肺复张术与PEEP调定.ppt

RecruitmentManeuver72:117-32,LungprotectiveventilationinARDS:theopenlungmaneuver450mmHgonpureoxygen.Whenalungis“open”,TitratingPEEPfellowingRM,Pdeflex+2cmH2O,(PVcurve)Super-syringeLow-flowMultipleocclusionLinearramping(HamiltonGalilioGold)OxygenationPaO2drop10%,PVcurveforPdeflex,Recognizable?Andpercentageofthem?IsthisPdeflexconstantovertime?OrRM?IsPdeflexafterRMrepeatable?IsPEEPonPdeflexclinicallypractical?Notansweredyet,Pflex,“maximumdifferenceof11cmH2Oforthesamepatient”AMJRESPIRCRITCAREMED2000;161:432439.R.SCOTTHARRIS,DEANR.HESS,andJOSG.VENEGAS,PEEP/FIO2target(814cmH2O)PEEPatPFLEX(1418cmH2O)PEEPenoughtofullyavoidairwaycollapse(1626cmH2O),Amato:2004China,ARDSnet,MARCELOAMATO,M.D.,etal.(NEnglJMed1998;338:347-54.),EFFECTOFAPROTECTIVE-VENTILATIONSTRATEGYONMORTALITYINTHEACUTERESPIRATORYDISTRESSSYNDROME,LapinskyICM1999;25:1297,TitratingPEEPfellowingRMAccordingtooxygenation,Anesthesiology,V99,No5,Nov2003KhaledA.Sedeek,M.D.,*MuneyukiTakeuchi,M.D.,*KlaudiuszSuchodolski,M.D.,*SaraO.Vargas,M.D.,MotomuShimaoka,M.D.,JayJ.Schnitzer,M.D.,RobertM.Kacmarek,R.R.T.,Ph.D.,ThePEEPorPAWprecedingthatcausingthePaO2decreasewasconsideredoptimal.untilthetargetPaO2decreasedbymorethan10%fromtheabovetargetlevel.,TitratingPEEPaccordingtooxygenation,Isitpracticalforclinical?Possible.IscontinuousPaO2practical?Notyet.SpO2isprobablyausefultool,HicklingK.AJRCCM2001;163:69-78.,HicklingK.AJRCCM2001;163:69-78.,Useofdynamiccomplianceforopenlungpositiveend-expiratorypressuretitrationinanexperimentalstudy,Conclusions:Inthisexperimentalmodel,thecontinuousmonitoringofdynamiccomplianceidentifiedthebeginningofcollapseafterlungrecruitment.Thesefindingswereconfirmedbyoxygenationandcomputedtomographyscans.ThismethodmightbecomeavaluablebedsidetoolforidentifyingthelevelofPEEPthatpreventsend-expiratorycollapse.,FernandoSuarez-Sipmann,MD;StephanH.Bhm,MD;GerardoTusman,MD,etal.CritCareMed2007Vol.35,No.1,CritCareMed2007Vol.35,No.1,Useofdynamiccomplianceforopenlungpositiveend-expiratorypressuretitrationinanexperimentalstudyEighthealthypigsLunglavagesCTsliceswereobtained2cmcranialoftherightdiaphragmaticdome,Protocol,Result,CONCLUSIONS,dynamiccomplianceidentifiedthebeginningoflungcollapseinapigmodel.thecontinuousmonitoringofdynamiccompliancemightbecomeavaluablebedsidetoolforeasilyidentifyingthelevelofPEEPthatpreventsend-expiratorylungcollapse？,ClinicalObservation,ClinicalObservation,急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南（2006）中华医学会重症医学分会,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,RecruitmentManeuver,MassachusettsGeneralHospital,PerformanceofRMMGH,SetFIO2at1.0Wait10minutesInsureappropriatesedationMayneedtodomultipleRMs,PerformanceofRMMGH,30cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell35cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell40cmH2OCPAPfor30to40secAllow15to20minutesbetweenRM,MonitoringduringRM(MGH),TheRMshouldbeabortedif:MAP20mmHgSpO2130or20%)PaO2/FiO2improve：92%27%NobarotraumaTraumaorsepsisARDS(earlyARDS)Responsive:(18/22)81.8%PaO2/FiO2improve:71%26%NobarotraumaLegionnairesDisease1pt,nonresponsive,RMonlyonetimeSeveresubcutaneousemphysema,Subcutaneousemphysema,ECMOonARDS,APRV,Result,HypoxiaafterCPB&openheartsurgeryAllptsappearedobviousABPdropin1stRMSpO2droptogetherwithABPdropABPdro