ARDS患者的肺复张讲解课件.ppt
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- ARDS 患者 肺复张 讲解 课件
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1、北京协和医院杜斌内容w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题内容w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题ARDS的肺保护性通气策略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、.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041ARDS的肺保护性通气策略w 小潮气量(6 ml/kg IBW)避免过度膨胀造成的容积伤(volutrauma)w 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=PL x(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积
3、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 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 valueVt,ml411 55664 84 0.01Vt,ml/kg6 110 1 0.01setPEEP,cmH2O10 410 4n.s.PEEPtot,cmH2O11 411 4n.s.Pplat,cmH
4、2O23 830 10 0.01Richard 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 valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,mmHg165
5、 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 25121 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 R
6、ecruitment 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小潮气量通气的问题Richard JC
7、,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w 俯卧位w 足够的PEEPw 足够的潮气量和(或)叹气?w 肺复张手法肺复张手法w 减少水肿(?)w 最低可接受的FiO2(?)w 自主呼吸(?)内容w 小潮气量通气的问题w 肺复张
8、的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 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
9、,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低位转折点低位转折点之上仍有肺之上仍有肺组织复张组织复张肺泡的开放压与闭合压肺泡开放压与闭合压0102030405005101520253035404550Opening pressurePaw(cmH2O)Crotti S,Mascheroni D,Cai
10、roni 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 pressureARDS的肺开放RM能够使肺开放RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minHalter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto
11、 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 fo
12、r alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.肺复张的各种方法w CPAP(SI)w incremental PEEPw PCVw Sigh(modified)w HFOVw 俯卧位w SI改善氧合050100150200250baseline15 min1 hr4 hrs6 hrsPaO2/FiO2ARDSpARDSexpTugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L,Akpir K,Cakar N.
13、Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome:Focusing on pulmonary and extrapulmonary forms.Crit Care Med 2003;31:738-744Sustained Inflation:45 cmH2O x 30 sSI改善氧合0100200300400baselinepre-RM2 min post-RM 20 min post-RM 40 min
14、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 lung endothelial injury.Crit Care Med 2005;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval叹
15、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 cmH2OVt减少2 ml/kg前2次呼吸除外直至Vt 2 ml/kg,PE
16、EP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 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
17、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;159:872-880Sigh:3 consecutive sighs/min at Pplat 45 cmH2O叹气的设置Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh
18、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,s=3 5 sf=1 bpm叹气改善呼吸力学及氧合Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Ce
19、reda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94ARDS对RM的反应Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar JL,Fernandez R,Blanch L.Recruitment Maneuvers d
20、uring 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 i
21、njury.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w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw
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