ARDS患者肺复张课件.ppt
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- ARDS 患者 肺复张 课件
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1、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患者数患者数潮气量潮气量病死率病死率作者作者小潮气量小潮气量对照对照小潮气量小潮气量对照对照小潮气量小潮气量对照对照P值值Amato29246.1 0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.247380.38
2、Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041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)F=PL x(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积V:复张后容积如果:PL=30 cmH2O,V0/V=1/10则:F=140 cmH2OMead J,Takishima T,Leith D.Stress distribut
3、ion in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):596-608LVt(n=15)CVt(n=15)P valueVt,ml411 55664 84 0.01Vt,ml/kg6 110 1 0.01setPEEP,cmH2O10 410 4n.s.PEEPtot,cmH2O11 411 4n.s.Pplat,cmH2O23 830 10 0.01Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tida
4、l Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,mmHg165 84183 83n.s.SaO2,%94.8 5.097.6 2.1 0.05PaCO2,mmHg60 3538 21 0.001pH7.21 0.17.36 0.1 0.001SBP,mmHg125 251
5、21 20n.s.DBP,mmHg60 960 10n.s.HR,bpm101 1593 15n.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;163:1609-1613Richard JC,Maggiore SM,Jonson B,Mancebo J
6、,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俯卧位足够的PEEP足够的潮气量和(或)叹气?肺复张手法肺复张手法减少水肿(?)最低可接受的FiO2(?)自主呼吸(?)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Hickl
7、ing 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 Lo
8、wer Inflection Point.Am J Respir Crit Care Med 1999;159:1172-1178低位转折点低位转折点之上仍有肺之上仍有肺组织复张组织复张0102030405005101520253035404550Opening pressurePaw(cmH2O)Crotti S,Mascheroni D,Caironi P,Pelosi P,Ronzoni G,Mondino M,Marini JJ,Gattinoni L.Recruitment and derecruitment during acute respiratory failure:a cl
9、inical study.Am J Respir Crit Care Med 2001:164:131-140.Closing pressureRM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minHalter 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/Derecrui
10、tment.Am J Respir Crit Care Med 2003;167:1620-1626Lapinsky 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.CPAP(SI)incremental PEEPPCVSigh(modified)HFOV俯卧位05010015020
11、0250baseline15 min1 hr4 hrs6 hrsPaO2/FiO2ARDSpARDSexpTugrul 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 2
12、003;31:738-744Sustained Inflation:45 cmH2O x 30 s0100200300400baselinepre-RM2 min post-RM 20 min post-RM 40 min post-RM 60 min post-RMPaO2/FiO2Frank JA,McAuley DF,Gutierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lu
13、ng endothelial injury.Crit Care Med 2005;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min intervalLim 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
14、:A preliminary study.Crit Care Med 2001;29:1255-1260充气阶段,每30秒PEEP增加5 cmH2OVt减少2 ml/kg前2次呼吸除外直至Vt 2 ml/kg,PEEP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段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
15、 acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260Pelosi 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;159:872-880Sigh:3 consecutive sighs/min at Pplat 45 cm
16、H2OPatroniti 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;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,
17、s=3 5 sf=1 bpmPatroniti 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;96:788-94Villagra A,Ochagavia A,Vatus S,Murias G,Fernan
18、dez 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;165:165-170Henzler D,Mahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determine the eff
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