ARDS肺复张的临床实施课件

1、BP 70/50，HR 170, cvp 8. NE 5 PHE 5 FiO2 70%, PEEP 12 Ph24 SaO2 90% ARDS常见的临床综合征BP 70/50，HR 170, cvp 8. NE 5 内容提要病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素内容提要病理生理特点30 kg 猪肺灌洗复制ARDS模型压力控制通气PCVPaw 13 cmH2O PEEP 5 cmH2OARDS-肺泡塌陷广泛存在30 kg 猪ARDS-肺泡塌陷广泛存在肺容积明显降低(a)肺泡水肿 (b)肺泡表面活性物质的消耗或不足(c)肺间质水肿压迫远端细支气管肺顺应性明显

2、降低通气/血流比例失调 肺内分流和死腔样通气ARDS的病理生理肺容积明显降低ARDS的病理生理CT scan70-80% 的肺野呈现高密度区分布：下垂部位(dependent field)提示：1. 参与通气的肺泡区域明显减少(20-30%) 2. 肺损伤具有不均一性肺容积减少Small lung Baby LungCT scan肺容积减少Small lung Baby肺顺应性明显降低Reduced range of volume excursion: Low complianceFlattening at low and high volumes: Lower and upper infle

3、ction pointsVolumePressureNORMALARDS顺应性曲线明显向右下移位肺顺应性明显降低Reduced range of volum肺内分流增加肺泡塌陷：ARDS重力依赖区 炎症或不张区生理性低氧缩血管反应：障碍肺内分流增加肺泡塌陷：ARDS重力依赖区HEARTSPARDS-Gattinoni分区1.过度通气区或“干区” “baby lung2. 可复张区或湿区3. 实变区HEARTSPARDS-Gattinoni分区1.过度内容提要病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素内容提要病理生理特点PEEP肺复张与低氧血症改善Gattin

4、oni L, Caironi P, Pelosi P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711 A .低氧血症PEEP肺复张与低氧血症改善Gattinoni L, PressureVolumePressure wedgeShear forceB. 剪切力(Shear force)PressureVolumePressure wedgeShDR-RM 盐水灌肺制造家兔ARDS模型低流速法测定LIP水平肺保护通气3h,Vt6ml/kg,PEEP=LIPDR后予SI的RMDR后予PCV的RM每小时的0、10、20、30、40分钟将呼

5、吸机脱开1分钟制造肺泡的重复去复张(DR)动物处死，取肺病理检查、测湿/干重比、测TNF-mRNA表达、转录因子NF-B的活性 、MPO及MDA活性对照组ARDS组LP组DR组PCV组SI组动物准备DR-RM 盐水灌肺制造家兔ARDS模型低流速法测定LIP123456 1、2、3、4、5和6泳道分别为正常、ARDS、DR、LP、SI和PCV组肺复张手法对重复去复张ARDS家兔肺组织NF-B 活性的影响123456 1、2、3、4、肺复张手法对重复去复张ARD肺复张手法对重复去复张ARDS家兔 肺组织TNFmRNA 表达的影响 0123456 1、2、3、4、5和6泳道分别为Normal、ARD

6、S、LP、DR、SI和PCV组0泳道为分子质量标准肺复张手法对重复去复张ARDS家兔 肺组织TNF肺复张手法对重复去复张ARDS 家兔PaO2 的影响肺复张手法对重复去复张ARDS C.感染与肺不张全麻-肺不张的发生率 90%择期腹部手术：肺不张肺部感染9.6%择期心脏手术：肺不张肺部感染5.7%肥胖病人手术：25%-30%发生肺不张肺部感染 CHEST 1997; 111:564-71C.感染与肺不张全麻-肺不张的发生率 90%CHEST Qiu Haibo. Chin J Emerg Med, 2001, 10(5): 293-294 气压伤 生物伤启动炎症反应炎症介质移位细菌毒素移位MO

7、DS/MOFD.气压伤、生物伤与MODSFrom SluskyQiu Haibo. Chin J Emerg Med, 2ARDSmotor of MODS邱海波. 中华急诊医学杂志, 2001, 10(5): 293-294 Biotrauma Barotrauma initiate a cascade of proinfla mediators肺是炎症细胞激活和聚积的重要场所肺实质细胞可释放炎症介质 Mediator translocationBacteria and LPS translocationMODS/MOFARDSmotor of MODS邱海波. 中华急诊医学杂腹部手术后肺不

8、张及增加气道内正压的肺复张作用将大鼠常规镇静肌松通气参数 : Vt 8 ml/kg; f 38 40 / min; PEEP 1 cm H2O; FiO2 0.21 剖腹术(series1) 非剖腹术 (series2) 复张组: 复张方法： (PEEP 增加到 8 cm H2O，10个呼吸周期, 每 30 分钟一次). PEEP 降至2 cm H2O 通气 无复张组 : 0 PEEP 不采取任何肺复张手法Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.肺泡塌陷与复张对预后影响的实验研究腹部手术后肺不张及增加气道内正压的肺复张

9、作用将大鼠常规镇静肌Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.Duggan M. Am J Respir Crit CaDuggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.持续肺泡塌陷-预后不良Duggan M. Am J Respir Crit Ca临床研究: 塌陷肺泡越多, 病死率越高N Engl J Med 2006;354:1775-86临床研究: 塌陷肺泡越多, 病死率越高N Engl J MVillar and Amato trialVillar

10、 J. Crit Care Med 2006; 34:1311Villar and Amato trialVillar 内容提要病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素内容提要病理生理特点20406080100Pressure cmH2O102030406050Total Lung Capacity %R = 22%R = 81%R = 100%R = 93%肺复张是压力依赖性过程00R = 0%R = 59%From Pelosi et alAJRCCM 20011/5 of “Recruitable” Units20406080100Pressure

11、cmH2O102肺复张是压力依赖性过程 40 SECONDS肺复张是压力依赖性过程 40 SECONDS肺复张的常用方法控制性肺膨胀(SI)PEEP递增法压力控制法(PCV)45 for 40 s 35 Peak45/16 and 1:2 for 120 sPCV Advantages-Same Recruiting Pressure-Repeated Maneuvers-Lower Mean Pressure-Preserved Ventilation肺复张的常用方法控制性肺膨胀(SI)45 for 40 s CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2.

12、 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CPAP模式: PS 0, PEEP 30-40 cmH内容提要病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素内容提要病理生理特点肺泡完全复张的临床标准氧合标准CT标准EIT标准肺泡完全复张的临床标准氧合标准肺泡完全复张的临床标准-PaO2/FiO2PaO2/FiO2400 PaO2 + PaCO2 400 2.PaO2/FiO2 降低5%肺泡完全复张的临床标准-PaO2/FiO2PaO2/FPaO2 + Pa

13、CO2 400 (at 100% oxygen): 维持肺开放的可靠指标达到PaO2 + PaCO2 400时： CT显示只有5% 的肺泡塌陷 PaO2 + PaCO2 400对塌陷肺泡的预测： ROC曲线下面积 0.943Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006肺泡完全复张的临床标准-CTPaO2 + PaCO2 400 (at 100% ox肺泡完全复张的临床标准-CTBorges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 1

14、11, 2006动脉氧合与塌陷肺组织重量明显呈负相关 (R = 0.91)肺泡完全复张的临床标准-CTBorges JB, ,Lower vs higher Percentage of Potentially Recruitable LungARDS塌陷肺泡都能重新开放吗?N Engl J Med 2006;354:1775-86Lower vs higher Percentage ofPEEP 5cmH2O Ppla 20cmH2OPEEP 17cmH2O Ppla 40cmH2OPEEP 25cmH2O Ppla 40cmH2OPEEP 25cmH2O Ppla 60cmH2OCorres

15、pondence: Amato, N Engl J Med 2006, 355:319PEEP 5cmH2O Ppla 20cmH2OPEEP 内容提要病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素内容提要病理生理特点Prespective, randomized study: Effect of RM on ARDSPrespective, randomized crossover study34 ICU at 19 hospRM: CPAP over 510 s to 35 cm H2OPEEP: FIO2/PEEPstep to maintain SpO2

16、 8895%.CCM, 2003, 31(11): 2592-7肺泡复张的决定因素(1): 肺内 vs 肺外源性ARDS Prespective, randomized study:ARDS Trial Network, Crit Care Med 2003; 31(11):2592-2597Starting Conditions For the ARDSnet Recruiting TrialPrimaryARDS Trial Network, Crit Care 为什么RM改善氧合不明显？病人的特点：入组时Ppla 26.4肺内原因ARDS占65% Paw cmH2O %051015202

17、5303540455001020304050Crotti et al. AJRCCM 2001.PPLATPRECRUITOpening Pressures: Primary ARDS 为什么RM改善氧合不明显？病人的特点：Paw cmH2ORM能够实现ARDS肺完全开放实现 open the lung and keep the lung open in the 24/26 patsBorges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006RM能够实现ARDS肺完全开放实现 open the lun麻醉导致的非炎

18、症性肺泡塌陷肺泡复张的决定因素(2): 病理特征Rothen HU. Dynamics of reexpansion of atelectasis during general anaesthesia. Br J Anaesth1999; 82: 5516Lim, et, al. Anesthesiology 2003; 99:71ARDS导致的炎症性肺泡塌陷麻醉导致的非炎症性肺泡塌陷肺泡复张的决定因素(2): 病理SuperimposedPressureOpeningPressureInflated0Alveolar Collapse(Reabsorption)20-60 cmH2OSmal

19、l AirwayCollapse10-20 cmH2OConsolidation(modified from Gattinoni)Regional Spectrum of Opening PressuresSuperimposedPressureOpeningPre肺泡复张的决定因素(3): 压力与时间实现 open the lung and keep the lung open in the 24/26 patsBorges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006肺泡复张的决定因素(3): 压力与时间实现

20、 open thMultiple maneuvers- 获得理想的复张效应Fujino et al, Crit Care Med 2001; 29(8):1579-1586Multiple maneuvers- 获得理想的复张效肺泡复张的决定因素(4):ARDS病程(早期vs 后期) N=17 ARDS with a lung protective ventEarly ARDS (n=9) vs Late ARDS (n=8, 7d)RM: PCV 2min at PIP 50cmH2O/PEEP PUIPAm J Respir Crit Care Med, 2002, 165:165170肺

21、泡复张的决定因素(4):ARDS病程(早期vs 后期不同RM方法的肺复张效应不同PCVVolume increments at 15 min Post-RM in VILI Model不同RM方法的肺复张效应不同PCVVolume incremPaw cmH2O %Opening and Closing Pressures0510152025303540455001020304050 Opening pressureClosing pressure5 patients,ALI / ARDSFrom Crotti et alAJRCCM 2001.Some units cantbe kept o

22、pen by any reasonable PEEP!肺泡复张的决定因素(5): 循环耐受情况Paw cmH2O %Opening and ClosiAn RM Can Profoundly Depress COAveraged Data from 3 ModelsS-C Lim, et al 2004An RM Can Profoundly Depress RM Effect on CO Varies Among Injury ModelsAveraged data for 3 RM Methods PNMVILIS-C Lim, CCM 2004RM Effect on CO Varies

23、 Among IEffect of RM Method on CO in Pneumonia ModelSIPCVS-C Lim, CCM 2004Effect of RM Method on CO in P肺泡复张的决定因素(6):肺泡过度膨胀Clinical exp of Gattinonii 低可复张的ARDS患者Higher PEEP: little benefit and may actually be harmful. 多数肺泡( 60 %)处于开放状态高PEEP和肺复张对开放的肺泡可能是有害的高可复张的ARDS患者the use of higher PEEP levels see

24、ms appropriate In our daily practicePEEP 15 cmH2OPEEP 150 mlNonrecruiters: 150 ml预测: ARDS肺复张效应N=19 ARDSAm J Res影响ARDS肺复张效应的因素Am J Respir Crit Care Med Vol 171. pp 10021008, 2005影响复张响应的预测因素 (原发病No effect)PEEP - PaO2/FiO2PEPP - ComplPEEP - Stress index (b) 影响ARDS肺复张效应的因素Am J Respir Crit内容提要RM的病理生理基础与实

25、施RM造成的循环问题突破RM的循环限制内容提要RM的病理生理基础与实施RM导致的血流动力学改变ARDS pats n=10 SI的实施：30cmH2O，20s SI时PAP、CVP、PAWP、PVRI和RVSWI均显著增加(P 12%RM面临的循环困境LMRs: 40 cmH2O for 10 s or 20 s CO reduction 50%LV end-diastolic area 45%Mean arterial pressure drop 20%Of course, hemodynamic status return stable within 3minIntensive Care

26、Med (2005) 31:11891194Prospective randomized cross-oAn RM Can Profoundly Depress COAveraged Data from 3 ModelsS-C Lim, et al 2004CO降低的原因ContractilityAfterloadPreloadAn RM Can Profoundly Depress Prospective randomized cross-over studyPats with CABGRM (40 cmH2O X 10 s/20sRM循环干扰的机制： Effect of RM on LV

27、preloadIntensive Care Med (2005) 31:11891194TEE: transgastric ED short axis view of the LVA before a 10s LRMB at the end of a 10-s LRMC before a 20s LRMD at the end of a 20-s LRMProspective randomized cross-oRM循环干扰的机制：Effect of RM on RV afterloadIncrease in RV afterloadAlveolar overdistention of aer

28、ated lung areasHypoxic vasoconstriction in atelectatic lung areasAtelectasis causes vascular leak and lethal right ventricular failure in uninjured rat lungs. Am J Respir Crit Care Med 2003, 167:1633-1640.Ventilation above closing volume reduces pulmonary vascular resistance hysteresis. Am J Respir

29、Crit Care Med 1998, 158:1114-1119.RM效应RM循环干扰的机制：Effect of RM on RV Randomized, controlled, cross-over studyPig ARDS model by lung-lavageRM: 12s-s X 40 cm H2O OR 30-s X 40 cm H2ORM循环干扰的机制：Effect of RM on Leftward septal shiftEchocardiogram: via the short axis end-diastolic view of the RV and LVBefore

30、 RM and at the end of a 30-s RMIntensive Care Med (2006) 32:585594Randomized, controlled, cross-Critical Care 2006, 10:R86Effect of RM on LVEffect of RMContractility and Afterload (SVR): NOTPreload: decreasePig with ARDS by repeated lung lavageConventional MV (CMV): PEEP 5 cmH2O +Vt 810 ml/kg. No RM

31、OLC ventilation: RM for PaO2/FiO2 60 kPa. Vt 68 ml/kgCritical Care 2006, 10:R86EffeRM Effect on CO Varies Among Injury ModelsAveraged data for 3 RM Methods PNMVILIS-C Lim, CCM 2004突破循环限制血流动力学干扰 vs ARDS病因(a)RM Effect on CO Varies Among IPigs with BAL vs LPS-induced ALIRM for 1 minvital capacity manoe

32、uvres (ViCM) at SI30 OR SI40 cmH2OPCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kgIntensive Care Med (2005) 31:112120Aortic blood flow (ABF)Mesenteric blood flow (QPV)BAL-ARDSLPS-ARDS突破循环限制血流动力学干扰 vs ARDS病因(a)Pigs with BAL vs LPS-induced A1.RM使三种 ARDS模型 CI均明显下降

33、2.CI盐酸组降低37% 油酸组 19% 生理盐水组 23%3盐酸组5min后接近 RM前水平 不同病因的ARDS vs RM对CI的影响1.RM使三种 不同病因的ARDS vs RM对CI的影Effect of RM Method on CO in Pneumonia ModelSIPCVS-C Lim, CCM 2004突破循环限制血流动力学干扰 vs RM方法(b)Effect of RM Method on CO in P*HCI吸入复制模型CI降低程度不同PCV: 降低25%SI: 降低46%IP: 降低39% RM方法不同对CI的影响*HCI吸入复制模型RM方法不同对CI的Pigs

34、 with BAL vs LPS-induced ALIRM for 1 minvital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2OPCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kgIntensive Care Med (2005) 31:112120Aortic blood flow (ABF)Mesenteric blood flow (QPV)BAL-ARDSLPS-ARDS突破循环限制血流动力学干扰 vs R

35、M方法(b)Pigs with BAL vs LPS-induced A突破循环限制血流动力学干扰 vs RM方法(b)Intensive Care Med (2006) 32:585594突破循环限制血流动力学干扰 vs RM方法(b)Inten突破循环限制血流动力学干扰 vs Volume expansion(c) Volume status in pats with ARDS Intensive Care Med (2006) 32:585594突破循环限制血流动力学干扰 vs Volume expanPigs with ARDS, RM for 1 minvital capacity

36、manoeuvres (ViCM) at SI30 OR SI40 cmH2OPCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kgIntensive Care Med (2005) 31:112120Aortic blood flow (ABF)Mesenteric blood flow (QPV)BAL-ARDSLPS-ARDS突破循环限制血流动力学干扰 vs Volume expansion(c) Pigs with ARDS, RM for 1 minInRandom

37、ized, controlled, cross-over studyPig ARDS model by lung-lavageRM: 12s-s X 40 cm H2O OR 30-s X 40 cm H2OVolume status: under hypovolemia, normovolemia and hypervolemiaEffect of volume status on Leftward septal shiftEchocardiogram Screen: via the short axis end-diastolic view of the left and right ve

38、ntriclesBefore RM and at the end of a 30-s RMIntensive Care Med (2006) 32:585594突破循环限制血流动力学干扰 vs Volume/septal shift (d)Randomized, controlled, cross-hypovolemia, normovolemia and hypervolemia突破循环限制血流动力学干扰 vs Volume/septal shift (d)hypovolemia, normovolemia and Anesthetized pigsA bronchial blocker w

39、as inserted in the right lower lobe, which was selectively lavaged to create a dense lobar collapse. Randomized into two groupsSelective lung RM (using the inner lumen of the bronchial blocker)General lung RMRM 40cmH2O for 30 s突破循环限制血流动力学干扰 vs Selective RM (e)Before (A) and after (B) selective lobar recru