患者的肺复张ppt课件

ARDS患者的肺复张 ALI ARDS的定义 ALI急性起病胸片对称的侵润影PaO2 FiO2 300mmHgPAWP 18mmHg或没有左心衰的证据 ARDS急性起病胸片对称的侵润影PaO2 FiO2 200mmHgPAWP 18mmHg或没有左心衰的证据 ARDS肺部形态学的改变 PuybassetL etal Regionaldistributionofgasandtissueinacuterespiratorydistresssyndrome I Consequencesforlungmorphology IntensiveCareMed2000 26 857 69 ARDS肺部形态学的改变 GattinoniL etal Relationshipsbetweenlungcomputedtomographicdensity gasexchangeandPEEPinacuterespiratoryfailure Anesthesiology1988 69 824 32 ARDS肺部形态学的改变 PatronitiN BellaniG MaggioniE ManfioA MarcoraB PesentiA Measurementofpulmonaryedemainpatientswithacuterespiratorydistresssyndrome CritCareMed2005 33 2547 2554 ARDS肺部形态学的改变 GATTINONI 3ZONES过度膨胀 干 婴儿肺 湿 PEEP可使其复张塌陷或实变区域 GattinoniL JThoracImag1986 1 3 25 ARDS肺部形态学的改变 婴儿肺 BABYLUNG 的概念通气的肺仅相当于正常肺的20 30 ARDS患者肺容积的减少并非意味胸腔内总容积的减少仅仅是实变组织替代了气体 GattinoniL etal Relationshipsbetweenlungcomputedtomographicdensity gasexchangeandPEEPinacuterespiratoryfailure Anesthesiology1988 69 824 32 气压伤 barotrauma 机械通气导致肺过度牵张所引起的肺损伤容积伤 volutrauma Normalratlungs PIP45 5min PIP45 20mins 剪切力损伤 atelectrauma 指由于肺泡反复塌陷和复张所造成的损伤 肺泡塌陷时的剪切力损伤 驱动压力30cmH2O时通气肺泡与不通气肺泡交界处的剪切力可高达140cmH2O Mead1970 F PLx V0 V 2 3 ARDS保护性肺通气策略 机械通气时有两个肺损伤区域肺容积过低可导致剪切力损伤肺容积过高可导致肺泡过度牵张 引起容积伤 FroeseAB CritCareMed1997 25 906 肺开放与ARDS EditorialOpenupthelungandkeepthelungopenB LachmannDept ofAnesthesiology ErasmusUniversityRotterdam TheNetherlands 1992 18 319 321 肺泡通气与吹气球 肺复张与ARDS ARDS的肺复张 CPAPCPAP30 45cmH2OPCVPC15cmH2OPEEP30 45cmH2O叹气 Sigh 肺复张操作 肺复张前5 10分钟将FiO2提高到1 0通常需0要镇静以保证肺复张过程中无自主呼吸首先用CPAP30cmH2O共30 40秒之后仔细评估效果 肺复张操作 如果效果不明显 但患者耐受较好应在15 20分钟后用更高水平的CPAP 35 40cmH2O 进行肺复张如果第二次肺复张操作效果也不佳应当进行第三次肺复张操作CPAP40cmH2O 肺复张操作 部分患者可能需要进行多次肺复张操作才能显示效果Fujinoetal AJRCCM1999 肺复张操作 尚不清楚是否需要使用40cmH2O以上的压力动物试验表明高达60cmH2O的压力是安全的尽管这样高的压力仍处于试验阶段 且需要在密切监测的条件下谨慎实施FujinoetalAJRCCM1999 肺复张操作 如果CPAP40cmH2O30 40秒不足以使肺复张PCV20cmH2O PEEP30cmH2O I E1 1 f10bpmfor2min如果仍然无效PCV20cmH2O PEEP40cmH2O I E1 1 f10bpmfor2min一些动物可能出现CO轻度下降 PAP升高所有试验动物在10分钟内血流动力学均恢复到肺复张前的状态FujinoetalAJRCCM1999 如果判断肺复张成功 PaO2 FiO2 300mmHg或PaO2 PaCO2 400mmHg 肺复张能够改善ARDS氧合 LapinskySE AubinM MehtaS BoiteauP SlutskyAS Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure IntensiveCareMed1999 25 1297 1301 肺复张能够改善氧合 SchreiterD ReskeA StichertB SeiwertsM BohmSH KloeppelR JostenC Alveolarrecruitmentincombinationwithsufficientpositiveendexpiratorypressureincreasesoxygenationandlungaerationinpatientswithseverechesttrauma CritCareMed2004 32 968 975 肺复张能够维持肺泡稳定 SchreiterD ReskeA StichertB SeiwertsM BohmSH KloeppelR JostenC Alveolarrecruitmentincombinationwithsufficientpositiveendexpiratorypressureincreasesoxygenationandlungaerationinpatientswithseverechesttrauma CritCareMed2004 32 968 975 PEEP能够有效维持氧合 LapinskySE AubinM MehtaS BoiteauP SlutskyAS Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure IntensiveCareMed1999 25 1297 1301 反复肺复张的作用 FujinoY GoddonS DolhnikoffM HessD AmatoMBP KacmarekRM Repetitivehigh pressurerecruitmentmaneuversrequiredtomaximallyrecruitlunginasheepmodelofacuterespiratorydistresssyndrome CritCareMed2001 29 1579 1586 肺复张对脑氧代谢的影响 BeinT KuhrLP BeleS PlonerF KeylC TaegerK Lungrecruitmentmaneuverinpatientswithcerebralinjury effectsonintracranialpressureandcerebralmetabolism IntensiveCareMed2002 28 554 558 肺复张对内脏血流的影响 NunesS RothenHU BranderL TakalaJ JakobSM ChangesinSplanchnicCirculationDuringanAlveolarRecruitmentManeuverinHealthyPorcineLungs AnesthAnalg2004 98 1432 8 肺复张的副作用 血流动力学紊乱延迟到血流动力学稳定后再进行发生气压伤需对以下患者评估利弊既往肺部囊性或大泡性疾病既往肺部漏气 肺复张期间对患者的监测 动脉血压脉搏和心律SpO2如果出现并发症立即终止肺复张操作 肺复张对护士的要求 了解肺复张的目的密切监测生命体征的变化肺复张后不要轻易脱开呼吸机吸痰 吸痰对氧合及肺容积的影响 DyhrT BondeJ LarssonA Lungrecruitmentmaneuversareeffectivetoregainlungvolumeandoxygenationafteropenendotrachealsuctioninginacuterespiratorydistresssyndrome CritCare2003 7 55 62 吸痰管大小与压力改变 MorrowBM FutterMJ ArgentAC Endotrachealsuctioning fromprinciplestopractice IntensiveCareMed2004 30 1167 1174 吸痰导致氧合下降 LasockiS LuQ SartoriusA FouillatD RemerandF RoubyJ J OpenandClosed circuitEndotrachealSuctioninginAcuteLungInjury EfficiencyandEffectsonGasExchange Anesthesiology2006 104 39 47 吸痰对氧合的影响 LindgrenS AlmgrenB HgmanM LethvallS HoultzE LundinS StenqvistO Effectivenessandsideeffectsofclosedandopensuctioning anexperimentalevaluation IntensiveCareMed2004 30 1630 1637 肺复张防止吸痰导致的肺容积减少 SWIVELpsvCLOSEDpsvCLOSEDSWIVELDISCONNECTION PreventionofEndotrachealSuctioning inducedAlveolarDerecruitmentinAcuteLungInjuryMaggioreSM LelloucheF PigeotJ TailleS DeyeN DurrmeyerX RichardJ C ManceboJ LemaireF BrochardL AmJRespirCritCareMed2003 167 1215 1224 肺复张能够防止吸痰导致的氧合下降 LasockiS LuQ Sartoriu