呼吸机波形解读课件

1、PV tool and lung recruitmentChengdu mechanical ventilation training. Sept. 2011Dr Jean-Michel ArnalIntensive Care Unit. Hpital Font PrToulon FAtelectrauma resulting from repeated alveolar recruitment/ derecruitmentBarotrauma and/or volutrauma resulting from lung overdistensi

2、on Mechanisms of Ventilator Induced Lung InjuriesMechanical InjuryBiotrauma: alveolar inflammation Inflammatory InjuryPrevention of VILIReduced tidal volume and airway pressure limitation strategyRecruitment strategy: recruitment maneuver + PEEP to avoid derecruitmentWhat do we know about ARDS?Lower

3、 tidal volume and airway pressure limitation decreases mortalityNo effect of PEEP on mortalityARDS network. N Engl J Med 2000ALVEOLI. Brower. N Engl J Med 2004EXPRESS. Mercat JAMA 2008LOVS. Meade. JAMA 2008Effect of PEEP on mortality in ARDSALVEOLI. Brower. N Engl J Med 2000PEEP = 8,3 3,2 cmH2O13,2

4、3,5 cmH2On = 549Effect of PEEP on mortality in ARDSBriel. JAMA 2010What do we know about PEEP?PEEP does not recruit or just a littleCollapse / re-expansion occurs during tidal volumeRecruitment of previously collapsed lung with a recruitment maneuverPEEP may avoid collapse and derecruitment in a lun

5、g previously expanded/recruitedDont set PEEP without recruiting the lung!RecruitmentCollapsed compliant airways/ alveoliFluid occlusion of non collapsed airwaysAm J Respir Crit Care Med 200624 sur 26 patientsAm J Respir Crit Care Med 2006n = 68 Recruitability depends onType of ARDSTime from the begi

6、nning of the diseasePressureChest wall complianceType of ARDSMechanism: extra pulmonary pulmonaryLocalization: diffuse lobarEtiology: aspiration pneumonia CAPRiva. Crit Care Med 2008Puybasset. Intensive Care Med 2000Time from the beginning of the diseaseEarly phaseProtein rich edema fluids and polyn

7、eutrophilsLate phaseFibrosing alveolitis24 on 26 patientsPressureBorges. Am J Resp Crit Care Med 2006Chest wall complianceChest wall complianceAirway pressure is a rough estimate of transpulmonary pressureTalmor. Crit Care Med 2006Assessment of recruitabilityEarly in the management of ARDSWhen hemod

8、ynamic condition is controlledLow flow inflation and deflation PV curve from 0 to 40 cmH2OAssessment of recruitabilityAssessment of recruitabilityShape of the curveGrasso. AJRCCM 2005Assessment of recruitabilityLinear complianceMaggiore. AJRCCM 2001CLIN = 37 mL/cmH2OCLIN = 83 mL/cmH2OAssessment of r

9、ecruitabilityLinear complianceAssessment of recruitabilityHysteresisDemory.Intensive Care Med 20086 798 cmH2O.ml25 115 cmH2O.mlDemory. Intensive Care Med 2008Assessment of recruitabilityHysteresisAssessment of recruitabilityHysteresis and volume difference at 20 cmH2ODemory.Intensive Care Med 2008r2

10、 = 0.97Assessment of recruitability300200100Assessment of recruitabilityCLIN = 20 cmH2O/mLCLIN = 60 cmH2O/mLHMAX = 50 mLHMAX = 200 mLClinical caseClinical caseMr. Be M, 63 years oldLeukemia treated by steroidsAcute respiratory failureCommunity acquired pneumoniaMrs. Le D, 72 years oldLymphoma treate

11、d by chemotherapyAcute respiratory failureCommunity acquired pneumoniaClinical caseMr. Be M, 63 years oldMrs. Le D, 72 years oldDecision at the bedsideLow potential of recruitabilityHigh potential of recruitabilityLower inflection pointNonePresentLinear complianceLowHighHysteresisLowHighDecision at

12、the bedsideLow potential of recruitabilityHigh potential of recruitabilityLower inflection pointNonePresentLinear complianceLowHighHysteresisLowHigh1/3 of patientsNo recruitment maneuverLow PEEP: 5 10 cmH2O2/3 of patientsRecruitment maneuverHigh PEEP: 10 cmH2ODefinition of a recruitment maneuverUse

13、of a transient increase in transpulmonary pressure to reopen previously collapsed or non aerated lung units.Justification and goal for RMARDS is characterized by a natural tendency for lung collapse: lung edema, surfactant dysfunction, low VT, high FiO2, repeated tracheal suctioningGoal: keep the lu

14、ng open and prevent VILIMethod for RMCPAP method: increase PEEP to 40 cmH2O for 40 sSighs: periodically increase VT or PINSPProgressive increase in PEEPProne positioningGrasso. Anesthesiology 2002Pelosi. AJRCCM 1999. Barbas AJRCCM 2001Albert. AJRCCM 2000Borges. AJRCCM 2006Time consuming, no direct m

15、onitoringVolume recruited depends onPrevious recruitmentTranspulmonary inflation pressureDurationPEEP setting after the RMPressure and timeAlbert.J Appl Physiol 2009TimeRothen.BJA 199912 anaesthetized patients with healthy lung = 2,6 sOptimal duration of the recruitment maneuverArnal. Intensive Care

16、 Med 2011 = 2,3 1,3 sn= 50Optimal duration of the recruitment maneuverRecruitment maneuver*Arnal. Intensive Care Med 2011 n= 50Sustained inflation recruitment maneuverQuick, safe with volume recruited assessmentInspiratoryExpiratory = 40 cmH2O pneumotachographPawVolume increase during a sustained inflation recruitment maneuverVolume increase during a sustained inflation recruitment maneuverVRM= 100 mLVRM= 240 mLVolume increase during a sustained inflation recruitment maneuverClinical caseMr. Be M, 63 years oldMrs. Le D, 72 y