肺保护机械通气seminar

1、lung protective mechanical ventilation 肺保护性机械通气肺保护性机械通气 adoption 110;556 translocation of cells bilek, a. m.d. p. gaver iii j appl physiol 94: 770783, 2003 translocation of cells disrupt the alveolar epithelium tears in capillary endothelium biotruama? inciting event pmns/macs endothelium epithelium

2、 adhesionproteaseso2 radicals coagulation proteins cytokines il-6 il-8 il-10 il-8-ratnf-a ena-78mip-1a transferrin paf complement lpb ltb4 ltc4 magaret parker, md, fccm. (sccm chair 2004) ventilation strategies 160:109-16 2d graph 2 time (hours) 01234 tnf-a(pg/ml) 0 100 200 300 400 500 600 700 800 h

3、vzp hvp lvzp lvp lvpr 2d graph 1 time (hours) 01234 mip-2 (pg/ml) 0 1000 2000 3000 4000 5000 hvzp hvp lvzp lvp lvpr * * * * (4) (3)(4) (3) vt, ml/kg peep, cmh2o hvzphvplvzplvp 16 16 5 5 55 cytokines in humans stuber et al int care med 2002;28:834-841 jama 289:2104-2112,2003 systemic effects of vili

4、imai et al jama 289:2104-2112,2003 biophysical injury shear overdistention cyclic stretch d intrathoracic pressure alveolar-capillary permeability cardiac output organ perfusion biochemical injury (biotrauma) cytokines, complement, pgs, lts, ros, proteases bacteria epithelium/ interstitium neutrophi

5、ls distal organ dysfunction mechanical ventilation slutsky, tremblay am j resp crit care med. 1998;157:1721-5 death hudson et al, chest 116:74s-2s ards mortality decreased abruptly shanghai ards study group. 15 icus in 12 university hospitals in shanghai in-hospital mortality of ards patients were 6

6、8.5% and 90-day mortality of ards patients were 70.4%, protect the lungs? peep=? vt=? pip=? pplateau=? rm ? mode ? protect the lungs? how? peep too low: recruitment/derecruitment injury pplateau too high: overdistention barotrauma volutrauma marcelo amato, m.d.,et al. (n engl j med 1998;338:347-54.)

7、 effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome methods study population marcelo bp amato, md pv curve (static) p-v curve methodology the supersyringe technique recruitment maneuver and pv curve hysteresis optimal peep recruited vol. 8 30 prssure

8、small tidal volume (5 ml/kg) rimensberger pc crit care med 1999; 27:1946-52 27:1940-45 better oxygenation better compliance better lung volumes less lung injury (histologically) the ventilatory cycle can be boosted on the deflation limb post-operative atelectasis healthy lung 40 cmh2o peak alveolar

9、pressure held for 7-15 sec needed to reopen lung rothen br j anaesth 1993;71:788 rothen br j anaesth 1998;81:681 rothen br j anaesth 1999;82:551 recruitment maneuver massachusetts general hospital performance of rm mgh 30 cmh2o cpap for 30 to 40 sec if unresponsive but tolerated well 35 cmh2o cpap f

10、or 30 to 40 sec if unresponsive but tolerated well 40 cmh2o cpap for 30 to 40 sec allow 15 to 20 minutes between rm performance of rm mgh set fio2 at 1.0 wait 10 minutes insure appropriate sedation may need to do multiple rms monitoring during rm (mgh) the rm should be aborted if: map 20 mmhg spo2 1

11、30 or 400 mmhg amato j. j. haitsma, b. lachmann minerva anestesiol 2006;72:117-32 lung protective ventilation in ards: the open lung maneuver 450 mmhg on pure oxygen. when a lung is “open” hickling k. ajrccm 2001;163:69-78. stepwise recruitment strategy time 0 10 20 30 40 50 60 70 45 50 55 60 baseli

12、ne tmax = 20 min 25 cmh2o airway pressures (cmh2o) 40 cpap ola dp = 15 cmh2o marcelo amato, m.d.,et al. (n engl j med 1998;338:347-54.) lim ccm 2001;29:1255 foti icm 1999;26:501 treatment with oscillation and an open lung strategy (tools) crit care med 2005; 33(3): 479 multi-center: toronto, paris,

13、cardiff，boston ferguson, kacmarek, slutsky, et al. new protocol with hfov and rm 25 patients with early ards inclusion: age18, p/f75, significant heart disease, details of protocol rm: mpaw 40 cmh2o 40 sec 3 repeated rm: twice daily at least hfov: p=60 cmh2o, f=5hz results p/f increase: 200117 vs 92

14、36 mmhg fio2 reduce: 0.50.2 vs 0.90.1 rm: 411 (median: 7) / patient rm aborted: 8/244(3.3%) in 6 patients rm abolition reason: , but recovered quickly. 4/6 intolerant patients: tolerated later. stepwise peep recruitment maneuvers (amatos team) stepwise peep recruitment maneuvers can open collapsed a

15、rds lungs. higher levels of peep are necessary to maintain the lungs open and assure homogenous ventilation in ards. stepwise peep rm practice 26 pts 5 cmh2o steps pinsp reached 60 cmh2o 2/26, pao2 + paco2 400 mmhg not reached open the lung and keep the lung open in 24/26 titrating peep by oxygenati

16、on no barotrauma rm in our icu 心脏外科术后低氧患者16例 男10例，女6例 年龄：5269 多发伤并发ali/ards患者18例 男13例，女6例 年龄：1356 军团菌病1例，女、26岁， msof/ards， pao2/fio2: 49/85% 所有病例均为机械通气疗效不佳的低氧血症 pao2/fio2: 57.6166mmhg 方 法 所有患者均行有创动脉压持续监测 spo2持续监测 cvp持续监测 清醒患者适当镇静 复张术（rm）前排除气压伤 排除肺气肿患者 protocol mode: peep+pcv or peep+psv peep: increm

17、ent 2 cmh2o interval: 2 min peep target: 16/1st rm, 20/2nd rm, 2630/3rd rm pipmax: 45 cmh2o abort if abp or spo2 start fall rest interval: 1530 min may repeat twice a day 结 果 心脏外科术后低氧患者 有效：100% pao2/fio2 improve：110%36% 无并发症 多发伤并发ali/ards患者 有效：92% pao2/fio2 improve：86%32% 无并发症 军团菌病1例，无效，出现气压伤 rm一次，p

18、eepmax: 22, pipmax: 32 纵隔气肿 subcutaneous emphysema 结 果 心脏外科术后低氧患者 所有患者在第一次rm出现血压迅速下降 血压下降同时伴随spo2下降 第一次rm在peep1216出现血压下降 在以后的rm中，耐受性增强 多发伤并发ali/ards患者 12/18（66.6%）在第一次rm出现血压迅速下降 血压下降同时伴随spo2下降 在以后的rm中，耐受性增强 临床观察 252例次rm有93次血压短暂降低（37%） 出现血压下降的peep水平为623cmh2o, 平均13.9cmh2o peep降低之后动脉恢复到原来水平 所有病人有创持续血压监

19、测 1例经心超证实卵圆孔未闭，在peep=6时 发生右向左分流，同时spo2下降 张翔宇，等，中国危重病急救医学，张翔宇，等，中国危重病急救医学，2007，19（9） use of dynamic compliance for open lung positive end- expiratory pressure titration in an experimental study conclusions: in this experimental model, the continuous monitoring of dynamic compliance identified the beg

20、inning of collapse after lung recruitment. these findings were confirmed by oxygenation and computed tomography scans. this method might become a valuable bedside tool for identifying the level of peep that prevents end-expiratory collapse. result clinical observation clinical observation performanc

21、e of rm set fio2 at 1.0 allow time for stabilization insure appropriate sedation insure hemodynamic stability performance of rm - pcv pressure control ventilation: peep 20-30 cmh2o peak inspir press 40-50 cmh2o inspir time: 1 to 3 sec rate: 8 to 20/ min time 1 to 3 min set peep at 20, ventilate vc,

22、vt 4 to 6 ml/kg pbw, increase rate, avoid auto-peep measure dynamic compliance decrease peep 2 cm h2o performance of rm - pcv measure dynamic compliance repeat until max compliance determined optimal peep max comp peep+2 to 3 cm h2o repeat recruitment maneuver and set peep at the identified settings

23、, adjust ventilation after peep and ventilation set and stabilized, decrease fio2 until po2 in target range if response is poor, repeat rm, peep 25, peak pressure 45 if response is poor, repeat rm, peep 30, peak pressure 50 lung recruitment perform early in ards ideal approach to rm most likely pc,

24、limited patient data available using pc! works better in extra pulmonary than primary ards? more difficult to recruit the lung the stiffer the chest wall! start with low pressure, increase as tolerated and needed! if benefit lost after rm, peep inadequate! current conclusion guidelines? not availabl

25、e yet titrating peep fellowing rm pdeflex + 2cmh2o, (pv curve) super-syringe low-flow multiple occlusion linear ramping (hamilton galilio gold) oxygenation pao2 drop 10% pv curve for pdeflex recognizable? and percentage of them? is this pdeflex constant over time? or rm? is pdeflex after rm repeatab

26、le? is peep on pdeflex clinically practical? not answered yet pflex “maximum difference of 11 cm h2o for the same patient” am j respir crit care med 2000;161:432439. r. scott harris, dean r. hess, and jos g. venegas titrating peep according to oxygenation is it practical for clinical? possible. is c

27、ontinuous pao2 practical? not yet. spo2 is probably a useful tool new engl j med 2004; 351: 327-336 nih peep selected according to a table to achieve minimal physiological oxygenation (88-95%) patients ( n=983) ards/ ali p plat (cmh2o) 30 peep (cmh2o) 16.3 3 rr (b/min) 30 tv ( ml /kg ) 6 9.1 4 the l

28、ovs: lung open ventilation canadian study canadian trial oxygenation was better in high peep compliance was better in high peep less rescue therapies in high peep 0,4 0,5 0,6 0,7 0,8 0,9 1 0102030405060 days after randomization probability of survival low peep high peep peep selected according to a

29、table to achieve minimal physiological oxygenation + rm stewart t et al jama. 2008;299(6):637-645 patients ( n=752 ) ards/ ali p plat (cmh2o) 30 peep (cmh2o) 14.9 4 rr (b/min) 30 tv ( ml /kg ) 6 7.4 4 french trial “express” peep selected to avoid overdistension or to achieve maximal recruitment peep

30、 set for peep tot 5-9 cmh2o peep set for plat 28-30 cmh2o oxygenation was better in max distension higher ventilation free days in max distension higher organ failure free days in max distension mercat a et al jama. 2008;299(6):646-655 mercat a et al jama. 2008;299(6):646-655 肺复张术对血流动力学的影响 rm on hem

31、odynamics peep的禁忌症 未经有效治疗的气胸 低容量（hypovolume） 腔静脉-肺动脉分流术（fontan, glenn, et al） 张翔宇，in 顾恺时胸心外科手术学 2003,上海 contraindication to peep/cpap relative contraindication: absolute contraindication: amato(1998): methods study population details of results hemodynamics (same trail) am j respir crit care med. 19

32、97 nov;156(5):1458-66. immediate increase in heart rate (p = 0.0002), cardiac output (p = 0.0002), oxygen delivery (do2l, p = 0.0003), mixed venous po2 (p = 0.0006), maintained systemic oxygen consumption (p = 0.52) mean pulmonary arterial pressure markedly increased (mean increment 8.8 mm hg; p 0.0

33、001) pulmonary vascular resistance did not change (p = 0.32) hemodynamics (same trail) am j respir crit care med. 1997 nov;156(5):1458-66 cardiac filling pressures increased (p 0.001) systemic vascular resistance fell (p = 0.003) these alterations were progressively attenuated in the course of the first 36 h plasma lactate suffered a progr