1、邱海波东南大学附属中大医院ICU东南大学急诊(jzhn)与危重病医学研究所,ARDS肺复张的实施(shsh),科学与艺术(ysh)的困惑,第一页，共三十七页。,内容提要(ni rn t yo),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(ln chun)实施Prone positionSpontaneous breathingHigh VT and sighRM,第二页，共三十七页。,ARDSnet:小潮气量通气(tng q),ARDS Net.N Engl J Med.2000 May 4;342(18):1301-8.,第三页，共三十七页。,Low tidal v
2、olume:more alv collapse,小Vt不能复张塌陷肺泡(fipo)，加重低氧血症实施肺保护性通气策略至少1525%患者需提高FiO2,邱海波(hi b),刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205,第四页，共三十七页。,LIP：塌陷肺泡(fipo)开始复张的压力 不是全部塌陷肺泡(fipo)复张的压力,PEEP not enough:more alv keep collapse,第五页，共三十七页。,30 kg PigPost LavagePCVPaw 13 cmH2O PEEP 5 cmH2O,Experimental study-Pig with AR
3、DS,第六页，共三十七页。,许红阳，邱海波(hi b).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 Trial11 ARDS pats,第七页，共三十七页。,内容提要(ni rn t yo),肺保护性通气策略不能解决(jiju)解决(jiju)的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM,第八页，共三十七页。,A.Hypoxamia
4、 B.Shear forcesC.Surfactants inactivate D.Biotrauma and MODS,Pathophysiology Consolidation and alv collapse,第九页，共三十七页。,A.低氧血症,肺泡塌陷：ARDS重力依赖(yli)区 炎症或不张区生理性低氧缩血管反响：障碍,第十页，共三十七页。,How Does Excessive Mechanical Stress Inflame the Lung?,“Shear,第十一页，共三十七页。,Verbrugge et al.Crit Care Med 1999;27：779,Ventila
5、tor-associated lung injury,Purine:a marker of ATP breakdown and VILI42 SD ratsPCV 6minPCV Pre/PEEPBALF purine and protein,第十二页，共三十七页。,Lachmann.ICM,1994;20:6-11,Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way1mg surfactant=inhibitory effect of 1mg plasma protein,C.Surfactant
6、 灭活,第十三页，共三十七页。,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 inflation,Rouby JJ.Am J Respir Crit Care Med,2001,165:1182,第十四页，共三十七页。,D.预防(yfng)Biotrauma和MODS,Marini JJ
7、,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,第十五页，共三十七页。,内容提要(ni rn t yo),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(ln chun)实施Prone positionSpontaneous breathingHigh VT and sighRM,第十六页，共三十七页。,
8、俯卧位通气(tng q)的病理生理特征,改善通气过程 胸膜(xingm)腔压力梯度 顺应性胸壁促进分泌物的去除,Closingpressure,Closing pressure,第十七页，共三十七页。,Time 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(shsh)俯卧位通气时间的选择.中华内科杂志2004,43(12):883-887,第十八页，共三十
9、七页。,内容提要(ni rn t yo),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(ln chun)实施Prone positionSpontaneous breathingHigh VT and sighRM,第十九页，共三十七页。,保存自主(zzh)呼吸的优点,第二十页，共三十七页。,内容提要(ni rn t yo),肺保护性通气策略不能解决解决的问题肺泡塌陷(txin)的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM,第二十一页，共三十七页。,Paw cmH2O,%,Ope
10、ning and Closing Pressures,0,5,10,15,20,25,30,35,40,45,50,0,10,20,30,40,50,5 patients,ALI/ARDS,From Crotti et alAJRCCM 2001.,Some units cantbe kept open by any reasonable PEEP!,第二十二页，共三十七页。,Amato:CT+PV Curve,Heart,Sp,P,V,LIP,UIP,Insp recruit,Larger Vt/Sigh:Pressure must be high enoughEven up to UIP,
11、第二十三页，共三十七页。,内容提要(ni rn t yo),肺保护性通气策略不能解决解决的问题(wnt)肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM,第二十四页，共三十七页。,许红阳，邱海波.ARDS绵羊肺复张容积(rngj)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 Trial11 ARDS pats,第二十五页，共三十七页。,Recrui
12、tment is Time-Dependent,40 SECONDS,第二十六页，共三十七页。,内容提要(ni rn t yo),肺保护性通气策略(cl)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 positionSpontaneous breathingHigh VT and sighHigh PEEPRM,第二十七页，共三十七页。,Recruitment mannuvers,Basic PrinciplesMethods for RecruitmentExperimental Studies and Clinical TrialsEfficacyHazards,第二
13、十八页，共三十七页。,1.控制性肺膨胀(SI)法2.PEEP递增法3.压力(yl)控制(PCV)法,Methods for Recruitment,第二十九页，共三十七页。,CPAP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(boch)键按住，持续20-40s,控制性肺膨胀(png zhng)(SI)法,第三十页，共三十七页。,Multiple Maneuvers May Be Needed For Optimum RM Effect,Fujino et al,Crit Ca
14、re Med 2001;29(8):1579-1586,第三十一页，共三十七页。,Post-RM PEEP Determines PaO2,Post-RM-PEEP肺开放效应(xioyng)持续时间的决定因素,CCM,2004,32:2371-2377,28 mixed-breed pigsModels of ARDS:OAVILIPneumonia(PNM)RMSIIncreased PEEPPCV,第三十二页，共三十七页。,肺开放(kifng)后的PEEP选择-PaO2/FiO2,1.RM后 PEEP:20cmH2O2.PEEP递减(djin):2cmH2O/5min3.PEEP阈值:Pa
15、O2/FiO25%4.PEEP:PEEP阈值+2cmH2O,第三十三页，共三十七页。,BASELINE VENTILATIONTidal volume=6ml/kgPEEP=5cmH2O,Modify PEEP to get a1.10.9,recruiting maneuver,Measure,1.10.9Leave PEEP unchanged,stress index 0.9,1.1Decrease PEEP until 1.1stress index 0.9,Crit Care Med,2004,32:1018-1027,肺开放(kifng)后的PEEP选择-Stress index,
16、第三十四页，共三十七页。,Implications,RM 的有效性ALI的病因(bngyn)(direct vs in direct)Post RM PEEPMethod in certain settingsRM hazards are greatest and effectiveness least in pneumonia-caused acute lung injuryPCV may be better tolerated than SI,第三十五页，共三十七页。,Recommendations,Use PCV in preference to SISafer,“multiple,effective,maintains ventilation,simpleMonitor hemodynamics during recruiting interval.以下情况需重复作RM:体位改变,管路(un l)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 consolida
