nullARDS肺复张的实施ARDS肺复张的实施邱海波
东南大学附属中大医院ICU
东南大学急诊与危重病医学研究所科学与艺术的困惑内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
RM ARDSnet: 小潮气量通气ARDSnet: 小潮气量通气ARDS Net. N Engl J Med. 2000 May 4;342(18):1301-8.Low tidal volume: more alv collapseLow tidal volume: more alv collapse小Vt不能复张塌陷肺泡,加重低氧血症
实施肺保护性通气策略
至少15~25%患者需提高FiO2
邱海波, 刘大为, 陈德昌等. 中华麻醉学杂志, 1998, 18: 202-205PEEP not enough: more alv keep collapseLIP:塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力PEEP not enough: more alv keep collapsenull30 kg Pig
Post Lavage
PCV
Paw 13 cmH2O PEEP 5 cmH2OExperimental study-Pig with ARDSnull许红阳,邱海波. ARDS绵羊肺复张容积测定方法的比较. 中国危重病急救医学, 2004, 16: 413.
邱海波. PEEP对ARDS肺复张容积及氧合影响的临床研究. 中国危重病急救医学,2004, 16: 399.Clinical Trial-11 ARDS pats内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
RM nullA. Hypoxamia
B. Shear forces
C. Surfactants inactivate
D. Biotrauma and MODSPathophysiology
Consolidation and alv collapsenullA .低氧血症肺泡塌陷:ARDS重力依赖区
炎症或不张区
生理性低氧缩血管反应:障碍
nullHow Does Excessive Mechanical
Stress Inflame the Lung?“Shear”nullVerbrugge et al. Crit Care Med 1999;27:779Ventilator-associated lung injuryPurine: a marker of
ATP breakdown
and VILI
42 SD rats
PCV 6min
PCV Pre/PEEP
BALF purine and
proteinnullLachmann. ICM, 1994; 20:6-11Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way
1mg surfactant
=
inhibitory effect of 1mg plasma proteinC. Surfactant 灭活 Surfactant move away Surfactant move away When lung regions collapse at end –expiration, surfactant molecules move away from the alv surface toward terminal bronchioles
and
cannot be reused during next inflationRouby JJ. Am J Respir Crit Care Med, 2001, 165: 1182 D. 预防Biotrauma和MODSD. 预防Biotrauma和MODSMarini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two Crit Care Med. 2004 Jan;32(1):250-5.“Stretch”“Shear”Airway Trauma内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
RM 俯卧位通气的病理生理特征俯卧位通气的病理生理特征改善通气过程
胸膜腔压力梯度
顺应性胸壁
促进分泌物的清除Closing
pressureClosing
pressurenullTime course of Prone on PaO2/FiO2
between ARDSp vs ARDSexp Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp 黄英姿, 邱海波. 肺内外源性ARDS实施俯卧位通气时间的选择.
中华内科杂志2004, 43(12):883-887内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
RM 保留自主呼吸的优点保留自主呼吸的优点内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
RM nullPaw [cmH2O] %Opening and Closing Pressures05101520253035404550010203040505 patients,
ALI / ARDSFrom Crotti et al
AJRCCM 2001.
Some units can’t
be kept open by
any reasonable PEEP!Amato: CT + PV CurveAmato: CT + PV CurveHeartSpPVLIPUIPInsp recruitLarger Vt/Sigh: Pressure must be high enough
Even up to UIP 内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
High PEEP
RM null许红阳,邱海波. ARDS绵羊肺复张容积测定方法的比较. 中国危重病急救医学, 2004, 16: 413.
邱海波. PEEP对ARDS肺复张容积及氧合影响的临床研究. 中国危重病急救医学,2004, 16: 399.Clinical Trial-11 ARDS patsRecruitment is Time-DependentRecruitment is Time-Dependent~ 40 SECONDS内容提要内容提要肺保护性通气策略不能解决解决的问题
肺泡塌陷的病理生理后果
肺复张的临床实施
Prone position
Spontaneous breathing
High VT and sigh
High PEEP
RM Recruitment mannuvers Recruitment mannuversBasic Principles
Methods for Recruitment
Experimental Studies and Clinical Trials
Efficacy
Hazards
null1. 控制性肺膨胀(SI)法
2. PEEP递增法
3. 压力控制(PCV)法Methods for RecruitmentCPAP模式:
PS 0, PEEP 30-40 cmH2O, 20-50s
2. BIPAP:
Ph /PL 30-40cmH2O, 20-50s
3. Insp Hold:
将吸气保持键按住,持续20- 40sCPAP模式:
PS 0, PEEP 30-40 cmH2O, 20-50s
2. BIPAP:
Ph /PL 30-40cmH2O, 20-50s
3. Insp Hold:
将吸气保持键按住,持续20- 40s控制性肺膨胀(SI)法Multiple Maneuvers May Be Needed For Optimum RM EffectMultiple Maneuvers May Be Needed For Optimum RM EffectFujino et al, Crit Care Med 2001; 29(8):1579-1586Post-RM PEEP Determines PaO2Post-RM PEEP Determines PaO2Post-RM-PEEP-
肺开放效应持续时间的决定因素CCM, 2004, 32: 2371-237728 mixed-breed pigs
Models of ARDS:
OA
VILI
Pneumonia(PNM)
RM
SI
Increased PEEP
PCV肺开放后的PEEP选择----PaO2/FiO2肺开放后的PEEP选择----PaO2/FiO21. RM后 PEEP: 20cmH2O
2. PEEP递减: 2cmH2O/5min
3. PEEP阈值:
PaO2/FiO2<400的PEEP
或PaO2/FiO2 降低>5%
4. PEEP:
PEEP阈值 +2cmH2O
肺开放后的PEEP选择---- Stress indexBASELINE VENTILATION
Tidal volume=6ml/kg
PEEP=5cmH2OModify PEEP to get a
1.1>b>0.9recruiting maneuverMeasureb1.1>b>0.9
Leave PEEP unchangedb<0.9
Increase PEEP until 1.1>stress index >0.9b>1.1
Decrease PEEP until 1.1>stress index >0.9Crit Care Med, 2004, 32: 1018-1027肺开放后的PEEP选择---- Stress indexImplicationsImplicationsRM 的有效性
ALI的病因 (direct vs in direct)
Post RM PEEP
Method in certain settings
RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury
PCV may be better tolerated than SIRecommendationsRecommendationsUse PCV in preference to SI
Safer, “multiple”, effective, maintains ventilation, simple
Monitor hemodynamics during recruiting interval.
以下情况需重复作RM: 体位改变, 管路断开, 呼吸力学特征或PaO2明显恶化
对于顽固性难治性ARDS患者, 可考虑反复RM和更高的压力
Employ Prone Position and/or PEEP to consolidate RM benefit.