AECOPD：PaCO2的治疗目标和机械通气策略

AECOPD： PaCO2的治疗目标和机械通气策略 (mini ECMO) F/42 COPD and asthma压力控制通气PEEPi 20 cmH2O从眼眶到肚脐都是皮下气肿PaCO2 55mmHg下一步应该做什么？ASAIO Journal 2009; 55:420422.18 F 双腔右颈内置管血流速 800ml/min气流速 10l/minVenovenous carbon dioxide removal was maintained for 88 hours. Subcutaneous emphysema was almost completely resolved at this time. She was extubated 48 hours after decannulation and discharged on hospital day 13.M/74，既往有哮喘病史，无常规治疗窒息、休克pH 7.08, PaO2/FIO2 158.2mmHg,PaCO2 106.5mmHg.对沙丁胺醇、茶碱、激素等无反应镇静镇痛肌松低 PEEP低频率、延长呼气时间收入 ICU，采取重症哮喘通气策略VT200mlPaCO2 147.52mmHg, pH 6.87严重休克左股动静脉置管分别 15及 17-Fr血流速 1.5 L/min初始的最大气流速 15L/minAfter the PaCO2 had remained stable for 93 hrs between 45 and 60 mm Hg and signs of bronchospasm had resolved, oxygen flow to the Novalung was reduced to zero. The extracorporeal circuit was kept in place for a further 28 hrs and then disconnected.NPPV 治疗 COPDNIPPV的禁忌严重呼吸性酸中毒意识状态改变面部创伤血流动力学不稳定喀血64例 COPD， 40例 NIV失败，要求有创通气AECOPD时的呼吸机制 气流阻力升高气流受限PEEPi and hyperinflation 呼吸浅快肌无力高碳酸呼吸泵衰竭分钟通气量升高AECOPD时的通气策略Pmus + Pappl = (flow x R,RS) + (volume x E,RS) + PEEPiPaCO2= VCO2/VE*(1-VD/VT)UNLOAD Pmus BY INCREASING VEUNLOAD Pmus BY DECREASING VE低肺牵张策略低潮气量低呼吸频率减低吸呼比Gattinoni L. JAMA 1986;256:881886.LFPPV-ECCO2R动物实验呼吸频率每分钟 0.66、 1、 2、 4次潮气量 3、 10、 15ml/kg最小频率及 10-15ml/kg,能维持生命 7小时Gattinoni。 Anesth Analg. 1978 Jul-Aug;57(4):470-7. 43例严重急性呼衰患者非对照研究 肺静息频率 3-5次 /分PEEP： 15-25cmH2O“ 低 ” 峰压 35-45cmH2OJAMA 1986;256:881-886结果：改善肺功能 71%，存活 48.8%Lung function improvedin thirty-one patients (72.8%) .Improvement in lung function, when present, always occurred within 48 hours 21 patients (48.8%) eventually survivedThe mean time on bypass for the survivors was 5.4 3.5 daysBlood loss averaged 1800 850mL/dECCO2R的随机对照研究40例重症 ARDS患者30天生存率： MV（ 42%） vs.EC(33%)严重并发症：出血、溶血、神经系统 损害Am J Respir Crit Care Med. 1994； 149(2 Pt 1):295-305.Extracorporeal support for ARDS should be restricted to controlled clinical trials 与 6 mL/kg 潮气量相比， 3 mL/kg的潮气量结合体外 CO2 清除是否减轻呼吸机相关性肺损伤 14只猪 评价器官功能和组织病理学Crit Care Med 2007; 35organ function and organ injury assessment didnot reveal significant improvements when comparedwith conventional strategy whether VT lower than 6 ml/kg may enhance lung protection and that consequent respiratory acidosis may be managed by extracorporeal carbon dioxide removal. 32 patients ventilated with a VT of 6ml/kg Measurements: lung morphology computed tomography,and pulmonary inflammatory cytokine