肺保护机械通气2009seminar

LungProtectiveMechanicalVentilation

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LungprotectivestrategyVentilatorInducedLungInjury,VILILungprotectivestrategyPEEPVTRecruitmentManeuver,RMPIP=?Pplateau=?Mode?VentilatorInducedLungInjury

VILIOverdistentionBarotraumaVolutraumaRecruitment/DerecruitmentInjuryTranslocationofCellsBiotraumaVILI：

Recruitment/DerecruitmentInjury

PIP=14,PEEP=0PIP=45,PEEP=10PIP=45,PEEP=0Webb&TierneyARRD1974;110;556VentilationStrategies&BALCytokinesTremblay,Valenza,Ribeiro,Li,SlutskyJClinicalInvestigation99:944-52,199773MVHP1510HVZPCcontrol40identicaldV/dtVT(cc/kg)PEEPcmH2O15MVZP1002001,2001,400*§§CMVHPMVZPHVZPTNF-a,pg/ml50倍！VentilatoryStrategyandBALCytokinesTremblay,Valenza,Ribeiro,Li,SlutskyJClinicalInvestigation99:944-52,1997*

p<0.05vs.C,MVHP,MVZP&p<0.05vs.C,MVHP#

p<0.05vs.CArthurSSlutskySerumCytokinesinAcidAspirationModel

Chiumello,Pristine,SlutskyAJRCCM1999;160:109-16Vt,ml/kgPEEP,cmH2OHVZPHVPLVZPLVP16165555CytokinesinHumans

StuberetalIntCareMed2002;28:834-841JAMA289:2104-2112,2003SystemicEffectsofVILI

ImaietalJAMA289:2104-2112,2003BiophysicalInjuryshear

overdistentioncyclicstretchDintrathoracicpressurealveolar-capillarypermeabilitycardiacoutputorganperfusionBiochemicalInjury(Biotrauma)mfcytokines,complement,PGs,LTs,ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistalOrganDysfunctionMechanicalVentilationSlutsky,TremblayAmJRespCritCareMed.1998;157:1721-5DEATHProtectthelungs?PEEP=?VT=?PIP=?Pplateau=?RM?PEEP=?PEEP/FiO2combination?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

SSC2008CritCareMed2008Vol.36,No.1SSC2008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）SSC20084.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30～45º.（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。SSC20088.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，：①可唤醒，②血流动力学稳定（不用升压药），③没有新的潜在严重疾患，④只需低通气量和低PEEP，⑤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

VT6ml/kgPplateau<PuipPplateau<30cmH2O肺复张术Lungrecruitmentmaneuver,RMSIPCStepwiseRMRecruitmentManeuverMassachusettsGeneralHospitalPerformanceofRM@MGH30cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell35cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell40cmH2OCPAPfor30to40secAllow15to20minutesbetweenRMPerformanceofRM@MGHSetFIO2at1.0Wait10minutesInsureappropriatesedationMayneedtodomultipleRMsMonitoringduringRM(MGH)TheRMshouldbeabortedif:MAP<60mmHgordecreasesby>20mmHgSpO2<88%Heartrate>130or<60/minuteNewarrhythmiasAmatoNEJM1998;338:34735–40cmH2OCPAPfor30to40secAtenrollmentAfterventilatordisconnectNoseverehemodynamiccompromiseNobarotraumaAmato:2004ChinaFULLRECRUITMENT: PaO2+PaCO2>400mmHgAmatoARDSprotocolRecruitFIO2=1TitratePEEPTitratePdrivingWAIT(<15)FIO2≤30%(HighPEEP+PSV)WAITFIO2≤30%(HighPEEP+PSV)DecreasePSdownto8DecreasePEEPdownto12NIMV(CPAP=12,PS=8)PEEP/FIO2target

(≈8～14cmH2O)PEEPatPFLEX

(≈14～18cmH2O)PEEPenoughtofullyavoid airwaycollapse

(≈16～26cmH2O)Amato:2004China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+PCVorPEEP+PSVPEEP:increment2cmH2OInterval:2minPEEPtarget:16/1stRM,20/2ndRM,26~30/3rdRMPIPmax:45cmH2OAbortifABPorSpO2startfallRestinterval:15～30minMayrepeattwiceaday结果心脏外科术后低氧患者有效：100%PaO2/FiO2improve：110%±36%

无并发症多发伤并发ALI/ARDS患者有效：92%PaO2/FiO2improve：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6～23cmH2O,平均13.9cmH2OPEEP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）CritCareMed2007Vol.35,No.1

FernandoSuarez-Sipmann,etalUseofdynamiccomplianceforopenlungpositiveend-expiratorypressuretitrationinanexperimentalstudyEighthealthypigsLunglavagesCTsliceswereobtained2cmcranialoftherightdiaphragmaticdomeProtocolResultSuarez-Sipmann’sclusiondynamiccomplianceidentifiedthebeginningoflungcollapseinapigmodel.thecontinuousmonitoringofdynamiccompliancemightbecomeavaluablebedsidetoolforeasilyidentifyingthelevelofPEEPthatpreventsend-expiratorylungcollapse？？？Bob’snewprotocol2007PerformanceofRMSetFIO2at1.0AllowtimeforstabilizationInsureappropriatesedationInsurehemodynamicstabilityBob’snewprotocolPerformanceofRM-PCVPressurecontrolventilation:PEEP20-30cmH2OPeakInspirPress40-50cmH2OInspirTime:1to3secRate:8to20/minTime1to3minSetPEEPat20,ventilateVC,VT4to6ml/kgPBW,increaserate,avoidauto-PEEPMeasuredynamiccomplianceDecreasePEEP2cmH2OBob’snewprotocolPerformanceofRM-PCVMeasuredynamiccomplianceRepeatuntilmaxcompliancedeterminedOptimalPEEPmaxcompPEEP+2to3cmH2ORepeatrecruitmentmaneuverandsetPEEPattheidentifiedsettings,adjustventilationAfterPEEPandventilationsetandstabilized,decreaseFIO2untilPO2intargetrangeIfresponseispoor,repeatRM,PEEP25,PeakPressure45Ifresponseispoor,repeatRM,PEEP30,PeakPressure50Bob’snewprotocol2007LungRecruitmentPerformearlyinARDSIdealapproachtoRMmostlikelyPC,limitedpatientdataavailableusingPC!WorksbetterinextrapulmonarythanprimaryARDS?Moredifficulttorecruitthelungthestifferthechestwall!Startwithlowpressure,increaseastoleratedandneeded!IfbenefitlostafterRM,PEEPinadequate!Bob’snewprotocolAcomparisonofmethodstoidentifyopen-lungPEEP.

CaramezMP,KacmarekRM,etal

InthisanimalmodelofARDS,dynamictidalrespiratorycompliance,maximumPaO2,maximumPaO2+PaCO2,minimumshunt,inflationlowerPflexandPmci,iyieldsimilarvaluesforPEEPfollowingarecruitmentmaneuver.IntensiveCareMed.2009Apr;35(4):740-7.

Patients(n=549)

ARDS/ALI

Pplat(cmH2O)

<30

PEEP(cmH2O)

12.9±4

8.4±4

RR(b/min)30

TV

(ml/Kg) <6

TheNIHrandomizedmulticenterstudyassessingtheeffectonmortalityoflowvshighPEEPinARDS

NewEnglJMed2004;351:327-336NIHPEEPselectedaccordingtoaTabletoachieveminimalphysiologicaloxygenation(88-95%)

Patients(n=983)

ARDS/ALI

Pplat(cmH2O)

<30

PEEP(cmH2O)

16.3±3

RR(b/min)

30

TV

(ml/Kg)

<6

9.1±4TheLOVS:LungOpenVentilationCanadianStudy

CanadianTrial

OxygenationwasbetterinHighPEEPCompliancewasbetterinHighPEEPLessrescuetherapiesinHighPEEP0,40,50,60,70,80,910102030405060DaysafterrandomizationProbabilityofsurvivalLowPEEPHighPEEPPEEPselectedaccordingtoatabletoachieveminimalphysiologicaloxygenation+RMStewartTetalJAMA.2008;299(6):637-645

Patients(n=752)

ARDS/