肺复张术与PEEP调定PPT课件

According to oxygenation
The PEEP or PAW preceding that causing the PaO2 decrease was considered optimal. until the target PaO2 decreased by more than 10% from the above target level.

Vt
too high too
Pplateau
high
PIP=14, PEEP=0 PIP= 45, PEEP=10
PIP= 45, PEEP = 0
Webb&Tierney ARRD 1974;110;556
Inciting Event
PMNs/Macs Proteases O2 radicals Endothelium Epithelium
Adhesion Coagulation Proteins Cytokines
PAF
ENA-78
IL-6 TNF-a IL-8
MIP-1a
IL-10
LTC4
LTB4
LPB
IL-8-RA
Transferrin
Complement
PEEP=? RM ? Pplateau=? VT=? PIP=? Mode ?
• Multiple occlusion
• Linear ramping – (Hamilton Galilio Gold)

Oxygenation
• PaO2 drop >10%

Recognizable? And percentage of them? Is this Pdeflex constant over time? Or RM? Is Pdeflex after RM repeatable? Is PEEP on Pdeflex clinically practical? Not answered yet
3000
2500
Open-lung PEEP 18 cmH2O Incremental PEEP 25 Decremental PEEP 15 Incremental PEEP 20 Decremental PEEP 10 Decr PEEP 5 Incremental PEEP 10 cmH2O
2000
Volume (ml)
1500
1000
500
40
30 20
Opening pressure Closing pressure
%பைடு நூலகம்
10
0 0 5
5 patients, ALI / ARDS
10 15 20 25 30 35 40 45 50 Airway Pressure [cmH2O]

Methodology
• Sustained inflation • Stepwise Recruitment Strategy

Is it practical for clinical? Possible. Is continuous PaO2 practical? Not yet. SpO2 is probably a useful tool
Figure 2
Hickling K. AJRCCM 2001;163:69-78.
Recruitment Maneuver & PEEP Titration
肺复张术与PEEP调定

Overdistention
• Barotrauma • Volutrauma
Recruitment/Derecruitment Injury Translocation of Cells Biotrauma
1.0
PEEP
5
5
8
8
10
10
10
12
14
14
14
16
18
20-24
EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME
Titrating PEEP fellowing RM

Recruitment Maneuver and PV curve hysteresis
Opening and Closing Pressures
50
Am J Respir Crit Care Med Vol 164. pp 131–140,2001 Marini & Gattinoni
Amato: 2004 China
1. PEEP / FIO2 target (≈
8～14
cmH2O)
2. PEEP at PFLEX
(≈ 14～18
cmH2O)
3. PEEP enough to fully avoid airway collapse
(≈ 16～26
cmH2O)
FiO2
0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9
Lung protective ventilation in ARDS: the open lung maneuver 450 mmHg on pure oxygen. When a lung is “open”

Pdeflex + 2cmH2O, (PV curve)
• Super-syringe • Low-flow
• Pressure control
• with prone position, with HFOV, et al

Titrating PEEPdeflex after RM
• PV curve (looking for Pdeflex)
• Oxygenation (PaO2 drop >10%)
FULL RECRUITMENT: PaO2 + PaCO2 > 400 mmHg FiO2=100%
“maximum
difference of 11 cm H2O for the same patient” AM J RESPIR CRIT CARE MED 2000;161:432–439. R. SCOTT HARRIS, DEAN R. HESS, and JOSÉ G. VENEGAS