ARDS患者的肺复张

小潮气量通气的问题
LVt (n = 15) Vt, ml Vt, ml/kg 411 55 61 CVt (n = 15) 664 84 10 1 P value < 0.01 < 0.01
setPEEP, cmH2O
PEEPtot, cmH2O Pplat, cmH2O
10 4
肺泡的开放压与闭合压
肺泡开放压与闭合压
50 40
Opening pressure Closing pressure
30
20 10 0 0 5 10 15 20 25 30 35 40 45 50
Paw (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.
ARDS的肺开放
Editorial
Open up the lung and keep the lung open
B. Lachmann
Dept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands
(1992) 18:319-321
Frank JA, McAuley 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: 181-188
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
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
Hickling KG. The pressure-volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998: 158: 194-202.
小潮气量通气的问题
LVt (n = 15) PaO2, mmHg PaO2/FiO2, mmHg 136 80 165 84 CVt (n = 15) 156 82 183 83 P value n.s. n.s.
SaO2, %
PaCO2, mmHg pH SBP, mmHg DBP, mmHg HR, bpm
肺复张的各种方法
CPAP (SI) incremental PEEP PCV Sigh (modified) HFOV 俯卧位 …
SI改善氧合
250 200
PaO 2/FiO 2
150
100
50
Sustained Inflation: 45 cmH2O x 30 s
baseline 15 min 1 hr 4 hrs
ARDSp ARDSexp
6 hrs
0
Tugrul S, Akinci O, Ozcan PE, Ince, 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: 738-744
– 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 = PL x (V0/V)2/3
F: PL: V0 : V: 如果: 则: 剪切力 跨肺压 最初容积 复张后容积 PL = 30 cmH2O, V0/V = 1/10
F = 140 cmH2O
Mead J, Takishima T, Leith D. Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 1970; 28(5): 596-608
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
RM能够使肺开放
RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 min
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
SI改善氧合
400
300
PaO 2/FiO 2
200
100
0 baseline pre-RM
Sustained Inflation: 30 cmH2O x 30 s Twice with 1 min interval
2 min post-RM 20 min post-RM 40 min post-RM 60 min post-RM
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
11 4 23 8
10 4
11 4 30 10
n.s.
n.s. < 0.01
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
低位转折点 之上仍有肺 组织复张
Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. Pressure–Volume 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
ARDSnet
Villar
432
50
429
45
6.ຫໍສະໝຸດ Baidu 0.1¶
7.3 0.9¶
11.7 0.1¶
10.2 1.2¶
31
34
40
55
0.007
0.041
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
ARDS的肺保护性通气策略
患者数 作者 Amato Stewart Brochard Brower 小潮气量 29 60 58 26 对照 24 60 58 26 潮气量 小潮气量 6.1 0.2† 7.2 0.8‡ 7.2 0.2§ 7.3 0.1¶ 对照 11.9 0.5† 10.6 0.2‡ 10.4 0.2§ 10.2 0.1¶ 病死率 小潮气量 38 50 47 50 对照 71 47 38 46 P值 < 0.001 0.72 0.38 0.60
94.8 5.0
60 35 7.21 0.1 125 25 60 9 101 15
97.6 2.1
38 21 7.36 0.1 121 20 60 10 93 15
< 0.05
< 0.001 < 0.001 n.s. n.s. n.s.
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
肺复张能够改善ARDS氧合
Lapinsky 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.
叹气的设置
充气阶段, 每30秒 PEEP增加5 cmH2O Vt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 cmH2O for 30 s 放气阶段
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
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