呼吸机所致肺损伤与肺保护性通气策略

():100020,(ALI),(ventilator2inducedlunginjury,VILI)VILIALI,ALI1.:():,,,,,,2.[1]:Dreyfuss()(),,,(volumedamage)(overstretch)3.[2]:ALI,,,ALI,(shearingforce)4.[3]:,,,VILI[427],ALI,,VILIVILI,:,(),,(PEEP);,PEEP,,,,,PEEPVILI,PEEPVILIALI,2(P2V)S(lowerinflectionpoint,LIP),(Pinflex)PEEPPinflex,,,(upperinflectionpoint,UIP),Pdeflex,,,,P2V:(1)(super2syringemethod):,13L,50200ml,15s,2P2V4050cmH2O,,,(6090s),(2)(ventilatormethod):,,XYP2V,(inspirationhold)35s,,,,(3)(lowflowmethod):(25L/min,),,P2VP2V,,,,,P2V:(1)P2V,,(2)Pinflex,(3)PEEP,,PEEP,53620015258110NatlMedJChina,May25,2001,Vol81,No.10©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.1Amato[8](1998)Brocchard[9](1998)Brower[10](1999)Stewart[11](1998)NIH[12](2000)LIS2.5,PCWP16LIS2.5Pao2/FiO2200Pao2/FiO2250Pao2/FiO23005311652120861VTVTVT6ml/kgVT=610ml/kgVT8ml/kgIBWVT=8ml/kgVT=6ml/kgIBWVT=12ml/kgCPAPVT1015ml/kgVT1012ml/kgIBWVT1015ml/kgIBWVT=12ml/kgIBWPEEPVTPflex+2cmH2O015cmH2O,PaO2/FiO2520cmH2O,PaO2/FiO2520cmH2O,PaO2/FiO2PaO2/FiO2(VT)Pplat(cmH2O)3037263225322228253234PEEP(cmH2O)16711111099789VT(mlml/kg)3507707107107116.211.8PaCO2(mmHg)553260415040544645%71%347%38%50%46%50%47%31%39.8%37%42%314%12%4%8%10%7%10%11%:VT:;LIS:;MV:;IBW:;PIP:;Pplat:;Pflex:P2V;Pdrive:,3VT,P0.05(4),(DO2)QS/QTPEEP812cmH2O,,,68ml/kg,3035cmH2O,,PaCO2,,(permissivehypercapnia,PHC)PHC,,,PHCPaCO2,pH7.20,,,,1[8],AmatoNIHALI,:(1)PEEP;(2);(3)NIHPEEPALI,,Amato(recruitmentmaneuver,RM),,ALI,RM,(2),,,AmatoALI,(sigh),RM,RMALI,():11??212?1DreyfussD,SaumonG.Ventilator2inducedlunginjury:lessonsfromexperimentalstudies.AmJRespirCritCareMed,1998,157:2942323.2SlutskyAS.LungInjuryCausedbyMechanicalVentilation.Chest,1999,116:9S215S.3TremblayLN,SlutskyAS.Ventilator2inducedinjury:frombarotraumatobiotrauma.ProcAssocAmPhysicians,1998,110:4822488.4BernardGR,ArtigasA,BrighamRL,etal.ReportoftheAmerican2EuropeanconsensusconferenceonARDS:definitions,mechanisms,relevantoutcomesandclinicaltrialcoordination.IntensiveCareMed,1994,20:2252232.5ArtigasA,BernardGR,CarletJ,etal.TheAmerican2EuropeanconsensusconferenceonARDS,part2:ventilatory,pharmacologic,supportivetherapy,studydesignstrategies,andissuresrelatedtorecoveryandremodeling.AmJRespirCritCareMed,1998,157:133221347.63620015258110NatlMedJChina,May25,2001,Vol81,No.10©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.6TobinMJ,BrochardL,etal.Respiratorypressure2volumecurves.In:TobinMJeds.Principlesandpracticeofintensivecaremonitoring1NewYork:McGram2HillCompaniesInc,1998.5972616.7RussellJ,etal.Internationalconsensusconferenceinintensivecaremedicine:ventilator2associatedlunginjuryinARDS.IntensiveCareMed,1999,25:144421452.8AmatoMB,BarbasCS,MedeirosDM,etal.Effectofaprotectivestrategyonmortalityintheacuterespiratorydistresssyndrome.NEnglJMed,1998,338:3472354.9BrochardL,ThoravalF,RoupieE,etal.Tidalvolumereductionforpreventionofventilator2inducedlunginjuryinacuterespiratorydistresssyndrome.TheMulticenterTrailGrouponTidalVolumereductioninARDS.AmJRespirCritCareMed,1998,158:183121838.10BrowerR,ShanhokltzC,ShadeD,etal.Randomizedtrialofsmalltidalvolumeventilation(STV)inARDS.CritCareMed,1999,27:149221498.11StewartTE,MeadeMO,etal.Evaluationofaventilationstrategytopreventbarotraumainpatientswithhighriskforacuterespiratorydistresssyndrome.NEnglJMed,1998,338:3552361.12TheAcuteRespiratoryDistressSyndromeNetwork..Ventilationwithlowertidalvolumesascomparedwithtraditionaltidalvolumesforacutelunginjuryandtheacuterespiratorydistresssyndrome.NEnglJMed,2000,342:130121308.(:2001204225)(:)2001,:;;:2:8001000(),A4,:510600,17,:200161520019,,11:20019396(92)21:31:41600,51:,,61(1):(2)800(3)(),,,(4)42100710,(5):200153071:;:[phone],65122268,65221435;:(010)6523417781:73620015258110NatlMedJChina,May25,2001,Vol81,No.10©1995-2005TsinghuaTongfangOpticalDiscCo.,Ltd.Allrightsreserved.