ARDS病人的机械通气课件.ppt

1、Small Tidal volumeVentilation in ARDSHaibo QiuDepartment of Critical Care MedicineZhong-Da hospital and School of Clinical MedicineSoutheast UniversityRational for small tidal volume ventilationAm J Respir Crit Care Med,2001,164:17011711.HEARTSPARDS-Gattinoni分区分区1.1.过度通气区或过度通气区或“干区干区”“baby lungbaby

2、lung2.2.可复张区或湿区可复张区或湿区3.3.实变实变区区Controversy in small tidal volume ventilationSmall tidal volume and PplatSmall tidal volume and alveolar decruitmentSmall tidal volume and alveolar overinflationSmall tidal volume and PEEPiHow to set tidal volume?Crit Care Med,2005,33:1141-1143.Mechanical ventilation

3、in ARDS:One size does not fit all Am J Respir Crit Care Med,2002,166:15101514.Am J Respir Crit Care Med,2005,172:12411245.N=15Devided into the ARDSnet and the stress index strategyARDSnetStress indexAm J Respir Crit Care Med Vol 176.pp 761767,2007ARDSnetStress indexThe level of IL-6 at the end of st

4、udyAlveolar hyperinflation in patients with focal ARDS ventilated with the ARDSnet protocol is attenuated by a physiologic approach to PEEP setting based on the stress index measurement.Controversy in small tidal volume ventilationSmall tidal volume and PplatSmall tidal volume and alveolar decruitme

5、ntSmall tidal volume and alveolar overinflationSmall tidal volume and PEEPiHow to set tidal volume?TIDAL recruitment end-expiration end-inspiration*P0.05 between LVt and CVt;*P0.01Am J Respir Crit Care Med,2001,163:16091613.*P0.01 vs.PlipVt6;#P0.01 vs.PlipVt10;$P0.05 vs.PlipVt6Crit Care Med,2003,31:

6、8992.Controversy in small tidal volume ventilationSmall tidal volume and PplatSmall tidal volume and alveolar decruitmentSmall tidal volume and alveolar overinflationSmall tidal volume and PEEPiHow to set tidal volume?TIDAL hyperinflation end-expiration end-inspiration more protected patients less p

7、rotected patientsAm J Respir Crit Care Med,2007,175:160166.Controversy in small tidal volume ventilationSmall tidal volume and PplatSmall tidal volume and alveolar decruitmentSmall tidal volume and alveolar overinflationSmall tidal volume and PEEPiHow to set tidal volume?Am J Respir Crit Care Med,20

8、02,165:12711274.*/*P0.01Intensive Care Med,2002,28:10781083.Crit Care Med,2005,33:527532.Controversy in small tidal volume ventilationSmall tidal volume and PplatSmall tidal volume and alveolar decruitmentSmall tidal volume and alveolar overinflationSmall tidal volume and PEEPiHow to set tidal volum

9、e?How to set tidal volume the best ventilatory strategy should be ideally adapted to the size of the aerated lungIntensive Care Med,2005,31:776784.Lung stress and strainpatients with ALI/ARDS control subjectsAm J Respir Crit Care Med,2008,178:346355.Smaller tidal volume in ARDS?l Evidence that the A

10、RDSnet strategy is injurious in some more severe patientsl Is 6ml/kg small enough,and is Pplat30cmH2O sufficient in these patients?NO!A rat model of acid-induced lung injuryVentilated with different Vt and PEEP Measure ELWI、RTI40Am J Respir Crit Care Med 2002 165.242The smaller,the better?J Appl Phy

11、siol,2007,103:15511559.严重严重ARDS患者肺容积减小非患者肺容积减小非常严重，即使给予常严重，即使给予6ml/kg的潮的潮气量平台压仍然很高气量平台压仍然很高而较低的平台压有好的肺保护而较低的平台压有好的肺保护作用作用使用更小的潮气量来降低平台使用更小的潮气量来降低平台压，通过增加压，通过增加PEEP以及使用以及使用veno-veno bypass清除清除CO2Anesthesiology,2009,111:82635.Anesthesiology,V 111,No 4,Oct 2009Patients in ARDSnet 28Pplat30*p0.001 betwe

12、en two groups at study entry p0.05 after 72h in ARDSnet 25Pplat28 p0.05 after 72h in ARDSnet 28Pplat30Anesthesiology,2009,111:82635.25Pplat28entryafter 72h28Pplat30 entry after 72hARDS Shallow and rapid breathingVolume of alv is determined by vagus reflex feedback Hering-Breuer reflexPaCO2 How to se

13、t Vt for pat with ARDS?0.02.04.06.08.010.012.014.0Pre-DualPre-DualDual-ALIDual-ALIDual-RtVagoDual-RtVagoDual-DualVagoDual-DualVagoVt/kg(ml/kg)How to set Vt for pat with ARDS?02468101214163040506070Vt(ml/kg)PaCO2(mmHg)Effect of PaCO2 on tidal volume at dual lung or single lung with or without ALIPre

14、ALI-L2Pre ALI-L1ALI-L2ALI-L1How to set Vt for pat with ARDS?CO2 removal-to keep PaCO2 stableCO2 removal-to keep PaCO2 stable Hering-Breuer reflex-Major item for Vt Hering-Breuer reflex-Major item for Vt How to set Vt for pat with ARDS?Ventilatory feedbackNeurally Adjusted Ventilatory Assist(NAVA)Sin

15、derby C,Nat Med 1999;5:14331436New technologyHow to set Vt?CO2 removal+EAdi guided MVConclusion We should reduce tidal volume in patients with ALI/ARDS The more physiological rational to set tidal volume is based on stress/strain In some more severe patients,smaller tidal volume may be used Smaller tidal volume may not always be better