医学资料ARDS肺复张的实施(邱海波)

1、邱海波东南大学附属中大医院ICU东南大学急诊与危重病医学研究所ARDS肺复张的实施科学与艺术的困惑2021/7/19 星期一内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM 2021/7/19 星期一ARDSnet: 小潮气量通气Low Tidal VolumesTraditional Tidal VolumesP-valueDeath before discharge home and breathing without assistant (%)31.0

2、39.80.007Breathing without assistance by days (%)65.755.00.001NO of ventilator free days Day1-28121110110.007Boratrauma, Day1-28(%)10110.43NO of days without failure of nonpulmonary organs or systems Day1-28151112110.006ARDS Net. N Engl J Med. 2000 May 4;342(18):1301-8.2021/7/19 星期一Low tidal volume:

3、 more alv collapse小Vt不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略至少1525%患者需提高FiO2邱海波, 刘大为, 陈德昌等. 中华麻醉学杂志, 1998, 18: 202-2052021/7/19 星期一Collapsed airwayV1V2PressureVolumeV1V1 + V2Opening pressureNormalARDSPEEP adjustmentLIP：塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力PEEP not enough: more alv keep collapse2021/7/19 星期一30 kg PigPost Lava

4、gePCVPaw 13 cmH2O PEEP 5 cmH2OExperimental study-Pig with ARDS2021/7/19 星期一许红阳，邱海波. ARDS绵羊肺复张容积测定方法的比较. 中国危重病急救医学， 2004, 16: 413.邱海波. PEEP对ARDS肺复张容积及氧合影响的临床研究. 中国危重病急救医学，2004, 16: 399.Clinical Trial11 ARDS pats2021/7/19 星期一内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHi

5、gh VT and sighRM 2021/7/19 星期一A. Hypoxamia B. Shear forcesC. Surfactants inactivate D. Biotrauma and MODSPathophysiology Consolidation and alv collapse2021/7/19 星期一A .低氧血症肺泡塌陷：ARDS重力依赖区 炎症或不张区生理性低氧缩血管反应：障碍2021/7/19 星期一How Does Excessive Mechanical Stress Inflame the Lung?“Shear”2021/7/19 星期一Verbrugg

6、e et al. Crit Care Med 1999;27：779Ventilator-associated lung injuryPurine: a marker of ATP breakdown and VILI42 SD ratsPCV 6minPCV Pre/PEEPBALF purine and protein2021/7/19 星期一Lachmann. ICM, 1994; 20:6-11Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way1mg surfactant = inhibit

7、ory effect of 1mg plasma proteinC. Surfactant 灭活 2021/7/19 星期一Surfactant move away When lung regions collapse at end expiration, surfactant molecules move away from the alv surface toward terminal bronchioles and cannot be reused during next inflationRouby JJ. Am J Respir Crit Care Med, 2001, 165: 1

8、182 2021/7/19 星期一D. 预防Biotrauma和MODSMarini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two Crit Care Med. 2004 Jan;32(1):250-5.“Stretch”“Shear”Airway Trauma2021/7/19 星期一内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh

9、VT and sighRM 2021/7/19 星期一俯卧位通气的病理生理特征改善通气过程 胸膜腔压力梯度 顺应性胸壁促进分泌物的清除ClosingpressureClosing pressure2021/7/19 星期一Time course of Prone on PaO2/FiO2 between ARDSp vs ARDSexp Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp 黄英姿, 邱海波. 肺内外源性ARDS实施俯卧位通气时间的选择.中华内科杂志2004, 43(12):883-88720

10、21/7/19 星期一内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM 2021/7/19 星期一保留自主呼吸的优点2021/7/19 星期一内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM 2021/7/19 星期一Paw cmH2O %Opening and Closing Pressures0510152025303

11、540455001020304050 Opening pressureClosing pressure5 patients,ALI / ARDSFrom Crotti et alAJRCCM 2001.Some units cantbe kept open by any reasonable PEEP!2021/7/19 星期一Amato: CT + PV CurveHeartSpPVLIPUIPInsp recruitLarger Vt/Sigh: Pressure must be high enoughEven up to UIP 2021/7/19 星期一内容提要肺保护性通气策略不能解决

12、解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM 2021/7/19 星期一许红阳，邱海波. ARDS绵羊肺复张容积测定方法的比较. 中国危重病急救医学， 2004, 16: 413.邱海波. PEEP对ARDS肺复张容积及氧合影响的临床研究. 中国危重病急救医学，2004, 16: 399.Clinical Trial11 ARDS pats2021/7/19 星期一Recruitment is Time-Dependent 40 SECONDS2021/7/19 星期

13、一内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM 2021/7/19 星期一 Recruitment mannuversBasic PrinciplesMethods for RecruitmentExperimental Studies and Clinical TrialsEfficacyHazards2021/7/19 星期一1. 控制性肺膨胀(SI)法2. PEEP递增法3. 压力控制(PCV)法Methods for Recru

14、itment2021/7/19 星期一CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续20- 40s控制性肺膨胀(SI)法2021/7/19 星期一Multiple Maneuvers May Be Needed For Optimum RM EffectFujino et al, Crit Care Med 2001; 29(8):1579-15862021/7/19 星期一Post-RM PEEP Determines PaO2Averag

15、ed data from three modelsRMS-C Lim, CCM 2004Transient BenefitPost-RM-PEEP肺开放效应持续时间的决定因素CCM, 2004, 32: 2371-237728 mixed-breed pigsModels of ARDS:OAVILIPneumonia(PNM)RMSIIncreased PEEPPCV2021/7/19 星期一肺开放后的PEEP选择-PaO2/FiO21. RM后 PEEP: 20cmH2O2. PEEP递减: 2cmH2O/5min3. PEEP阈值: PaO2/FiO25%4. PEEP: PEEP阈值

16、+2cmH2O2021/7/19 星期一BASELINE VENTILATIONTidal volume=6ml/kgPEEP=5cmH2OModify PEEP to get a1.10.9recruiting maneuverMeasure1.10.9Leave PEEP unchangedstress index 0.91.1Decrease PEEP until 1.1stress index 0.9Crit Care Med, 2004, 32: 1018-1027肺开放后的PEEP选择- Stress index2021/7/19 星期一ImplicationsRM 的有效性ALI的病因 (direct vs in direct)Post RM PEEPMethod in certain settingsRM hazards are greatest and effectiveness least in pneumonia-caused acute lung injuryPCV may be better tolerated than SI2021/7/19 星期一RecommendationsUse PCV in p