肺保护机械通气seminar2008a.ppt

lungprotectivemechanicalventilation肺保护性机械通气adoption discussion 张翔宇sicu上海同济大学上海市第十人民医院 ventilatorinducedlunginjuryvili overdistentionbarotraumavolutraumarecruitment derecruitmentinjurytranslocationofcellsbiotrauma overdistentionbarotrauma volutrauma vili recruitment derecruitmentinjury pip 14 peep 0pip 45 peep 10pip 45 peep 0webb556 translocationofcells bilek a m d p gaveriii japplphysiol94 770 783 2003 translocationofcells disruptthealveolarepitheliumtearsincapillaryendothelium ventilationstrategies balcytokinestremblay valenza ribeiro li slutskyjclinicalinvestigation99 944 52 1997 50倍 ventilatorystrategyandbalcytokines tremblay valenza ribeiro li slutskyjclinicalinvestigation99 944 52 1997 p 0 05vs c mvhp mvzp p 0 05vs c mvhp p 0 05vs c arthursslutsky serumcytokinesinacidaspirationmodelchiumello pristine slutskyajrccm1999 160 109 16 cytokinesinhumansstuberetalintcaremed2002 28 834 841 jama289 2104 2112 2003 systemiceffectsofviliimaietaljama289 2104 2112 2003 mechanicalventilation slutsky tremblayamjrespcritcaremed 1998 157 1721 5 hudsonetal chest116 74s 2s ardsmortalitydecreasedabruptly shanghaiardsstudygroup 15icusin12universityhospitalsinshanghaiin hospitalmortalityofardspatientswere68 5 and90 daymortalityofardspatientswere70 4 intensivecaremed 2004dec 30 12 2197 203 protectthelungs peep vt pip pplateau rm mode protectthelungs how peeptoolow recruitment derecruitmentinjurypplateautoohigh overdistentionbarotraumavolutrauma marceloamato m d etal nengljmed1998 338 347 54 effectofaprotective ventilationstrategyonmortalityintheacuterespiratorydistresssyndrome methodsstudypopulation marcelobpamato md pvcurve static 8 30 prssure smalltidalvolume 5ml kg rimensbergerpccritcaremed1999 27 1946 5227 1940 45 theventilatorycyclecanbeboostedonthedeflationlimb recruitmentmaneuver massachusettsgeneralhospital performanceofrm mgh 30cmh2ocpapfor30to40secifunresponsivebuttoleratedwell35cmh2ocpapfor30to40secifunresponsivebuttoleratedwell40cmh2ocpapfor30to40secallow15to20minutesbetweenrm performanceofrm mgh setfio2at1 0wait10minutesinsureappropriatesedationmayneedtodomultiplerms monitoringduringrm mgh thermshouldbeabortedif map20mmhgspo2130or 60 minutenewarrhythmias amatonejm1998 338 347 35 40cmh2ocpapfor30to40secatenrollmentafterventilatordisconnectnoseverehemodynamiccompromisenobarotrauma amato 2004china fullrecruitment pao2 paco2 400mmhg amato ardsprotocol recruit fio2 1 titratepeep titratepdriving wait 15 fio2 30 highpeep psv wait fio2 30 highpeep psv decreasepsdownto8 decreasepeepdownto12 nimv cpap 12 ps 8 j j haitsma b lachmannminervaanestesiol2006 72 117 32 lungprotectiveventilationinards theopenlungmaneuver450mmhgonpureoxygen whenalungis open stepwiserecruitmentstrategy time 0 10 20 30 40 50 60 70 45 50 55 60 baseline 25cmh2o airwaypressures cmh2o 40 cpap ola dp 15cmh2o marceloamato m d etal nengljmed1998 338 347 54 effectofaprotective ventilationstrategyonmortalityintheacuterespiratorydistresssyndrome limccm2001 29 1255 fotiicm1999 26 501 treatmentwithoscillationandanopenlungstrategy tools critcaremed2005 33 3 479 multi center toronto paris cardiff bostonferguson kacmarek slutsky etal newprotocolwithhfovandrm25patientswithearlyardsinclusion age 18 p f75 significantheartdisease stepwisepeeprecruitmentmaneuvers amato steam stepwisepeeprecruitmentmaneuverscanopencollapsedardslungs higherlevelsofpeeparenecessarytomaintainthelungsopenandassurehomogenousventilationinards curropincritcare 2005feb 11 1 18 28 stepwisepeeprmpractice 26pts5cmh2ostepspinspreached60cmh2o2 26 pao2 paco2 400mmhgnotreachedopenthelungandkeepthelungopenin24 26titratingpeepbyoxygenationnobarotrauma amjrespircritcaremed 2006may11 rminouricu 心脏外科术后低氧患者16例男10例 女6例年龄 52 69多发伤并发ali ards患者18例男13例 女6例年龄 13 56军团菌病1例 女 26岁 msof ards pao2 fio2 49 85 所有病例均为机械通气疗效不佳的低氧血症pao2 fio2 57 6 166mmhg 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 subcutaneousemphysema 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 useofdynamiccomplianceforopenlungpositiveend expiratorypressuretitrationinanexperimentalstudy conclusions inthisexperimentalmodel thecontinuousmonitoringofdynamiccomplianceidentifiedthebeginningofcollapseafterlungrecruitment thesefindingswereconfirmedbyoxygenationandcomputedtomographyscans thismethodmightbecomeavaluablebedsidetoolforidentifyingthelevelofpeepthatpreventsend expiratorycollapse fernandosuarez sipmann md stephanh b hm md gerardotusman md etal critcaremed2007vol 35 no 1 result clinicalobservation clinicalobservation bob snewprotocol performanceofrm setfio2at1 0allowtimeforstabilizationinsureappropriatesedationinsurehemodynamicstability bob snewprotocol performanceofrm pcv pressurecontrolventilation peep20 30cmh2opeakinspirpress40 50cmh2oinspirtime 1to3secrate 8to20 mintime1to3minsetpeepat20 ventilatevc vt4to6ml kgpbw increaserate avoidauto peepmeasuredynamiccompliancedecreasepeep2cmh2o bob snewprotocol performanceofrm pcv measuredynamiccompliancerepeatuntilmaxcompliancedeterminedoptimalpeepmaxcomppeep 2to3cmh2orepeatrecruitmentmaneuverandsetpeepattheidentifiedsettings adjustventilationafterpeepandventilationsetandstabilized decreasefio2untilpo2intargetrangeifresponseispoor repeatrm peep25 peakpressure45ifresponseispoor repeatrm peep30 peakpressure50 bob snewprotocol lungrecruitment performearlyinardsidealapproachtormmostlikelypc limitedpatientdataavailableusingpc worksbetterinextrapulmonarythanprimaryards moredifficulttorecruitthelungthestifferthechestwall startwithlowpressure increaseastoleratedandneeded ifbenefitlostafterrm peepinadequate bob snewprotocol currentconclusion peep pflex 2 peep pdeflex vt 6ml kg vt pplat 30 vt pplat puip guidelines notavailableyet marinijj gattinonil critcaremed 2004jan 32 1 250 5 ventilatorymanagementofacuterespiratorydistresssyndrome aconsensusoftwo conclusions preventionofventilator inducedlunginjurywhileaccomplishingtheessentiallife supportingrolesofmechanicalventilationisacomplexundertakingthatrequiresapplicationofprinciplesfoundedonabroadexperimentalandclinicaldatabaseandontheresultsofwell executedclinicaltrials atthebedside executionofaneffectivelung protectiveventilationstrategyremainsanempiricalprocessbestguidedbyintegratedphysiologyandareadinesstorevisethemanagementapproachdependingontheindividual sresponse titratingpeepfellowingrm pdeflex 2cmh2o pvcurve super syringelow flowmultipleocclusionlinearramping hamiltongaliliogold oxygenationpao2drop 10 pvcurveforpdeflex recognizable andpercentageofthem isthispdeflexconstantovertime orrm ispdeflexafterrmrepeatable ispeeponpdeflexclinicallypractical notansweredyet pflex maximumdifferenceof11cmh2oforthesamepatient amjrespircritcaremed2000 161 432 439 r scottharris deanr hess andjos g venegas 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 patients n 549 ards alipplat cmh2o 30peep cmh2o 12 9 48 4 4rr b min 30tv ml kg 6 thenihrandomizedmulticenterstudyassessingtheeffectonmortalityoflowvshighpeepinards newengljmed2004 351 327 336 peepselectedaccordingtoatabletoachieveminimalphysiologicaloxygenation 88 95 patients n 983 ards alipplat cmh2o 30peep cmh2o 16 3 3rr b min 30tv ml kg 6 9 1 4 thelovs lungopenventilationcanadianstudy canadiantrial oxygenationwasbetterinhighpeepcompliancewasbetterinhighpeeplessrescuetherapiesinhighpeep peepselectedaccordingtoatabletoachieveminimalphysiologicaloxygenation rm stewarttetaljama 2008 299 6 637 645 patients n 752 ards alipplat cmh2o 30peep cmh2o 14 9 4rr b min 30tv ml kg 6 7 4 4 frenchtrial express peepselectedtoavoidoverdistensionortoachievemaximalrec