ARDS患者的肺复张医学ppt课件.ppt

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1、ARDS患者的肺复张北京协和医院杜斌幸运内容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肺复张存在的问题幸运内容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肺复张存在的问题幸运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 1.234550.041幸运ARDS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)幸运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

3、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 distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):596-608幸运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

4、,cmH2O23 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幸运小潮气量通气的问题LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,m

5、mHg165 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 a

6、nd a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613幸运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幸运受损的肺组织如何复

7、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(?)幸运内容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肺复张存在的问题幸运肺泡的开放压与闭合压幸运PEEP不能使肺复张幸运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

8、Respir Crit Care Med 1998:158:194-202.幸运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 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幸运肺泡的开放压与闭合压幸

9、运肺泡开放压与闭合压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 clinical study.Am J Respir Crit Care Med 2001:164:131-140.Closing pressure幸运ARDS的肺开放E

10、ditorialOpen up the lung and keep the lung openB.LachmannB.LachmannDept.of Anesthesiology,Erasmus University Rotterdam,The NetherlandsDept.of Anesthesiology,Erasmus University Rotterdam,The Netherlands(1992)18:319-321(1992)18:319-321幸运RM能够使肺开放RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minHalter JM,Steinberg

11、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/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626幸运肺复张能够改善ARDS氧合Lapinsky SE,Aubin M,Mehta S,Boiteau P,Slutsky AS:Safety and effi

12、cacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.幸运肺复张的各种方法wCPAP(SI)wincremental PEEPwPCVwSigh(modified)wHFOVw俯卧位w幸运SI改善氧合Tugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L,Akpir K,Cakar N.Effects of sustained inflation and

13、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 s幸运SI改善氧合Frank JA,McAuley DF,Gutierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained

14、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幸运叹气的设置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 recru

15、itment 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,PEEP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段幸运叹气改善氧合Lim CM,Koh Y,Park W,Chin JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mechanistic s

16、cheme 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幸运叹气对氧合及呼吸力学的影响Pelosi P,Cadringher P,Bottino N,Panigada M,Carrieri F,Riva E,Lissoni A,Gattinoni L.Sigh in acute respiratory distress syn

17、drome.Am J Respir Crit Care Med 1999;159:872-880Sigh:3 consecutive sighs/min at Pplat 45 cmH2O幸运叹气的设置Patroniti 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

18、Ventilation.Anesthesiology 2002;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,s=3 5 sf=1 bpm幸运叹气改善呼吸力学及氧合Patroniti 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 Unde

19、rgoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94幸运ARDS对RM的反应Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez 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;165:165-170

20、幸运肺复张 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幸运肺复张 CT的提示Henzler D,Mahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Mul

21、tislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359幸运内容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肺复张存在的问题幸运RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Mor

22、phometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Comput

23、ed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运RM vs.PEEPLim CM,Lee SS,Lee JS,

24、Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Man

25、euver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运内容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肺复张存在的问题幸运为什么肺复张作用不能持久?baseline3 min post-RM30 min post-RMPaO2/FiO2(mmHg)139 46246 111138 39PaCO2(mmHg)48.6 12.147.6 1346.4 12SvO2(

26、%)70.4 6.172.4 5.670 6.2Qs/Qt(%)30.8 5.821.5 9.729.2 7.4Crs(ml/cmH2O)34.1 12.636.9 15.135.7 13.5Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distr

27、ess Syndrome.Anesthesiology 2004;101:620-5幸运为什么肺复张作用不能持久?w肺复张的方法?SI:50 cmH2O x 30 sw作者认为Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Synd

28、rome.Anesthesiology 2004;101:620-5幸运RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body po

29、sition of the patient.Crit Care Med 2003;31:411-418幸运RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung i

30、njury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM only幸运RM后的PEEP幸运RM后的PEEP能够稳定肺泡Halter 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/Derecruit

31、ment.Am J Respir Crit Care Med 2003;167:1620-1626幸运RM后的PEEP能够稳定肺泡RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEEP 10 cmH2OHalter 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 Re

32、cruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626幸运肺泡稳定能够改善PaO2McCann UG,Schiller HJ,Gatto LA,et al.Alveolar mechanics alter hypoxic ulmonary vasoconstriction.Crit Care med 2002;30:1315-1321幸运RM后的PEEPLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomp

33、arison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377幸运RM+PEEP vs.PEEP onlyLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Me

34、d 2004;32:2371-2377RM+PEEPPEEP only幸运PEEP的设置wRM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平w最初将PEEP设置为20 cmH2Ow然后将FiO2减小到最低水平维持SpO2 90 95%w每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降幸运PEEP的设置w氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEPw一旦确认,则需重复肺复张操作,然后把PEEP和FiO2重新设置在上述水平对于多数ARDS患者,PEEP介于15 20 cmH2O之间某些患者 20 cmH2O幸运PEEP的设置w如果将PEEP设置于20 cmH2O

35、后,仍发现PaO2/FiO2显著下降按照最初的PEEP设置25 cmH2O重复肺复张然后按照上述方法调节FiO2和PEEP幸运PEEP的设置w将PEEP从不必要的高水平逐渐降低w不要将PEEP由低水平增加到高水平如同P-V曲线所示,根据设置方法不同,同样水平的PEEP所维持的肺容积不同如果在肺泡塌陷后设置PEEP(增加PEEP),则所设置的PEEP水平可以使肺容积减少,PaO2降低幸运PEEP/FiO2的调整推荐意见w降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷w一般情况下FiO2应当减低到 5 min)时w如果没有观察到氧合下降,则需要每日进行一次或两次肺复张未知幸运总结w肺复张是肺

36、保护性通气策略的重要组成w开放肺并维持肺开放是其理论基础应用气道高压使塌陷肺泡开放应用足够的PEEP维持肺泡开放w肺复张对循环的影响w肺复张尚未解决的问题压力时间频率适应症幸运幸运PEEP能否使肺复张?wPEEP能够防止肺泡塌陷(derecruitment)w低水平的PEEP只能使很少的肺复张对于ARDS,将压力持续维持在常用的PEEP水平(300 mmHg幸运幸运The P-V CurvewOn the inflation limb of the curvewlower inflection point(Pflex)a region of changing slope in early in

37、flation where lung recruitment beginsthe minimal PEEP necessaryto prevent partial derecruitment of the lung during exhalation幸运The P-V CurvewOn the expiratory limbwthe point of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during exhalationthe maximum PEEP req

38、uiredto prevent derecruitment幸运The P-V Curvewthese two“points”identify the range of PEEP needed in ARDSPflex=the minimumPMCEX=the maximumwIdeally,a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEP幸运幸运幸运幸运幸运RM后的PEEP影响PaO2Lim CM,Adams AB,Simon

39、son DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377幸运幸运肺泡开放压与闭合压0102030405005101520253035404550Opening pressureClosing 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 clinical study.Am J Respir Crit Care Med 2001:164:131-140.幸运