ARDS肺复张的实施(邱海波)

邱海波东南大学附属中大医院ICU东南大学急诊与危重病医学研究所,ARDS肺复张的实施,科学与艺术的困惑,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM,ARDSnet:小潮气量通气,ARDSNet.NEnglJMed.2000May4;342(18):1301-8.,Lowtidalvolume:morealvcollapse,小Vt不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略至少1525%患者需提高FiO2,邱海波,刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205,LIP：塌陷肺泡开始复张的压力不是全部塌陷肺泡复张的压力,PEEPnotenough:morealvkeepcollapse,30kgPigPostLavagePCVPaw13cmH2OPEEP5cmH2O,Experimentalstudy-PigwithARDS,许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.,ClinicalTrial11ARDSpats,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM,A.HypoxamiaB.ShearforcesC.SurfactantsinactivateD.BiotraumaandMODS,PathophysiologyConsolidationandalvcollapse,A.低氧血症,肺泡塌陷：ARDS重力依赖区炎症或不张区生理性低氧缩血管反应：障碍,HowDoesExcessiveMechanicalStressInflametheLung?,“Shear”,Verbruggeetal.CritCareMed1999;27：779,Ventilator-associatedlunginjury,Purine:amarkerofATPbreakdownandVILI42SDratsPCV6minPCVPre/PEEPBALFpurineandprotein,Lachmann.ICM,1994;20:6-11,Intra-alveolarproteinsinactivatealvsurfactantinadose-dependentway1mgsurfactant=inhibitoryeffectof1mgplasmaprotein,C.Surfactant灭活,Surfactantmoveaway,Whenlungregionscollapseatendexpiration,surfactantmoleculesmoveawayfromthealvsurfacetowardterminalbronchiolesandcannotbereusedduringnextinflation,RoubyJJ.AmJRespirCritCareMed,2001,165:1182,D.预防Biotrauma和MODS,MariniJJ,GattinoniL.Ventilatorymanagementofacuterespiratorydistresssyndrome:aconsensusoftwoCritCareMed.2004Jan;32(1):250-5.,“Stretch”,“Shear”,AirwayTrauma,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM,俯卧位通气的病理生理特征,改善通气过程胸膜腔压力梯度顺应性胸壁促进分泌物的清除,Closingpressure,Closingpressure,TimecourseofProneonPaO2/FiO2betweenARDSpvsARDSexp,TimeresponseofPronepositiononPaO2/FiO2betweenARDSpvsARDSexp,黄英姿,邱海波.肺内外源性ARDS实施俯卧位通气时间的选择.中华内科杂志2004,43(12):883-887,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM,保留自主呼吸的优点,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM,PawcmH2O,%,OpeningandClosingPressures,0,5,10,15,20,25,30,35,40,45,50,0,10,20,30,40,50,5patients,ALI/ARDS,FromCrottietalAJRCCM2001.,SomeunitscantbekeptopenbyanyreasonablePEEP!,Amato:CT+PVCurve,Heart,Sp,P,V,LIP,UIP,Insprecruit,LargerVt/Sigh:PressuremustbehighenoughEvenuptoUIP,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighHighPEEPRM,许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.,ClinicalTrial11ARDSpats,RecruitmentisTime-Dependent,40SECONDS,内容提要,肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighHighPEEPRM,Recruitmentmannuvers,BasicPrinciplesMethodsforRecruitmentExperimentalStudiesandClinicalTrialsEfficacyHazards,1.控制性肺膨胀(SI)法2.PEEP递增法3.压力控制(PCV)法,MethodsforRecruitment,CPAP模式:PS0,PEEP30-40cmH2O,20-50s2.BIPAP:Ph/PL30-40cmH2O,20-50s3.InspHold:将吸气保持键按住，持续20-40s,控制性肺膨胀(SI)法,MultipleManeuversMayBeNeededForOptimumRMEffect,Fujinoetal,CritCareMed2001;29(8):1579-1586,Post-RMPEEPDeterminesPaO2,Post-RM-PEEP肺开放效应持续时间的决定因素,CCM,2004,32:2371-2377,28mixed-breedpigsModelsofARDS:OAVILIPneumonia(PNM)RMSIIncreasedPEEPPCV,肺开放后的PEEP选择-PaO2/FiO2,1.RM后PEEP:20cmH2O2.PEEP递减:2cmH2O/5min3.PEEP阈值:PaO2/FiO25%4.PEEP:PEEP阈值+2cmH2O,BASELINEVENTILATIONTidalvolume=6ml/kgPEEP=5cmH2O,ModifyPEEPtogeta1.10.9,recruitingmaneuver,Measure,1.10.9LeavePEEPunchanged,stressindex0.9,1.1DecreasePEEPuntil1.1stressindex0.9,CritCareMed,2004,32:1018-1027,肺开放后的PEEP选择-Stressindex,Implications,RM的有效性ALI的病因(directvsindirect)PostRMPEEPMethodincertainsettingsRMhazardsaregreatestandeffectivenessleastinpneumonia-causedacutelunginjuryPCVmaybebettertoleratedthanSI,Recommendations,UsePCVinpreferencetoSISafer,“multiple”,