1、ARDS患者的肺复张 北京协和医院 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 ARDS的肺保护性通气策略 患者数患者数 潮气量潮气量 病死率病死率 作者作者 小潮气量小潮气量 对照对照 小潮气量小潮气量 对照对照 小潮气量小潮气量 对照对照 P值值 Amato 29 24 6.1 0.2 11.9 0.5 38 71 0.0
2、01 Stewart 60 60 7.2 0.8 10.6 0.2 50 47 0.72 Brochard 58 58 7.2 0.2 10.4 0.2 47 38 0.38 Brower 26 26 7.3 0.1 10.2 0.1 50 46 0.60 ARDSnet 432 429 6.3 0.1 11.7 0.1 31 40 0.007 Villar 50 45 7.3 0.9 10.2 1.2 34 55 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(atelec
3、trauma)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: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 LVt(n=15)CVt(n=15)P value Vt,ml 411 55 664 84 0.01 Vt,ml/kg 6 1
4、 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 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;163:1609-1
5、613 小潮气量通气的问题 LVt(n=15)CVt(n=15)P value PaO2,mmHg 136 80 156 82 n.s.PaO2/FiO2,mmHg 165 84 183 83 n.s.SaO2,%94.8 5.0 97.6 2.1 0.05 PaCO2,mmHg 60 35 38 21 0.001 pH 7.21 0.1 7.36 0.1 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
6、 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 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:Respect
7、ive Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613 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 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 pressu
8、re-volume curve is greatly modified by recruitment.A mathematical model of ARDS lungs.Am J Respir Crit Care Med 1998:158:194-202.Jonson B,Richard JC,Straus C,Mancebo J,Lemaire F,Brochard L.PressureVolume Curves and Compliance in Acute Lung Injury:Evidence of Recruitment Above the Lower Inflection Po
9、int.Am J Respir Crit Care Med 1999;159:1172-1178 低位转折点低位转折点之上仍有肺之上仍有肺组织复张组织复张 肺泡的开放压与闭合压 肺泡开放压与闭合压 0 10 20 30 40 50 0 5 10 15 20 25 30 35 40 45 50 Opening pressure Paw(cmH2O)Crotti S,Mascheroni D,Caironi P,Pelosi P,Ronzoni G,Mondino M,Marini JJ,Gattinoni L.Recruitment and derecruitment during acute
10、respiratory failure:a clinical study.Am J Respir Crit Care Med 2001:164:131-140.Closing pressure 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 RM能够使肺开放 RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 min H
11、alter 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 肺复张能够改善ARDS氧合 Lapinsky SE,Aubin M,Mehta S,Boiteau P,Slutsky
12、 AS:Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.肺复张的各种方法 CPAP(SI)incremental PEEP PCV Sigh(modified)HFOV 俯卧位 SI改善氧合 050100150200250baseline15 min1 hr4 hrs6 hrsPaO2/FiO2ARDSpARDSexpTugrul S,Akinci O,Ozca
13、n 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 Sustained Inflation:45 cmH2O x 30 s SI改善氧合 0100200300400base
14、linepre-RM2 min post-RM 20 min post-RM 40 min post-RM 60 min post-RMPaO2/FiO2Frank 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 Sustained Infl
15、ation:30 cmH2O x 30 s Twice with 1 min interval 叹气的设置 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 充气阶段
16、,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 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 叹气对氧合及呼吸力学的影响 Pelosi P,Cadringher P,Bottino N,Panigada M,Carrieri F,Riva E,Lissoni A,Gattinoni L.Sigh in acute respiratory distress syndrome.Am J Respi
