ARDS患者的肺复张nursing.ppt

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/FiO2300mmHgPAWP18mmHg或没有左心衰的证据,ARDS急性起病胸片对称的侵润影PaO2/FiO2200mmHgPAWP18mmHg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2030%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,CPAPCPAP3045cmH2OPCVPC15cmH2OPEEP3045cmH2O叹气(Sigh),肺复张操作,肺复张前510分钟将FiO2提高到1.0通常需要镇静以保证肺复张过程中无自主呼吸首先用CPAP30cmH2O共3040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1520分钟后用更高水平的CPAP(3540cmH2O)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CPAP40cmH2O3040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/FiO2300mmHg或PaO2+PaCO2400mmHg,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