急性肺损伤（ALI）.ppt

第二十二章急性肺损伤（ALI）急性呼吸窘迫综合征（ARDS）ACUTELUNGINJURYACUTERESPIRATORYDISTRESSSYNDROME,徐州医学院麻醉学系危重病医学教研室孟雷,概述,DAD:diffusealveolardamage（弥漫性肺泡损害）Etiology:shock,infection,trauma,aspiration,drugs,inhalationetc.ALI1:17,ALI138:720.,临床分期,ARDS分期：第一期：原发病临床表现第二期：轻度呼吸困难第三期：呼吸窘迫第四期：严重呼吸窘迫,4.DiagnosisCriteria,ALI:PaO2/FiO2300(whateverPEEP)BilateralinfiltratesonchestradiographPAWP18mmHgornoclinicalfindingssuggestiveofincreasedLAPARDS:PaO2/FiO2200(whateverPEEP)BilateralinfiltratesonchestradiographPAWP18mmHgornoclinicalfindingssuggestiveofincreasedLAP,FromBernardGR,ArtigasA,BrighamKL,etal:TheAmerican-EuropeanconsensusconferenceonARDSdefinitions.AmJRespirCritCareMed1994;149:818,患者，女性，63，误吸。38mmHg,100%9h后：56mmHg,50%13h后：65mmHg,50%20h后：79mmHg,50%34h后：73mmHg,50%,5.治疗therapyortreatment,积极治疗原发疾病7.部分液体通气控制感染8.表面活性物质替代机械通气支持9.免疫疗法的应用降低肺血管阻力10.营养代谢支持疗法肾上腺糖皮质激素12.循环功能的支持体外膜肺氧合,FluidTherapy,ConventionalApproach:AimsofresuscitationinARDS:AttainnormalvitalsignswhilePAWPiskeptaslowaspossible.Fluidrestrictionanddiureticadministration.(1)InputandoutputrecordsoflargeamountoffluidsgivenbeforthediagnosisofARDSwasgiven.(2)Clinicalevidenceofexcessivefluidretention,suchasperipheraledema.(3)Clinicalradiologicevidenceofpulmoarycongestiveandedema(4)Improvementinarterialbloodgasvaluesafterdiuretictherapy,FluidTherapy,Critiqueofconventionalapproach:Pulmonaryedemamaybecausedbysomanydiseases.Inpostoperative,posttraumaandsepsispatients,pulmonaryedemaisduetooverexpansionoftheinterstitium,nottoplasmavolumeoverload.Peripheralandpulmonaryedemareflect:interstitialfluidvolumesincrease,plasmaoncoticpressuredecrease,nutritionalfailure,endothelialpermeabilityincrease,lunghypoxiaoranaphylactoidreactions(过敏反应)HypovolumiaisamajorpathophysiologicfactorofARDS;pulmonaryedemaisaneffect,notthecauseof,ARDS.,FluidTherapy,Fluidtherapeuticgoalsvalues:CI4.5L/min.m2DO2600ml/min.m2VO2170ml/min.m2Bloodvolume500mlgreaterthannormal3.2L/min.m2(men)2.7L/min.m2(women)Allthesevaluesshouldbereachedwithin812hpostoperativelyoraftertrauma,FromShoemakerWC,AyresSM,AkeGrenvik,HolbrookPR.TextbookofCriticalCare,4thEdition.HarcourtPublishersLimited.2000.1397.,FluidTherapy,Forpatientswithseverelunginjury,lessismore.inanewsreleasefromtheNationalHeart,LungandBloodInstitutewiththisheadline.Fluidmanagementisacomplexissue,and,untilnow,itwasnotclearwhetherprovidingmoreorlessfluidswasmorebeneficial.Currenttrendsinusualcareappeartomorecloselyresembletheliberalfluidmanagementarmofthisstudy-thestdyarmwithworseoutcomes.GordonBemard,chairofNIHARDSNetworkSteeringCommittee,MechanicalVentilation,Lung-protectivestrategies(肺保护策略):Permissivehypercapnia(允许性高碳酸血症)Lowtidalvolume+highPEEPRecruitmentmaneuver(肺复张法)Proneposition(俯卧位)NOinhalationExtracorporealgasexchange(体外气体交换)ECMO(体外膜肺氧合)ECCO2OR(体外CO2清除),Lungprotectiveventilation,Lowtidalvolume:6ml/kgvs1012ml/kgPeakairwaypressure30cmH2ODrivingpressure20cmH2OPaCO260mmHgpH7.20HighPEEPthanconventionalvalues,Lungprotectiveventilation-physiologicconsequenciesofhypercapnia,Cellulareffects:intracellularacidosisIntheabsenceofhypoxemia,intracellularacidosisappearstobewelltoleratedincriticalillpatients.Cardiovasculareffects:highsympatheticactivityIncrease:HR,BP,PVRDecrease:SVRCNSeffects:CBFandICPincreaseConsciousness:severeagitation,seizure,coma.,Lungprotectiveventilation-recruitmentmaneuver,Openthelungandkeepthelungopen,Lungprotectiveventilation-stepwiserecruitmentmaneuver,PEEPtitrationdependon:Pdeflex、PaCO2、CompliancePEEPincrement:23cmH2OMaintain:12minutesPEEPtarget:16/1stRM;20/2ndRM;26-30/3rdRMPIPmax:40cmH2OInterval:twiceaday,Proneposition俯卧位,Physiologiceffects:ReexpandconsolidateddepedentlungregionImproveV/QmatchingReduc