ards患者的肺复张北京协和医院.pptx

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1、内容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第1页/共119页内容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第2页/共119页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 0.810.6 0.250470.72

2、Brochard58587.2 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第3页/共119页ARDS的肺保护性通气策略小潮气量(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)第4页/共119页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V:复张后容积如

3、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第5页/共119页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,cm

4、H2O23 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第6页/共119页小潮气量通气的问题LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/Fi

5、O2,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 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 PE

6、EP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613第7页/共119页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

7、第8页/共119页受损的肺组织如何复张俯卧位足够的PEEP足够的潮气量和(或)叹气?肺复张手法减少水肿(?)最低可接受的FiO2(?)自主呼吸(?)第9页/共119页内容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第10页/共119页肺泡的开放压与闭合压第11页/共119页PEEP不能使肺复张第12页/共119页LIP:仅仅是肺复张的开始Hickling KG.The pressure-volume curve is greatly modified by recruitment.A mathemati

8、cal model of ARDS lungs.Am J Respir Crit Care Med 1998:158:194-202.第13页/共119页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

9、点之上仍有肺组织复张第14页/共119页肺泡的开放压与闭合压第15页/共119页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:

10、164:131-140.Closing pressure第16页/共119页ARDS的肺开放EditorialOpen up the lung and keep the lung openB.LachmannB.LachmannDept.of Anesthesiology,Erasmus University Rotterdam,The Dept.of Anesthesiology,Erasmus University Rotterdam,The NetherlandsNetherlands(1992)18:319-321(1992)18:319-321第17页/共119页RM能够使肺开放RM

11、: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/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626第18页/共119页肺复张能够改善ARDS氧合L

12、apinsky 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.第19页/共119页肺复张的各种方法CPAP(SI)incremental PEEPPCVSigh(modified)HFOV俯卧位第20页/共119页SI改善氧合Tugrul S,Akinci O,Ozcan PE,I

13、nce,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 2003;31:738-744Sustained Inflation:45 cmH2O x 30 s第21页/共119页SI改善氧合Frank JA,McAuley

14、 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第22页/共119页叹气的设置Lim CM,Koh Y,Park W,Chin JY,Shim

15、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,PEEP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放

16、气阶段第23页/共119页叹气改善氧合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第24页/共119页叹气对氧合及呼吸力学的影响Pelosi P,Cadringh

17、er 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第25页/共119页叹气的设置Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improve

18、s 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第26页/共119页叹气改善呼吸力学及氧合Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM

19、,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94第27页/共119页ARDS对RM的反应Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar JL,Fernandez R,Blanch L.Recruitmen

20、t Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome.Am J Respir Crit Care Med 2002;165:165-170第28页/共119页肺复张 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

21、 in experimental lung injury.Eur Radiol 2006;16:1351-1359第29页/共119页肺复张 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第30页/共119页内容小潮

22、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第31页/共119页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第32页/共119页R

23、M 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第33页/共119页RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morph

24、ometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第34页/共119页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

25、Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第35页/共119页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第36页/共119页内容小潮气量通气的

26、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第37页/共119页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(%)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,H

27、rmann 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 Syndrome.Anesthesiology 2004;101:620-5第38页/共119页为什么肺复张作用不能持久?肺复张的方法?SI:50 cmH2O x 30 s作者认为Oczenski W,Hrm

28、ann 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 Syndrome.Anesthesiology 2004;101:620-5第39页/共119页RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Le

29、e 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 position of the patient.Crit Care Med 2003;31:411-418第40页/共119页RM+PEEP vs.RM vs.PEEPLim CM,Jung

30、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 position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM only第41页

31、/共119页RM后的PEEP第42页/共119页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/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626第43页/共119页RM后的PEEP能够稳

32、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 Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:162

33、0-1626第44页/共119页肺泡稳定能够改善PaO2McCann UG,Schiller HJ,Gatto LA,et al.Alveolar mechanics alter hypoxic ulmonary vasoconstriction.Crit Care med 2002;30:1315-1321第45页/共119页RM后的PEEPLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in thr

34、ee models of acute lung injury.Crit Care Med 2004;32:2371-2377第46页/共119页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 Med 2004;32:2371-2377RM+PEEPPEEP only第47

35、页/共119页PEEP的设置RM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平最初将PEEP设置为20 cmH2O然后将FiO2减小到最低水平维持SpO2 90 95%每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降第48页/共119页PEEP的设置氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP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第49页/共119页PEEP的设置如果将PEEP设置于20 cmH2O后,仍发现PaO2/FiO2显著下降按照最

36、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第50页/共119页PEEP的设置将PEEP从不必要的高水平逐渐降低不要将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降低第51页/共119页PEEP/FiO2的调整推荐意见降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷一般情况下FiO2应当减低到 5 min)时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第84页/共119页总结肺复张是肺保护性

37、通气策略的重要组成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维持肺泡开放肺复张对循环的影响肺复张尚未解决的问题压力时间频率适应症第85页/共119页第86页/共119页PEEP能否使肺复张?PEEP能够防止肺泡塌陷(derecruitment)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第107页/共119页第108页/共119页The P-V CurveOn the inflation limb of the curvelower inflection point(Pflex)a region of ch

38、anging slope in early inflation where lung recruitment beginsthe minimal PEEP necessaryto prevent partial derecruitment of the lung during exhalation第109页/共119页The P-V CurveOn the expiratory limbthe point of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during

39、 exhalationthe maximum PEEP requiredto prevent derecruitment第110页/共119页The P-V Curvethese two“points”identify the range of PEEP needed in ARDSPflex=the minimumPMCEX=the maximumIdeally,a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEP第111页/共

40、119页第112页/共119页第113页/共119页第114页/共119页第115页/共119页RM后的PEEP影响PaO2Lim 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 Med 2004;32:2371-2377第116页/共119页第117页/共119页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.第118页/共119页感谢您的观看。第119页/共119页