呼吸治疗肺保护施丽萍PPT课件

.,1,呼吸机治疗的肺保护策略,浙江大学医学院附属儿童医院施丽萍,.,2,呼吸机相关性肺损伤acuteparenchymallunginjuryandanacuteinflammatoryresponseinthelung.cytokinesalveoliandthesystemiccirculationmultipleorgandysfunctionmortality,.,3,呼吸机相关性肺损伤ventilator-inducedlunginjury,容量性损伤Volutrauma（largegasvolumes）压力性损伤Barotrauma（highairwaypressure）不张性损伤Atelectotrauma（alveolarcollapseandre-expansion）生物性损伤Biotrauma（increasedinflammation）,.,4,肺损伤病理,alveolarstructuraldamagepulmonaryedema、inflammation、fibrosissurfactantdysfunctionotherorgandysfunctionexacerbatethedisturbanceoflungdevelopmentSeminNeonatol.2002Oct;7(5):353-60.,.,5,ApproachesinthemanagementofacuterespiratoryfailureinchildrenprotectiveventilatoryandpotentialprotectiveventilatorymodeslowertidalvolumeandPEEPpermissivehypercapniahigh-frequencyoscillatoryventilationairwaypressurereleaseventilationpartialliquidventilationimproveoxygenationrecruitmentmaneuverspronepositioningkinetictherapyreduceFiO2andfacilitategasexchangeinhalednitricoxideandsurfactantCurrOpinPediatr.2004Jun;16(3):293-8.,.,6,Canmechanicalventilationstrategiesreducechroniclungdisease?continuouspositiveairwaypressurepermissivehypercapniapatient-triggeredventilationvolume-targetedventilationproportionalassistventilationhigh-frequencyventilationSeminNeonatol.2003Dec;8(6):441-8,.,7,小潮气量和呼气末正压lowertidalvolumeandPEEP,.,8,VentilationwithlowertidalvolumesversustraditionaltidalvolumesinadultsforALIandARDS1202patientslowertidalvolume(7ml/kg)lowplateaupressure30cmH2Oversustidalvolume10to15ml/kgMortalityatday28long-termmortalitywasuncertainlowandconventionaltidalvolumewithplateaupressure31cmH2OwasnotsignificantlydifferentCochraneDatabaseSystRev.2004;(2):CD003844,.,9,Higherversuslowerpositiveend-expiratorypressuresinpatientswiththeacuterespiratorydistresssyndrome,549patientsacutelunginjuryandARDSlower-PEEPgroup8.33.2cmH2Ohigher-PEEPgroup13.23.5cmH2O(P0.001).tidal-volume6ml/kgend-inspiratoryplateau-pressure30cmH2OTheratesofdeath24.9%27.5%(p=0.48)Fromday1today28,breathingwasunassisted14.510.4days13.810.6days(p=0.5)clinicaloutcomesaresimilarwhetherlowerorhigherPEEPlevelsareused.NEnglJMed.2004Jul22;351(4):327-36.,.,10,Increasinginspiratorytimeexacerbatesventilator-inducedlunginjuryduringhigh-pressure/high-volumemechanicalventilationSprague-Dawleyratsnegativecontrolgrouplowpressures(PIP=12cmH2O),rate=30,iT=0.5,1.0,1.5secsexperimentalgroupshighpressures(PIP=45cmH2O),rate=10,iT=0.5,1.0,1.5secslungcompliance,PaO2/FiO2ratio,wet/drylungweight,anddrylung/bodyweightasinspiratorytimeincreased,staticlungcompliance(p=.0002)andPao2/Fio2(p=.001)decreased.Wet/drylungweights(p.0001)anddrylung/bodyweights(p15cmH2OCritCareMed.2003Apr;31(4Suppl):S317-23,.,35,ElectivehighfrequencyoscillatoryventilationversusconventionalventilationforacutepulmonarydysfunctioninpreterminfantsupdatedinMay20033275RandomizedcontrolledtrialscomparingHFOVandCVinpretermorlowbirthweightinfantswithpulmonarydysfunctionnoevidenceofeffectonCLDandmortalityat28-30daysPre-specifiedsubgroupanalysesShorttermneurologicalmorbidityGrade3or4IVHandPVL(nousinghighvolumestrategy)CochraneDatabaseSystRev.2003(4):CD000104,.,36,OpenlungventilationimprovesgasexchangeandattenuatessecondarylunginjuryinapigletmodelofmeconiumaspirationProspective,randomizedanimalstudy36newbornpiglets(6salinecontrols)PPV(OLC),HFOV(OLC),PPV(CON)ventilatedfor5hrsbronchoalveolarlavagefluidmyeloperoxidaseactivitylunginjuryscoreAlveolarproteininfluxnodifferentsuperioroxygenationandlessventilator-inducedlunginjuryCritCareMed.2004Feb;32(2):443-9,.,37,ChangesinmeanairwaypressureduringHFOVinfluencescardiacoutputinneonatesandinfants14patients1yearweight10kgHFOVstudygroup(n=9)MAP+5and-3cmH2Ocontrolgroup(n=5)CardiacoutputechocardiographyDopplertechniqueCardiacoutputthestudygroup(P=0.02)thegreatestchangeatthehighestPawat-11%(range:-19to-9)comparedwithbaseline.ActaAnaesthesiolScand.2004Feb;48(2):218-23,.,38,Randomizedtrialofhigh-frequencyoscillatoryventilationversusconventionalventilation:effectonsystemicbloodflowinverypreterminfants43infants29w8kgVitalsigns,airwaypressures,minuteventilation,Spo(2),andE(T)CO(2)wererecordedAPRVprovidedsimilarventilation,oxygenation,meanairwaypressure,hemodynamics,andpatientcomfortasSIMVAPRVsignificantlylowerinspiratorypeakandplateaupressuresPediatrCritCareMed.2001Jul;2(3):243-6,.,41,Airwaypressurereleaseventilationasaprimaryventilatorymodeinacuterespiratorydistresssyndrome58patientsrandomizedAPRVorSIMVPIPatAPRV-group(25.90.6vs.28.60.7cmH2O)(P=0.007).nodifferentPEEPandphysiologicalvariables(PaO2/FiO2,PaCO2,pH,minuteventilation,meanarterialpressure,cardiacoutput)Atday28,thenumberofventilator-fr