ARDS通气策略件.ppt

PulmonaryProtectiveVentilationInARDS ARDS及其通气策略的新进展 急性呼吸窘迫综合征 AcuteRespiratoryDistressSyndrome ARDS 心源性以外的各种肺内外致病因素急性 进行性缺氧性呼吸衰竭 导致 1肺间质2肺泡 ARDS是一种水循环障碍的 肺水肿 肺水肿 分类 按照病因及发生机制 ARDS 1 感染性肺水肿 pulmonaryedemaduetoinfection 2 毒素吸入性肺水肿 pulmonaryedemaduetopoison 3 淹溺性肺水肿 pulmonaryedemaduetodrowning 4 尿毒症性肺水肿 pulmonaryedemainuremia 5 氧中毒肺水肿 pulmonaryedemaduetooxygentoxicity 通透性肺水肿 病因及分类 ARDS肺水肿的成分 富含蛋白细胞碎片未激活的PS中性粒细胞巨噬细胞炎症介质 Apex Hilum Base 病变分布有重力依赖性 从肺前部到背部 1 正常区30 2 陷闭区20 30 3 实变区40 50 病理生理变化 间歇性分流切变力损伤肺循环阻力增加 病理生理变化 持续性分流肺循环阻力增加 力学曲线变化 1967年 Ashbaugh等首先描述 成人中的急性呼吸窘迫 1971年 Petty等正式命名 成人呼吸窘迫综合征 ARDS 1992年 美欧共识会 American EuropeanConsensusConference AECC 急性呼吸窘迫综合征 AcuteRespiratoryDiseaseSyndrome ARDS 首次提出ALI提出AECC标准 AECC诊断标准的局限 AnearlyPEEP FIO2trialidentifiesdifferentdegreesoflunginjuryinpatientswithacuterespiratorydistresssyndrome AmJRespirCritCareMed 2007 15 176 8 795 804 在 day1 时间点FiO2 0 5 PEEP 10 30min条件下 重新分类为ARDS ALI ARF 29 ARDS患者PAWP 18mmHg 或CVP升高 而其中97 PAWP升高的ARDS患者中有正常的心脏功能 结论 PAWP或CVP升高不能作为ARDS的排除标准 Pulmonary arteryversuscentralvenouscathetertoguidetreatmentofacutelunginjury NEnglJMed 2006May25 354 21 2213 24 CVP PAWP 8 18 BerlinDefinition2012柏林定义 Overdistention过度扩张Barotrauma压力伤Volutrauma容量伤Recruitment DerecruitmentInjury Atlectrauma 剪切伤 萎陷伤TranslocationofCells细胞形态移位Biotrauma生物伤OxidantInjury氧中毒 Shear Recruitment DerecruitmentInjury 跨肺压 若用30cmH2O的正压通气 则跨肺压约35cmH2O 两个肺单位之间产生高达140cmH2O的切变力 Bilek A M D P GaverIII JApplPhysiol94 770 783 2003 DisruptingthealveolarepitheliumTearingincapillaryendothelium MechanicalVentilation Slutsky TremblayAmJRespCritCareMed 1998 157 1721 5 Oxidantinjury keepFiO2 60Barotrauma keepalveolarinflationpressures 35cmH2OVolutrauma BabylungconceptorstretchinjuryAtelectrauma repeatedopeningandclosingBiotrauma releaseofinflammatorymediatorsandbacterialtranslocationOPENGENTLYANDKEEPTHEMOPEN温柔的打开肺泡 并保持开放 WhiteheadT SlutskyAS Thorax 2002 57 636 小潮气量 6ml kg理想体重 允许性高碳酸血症 控制气道平台压 30cmH2O 使用合适的PEEP 是迄今为止少有的被大规模随机对照研究证实 能降低ARDS患者死亡率的治疗措施 提高治疗干预强度 轻度ARDS 中度ARDS 严重ARDS 小潮气量通气 更高水平PEEP 无创通气 低 中水平PEEP 俯卧位通气 神经肌肉阻滞剂 高频振荡通气 ECCO2 R ECMO 30025020015010050 TidalvolumePlateaupressurespHPEEPVCvsPCVRecruitmentmaneuversHigh frequencyoscillatoryPronepositioningECMO 潮气量平台压允许性高碳酸血症呼气末正压定容与定压手法复张高频振荡通气俯卧位通气体外膜氧合 2000年 NEJM 861名成人ARDS患者治疗组 小潮气量 4 6ml kg 限制压力 平台压 30cmH2O 允许性高碳酸血症但保持pH大于7 3显著改善预后病死率39 8 31 自主呼吸天数10天 12天首次为小潮气量通气模式提供可靠的循证医学证据 ARDSNet 2000 HagerDNetal TidalVolumeReductioninPatientswithAcuteLungInjuryWhenPlateauPressuresAreNotHigh AJRCCM2005 Vol1721241 1245 多个研究比较 死亡率 787patientsfromARDSNetworkstudy 平台压 死亡率 30 PEEP 较高的呼气末正压 Meta BrielM MeadeM MercatA etal Highervslowerpositiveend expiratorypressureinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome JAMA2010 303 9 865 73 医院死亡率ICU死亡率气胸气胸后死亡脱机时间 允许性高碳酸血症的通气策略 33 流程图 起始选择与设置 潮气量 VTof8mL kgvsVTof10 15mL kgPEEP titratingPEEPashighaspossiblewithoutincreasingthemaximalPEItogreaterthan30cmH2O Purpose Todeterminewhetherventilationwithlowtidalvolume VT andlimitedairwaypressureorhigherpositiveend expiratorypressure PEEP improvesoutcomesforpatientswithARDSoracutelunginjury 住院死亡率 随访死亡率 气压伤 因严重低氧所致抢救性治疗的应用率 抢救性治疗的死亡率 第1天的PaO2 routineuseoflowVTtendstobebene cialinallpatientswithacutelunginjuryorARDSbecausethisventilationstrategyimprovedhospitalmortality HigherPEEPstrategiesduringlowerVTventilationdidnotimprovehospitalmortalityandcannotberecommendedinunselectedpatientswithacutelunginjuryorARDS HigherPEEPstrategiesduringlowerVTventilationmaypreventlife threateninghypoxemia PCV的优点 variableflowsomorecomfortableifdys synchrony prolongitimeforoxygenation controlpeakpressures RCTmulticenter 79patientswithARDSPCV n 37 versusVCV n 42 Pplat 35cmH2ONodifferenceinmortalitytrendtomorerenalfailureinVCVgroupBUTpatientsinVCVgrouphadahigherin housemortalityrelatedtohighernumberofextra pulmonaryorganfailures 78 vs51 TV8cc kgofweight Arecentsystematicreviewanalyzed40studiesthatevaluatedRMs 4wereRCTs 32prospectivestudies and4retrospectivecohortstudies Thesustainedinflationmethod 45 CPAPof35 50cmH2Ofor20 40seconds23 highpressurecontrol20 incrementalPEEP10 highVT sigh FanE WilcoxME BrowerRG etal Recruitmentmaneuversforacutelunginjury AmJRespirCritCareMed2008 178 11 1156 63 CurrentevidencesuggeststhatthatRMsshouldnotberoutinelyusedonallARDSpatientsunlessseverehypoxemiapersistsorasarescuemaneuvertoovercomeseverehypoxemia toopenthelungwhensettingPEEP orfollowingevidenceofacutelungderecruitmentsuchasaventilatorcircuitdisconnect结论 RM不常规用在所有的ARDS患者 除非持续的严重低氧血症 或者做为严重低氧血症的一种肺开放手段 设置PEEP 或者由于管路断开出现急性肺陷闭 FanE WilcoxME BrowerRG etal Recruitmentmaneuversforacutelunginjury AmJRespirCritCareMed2008 178 11 1156 63 PRONEPOSITIONING俯卧位通气 ComputedtomographyscanofthelungsshowingARDSwhenthepatientislyingsupine left andprone right GattinoniL ProttiA Ventilationintheproneposition forsomebutnotforall CMAJ2008 178 9 1174 6 TheProne SupineIIStudyisthelargestclinicaltrial N5342 inadultARDSpatients conductedin23centersinItalyand2inSpain20hours daySimilar28 daymortality 31 0 vs32 8 RR0 97 95 CI0 84 1 13 P 0 72 Mortalityinseverehypoxemiawasdecreasedinthepronegroup 37 8 inthepronegroupand46 1 inthesupinegroup RR 0 87 95 CI 0 66 1 14P 0 31 TacconeP PesentiA LatiniR etal Pronepositioninginpatientswithmoderateandsevereacuterespiratorydistresssyndrome arandomizedcontrolledtrial JAMA2009 302 1977 84 Effectofmechanicalventilationinthepronepositiononclinicaloutcomesinpatientswithacutehypoxemicrespiratoryfailure asystematicreviewandmeta analysis CMAJ2008 178 8 1153 61 短时间 长时间 P 0 32 P 0 68 SudS SudM FriedrichJO etal Effectofmechanicalventilationinthepronepositiononclinicaloutcomesinpatientswithacutehypoxemicrespiratoryfailure asystematicreviewandmeta analysis CMAJ2008 178 8 1153 61 第1天 第2天 第3天 P 0 001 P 0 001 P 0 001 镇静肌松气道阻塞短暂SpO2下降呕吐低血压心律失常深静脉脱落气管插管移位气管切开移位 High frequencyoscillatoryventilation HFOV高频振荡通气 54 Meta分析结论 维持高平均气道压以保持肺复张 避免肺泡周期性开放 闭合 均为小样本研究 2010 BMJ meta analysis 系统分析多项随机对照临床研究 HFOV提高氧合指数 显著降低死亡率 SudS SudM FriedrichJO etal Highfrequencyoscillationinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome ARDS systematicreviewandmeta analysis BMJ2010 340 c2327 ECMOissupportivecareandisnotintendedasaprimaryARDStreatmentCESARtrial Patientswererandomizedtoeitherconventionalcareat1of68tertiarycarecentersortoasinglecenterusingatreatmentprotocolthatincludedECMOThetrialwasstoppedforefficacyafter180patientsSurvivalwithoutseveredisabilityat6monthswas47 vs63 at6months PeekGJ MugfordM TiruvoipatiR etal Efficacyandeconomicassessmentofconventionalventilatorysupportversusextracorporealmembraneoxygenationforsevereadultrespiratoryfailure CESAR amulticentrerandomisedcontrolledtrial Lancet2009 374 9698 1351 63 58 NPPV无创通气 中国危重病急救医学 2006 18 12 706 710 预计病情能够短期缓解的早期ALI ARDS患者可考虑应用NIV B级 合并免疫功能低下的ALI ARDS患者早期可首先试用NIV B级 应用NIV治疗ALI ARDS应严密监测患者的生命体征及治疗反应 意识不清 休克 气道自洁能力障碍的ALI ARDS患者不宜应用NIV C级 NPPV被推荐的适应症及强度 高 中 低 AECOPD急性心源性肺水肿