肺保护机械通气2009seminarppt课件

Lung Protective Mechanical Ventilation 肺保护性机械通气 Adoption & discussion,张翔宇 急救重症科 上海同济大学 上海市第十人民医院,Lung protective strategy,Ventilator Induced Lung Injury, VILI Lung protective strategy PEEP VT Recruitment Maneuver, RM PIP=? Pplateau=? Mode ?,Ventilator Induced Lung Injury VILI,Overdistention Barotrauma Volutrauma Recruitment/Derecruitment Injury Translocation of Cells Biotrauma,VILI： Recruitment/Derecruitment Injury,PIP=14, PEEP=0 PIP= 45, PEEP=10 PIP= 45, PEEP = 0 Webb556,Ventilation Strategies & BAL Cytokines Tremblay, Valenza, Ribeiro, Li, Slutsky J Clinical Investigation 99:944-52, 1997,50倍！,Serum Cytokines in Acid Aspiration Model Chiumello, Pristine, Slutsky AJRCCM 1999;160:109-16,Cytokines in Humans Stuber et al Int Care Med 2002;28:834-841,JAMA 289:2104-2112,2003,Systemic Effects of VILI Imai et al JAMA 289:2104-2112,2003,Mechanical Ventilation,Slutsky, Tremblay Am J Resp Crit Care Med. 1998;157:1721-5,Protect the lungs?,PEEP=? VT=? PIP=? Pplateau=? RM ?,PEEP=?,PEEP/FiO2 combination? X!,ARDSnet, 2000, NEJM, 2000; 18: 1301,中华医学会重症医学分会,急性肺损伤/急性呼吸窘迫综合征诊断与治疗指南（2006） 推荐意见7：对ARDS患者实施机械通气时应采用肺保护性通气策略，气道平台压不应超过30-35cmH2O（推荐级别：B级） 推荐意见8：可采用肺复张手法促进ARDS患者塌陷肺泡复张，改善氧合（推荐级别：E级）,ALI/ARDS指南： 中华内科杂志,2007, 46(5):430-435,推荐意见9：应使用能防止肺泡塌陷的最低PEEP，有条件情况下，应根据静态P-V曲线低位转折点压力+2cmH2O来确定PEEP（推荐级别：C级） 推荐意见10：ARDS患者机械通气时应尽量保留自主呼吸（推荐级别：C级） 推荐意见11：若无禁忌证，机械通气的ARDS患者应采用30-45度半卧位（推荐级别：B级） 推荐意见12：常规机械通气治疗无效的重度ARDS患者，若无禁忌证，可考虑采用俯卧位通气（推荐级别：D,SSC 2008,Crit Care Med 2008 Vol. 36, No. 1,SSC 2008,推荐对ALI/ARDS病人应用6ml/kg（预测体重）的目标潮气量。（1B） 推荐对ALI/ARDS病人进行平台压监测，对于被动通气的病人初始平台压目标设定在30cmH2O;检测平台压时应当考虑到胸廓的顺应性。（1C） 推荐对ALI/ARDS病人在必要降低平台压或减少潮气量时施行允许性高碳酸血症（PaCO2水平高于病前）。（1C）,SSC 2008,4. 推荐设定PEEP以阻止张开的肺在呼气末塌陷。（1C） 5. 建议在有经验的单位，对于需要可能有害的FiO2和平台压的ALI/ARDS病人在没有不良后果高风险的条件下应用俯卧位通气。（2C） 6a. 除非有禁忌，推荐机械通气的病人床头抬高减少误吸风险，防止呼吸机相关性肺炎 。（1B） 6b. 建议床头抬高3045.（2C） 7. 建议无创通气（NIV）只能在少数轻中度低氧的、血流动力学稳定的、易于唤醒的、能够自我呼吸道保护的、能自主咳痰的、能很快恢复的ALI/ARDS病人考虑应用。,SSC 2008,8. 推荐制定一套适当的脱机方案，当患者还须满足以下条件时常规对机械通气患者施行自主呼吸试验以评估脱离机械通气的能力，：可唤醒，血流动力学稳定（不用升压药），没有新的潜在严重疾患，只需低通气量和低PEEP，面罩或鼻导管给氧可满足吸氧浓度要求。应选择低水平压力支持、持续气道正压（CPAP，5cmH2O）或T管进行自主呼吸试验（1A）。 9. 不推荐对ALI/ARDS患者常规应用肺动脉导管（1A）。 10. 对已有ALI且无组织低灌注证据的患者，推荐保守补液策略，以减少机械通气和住ICU天数（1C）。,潮气量 VT,6 ml/kg Pplateau Puip Pplateau 30cmH2O,肺复张术,Lung recruitment maneuver, RM SI PC Stepwise RM,Recruitment Maneuver,Massachusetts General Hospital,Performance of RM MGH,30 cmH2O CPAP for 30 to 40 sec If unresponsive but tolerated well 35 cmH2O CPAP for 30 to 40 sec If unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 sec Allow 15 to 20 minutes between RM,Performance of RM MGH,Set FIO2 at 1.0 Wait 10 minutes Insure appropriate sedation May need to do multiple RMs,Monitoring during RM (MGH),The RM should be aborted if: MAP 20 mmHg SpO2 130 or 60/ minute New arrhythmias,Amato NEJM 1998;338:347,35 40 cmH2O CPAP for 30 to 40 sec At enrollment After ventilator disconnect No severe hemodynamic compromise No barotrauma,Amato: 2004 China,FULL RECRUITMENT: PaO2 + PaCO2 400 mmHg,Amato,ARDS protocol,Recruit,FIO2 = 1,Titrate PEEP,Titrate Pdriving,WAIT,( 15 ),FIO2 30%,( High PEEP + PSV ),WAIT,FIO2 30%,( High PEEP + PSV ),Decrease PS down to 8,Decrease PEEP down to 12,NIMV (CPAP = 12, PS = 8),PEEP / FIO2 target ( 814 cmH2O) PEEP at PFLEX ( 1418 cmH2O) PEEP enough to fully avoid airway collapse ( 1626 cmH2O),Amato: 2004 China,张翔宇的 方 法,所有患者均行有创动脉压持续监测 SpO2持续监测 CVP持续监测 清醒患者适当镇静 复张术（RM）前排除气压伤 排除肺气肿患者,Protocol,Mode: PEEP+PCV or PEEP+PSV PEEP: increment 2 cmH2O Interval: 2 min PEEP target: 16/1st RM, 20/2nd RM, 2630/3rd RM PIPmax: 45 cmH2O Abort if ABP or SpO2 start fall Rest interval: 1530 min May repeat twice a day,结 果,心脏外科术后低氧患者 有效：100% PaO2/FiO2 improve：110%36% 无并发症 多发伤并发ALI/ARDS患者 有效：92% PaO2/FiO2 improve：86%32% 无并发症 军团菌病1例，无效，出现气压伤 RM一次，PEEPmax: 22, PIPmax: 32 纵隔气肿,临床观察,252例次RM有93次血压短暂降低（37%） 出现血压下降的PEEP水平为623cmH2O,平均13.9cmH2O PEEP降低之后动脉恢复到原来水平 所有病人有创持续血压监测 1例经心超证实卵圆孔未闭，在PEEP=6时发生右向左分流，同时SpO2下降,张翔宇，等，中国危重病急救医学，2007，19（9）,Crit Care Med 2007 Vol. 35, No. 1 Fernando Suarez-Sipmann, et al,Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study Eight healthy pigs Lung lavages CT slices were obtained 2 cm cranial of the right diaphragmatic dome,Protocol,Result,Suarez-Sipmanns clusion,dynamic compliance identified the beginning of lung collapse in a pig model. the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying the level of PEEP that prevents end-expiratory lung collapse ？,Bobs new protocol 2007,Performance of RM,Set FIO2 at 1.0 Allow time for stabilization Insure appropriate sedation Insure hemodynamic stability,Bobs new protocol,Performance of RM - PCV,Pressure control ventilation: PEEP 20-30 cmH2O Peak Inspir Press 40-50 cmH2O Inspir Time: 1 to 3 sec Rate: 8 to 20/ min Time 1 to 3 min Set PEEP at 20, ventilate VC, VT 4 to 6 ml/kg PBW, increase rate, avoid auto-PEEP Measure dynamic compliance Decrease PEEP 2 cm H2O,Bobs new protocol,Performance of RM - PCV,Measure dynamic compliance Repeat until max compliance determined Optimal PEEP max comp PEEP+2 to 3 cm H2O Repeat recruitment maneuver and set PEEP at the identified settings, adjust ventilation After PEEP and ventilation set and stabilized, decrease FIO2 until PO2 in target range If response is poor, repeat RM, PEEP 25, Peak Pressure 45 If response is poor, repeat RM, PEEP 30, Peak Pressure 50,Bobs new protocol 2007,Lung Recruitment,Perform early in ARDS Ideal approach to RM most likely PC, limited patient data available using PC! Works better in extra pulmonary than primary ARDS? More difficult to recruit the lung the stiffer the chest wall! Start with low pressure, increase as tolerated and needed! If benefit lost after RM, PEEP inadequate!,Bobs new protocol,A comparison of methods to identify open-lung PEEP. Caramez MP, Kacmarek RM, et al,In this animal model of ARDS, dynamic tidal respiratory compliance, maximum PaO2, maximum PaO2 + PaCO2, minimum shunt, inflation lower Pflex and Pmci,i yield similar values for PEEP following a recruitment maneuver.,Intensive Care Med. 2009 Apr;35(4):740-7.,Patients ( n=549 ) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 12.9 4 8.4 4 RR (b/min) 30 TV ( ml /Kg ) 6,The NIH randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDS,New Engl J Med 2004; 351: 327-336,PEEP selected according to a Table to achieve minimal physiological oxygenation (88-95%),Patients ( n=983) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 16.3 3 RR (b/min) 30 TV ( ml /Kg ) 6,9.1 4,The LOVS: Lung Open Ventilation Canadian Study,Canadian Trial,Oxygenation was better in High PEEP Compliance was better in High PEEP Less rescue therapies in High PEEP,PEEP selected according to a table to achieve minimal physiological oxygenation + RM,Stewart T et al JAMA. 2008;299(6):637-645,Patients ( n=752 ) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 14.9 4 RR (b/min) 30 TV ( ml /Kg ) 6,7.4 4,French Trial “Express”,PEEP selected to avoid overdistension or to achieve maximal recruitment PEEP set for PEEP tot 5-9 cmH2O PEEP set for Plat 28-30 cmH2O,Oxygenation was better in Max distension Higher ventilation free days in Max distension Higher organ failure free days in Max distension,Mercat A et al JAMA. 2008;299(6):646-655,The Express Study: randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDS,Critical Care 2009, 13:R22 Younsuck Koh, et al,Efficacy of positive end-expiratory pressure titration after the alveolar recruitment manoeuvre in patients with acute respiratory distress syndrome,Critical Care 2009, 13:R22 Younsuck Koh, et al,Efficacy of positive end-expiratory pressure titration after the alveolar recruitment manoeuvre in patients with acute respiratory distress syndrome. Younsuck Koh, et al,Critical Care 2009, 13:R22,MARCELO AMATO, M.D.,et al. (N Engl J Med 1998;338:347-54.),EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME,Mechanical Ventilation Guided by Esophageal Pressure in Acute Lung Injury,N Engl J Med 2008;359:2095-104.,N Engl J Med 2008;359:2095-104,N Engl J Med 2008;359:2095-104,N Engl J Med 360;8 February 19, 2009,N Engl J Med 359;20, november 13, 2008,Effect of the chest wall on pressurevolume curve analysis of