肺复张术与PEEP调定

Recruitment Maneuver 110;556 Inciting EventInciting Event PMNs/MacsPMNs/Macs EndotheliumEndothelium EpitheliumEpithelium AdhesionAdhesionProteasesProteasesOO 2 2 radicals radicals CoagulationCoagulation ProteinsProteins CytokinesCytokines IL-6IL-6 IL-8IL-8 IL-10IL-10 IL-8-RAIL-8-RATNF-TNF-a a ENA-78ENA-78MIP-1MIP-1a a TransferrinTransferrin PAFPAF ComplementComplement LPBLPB LTB4LTB4 LTC4LTC4 PEEP=? RM ? Pplateau=? VT=? PIP=? Mode ? Recruitment Maneuver and PV curve hysteresis Airway Pressure cmH2O % Opening and Closing Pressures 05101520253035404550 0 10 20 30 40 50 Opening pressure Closing pressure 5 patients, ALI / ARDS Am J Respir Crit Care Med Vol 164. pp 131140,2001 Marini 161:432439. R. SCOTT HARRIS, DEAN R. HESS, and JOS G. VENEGAS 1.1. PEEP / FIOPEEP / FIO 2 2 target target ( 8( 814 14 cmHcmH 2 2O O) ) 2.2. PEEP at PPEEP at PFLEX FLEX ( 14( 1418 18 cmHcmH 2 2O O) ) 3.3. PEEP enough to fully avoid PEEP enough to fully avoid airway collapseairway collapse ( 16( 1626 26 cmHcmH 2 2O O) ) Amato: 2004 China FiO2 FiO2 0.3 0.3 0.4 0.4 0.4 0.4 0.5 0.5 0.5 0.5 0.6 0.6 0.7 0.7 0.7 0.7 0.7 0.7 0.8 0.8 0.9 0.9 0.9 0.9 0.9 0.9 1.0 1.0 PEEP PEEP 5 5 5 5 8 8 8 8 10 10 10 10 10 10 12 12 14 14 14 14 14 14 16 16 18 18 20-24 20-24 EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROMETHE ACUTE RESPIRATORY DISTRESS SYNDROME Titrating PEEP fellowing RM According to oxygenation The PEEP or PAW preceding that causing the PaOThe PEEP or PAW preceding that causing the PaO 2 2 decrease was decrease was considered optimal. until the target PaO2 decreased by considered optimal. until the target PaO2 decreased by more than 10%more than 10% from the above target level.from the above target level. Is it practical for clinical? Possible. Is continuous PaO2 practical? Not yet. SpO2 is probably a useful tool Hickling K. AJRCCM 2001;163:69-78. Conclusions: In this experimental model, the continuous monitoring of dynamic compliance identified the beginning of collapse after lung recruitment. These findings were confirmed by oxygenation and computed tomography scans. This method might become a valuable bedside tool for identifying the level of PEEP that prevents end-expiratory collapse. Fernando Suarez-Sipmann, MD; Stephan H. Bhm, MD; Gerardo Tusman, Fernando Suarez-Sipmann, MD; Stephan H. Bhm, MD; Gerardo Tusman, MD, et al. Crit Care Med 2007 Vol. 35, No. 1MD, et al. Crit Care Med 2007 Vol. 35, No. 1 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 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 ？ 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。（E级） 中国危重病急救医学，2006；18（12）：706 Massachusetts General Hospital Set FIO2 at 1.0 Wait 10 minutes Insure appropriate sedation May need to do multiple RMs 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 The RM should be aborted if: MAP 20 mmHg SpO2 130 or 20%) PaO2/FiO2 improve：92%27% No barotrauma Trauma or sepsis ARDS (early ARDS) Responsive: (18/22) 81.8% PaO2/FiO2 improve: 71%26% No barotrauma Legionnaires Disease 1 pt, nonresponsive, RM only one time Severe subcutaneous emphysema ECMO on ARDSECMO on ARDS APRVAPRV Hypoxia after CPB & open heart surgery All pts appeared obvious ABP drop in 1st RM SpO2 drop together with ABP drop ABP drop occurred at PEEP121