肺复张临床实践李新宇

1、肺复张临床实践 李新宇临床面临的问题ARDS死亡率居高不下 总死亡率40-50%？萎陷的肺泡很难“保持开放”需要较高的通气压力和吸入氧浓度感染风险明显增加表面活性物质功能丧失容量伤导致VALIJAMA 2002; 287: 345-55. Intensive Care Med 2004; 30: 51-61. Am J Respir Crit Care Med 2007; 176: 795-804. 3 ARDS AND RM321如何实施RM？RM安全吗？RM真的能使肺复张吗？RM的理论基础对于ARDS的治疗，RM真的有用吗？4OpeningPressureSuperimposedPress

2、ureInflated0Alveolar Collapse(Reabsorption)20-60 cmH2OSmall AirwayCollapse10-20 cmH2OConsolidationRM的理论基础肺泡的开放压肺泡的不均一性RM的理论基础肺泡的开放压与闭合压肺泡开放压与闭合压Crotti S etal. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.肺泡开放压与闭合压Crott

3、i S etal. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.0102030405005101520253035404550Opening pressurePaw (cmH2O)Crotti S etal. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Res

4、pir Crit Care Med 2001: 164: 131-140.Closing pressure肺泡开放压与闭合压PEEP不能使肺复张RM理论基础EditorialOpen up the lung and keep the lung openB. LachmannDept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands (1992) 18:319-321ARDS的肺开放RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 minHalter JM, Steinberg JM, Sch

5、iller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626RM真的能使肺开放吗？至少可使患者暂时受益；改善氧合：持续 or 暂时，与PEEP设置有关有反应 or 无反应：与多因素有关，如病因、病程、复张时间、压力

6、、PEEP等 试验设计缺陷可能导致结果误读不对病程进行分层不对PEEP进行个体化设置Anesythesilogy 2002; 96: 795-802. Intensive Care Medicine 1999; 25: 1297-1301.Am J Respir Crit Med 1999; 159: 872080. Crit Care Med 2003; 31: 738-44Respiratory Care 2006; 51: 1132-9已有的研究结果NO年龄性别疾病基础病150岁男性重症肺炎、严重脓毒症、ARDS银屑病280岁男性重症肺炎、严重脓毒血症、呼吸衰竭COPD，肺心病，高血压，

7、冠心病374岁女性重症肺炎、严重脓毒血症、呼吸衰竭ARDS高血压，右肺腺癌，肺间质纤维化482岁女性肺部感染，严重脓毒症、肠梗阻术后高血压病，双膝关节置换术后573岁女性严重脓毒血症、ARDS、肺部感染高血压3级，糖尿病，冠心病，胆囊摘除661岁男性严重脓毒症、重症肺炎、多器官功能衰竭（呼衰、循环、肾）高血压病二尖瓣重度关闭不全二尖瓣后瓣脱垂756岁男性脓毒性休克、重症肺炎、ARDS、MODS（呼吸、循环、凝血、肝脏)863岁男性重症肺炎、ARDS、严重脓毒症高血压 皮肤病974岁男性重症肺炎、ARDS、严重度脓毒症高血压 右侧丘脑出血破入脑室我们的临床观察复张前后PaO2/FiO2变化早期正

8、确的RM可使部分患者获益ARDS肺的异质性不同ARDS对肺复张的反应ZEEP，PaO2= 153mmHgZEEP，PaO2= 89mmHgPEEP=10，PaO2= 159mmHgPEEP=12，PaO2= 128mmHgRM，PaO2= 113mmHgRM，PaO2= 313mmHgPEEP=10，PaO2= 189mmHgPEEP=12，PaO2= 329mmHg局灶型ARDS弥漫型ARDS不同程度ALI对肺复张的反应安全性关注的问题血流动力学气压伤复张压力基础疾病间隔时间复张时机影响安全性的因素RM对ARDS患者安全吗？影响患者的预后Response to RM = Balance肺复张

9、的利与弊肺泡复张肺泡过度充气VILI PaO2VILI DaO2CO 肺复张的利与弊肺泡复张肺泡过度充气肺复张标准操作应该如何做RMFiO2维持判断肺开放标准(塌陷肺泡 400PaO2/FiO2 300PaO2 + PaCO2 400RM基本思路Airway Pr.collapsedOpen1. Recruitment3. Re-recruitment2. Find closing pr.collapsed4. Maintain recruitmentOpen接密闭式吸痰器，镇静、肌松调整呼吸机模式PCV调整参数：PC=15或20 cmH2OPEEP=30cmH2OI：E=1:1FiO2=10

10、0%实施复张，T=40-50s调回呼吸机原参数调最佳PEEP肺复张的操作应该如何做RM应该如何做RM-持续气道正压法以CPAP或BIPAP模式调节气道正压40cmH2O，维持40秒设置吸气压在40cmH2O，按住吸气保持40秒应该如何做RMPEEP递增法保持吸气压与PEEP差值不变，每30秒递增PEEP5cm H2O，直到PEEP达35cm H2O，维持30秒，随后吸气压递增而PEEP每30秒递减5cm H2O应该如何做RMPRM应该如何做RMPRMRM后的PEEP能够复张肺吗？Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA,

11、 Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626RM后的PEEP能够稳定肺泡RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEEP 10 cmH2OHalter JM, Steinberg JM, Schi

12、ller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626RM后的PEEP能够稳定肺泡McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic pulmonary vasoconstriction. Crit Care med 2002; 30: 1315-1321肺泡稳定能够改善PaO2Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Cri