ARDS患者的肺复张-北协和杜斌教授

ARDS患者的肺复张北京协和医院杜斌内容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ARDS的肺保护性通气策略患者数潮气量病死率作者小潮气量对照小潮气量对照小潮气量对照P值Amato29246.10.2†11.90.5†38710.001Stewart60607.20.8‡10.60.2‡50470.72Brochard58587.20.2§10.40.2§47380.38Brower26267.30.1¶10.20.1¶50460.60ARDSnet4324296.30.1¶11.70.1¶31400.007Villar50457.30.9¶10.21.2¶34550.041ARDS的肺保护性通气策略小潮气量(6ml/kgIBW)–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)肺泡塌陷与复张造成的剪切力F=PLx(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=30cmH2O,V0/V=1/10则:F=140cmH2OMeadJ,TakishimaT,LeithD.Stressdistributioninlungs:amodelofpulmonaryelasticity.JApplPhysiol1970;28(5):596-608小潮气量通气的问题LVt(n=15)CVt(n=15)PvalueVt,ml41155664840.01Vt,ml/kg611010.01setPEEP,cmH2O104104n.s.PEEPtot,cmH2O114114n.s.Pplat,cmH2O23830100.01RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613小潮气量通气的问题LVt(n=15)CVt(n=15)PvaluePaO2,mmHg1368015682n.s.PaO2/FiO2,mmHg1658418383n.s.SaO2,%94.85.097.62.10.05PaCO2,mmHg603538210.001pH7.210.17.360.10.001SBP,mmHg1252512120n.s.DBP,mmHg6096010n.s.HR,bpm101159315n.s.RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613小潮气量通气的问题RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613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(?)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HicklingKG.Thepressure-volumecurveisgreatlymodifiedbyrecruitment.AmathematicalmodelofARDSlungs.AmJRespirCritCareMed1998:158:194-202.JonsonB,RichardJC,StrausC,ManceboJ,LemaireF,BrochardL.Pressure–VolumeCurvesandComplianceinAcuteLungInjury:EvidenceofRecruitmentAbovetheLowerInflectionPoint.AmJRespirCritCareMed1999;159:1172-1178低位转折点之上仍有肺组织复张肺泡的开放压与闭合压肺泡开放压与闭合压0102030405005101520253035404550OpeningpressurePaw(cmH2O)CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed2001:164:131-140.ClosingpressureARDS的肺开放EditorialOpenupthelungandkeepthelungopenB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands(1992)18:319-321RM能够使肺开放RM:PIP45cmH2O,PEEP35cmH2Ox1minHalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626肺复张能够改善ARDS氧合LapinskySE,AubinM,MehtaS,BoiteauP,SlutskyAS:Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure.IntensiveCareMed1999,25:1297-1301.肺复张的各种方法CPAP(SI)incrementalPEEPPCVSigh(modified)HFOV俯卧位…SI改善氧合050100150200250baseline15min1hr4hrs6hrsPaO2/FiO2ARDSpARDSexpTugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed2003;31:738-744SustainedInflation:45cmH2Ox30sSI改善氧合0100200300400baselinepre-RM2minpost-RM20minpost-RM40minpost-RM60minpost-RMPaO2/FiO2FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed2005;33:181-188SustainedInflation:30cmH2Ox30sTwicewith1mininterval叹气的设置LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260充气阶段,每30秒PEEP增加5cmH2OVt减少2ml/kg前2次呼吸除外直至Vt2ml/kg,PEEP25cmH2O暂停阶段CPAP30cmH2Ofor30s放气阶段叹气改善氧合LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260叹气对氧合及呼吸力学的影响PelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880Sigh:3consecutivesighs/minatPplat45cmH2O叹气的设置PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh=1.2xPIPpsvor35cmH2OTi,s=3–5sf=1bpm叹气改善呼吸力学及氧合PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94ARDS对RM的反应Villag