1、ARDS患者(hunzh)的肺复张,北京协和医院,第一页，共一百二十页。,内容(nirng),小潮气量通气的问题肺复张的理论与实践(shjin)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,第二页，共一百二十页。,内容(nirng),小潮气量通气的问题(wnt)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,第三页，共一百二十页。,ARDS的肺保护性通气(tng q)策略,第四页，共一百二十页。,ARDS的肺保护性通气(tng q)策略,小潮气量(6 ml/kg IB
2、W)防止过度膨胀(png zhng)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),第五页，共一百二十页。,肺泡(fipo)塌陷与复张造成的剪切力,F=PL x(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积(rngj)V:复张后容积如果:PL=30 cmH2O,V0/V=1/10那么:F=140 cmH2O,Mead J,Takishima T,Leith D.Stress distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(
3、5):596-608,第六页，共一百二十页。,小潮气量通气(tng q)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,第七页，共一百二十页。,小潮气量通气(tng q)的问题,Richard JC,Maggiore SM
4、,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,第八页，共一百二十页。,小潮气量通气(tng q)的问题,Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Vo
5、lume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613,第九页，共一百二十页。,受损的肺组织(zzh)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(jishu)的FiO2(?)自主呼吸(?),第十页，共一百二十页。,内容(nirng),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(b tn)复张方法的差异肺复张的临床适应症肺复张
6、的副作用肺复张存在的问题,第十一页，共一百二十页。,肺泡(fipo)的开放压与闭合压,第十二页，共一百二十页。,PEEP不能使肺复张,第十三页，共一百二十页。,LIP:仅仅(jnjn)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.,第十四页，共一百二十页。,Jonson B,Richard JC,Straus C,Manceb
7、o J,Lemaire F,Brochard L.PressureVolume 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,低位转折点之上仍有肺组织(zzh)复张,第十五页，共一百二十页。,肺泡的开放(kifng)压与闭合压,第十六页，共一百二十页。,肺泡开放(kifng)压与闭合压,Paw(cmH2O),Crotti S,Mascheroni D,C
8、aironi 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.,第十七页，共一百二十页。,ARDS的肺开放(kifng),EditorialOpen up the lung and keep the lung openB.LachmannDept.of Anesthesiology,Erasmu
9、s University Rotterdam,The Netherlands(1992)18:319-321,第十八页，共一百二十页。,RM能够(nnggu)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 Recruit
10、ment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626,第十九页，共一百二十页。,肺复张能够(nnggu)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.,第二十页，共一百二十
11、页。,肺复张的各种(zhn)方法,CPAP(SI)incremental PEEPPCVSigh(modified)HFOV俯卧(f w)位,第二十一页，共一百二十页。,SI改善(gishn)氧合,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 pulm
12、onary and extrapulmonary forms.Crit Care Med 2003;31:738-744,Sustained Inflation:45 cmH2O x 30 s,第二十二页，共一百二十页。,SI改善(gishn)氧合,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 inj
13、ury.Crit Care Med 2005;33:181-188,Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval,第二十三页，共一百二十页。,叹气(tn q)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 distres
14、s syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260,充气阶段,每30秒PEEP增加5 cmH2OVt减少(jinsho)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 cmH2Ofor 30 s放气阶段,第二十四页，共一百二十页。,叹气(tn q)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
15、sigh as a recruitment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260,第二十五页，共一百二十页。,叹气(tn q)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
16、J Respir Crit Care Med 1999;159:872-880,Sigh:3 consecutive sighs/min at Pplat 45 cmH2O,第二十六页，共一百二十页。,叹气(tn q)的设置,Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94,Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,s=3 5 sf=1 bpm,第二十七页，共一百二十页。,叹气改善呼吸(hx)力学及氧合,Patroniti N,Foti G,Cortinovis B,Maggioni E,B