ards患者的肺复张课件（可编辑）

ARDS患者的肺复张课件HOWHIGHAPRESSUREHOWLONGATIMEPATIENTPEAKAIRWAYPRESSUREOF46CMH2OTORECRUITCOLLAPSEDLUNGINARDSPATIENTSGATTINONIETALAJRCCM19863540CMH2OCPAPFOR3040SECPRIORTOESTABLISHINGALUNGPROTECTIVEVENTILATORYSTRATEGYWHENEVERMECHANICALVENTILATIONWASDISRUPTEDAMATOETALNEJM1998HOWHIGHAPRESSUREHOWLONGATIMEPATIENTINAPATIENTWITHSEPTICARDSINITIALRECRUITMENTMANEUVERSWITH40CMH2OCPAPFOR40SECFAILEDPEEP40CMH2OPEEPANDPCV20CMH2OATANIERATIOOF11WITHARATEOF10BPMFOR2MINUTESTOFULLYRECRUITTHELUNGMEDOFFETALCCM2000HOWHIGHAPRESSUREHOWLONGATIMEPATIENTTHESUCCESSOFPCVSCPAPINTHEEXAMPLESEMPHASIZETHERELATIONSHIPBETWEENPRESSUREANDTIMEFUJINOETALAJRCCM1999MEDOFFETALCCM2000THEOPTIMALRELATIONSHIPBETWEENTHESETWOVARIABLESTOIMIZEEFFICACYANDMAINTAINSAFETYREMAINSUNCLEARMECHANISMOFLUNGRECRUITMENTFIRSTTHEAIRWAYSMUSTBEOPENEDINORDERTORECRUITCOLLAPSEDLUNGAIRWAYOPENINGOCCURSBYEITHERMOVINGTHEMENISCUSFORMEDBYFLUIDLININGTHEAIRWAYTOWARDTHEPERIPHERYOROVERCOMINGTHEPARENCHYMATETHERINGPRESENTINACTUALCOLLAPSEDAIRWAYMECHANISMOFLUNGRECRUITMENTSECONDTHECOLLAPSEDALVEOLIMUSTBEOPENEDCOLLAPSEDINJUREDLUNGUNITSWITHINCREASEDSURFACETENSIONREQUIREVERYHIGHPRESSURESTOESTABLISHSUFFICIENTLATERALSTRESSTOOPENTHELUNGMEADETALJAP1970WHATISCLEARISTHATTHEOPTIMALMETHODOFLUNGRECRUITMENTINSURINGIMALEFFICACYANDSAFETYHASNOTBEENDETERMINEDSIDEEFFECTSOFRMSHEMODYNAMICCOMPROMISEDELAYEDUNTILPATIENTSHEMODYNAMICALLYSTABLEDEVELOPMENTOFBAROTRAUMATHEBENEFITSANDPOTENTIALRISKSMUSTBECAREFULLYWEIGHEDINPATIENTSWITHPREEXISTINGPULMONARYCYSTICORBULLOUSLUNGDISEASEPREEXISTINGAIRLEAKSMONITORINGOFPATIENTSARTERIALPRESSUREPULSERATEANDRHYTHMSPO2IFCOMPROMISEDEVELOPSTHERECRUITMENTMANEUVERABORTEDPERFORMANCEOFARMFIO2INCREASEDTO10FOR510MINUTESBEFORERMSEDATIONGENERALLYREQUIREDTOINSUREPASSIVEINFLATIONDURINGTHERECRUITMENTPERIOD30CMH2OCPAPFOR3040SECDURINGTHEFIRSTRMFOLLOWEDBYCAREFULASSESSMENTOFTHERESULTSPERFORMANCEOFARMIFTHERESPONSEISINADEQUATEBUTPATIENTTOLERANCEISGOODRMSHOULDBEREPEATEDIN1520MINUTESATAHIGHERCPAPLEVEL3540CMH2OIFTHERESPONSETOTHESECONDRMISINADEQUATEATHIRDRMAT40CMH2OCPAPSHOULDBEPERFORMEDPERFORMANCEOFARMCPAP4060PCV2MINPC20PEEP40F10IE11PCV30MINPC15PEEP20F20IE11FUJINOYGODDONSDOLHNIKOFFMHESSDAMATOMBPKACMAREKRMREPETITIVEHIGHPRESSURERECRUITMENTMANEUVERSREQUIREDTOIMALLYRECRUITLUNGINASHEEPMODELOFACUTERESPIRATORYDISTRESSSYNDROMECRITCAREMED20012915791586PERFORMANCEOFARMWHETHERTOUSEPRESSURESBEYOND40CMH2OSTILLUNCLEARANIMALDATAIMPLYTHATPRESSURESUPTO60CMH2OARESAFETHOUGHTHESEPRESSURESMUSTSTILLBECONSIDEREDEXPERIMENTALANDAPPLIEDVERYCAUTIOUSLYUNDERWELLMONITOREDCONDITIONSFUJINOETALAJRCCM1999PERFORMANCEOFARMIFACPAPOF40CMH2OFOR3040SECINSUFFICIENTTORECRUITTHELUNGPCV20CMH2OWITHPEEP30CMH2OIE11RATE10MINFOR2MINIFTHISISINEFFECTIVEPCV20CMH2OWITHPEEP40CMH2OIE11RATE10MINFOR2MINASMALLDROPINCOANDANINCREASEINPAPINSOMEANIMALSWITHACOMPLETERETURNTOPRERMHOMODYNAMICSTATUSWITHIN10MININALLANIMALSSTUDIEDFUJINOETALAJRCCM1999WHATISSUCCESSFULRECRUITMENTPAO2FIO2RATIO300MMHGTHEPVCURVEONTHEINFLATIONLIMBOFTHECURVELOWERINFLECTIONPOINTPFLEXAREGIONOFCHANGINGSLOPEINEARLYINFLATIONWHERELUNGRECRUITMENTBEGINSTHEMINIMALPEEPNECESSARYTOPREVENTPARTIALDERECRUITMENTOFTHELUNGDURINGEXHALATIONTHEPVCURVEONTHEEXPIRATORYLIMBTHEPOINTOFIMUMCURVATUREPMCEXTHEAREAWHERETHEIMUMVOLUMECHANGEUNITPRESSUREOCCURSDURINGEXHALATIONTHEIMUMPEEPREQUIREDTOPREVENTDERECRUITMENTTHEPVCURVETHESETWOPOINTSIDENTIFYTHERANGEOFPEEPNEEDEDINARDSPFLEXTHEMINIMUMPMCEXTHEIMUMIDEALLYACOMPLETEPVSHOULDBEPREFORMEDONALLPATIENTSIDENTIFYINGTHESEPOINTSTOALLOWACCURATESETTINGOFPEEPRM后的PEEP影响PAO2LIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377肺泡开放压与闭合压0102030405005101520253035404550OPENINGPRESSURECLOSINGPRESSUREPAWCMH2OCROTTISMASCHERONIDCAIRONIPPELOSIPRONZONIGMONDINOMMARINIJJGATTINONILRECRUITMENTANDDERECRUITMENTDURINGACUTERESPIRATORYFAILUREACLINICALSTUDYAMJRESPIRCRITCAREMED2001164131140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RM保护肺内皮而非肺泡上皮试验动物大鼠模型制备酸PH15吸入机械通气VT6MLKGPEEP5CMH2OFIO210F6070BPM复张操作30CMH2OX30SX2间隔1分钟FRANKJAMCAULEYDFGUTIERREZJADANIELBMDOBBSLMATTHAYMADIFFERENTIALEFFECTSOFSUSTAINEDINFLATIONRECRUITMENTMANEUVERSONALVEOLAREPITHELIALANDLUNGENDOTHELIALINJURYCRITCAREMED200533181188RM保护肺内皮而非肺泡上皮FRANKJAMCAULEYDFGUTIERREZJADANIELBMDOBBSLMATTHAYMADIFFERENTIALEFFECTSOFSUSTAINEDINFLATIONRECRUITMENTMANEUVERSONALVEOLAREPITHELIALANDLUNGENDOTHELIALINJURYCRITCAREMED200533181188RMARDS早期VS晚期VILLAGRAAOCHAGAVIAAVATUSSMURIASGFERNANDEZMFAGUILARJLFERNANDEZRBLANCHLRECRUITMENTMANEUVERSDURINGLUNGPROTECTIVEVENTILATIONINACUTERESPIRATORYDISTRESSSYNDROMEAMJRESPIRCRITCAREMED2002165165170原发性ARDS对RM反应不佳SALINELAVAGEOLEICACIDINJURYPNEUMONIAVANDERKLOOTTEBLANCHLYOUNGBLOODAMWEINERTCADAMSABMARINIJJSHAPIRORSNAHUMARECRUITMENTMANEUVERSINTHREEEXPERIMENTALMODELSOFACUTELUNGINJURYEFFECTONLUNGVOLUMEANDGASEXCHANGEAMJRESPIRCRITCAREMED200016114851494SUSTAINEDINFLATIONCPAP4030CPAP6030CPAP6030油酸损伤模型RM作用短暂LIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377PEEP8PEEP12PEEP16不同病因对RM的反应LIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377RMPEEPPEEPONLYRMARDSP与ARDSEXPLIMCMJUNGHKOHYLEEJSSHIMTSLEESDKIMWSKIMDSKIMWDEFFECTOFALVEOLARRECRUITMENTMANEUVERINEARLYACUTERESPIRATORYDISTRESSSYNDROMEACCORDINGTOANTIDERECRUITMENTSTRATEGYETIOLOGICALCATEGORYOFDIFFUSELUNGINJURYANDBODYPOSITIONOFTHEPATIENTCRITCAREMED200331411418SI改善氧合TUGRULSAKINCIOOZCANPEINCESESENFTELCILAKPIRKCAKARNEFFECTSOFSUSTAINEDINFLATIONANDPOSTINFLATIONPOSITIVEENDEXPIRATORYPRESSUREINACUTERESPIRATORYDISTRESSSYNDROMEFOCUSINGONPULMONARYANDEXTRAPULMONARYFORMSCRITCAREMED200331738744SUSTAINEDINFLATION45CMH2OX30S叹气ARDSP与ARDSEXPPELOSIPCADRINGHERPBOTTINONPANIGADAMCARRIERIFRIVAELISSONIAGATTINONILSIGHINACUTERESPIRATORYDISTRESSSYNDROMEAMJRESPIRCRITCAREMED1999159872880SIGH3CONSECUTIVESIGHSMINATPPLAT45CMH2O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RM不增加肺泡过度膨胀BUGEDOGBRUHNAHERNANDEZGETALLUNGCOMPUTEDTOMOGRAPHYDURINGALUNGRECRUITMENTMANEUVERINPATIENTSWITHACUTELUNGINJURYINTENSIVECAREMED200329218225肺复张对内脏血流的影响NUNESSROTHENHUBRANDERLTAKALAJJAKOBSMCHANGESINSPLANCHNICCIRCULATIONDURINGANALVEOLARRECRUITMENTMANEUVERINHEALTHYPORCINELUNGSANESTHANALG20049814328肺复张对胃肠道血流的影响CLAESSONJLEHTIPALOSWINSODDOLUNGRECRUITMENTMANEUVERSDECREASEGASTRICMUCOSALPERFUSIONINTENSIVECAREMED20032913141321肺复张对脑氧代谢的影响BEINTKUHRLPBELESPLONERFKEYLCTAEGERKLUNGRECRUITMENTMANEUVERINPATIENTSWITHCEREBRALINJURYEFFECTSONINTRACRANIALPRESSUREANDCEREBRALMETABOLISMINTENSIVECAREMED200228554558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肺泡开放压与闭合压0102030405005101520253035404550OPENINGPRESSUREPAWCMH2OCROTTISMASCHERONIDCAIRONIPPELOSIPRONZONIGMONDINOMMARINIJJGATTINONILRECRUITMENTANDDERECRUITMENTDURINGACUTERESPIRATORYFAILUREACLINICALSTUDYAMJRESPIRCRITCAREMED2001164131140CLOSINGPRESSURE即使使用足够的PEEP也不能使所有肺单位开放RM对哪些患者疗效好尚不清楚肺复张对哪类患者疗效更好肺复张对早期ARDSALI患者的效果更显著随着ARDS的进展肺进入纤维增殖期肺复张就无法有效改善氧合气压伤的危险反而增加RM对哪些患者疗效好ARDS的病因继发性ARDS全身性感染创伤等比原发性ARDS肺炎更容易复张目前的推荐意见在ARDSALI病程早期进行肺复张无论ARDS的病因如何肺复张操作的频率尚不清楚对某一患者进行肺复张操作的适宜频率以下情况应进行肺复张操作病程早期当肺泡塌陷时例如呼吸机脱开肺复张操作的频率对于ARDS患者脱离呼吸机能够导致肺泡迅速塌陷从而发生严重的低氧血症为避免呼吸机脱开建议采用密闭吸痰装置特殊雾化装置肺复张操作的频率肺复张操作当观察到SPO2持续降低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20CMH2O只能使小部分肺组织复张PEEP能否使肺复张ARDS患者的肺复张贯穿于整个吸气过程BYHICKLINGAJRCCM1998TIDALRECRUITMENTOCCURSBELOWOPTIMALPEEPPEEPATTHEOPTIMALLEVELGENERALLYRESULTSINADECREASEDQUASISTATICCOMPLIANCEWHENMEASUREDONTHEVENTILATORBYJONSONETALAJRCCM1999肺复张所需的压力正常潮气量通气也能使肺组织复张但是大部分肺组织可能仍未充分复张在有限的吸气时间内在目标气道峰压水平由于塌陷肺泡表面液体的粘滞性这些肺单位较高的表面张力间质组织的限制塌陷的肺组织需要较高的气道压力和较长的时间才能复张HOWHIGHAPRESSUREHOWLONGATIMEHEALTHYLUNGTRANSPULMONARYPRESSUREOF30CMH2OTORECRUITATELECTATICHEALTHYLUNGSGREAVESETALJAP1990PEAKALVEOLARPRESSURESOF40CMH2OFOR7TO15SECONDSTORECRUITLUNGSOFPREVIOUSLYHEALTHYNORMALPATIENTSFOLLOWING20MINUTESOFGENERALANESTHESIABYROTHENETALBRJANAESTH19931998RESOLUTIONOFATELECTASISDURINGA40CMH2ORMHASATIMECONSTANTOF26SECROTHENETALBRJANAESTH1999HOWHIGHAPRESSUREHOWLONGATIMEHEALTHYLUNGASARESULTINPREVIOUSLYHEALTHYINDIVIDUALSTHEVASTMAJORITYOFATELECTASISWOULDBERECRUITEDWITHINABOUT78SECHOWHIGHAPRESSUREHOWLONGATIMEANIMALPEAKAIRWAYPRESSURESOF55CMH2OFOR510MINTOOPENCOLLAPSEDLUNGINAPORCINEMODELOFARDSSJOSRANDETALICM1995TOIMALLYRECRUITLUNGINASHEEPSALINELAVAGELUNGINJUREDMODEL40CMH2OPEEP20CMH2OPCPPEAK60CMH2OIEOF11ANDARATEOF10BPMFOR2MINUTESFUJINOETALAJRCCM1999HOWHIGHAPRESSUREHOWLONGATIMEANIMALANIMALSRECRUITEDWITH40CMH2OCPAPFOR60SECNOTIMALLYRECRUITEDTOFULLYRECRUITTHELUNGMULTIPLE23RMSREQUIREDEVENATPEAKPRESSURESOF60CMH2O肺复张CT的提示HENZLERDMAHNKENAHWILDBERGERJEROSSAINTRGNTHERRWKUHLENRMULTISLICESPIRALCOMPUTEDTOMOGRAPHYTODETERMINETHEEFFECTSOFARECRUITMENTMANEUVERINEXPERIMENTALLUNGINJURYEURRADIOL20061613511359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RMVSPEEPLIMCMLEESSLEEJSKOHYSHIMTSLEESDKIMWSKIMDSKIMWDMORPHOMETRICEFFECTSOFTHERECRUITMENTMANEUVERONSALINELAVAGEDCANINELUNGSACOMPUTEDTOMOGRAPHICANALYSISANESTHESIOLOGY2003997180RMVSPEEPLIMCMLEESSLEEJSKOHYSHIMTSLEESDKIMWSKIMDSKIMWDMORPHOMETRICEFFECTSOFTHERECRUITMENTMANEUVERONSALINELAVAGEDCANINELUNGSACOMPUTEDTOMOGRAPHICANALYSISANESTHESIOLOGY2003997180RMVSPEEPLIMCMLEESSLEEJSKOHYSHIMTSLEESDKIMWSKIMDSKIMWDMORPHOMETRICEFFECTSOFTHERECRUITMENTMANEUVERONSALINELAVAGEDCANINELUNGSACOMPUTEDTOMOGRAPHICANALYSISANESTHESIOLOGY2003997180RMVSPEEPLIMCMLEESSLEEJSKOHYSHIMTSLEESDKIMWSKIMDSKIMWDMORPHOMETRICEFFECTSOFTHERECRUITMENTMANEUVERONSALINELAVAGEDCANINELUNGSACOMPUTEDTOMOGRAPHICANALYSISANESTHESIOLOGY2003997180RMVSPEEPLIMCMLEESSLEEJSKOHYSHIMTSLEESDKIMWSKIMDSKIMWDMORPHOMETRICEFFECTSOFTHERECRUITMENTMANEUVERONSALINELAVAGEDCANINELUNGSACOMPUTEDTOMOGRAPHICANALYSISANESTHESIOLOGY2003997180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为什么肺复张作用不能持久BASELINE3MINPOSTRM30MINPOSTRMPAO2FIO2MMHG1394624611113839PACO2MMHG4861214761346412SVO270461724567062QSQT308582159729274CRSMLCMH2O341126369151357135OCZENSKIWHRMANNCKELLERCLORENZLNKEPKAASCHWARZSFITZGERALDRDRECRUITMENTMANEUVERSAFTERAPOSITIVEENDEXPIRATORYPRESSURETRIALDONOTINDUCESUSTAINEDEFFECTSINEARLYADULTRESPIRATORYDISTRESSSYNDROMEANESTHESIOLOGY20041016205为什么肺复张作用不能持久肺复张的方法SI50CMH2OX30S作者认为OCZENSKIWHRMANNCKELLERCLORENZLNKEPKAASCHWARZSFITZGERALDRDRECRUITMENTMANEUVERSAFTERAPOSITIVEENDEXPIRATORYPRESSURETRIALDONOTINDUCESUSTAINEDEFFECTSINEARLYADULTRESPIRATORYDISTRESSSYNDROMEANESTHESIOLOGY20041016205RMPEEPVSRMVSPEEPLIMCMJUNGHKOHYLEEJSSHIMTSLEESDKIMWSKIMDSKIMWDEFFECTOFALVEOLARRECRUITMENTMANEUVERINEARLYACUTERESPIRATORYDISTRESSSYNDROMEACCORDINGTOANTIDERECRUITMENTSTRATEGYETIOLOGICALCATEGORYOFDIFFUSELUNGINJURYANDBODYPOSITIONOFTHEPATIENTCRITCAREMED200331411418RMPEEPVSRMVSPEEPLIMCMJUNGHKOHYLEEJSSHIMTSLEESDKIMWSKIMDSKIMWDEFFECTOFALVEOLARRECRUITMENTMANEUVERINEARLYACUTERESPIRATORYDISTRESSSYNDROMEACCORDINGTOANTIDERECRUITMENTSTRATEGYETIOLOGICALCATEGORYOFDIFFUSELUNGINJURYANDBODYPOSITIONOFTHEPATIENTCRITCAREMED200331411418RMPEEPRMONLYRM后的PEEPRM后的PEEP能够稳定肺泡HALTERJMSTEINBERGJMSCHILLERHJDASILVAMGATTOLALANDASSNIEMANGFPOSITIVEENDEXPIRATORYPRESSUREAFTERARECRUITMENTMANEUVERPREVENTSBOTHALVEOLARCOLLAPSEANDRECRUITMENTDERECRUITMENTAMJRESPIRCRITCAREMED200316716201626RM后的PEEP能够稳定肺泡RMPIP45CMH2OPEEP35CMH2OX1MINPEEP5CMH2OPEEP10CMH2OHALTERJMSTEINBERGJMSCHILLERHJDASILVAMGATTOLALANDASSNIEMANGFPOSITIVEENDEXPIRATORYPRESSUREAFTERARECRUITMENTMANEUVERPREVENTSBOTHALVEOLARCOLLAPSEANDRECRUITMENTDERECRUITMENTAMJRESPIRCRITCAREMED200316716201626肺泡稳定能够改善PAO2MCCANNUGSCHILLERHJGATTOLAETALALVEOLARMECHANICSALTERHYPOXICULMONARYVASOCONSTRICTIONCRITCAREMED20023013151321RM后的PEEPLIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377RMPEEPVSPEEPONLYLIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377RMPEEPPEEPONLYPEEP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20CMH2OPEEP的设置如果将PEEP设置于20CMH2O后仍发现PAO2FIO2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PEEPPEEP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PV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PEEPFIO2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045如果降低PEEP导致氧合下降应当重新设定PEEP肺泡塌陷时不应增加FIO2肺复张后氧合稳定所需时间TUGRULSCAKARNAKINCIOOZCANPEDISCIRESENFTELCILTAKPIRTIMEREQUIREDFOREQUILIBRATIONOFARTERIALOXYGENPRESSUREAFTERSETTINGOPTIMALPOSITIVEENDEXPIRATORYPRESSUREINACUTERESPIRATORYDISTRESSSYNDROMECRITCAREMED2005339951000LIP2肺复张后氧合稳定所需时间TUGRULSCAKARNAKINCIOOZCANPEDISCIRESENFTELCILTAKPIRTIMEREQUIREDFOREQUILIBRATIONOFARTERIALOXYGENPRESSUREAFTERSETTINGOPTIMALPOSITIVEENDEXPIRATORYPRESSUREINACUTERESPIRATORYDISTRESSSYNDROMECRITCAREMED2005339951000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不同RM方法的比较基础通气方式VCVVT10MLKGF20BPMIE12FIO205肺复张ODENSTEDTHLINDGRENSOLEGARDCERLANDSSONKLETHVALLSANEMANASTENQVISTOLUNDINSSLOWMODERATEPRESSURERECRUITMENTMANEUVERMINIMIZESNEGATIVECIRCULATORYANDLUNGMECHANICSIDEEFFECTSEVALUATIONOFRECRUITMENTMANEUVERSUSINGELECTRICIMPEDANCETOMOGRAPHYINTENSIVECAREMED20053117061714MODEFVTPCPEEPIETIMERPTVICMCPAP40303PCRMPCV20202011303SLRMVCV2010151215每分钟2次将吸气末暂停延长至7S不同RM方法的比较ODENSTEDTHLINDGRENSOLEGARDCETALSLOWMODERATEPRESSURERECRUITMENTMANEUVERMINIMIZESNEGATIVECIRCULATORYANDLUNGMECHANICSIDEEFFECTSEVALUATIONOFRECRUITMENTMANEUVERSUSINGELECTRICIMPEDANCETOMOGRAPHYINTENSIVECAREMED20053117061714SLRMPCRMVICM不同RM方法的比较ODENSTEDTHLINDGRENSOLEGARDCERLANDSSONKLETHVALLSANEMANASTENQVISTOLUNDINSSLOWMODERATEPRESSURERECRUITMENTMANEUVERMINIMIZESNEGATIVECIRCULATORYANDLUNGMECHANICSIDEEFFECTSEVALUATIONOFRECRUITMENTMANEUVERSUSINGELECTRICIMPEDANCETOMOGRAPHYINTENSIVECAREMED20053117061714不同RM方法的比较对于灌洗造成的急性肺损伤模型缓慢低压复张操作可以促进肺泡复张减少对循环系统的抑制避免对呼吸力学的不良影响ODENSTEDTHLINDGRENSOLEGARDCERLANDSSONKLETHVALLSANEMANASTENQVISTOLUNDINSSLOWMODERATEPRESSURERECRUITMENTMANEUVERMINIMIZESNEGATIVECIRCULATORYANDLUNGMECHANICSIDEEFFECTSEVALUATIONOFRECRUITMENTMANEUVERSUSINGELECTRICIMPEDANCETOMOGRAPHYINTENSIVECAREMED20053117061714不同RM方法的比较LIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377SUSTAINEDINFLATION45FOR40SINCREMENTALPEEPPIP35PEEP835PCVPIP45PEEP16IE122MIN对于VILI模型PCV是最佳的RM方法其他模型结果相似PEEP8PEEP12PEEP16LIMCMADAMSABSIMONSONDADRIESDJBROCCARDAFHOTCHKISSJRMARINIJJINTERCOMPARISONOFRECRUITMENTMANEUVEREFFICACYINTHREEMODELSOFACUTELUNGINJURYCRITCAREMED20043223712377ARDS患者的肺复张北京协和医院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ARDS的肺保护性通气策略患者数潮气量病死率作者小潮气量对照小潮气量对照小潮气量对照P值AMATO292461021190538710001STEWART60607208106025047072BROCHARD58587202104024738038BROWER26267301102015046060ARDSNET43242963011170131400007VILLAR504573091021234550041ARDS的肺保护性通气策略小潮气量6MLKGIBW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肺泡塌陷与复张造成的剪切力FPLXV0V23F剪切力PL跨肺压V0最初容积V复张后容积如果PL30CMH2OV0V110则F140CMH2OMEADJTAKISHIMATLEITHDSTRESSDISTRIBUTIONINLUNGSAMODELOFPULMONARYELASTICITYJAPPLPHYSIOL1970285596608小潮气量通气的问题LVTN15CVTN15PVALUEVTML4115566484001VTMLKG61101001SETPEEPCMH2O104104NSPEEPTOTCMH2O114114NSPPLATCMH2O2383010001RICHARDJCMAGGIORESMJONSONBMANCEBOJLEMAIREFBROCHARDLINFLUENCEOFTIDALVOLUMEONALVEOLARRECRUITMENTRESPECTIVEROLEOFPEEPANDARECRUITMENTMANEUVERAMJRESPIRCRITCAREMED200116316091613小潮气量通气的问题LVTN15CVTN15PVALUEPAO2MMHG1368015682NSPAO2FIO2MMHG1658418383NSSAO29485097621005PACO2MMHG603538210001PH72101736010001SBPMMHG1252512120NSDBPMMHG6096010NSHRBPM101159315NSRICHARDJCMAGGIORESMJONSONBMANCEBOJLEMAIREFBROCHARDLINFLUENCEOFTIDALVOLUMEONALVEOLARRECRUITMENTRESPECTIVEROLEOFPEEPANDARECRUITMENTMANEUVERAMJRESPIRCRITCAREMED200116316091613小潮气量通气的问题RICHARDJCMAGGIORESMJONSONBMANCEBOJLEMAIREFBROCHARDLINFLUENCEOFTIDALVOLUMEONALVEOLARRECRUITMENTRESPECTIVEROLEOFPEEPANDARECRUITMENTMANEUVERAMJRESPIRCRITCAREMED200116316091613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肺泡的开放压与闭合压PEEP不能使肺复张LIP仅仅是肺复张的开始HICKLINGKGTHEPRESSUREVOLUMECURVEISGREATLYMODIFIEDBYRECRUITMENTAMATHEMATICALMODELOFARDSLUNGSAMJRESPIRCRITCAREMED1998158194202JONSONBRICHARDJCSTRAUSCMANCEBOJLEMAIREFBROCHARDLPRESSUREVOLUMECURVESANDCOMPLIANCEINACUTELUNGINJURYEVIDENCEOFRECRUITMENTABOVETHELOWERINFLECTIONPOINTAMJRESPIRCRITCAREMED199915911721178低位转折点之上仍有肺组织复张肺泡的开放压与闭合压肺泡开放压与闭合压0102030405005101520253035404550OPENINGPRESSUREPAWCMH2OCROTTISMASCHERONIDCAIRONIPPELOSIPRONZONIGMONDINOMMARINIJJGATTINONILRECRUITMENTANDDERECRUITMENTDURINGACUTERESPIRATORYFAILUREACLINICALSTUDYAMJRESPIRCRITCAREMED2001164131140CLOSINGPRESSUREARDS的肺开放EDITORIALOPENUPTHELUNGANDKEEPTHELUNGOPENBLACHMANNDEPTOFANESTHESIOLOGYERASMUSUNIVERSITYROTTERDAMTHENETHERLANDS199218319321RM能够使肺开放RMPIP45CMH2OPEEP35CMH2OX1MINHALTERJMSTEINBERGJMSCHILLERHJDASILVAMGATTOLALANDASSNIEMANGFPOSITIVEENDEXPIRATORYPRESSUREAFTERARECRUITMENTMANEUVERPREVENTSBOTHALVEOLARCOLLAPSEANDRECRUITMENTDERECRUITMENTAMJRESPIRCRITCAREMED200316716201626肺复张能够改善ARDS氧合LAPINSKYSEAUBINMMEHTASBOITEAUPSLUTSKYASSAFETYANDEFFICACYOFASUSTAINEDINFLATIONFORALVEOLARRECRUITMENTINADULTSWITHRESPIRATORYFAILUREINTENSIVECAREMED19992512971301肺复张的各种方法CPAPSIINCREMENTALPEEPPCVSIGHMODIFIEDHFOV俯卧位SI改善氧合TUGRULSAKINCIOOZCANPEINCESESENFTELCILAKPIRKCAKARNEFFECTSOFSUSTAINEDIN