot be reused during next inflation,Rouby JJ.Am J Respir Crit Care Med,2001,165:1182,D.,预防,Biotrauma,和,MODS,Marini JJ,Gattinoni L.Ventilatory management of acute respiratory distress syndrome:a consensus of two Crit Care Med.2004 Jan;32(1):250-5.,“,Stretch”,“,Shear”,Airway Trauma,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,RM,俯卧位通气的病理生理特征,改善通气过程,胸膜腔压力梯度,顺应性,胸壁,促进分泌物的清除,Closing,pressure,Closing,pressure,Time course of Prone on PaO2/FiO2,between ARDSp vs ARDSexp,Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp,黄英姿,邱海波,.,肺内外源性,ARDS,实施俯卧位通气时间的选择,.,中华内科杂志,2004,43(12):883-887,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,RM,保留自主呼吸的优点,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,RM,Paw cmH,2,O,%,Opening and Closing Pressures,0,5,10,15,20,25,30,35,40,45,50,0,10,20,30,40,50,Opening,pressure,Closing,pressure,5 patients,ALI/ARDS,From Crotti et al,AJRCCM 2001.,Some units cant,be kept open by,any reasonable PEEP!,Amato:CT+PV Curve,Heart,Sp,P,V,LIP,UIP,Insp recruit,Larger Vt/Sigh:Pressure must be high enough,Even up to UIP,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,High PEEP,RM,许红阳，邱海波,.ARDS,绵羊肺复张容积测定方法的比较,.,中国危重病急救医学，,2004,16:413.,邱海波,.PEEP,对,ARDS,肺复张容积及氧合影响的临床研究,.,中国危重病急救医学，,2004,16:399.,Clinical Trial,11 ARDS pats,Recruitment is Time-Dependent,40 SECONDS,内容提要,肺保护性通气策略不能解决解决的问题,肺泡塌陷的病理生理后果,肺复张的临床实施,Prone position,Spontaneous breathing,High VT and sigh,High PEEP,RM,Recruitment mannuvers,Basic Principles,Methods for Recruitment,Experimental Studies and Clinical Trials,Efficacy,Hazards,1.,控制性肺膨胀,(SI),法,2.PEEP,递增法,3.,压力控制,(PCV),法,Methods for Recruitment,CPAP,模式,:PS 0,PEEP 30-40 cmH2O,20-50s 2.BIPAP:Ph/PL 30-40cmH2O,20-50s 3.Insp Hold:,将吸气保持键按住，持续,20-40s,控制性肺膨胀,(SI),法,Multiple,Maneuvers May Be Needed For Optimum RM Effect,Fujino et al,Crit Care Med,2001;29(8):1579-1586,Post-RM PEEP Determines PaO,2,Averaged data from three models,RM,S-C Lim,CCM 2004,Transient Benefit,Post-RM-PEEP,肺开放效应持续时间的决定因素,CCM,2004,32:2371-2377,28 mixed-breed pigs,Models of ARDS:,OA,VILI,Pneumonia(PNM,),RM,SI,Increased PEEP,PCV,肺开放后的,PEEP,选择,-PaO,2,/FiO,2,1.RM,后,PEEP:20cmH,2,O,2.PEEP,递减,:2cmH,2,O/5min,3.PEEP,阈值,:,PaO,2,/FiO,2,5%,4.PEEP:,PEEP,阈值,+2cmH,2,O,BASELINE VENTILATION,Tidal volume=6ml/kg,PEEP=5cmH,2,O,Modify PEEP to get a,1.1,0.9,recruiting maneuver,Measure,1.1,0.9,Leave PEEP unchanged,stress index,0.9,1.1,Decrease PEEP until 1.1,stress index,0.9,Crit Care Med,2004,32:1018-1027,肺开放后的,PEEP,选择,-Stress index,Implications,RM,的有效性,ALI,的病因,(direct vs in direct),Post RM PEEP,Method in certain settings,RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury,PCV may be better tolerated than SI,Recommendations,Use PCV in preference to SI,Safer,“multiple”,effective,maintains ventila