1、急性呼吸窘迫综合征肺复张的测定(cdng)与应用,邱海波东南大学附属中大医院(yyun)东南大学急诊与危重病研究所,第一页，共八十八页。,第二页，共八十八页。,第三页，共八十八页。,内容提要(ni rn t yo),ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点(tdin)评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,第四页，共八十八页。,Lung volume decreased markedly(TLC,VC,TV,FRC)-alveolar edem
2、a-pulmonary surfactant-Interstitial pumonary edema depress brochiole and induce spasmCompliance reduced significantlyVentilation/perfusion mismatch-intrapulmonary shunt and dead space like effects,ARDS病理(bngl)生理特点,ARDS病理(bngl)生理,第五页，共八十八页。,CT scan70-80%的肺野呈现高密度区分布：下垂部位(dependent field)提示：参与通气肺泡明显减少(
3、jinsho)(20-30%)肺损伤具有不均一性,肺容积(rngj)减少Small lung Baby Lung,ARDS病理(bngl)生理,第六页，共八十八页。,A and C finding in the acute or exudative phase,B and DFinding in the fibrosing-alveolitis phase,ARDS病理(bngl)生理,第七页，共八十八页。,肺容积(rngj)/顺应性明显降低,ARDS病理(bngl)生理,第八页，共八十八页。,Reduced range of volume excursion:Low complianceFl
4、attening at low and high volumes:Lower and upper inflection pointsBigatello:Br J Anaest 1996,Volume,Pressure,NORMAL,ARDS,顺应性曲线(qxin)明显右下移位,肺顺应性明显降低,ARDS病理(bngl)生理,第九页，共八十八页。,Upper and Lower Inflection Points,Lower呼气末肺泡塌陷吸气早期肺泡再开放Upper吸气末肺泡顺应性明显降低，肺泡过度(gud)膨胀,ARDS病理(bngl)生理,Volume,Pressure,Lower Infl
5、ection Point,Upper Inflection Point,第十页，共八十八页。,通气(tng q)/血流失调,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,ARDS病理(bngl)生理,第十一页，共八十八页。,Imagine the Hardness to Blow up a Ballon.,easy,hard,spatial&elastic limitations,Laplacian Law,It needs higher initial pressures to overcome the surface tension to open up
6、a bubble to wider diameters!,ARDS病理(bngl)生理,第十二页，共八十八页。,Sustain inflation Sigh小潮气量通气PHC,防止肺泡过度膨胀最正确(zu ji)PEEP防止剪切力(Shear force)性损害,Volume,Pressure,肺开放与保护性通气策略的根本(jbn)内容,ARDS病理(bngl)生理,第十三页，共八十八页。,Lung volume decreased markedly,Atelectrauma,Keep the lung open,Open the lung,Prevent volutrauma,SI and
7、Sigh,PEEP,ARDS病理(bngl)生理,第十四页，共八十八页。,内容提要(ni rn t yo),ARDS病理生理ARDS肺复张容积测定P-V曲线(qxin)法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,第十五页，共八十八页。,PV曲线(qxin)法,Step 1:测量PEEP所致的FRC(吸气(x q)末撤掉PEEP并延长呼气时间)FRCVE(ZEEP)VE(PEEP),肺复张容积(rngj)测定,第十六页，共八十八页。,PV曲线(qxin)法,
8、Step 2:分别(fnbi)描计ZEEP和PEEP的PV曲线 Step 3:肺复张容积：RV=V20(PEEP)+FRC V20(ZEEP),肺复张容积(rngj)测定,第十七页，共八十八页。,等压法,呼吸模式：BIPAP条件：Ph 20 cmH2O，PEEP分别为0、5、10、15 cmH2O，Ti 6S测定：延长呼气时间(shjin)，测定ZEEP呼出气量。在不同PEEP时吸气末撤掉PEEP，延长呼气时间，测定呼气量,肺复张容积(rngj)测定,第十八页，共八十八页。,等压法,肺复张容积(rngj)测定,第十九页，共八十八页。,P-V曲线(qxin)法与等压法的比较,肺复张容积(rngj
9、)测定,第二十页，共八十八页。,肺复张容积(rngj)测定P-V曲线法,等压法虽然简单，但准确性较差 不能代替P-V曲线(qxin)法目前肺复张容积的测定仍宜采用 P-V曲线法,肺复张容积(rngj)测定,第二十一页，共八十八页。,CT method,膈顶上(dn shn)1cm CT层面PEEP与ZEEP比较Gattinoni L.Am J Respir CCM,1995,151:1807全肺扫描区别过度膨胀，膨胀，局部复张和塌陷区 Luiz M,Rouby JJ.Am J Respir CCM,2001,163:1444,肺复张容积(rngj)测定,第二十二页，共八十八页。,CT法-Gat
10、tinoni,肺复张容积(rngj)测定,原理(yunl)CT空气=0Hu，CT水=1000 HuCT值=500Hu，肺组织50%空气+50%水ARDS塌陷肺CT值100Hu100Hu，塌陷肺泡复张 后，100Hu+100Hu内肺组织减少方法ZEEP和PEEP通气呼气末CT扫描膈肌顶上1cm计算CT值在100 Hu 100 Hu范围内体素结果之差,Gattinoni L.Am J Respir CCM,1995,151:1807,第二十三页，共八十八页。,原理 充气(chn q)不良区(100Hu500Hu)、正常充气区(500Hu 900Hu)、无充气区(100Hu+100Hu)和过度充气区
11、(900Hu1000Hu)。肺泡复张，充气不良和正常充气肺区体积增加 方法 ZEEP和PEEP呼气末螺旋CT，根据层面厚度计算不同CT值肺体积，肺复张后充气不良与正常充气肺组织体积增加值,肺复张容积(rngj)测定,CT法-Rouby,Luiz M,Rouby JJ.Am J Respir CCM,2001,163:1444,第二十四页，共八十八页。,Gattinonis vs Roubys CT法比较(bjio),肺复张容积(rngj)测定,第二十五页，共八十八页。,CT methods:Rouby vs Gattinoni,Luiz M,Rouby JJ.Am J Respir CCM,2
12、001,163:1444,肺复张容积(rngj)测定,第二十六页，共八十八页。,内容提要(ni rn t yo),ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导(zhdo)PEEP选择,第二十七页，共八十八页。,ARDS肺不张的影响(yngxing)因素-附加静水压,Hydrostatic pressure=(1 CT/-1000)Height Maximum sternovertebral dimention of hum
13、an thorax:20cmH2OPEEP 20cmH2O不能使ARDS患者肺泡(fipo)完全复张动物ARDS,Mean Airway pressure 25 cm H2O,ARDS肺复张应用(yngyng),第二十八页，共八十八页。,ARDS下肺气体(qt)含量明显降低,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺复张应用(yngyng),第二十九页，共八十八页。,CT section lcated 5 cm below the carina No differences were observed in the percentag
14、e of lower lobes located beneath the heart in two groups,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺不张的影响(yngxing)因素-heart lung interdependence,ARDS肺复张应用(yngyng),第三十页，共八十八页。,Cardiac mass and volume in ARDS,Cardiac mass was increased by 27%vs NS Mechanism of cardiac mass:Edema of cardiac wall
15、RV dilation secondary to pul hypertensionHyperkinetic state related to SIRS,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺复张应用(yngyng),第三十一页，共八十八页。,心脏下肺叶(fiy)气体量明显降低ARDS 73%vs NS 21%,Closed bar:Fraction of gas in lower lobes located beneath the heartOpen bar:lower lobes located outside the hear
16、t,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺复张应用(yngyng),第三十二页，共八十八页。,塌陷(txin)肺泡的分布,Local:Loss of aeration predominating in lower lobesDiffuse:Equal loss of aeration to the upper and lower lobes,ARDS肺复张应用(yngyng),第三十三页，共八十八页。,Lung morphology pattern,Local DiffuseLIPNoYesNormally aerated 5512%24 12%Poorly aerated 23 8%40 12%Distribution modal BimodalUnimodalPeak of CT distr-727Hu/27Hu7HuCompltot57 546 11,Vieira SRR.AJRCCM,1999,159:1612,ARDS肺复张应用(yngyng),第三十四页，共八十八页。,Diffuse distribution,
