ARDS患者的肺复张-北协和杜斌教授

Vt, ml
LVt (n = 15)
411 55
CVt (n = 15)
664 84
P value < 0.01
Vt, ml/kg
61
10 1
< 0.01
setPEEP, cmH2O
10 4
10 4
n.s.
PEEPtot, cmH2O
11 4
11 4
n.s.
Pplat, cmH2O
23 8 30 10 < 0.01
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
小潮气量通气的问题
LVt (n = 15)
CVt (n = 15)
P value
PaO2, mmHg PaO2/FiO2, mmHg SaO2, % PaCO2, mmHg pH
136 80 165 84 94.8 5.0 60 35 7.21 0.1
百度文库
156 82 183 83 97.6 2.1 38 21 7.36 0.1
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
50
47
7.2 0.2§ 10.4 0.2§
47
38
7.3 0.1¶ 10.2 0.1¶
50
46
6.3 0.1¶ 11.7 0.1¶
31
40
7.3 0.9¶ 10.2 1.2¶
34
55
P值 < 0.001
0.72 0.38 0.60 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
– 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:
剪切力
PL:
跨肺压
V0: 最初容积
V:
复张后容积
如果: PL = 30 cmH2O, V0/V = 1/10 则:
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
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.
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
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
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
1 hr
4 hrs
ARDSp ARDSexp
6 hrs
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
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.
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
小潮气量通气的问题
肺复张的各种方法
CPAP (SI) incremental PEEP PCV Sigh (modified) HFOV 俯卧位 …
SI改善氧合
PaO2/FiO2
250
200
150
100
50
0 baseline
Sustained Inflation: 45 cmH2O x 30 s
15 min
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
ARDS的肺保护性通气策略
作者 Amato Stewart Brochard Brower ARDSnet Villar
患者数
小潮气量
对照
29
24
60
60
58
58
26
26
432
429
50
45
潮气量
病死率
小潮气量
对照
小潮气量
对照
6.1 0.2† 11.9 0.5†
38
71
7.2 0.8‡ 10.6 0.2‡
叹气对氧合及呼吸力学的影响
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
SI改善氧合
PaO2/FiO2
400
300
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
肺泡的开放压与闭合压
肺泡开放压与闭合压
50
Opening
pressure
40
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.
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
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
n.s. n.s. < 0.05 < 0.001 < 0.001
SBP, mmHg
125 25
121 20
n.s.
DBP, mmHg
60 9
60 10
n.s.
HR, bpm
101 15
93 15
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