ARDS患者的肺复张-北协和杜斌教授PPT课件.ppt

ARDS患者的肺复张,北京协和医院杜斌,1,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,2,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,3,ARDS的肺保护性通气策略,4,ARDS的肺保护性通气策略,小潮气量(6ml/kgIBW)避免过度膨胀造成的容积伤(volutrauma)足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma),5,肺泡塌陷与复张造成的剪切力,F=PLx(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积V:复张后容积如果:PL=30cmH2O,V0/V=1/10则:F=140cmH2O,MeadJ,TakishimaT,LeithD.Stressdistributioninlungs:amodelofpulmonaryelasticity.JApplPhysiol1970;28(5):596-608,6,小潮气量通气的问题,RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613,7,小潮气量通气的问题,RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613,8,小潮气量通气的问题,RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613,9,受损的肺组织如何复张,俯卧位足够的PEEP足够的潮气量和(或)叹气?肺复张手法减少水肿(?)最低可接受的FiO2(?)自主呼吸(?),10,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,11,肺泡的开放压与闭合压,12,PEEP不能使肺复张,13,LIP:仅仅是肺复张的开始,HicklingKG.Thepressure-volumecurveisgreatlymodifiedbyrecruitment.AmathematicalmodelofARDSlungs.AmJRespirCritCareMed1998:158:194-202.,14,JonsonB,RichardJC,StrausC,ManceboJ,LemaireF,BrochardL.PressureVolumeCurvesandComplianceinAcuteLungInjury:EvidenceofRecruitmentAbovetheLowerInflectionPoint.AmJRespirCritCareMed1999;159:1172-1178,低位转折点之上仍有肺组织复张,15,肺泡的开放压与闭合压,16,肺泡开放压与闭合压,Paw(cmH2O),CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed2001:164:131-140.,17,ARDS的肺开放,EditorialOpenupthelungandkeepthelungopenB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands(1992)18:319-321,18,RM能够使肺开放,RM:PIP45cmH2O,PEEP35cmH2Ox1min,HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626,19,肺复张能够改善ARDS氧合,LapinskySE,AubinM,MehtaS,BoiteauP,SlutskyAS:Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure.IntensiveCareMed1999,25:1297-1301.,20,肺复张的各种方法,CPAP(SI)incrementalPEEPPCVSigh(modified)HFOV俯卧位,21,SI改善氧合,TugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed2003;31:738-744,SustainedInflation:45cmH2Ox30s,22,SI改善氧合,FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed2005;33:181-188,SustainedInflation:30cmH2Ox30sTwicewith1mininterval,23,叹气的设置,LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260,充气阶段,每30秒PEEP增加5cmH2OVt减少2ml/kg前2次呼吸除外直至Vt2ml/kg,PEEP25cmH2O暂停阶段CPAP30cmH2Ofor30s放气阶段,24,叹气改善氧合,LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260,25,叹气对氧合及呼吸力学的影响,PelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880,Sigh:3consecutivesighs/minatPplat45cmH2O,26,叹气的设置,PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94,Baseline:PSVSigh:BIPAPPEEPhigh=1.2xPIPpsvor35cmH2OTi,s=35sf=1bpm,27,叹气改善呼吸力学及氧合,PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94,28,ARDS对RM的反应,VillagraA,OchagaviaA,VatusS,MuriasG,FernandezMF,AguilarJL,FernandezR,BlanchL.RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome.AmJRespirCritCareMed2002;165:165-170,29,肺复张CT的提示,HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359,30,肺复张CT的提示,HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359,31,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,32,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,33,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,34,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,35,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,36,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,37,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,38,为什么肺复张作用不能持久?,OczenskiW,HrmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology2004;101:620-5,39,为什么肺复张作用不能持久?,肺复张的方法?SI:50cmH2Ox30s作者认为,OczenskiW,HrmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology2004;101:620-5,40,RM+PEEPvs.RMvs.PEEP,LimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418,41,RM+PEEPvs.RMvs.PEEP,LimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418,RM+PEEP,RMonly,42,RM后的PEEP,43,RM后的PEEP能够稳定肺泡,HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626,44,RM后的PEEP能够稳定肺泡,RM:PIP45cmH2O,PEEP35cmH2Ox1min,PEEP5cmH2O,PEEP10cmH2O,HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626,45,肺泡稳定能够改善PaO2,McCannUG,SchillerHJ,GattoLA,etal.Alveolarmechanicsalterhypoxiculmonaryvasoconstriction.CritCaremed2002;30:1315-1321,46,RM后的PEEP,LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377,47,RM+PEEPvs.PEEPonly,LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377,RM+PEEP,PEEPonly,48,PEEP的设置,RM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平最初将PEEP设置为20cmH2O然后将FiO2减小到最低水平维持SpO29095%每2030分钟降低PEEP2cmH2O直至患者SpO2下降,49,PEEP的设置,氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP一旦确认,则需重复肺复张操作,然后把PEEP和FiO2重新设置在上述水平对于多数ARDS患者,PEEP介于1520cmH2O之间某些患者20cmH2O,50,PEEP的设置,如果将PEEP设置于20cmH2O后,仍发现PaO2/FiO2显著下降按照最初的PEEP设置25cmH2O重复肺复张然后按照上述方法调节FiO2和PEEP,51,PEEP的设置,将PEEP从不必要的高水平逐渐降低不要将PEEP由低水平增加到高水平如同P-V曲线所示,根据设置方法不同,同样水平的PEEP所维持的肺容积不同如果在肺泡塌陷后设置PEEP(增加PEEP),则所设置的PEEP水平可以使肺容积减少,PaO2降低,52,PEEP/FiO2的调整,推荐意见降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷一般情况下FiO2应当减低到5min)时如果没有观察到氧合下降,则需要每日进行一次或两次肺复张未知,85,总结,肺复张是肺保护性通气策略的重要组成开放肺并维持肺开放是其理论基础应用气道高压使塌陷肺泡开放应用足够的PEEP维持肺泡开放肺复张对循环的影响肺复张尚未解决的问题压力时间频率适应症,86,87,PEEP能否使肺复张?,PEEP能够防止肺泡塌陷(derecruitment)低水平的PEEP只能使很少的肺复张对于ARDS,将压力持续维持在常用的PEEP水平(300mmHg,108,109,TheP-VCurve,Ontheinflationlimbofthecurvelowerinflectionpoint(Pflex)aregionofchangingslopeinearly