ARDS患者的肺复张-北京协和医院

1、ARDS患者的肺复张北京协和医院杜斌内容小潮气量量通气的的问题肺复张的的理论与与实践肺复张与与PEEP肺复张后后的PEEP不同复张张方法的的差异肺复张的的临床适适应症肺复张的的副作用用肺复张存存在的问问题内容小潮气量量通气的的问题肺复张的的理论与与实践肺复张与与PEEP肺复张后后的PEEP不同复张张方法的的差异肺复张的的临床适适应症肺复张的的副作用用肺复张存存在的问问题ARDS的肺保保护性通通气策略略患者数潮气量病死率作者小潮气量对照小潮气量对照小潮气量对照P值Amato29246.1 0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.250470.7

2、2Brochard58587.2 0.210.4 0.247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041ARDS的肺保保护性通通气策略略小潮气量量(6ml/kgIBW)避免过度度膨胀造造成的容容积伤(volutrauma)足够的PEEP防止肺泡泡复张造造成的剪剪切力损损伤(atelectrauma)肺泡塌陷陷与复张张造成的的剪切力力F =PLx (V0/V)2/3F:剪剪切力PL:跨肺肺压V0:最初初容积V:复复张后容容

3、积如果:PL= 30 cmH2O,V0/V= 1/10则:F =140 cmH2OMead J,TakishimaT,LeithD.Stressdistribution in lungs:a model of pulmonaryelasticity.JAppl Physiol1970;28(5):596-608小潮气量量通气的的问题LVt(n = 15)CVt(n = 15)P valueVt, ml411 55664 84 0.01Vt, ml/kg6 110 1 0.01setPEEP, cmH2O10 410 4n.s.PEEPtot, cmH2O11 411 4n.s.Pplat, c

4、mH2O23 830 10 0.01Richard JC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolume on Alveolar Recruitment:Respective RoleofPEEPandaRecruitmentManeuver.AmJRespirCritCare Med2001;163: 1609-1613小潮气量量通气的的问题LVt(n = 15)CVt(n = 15)P valuePaO2, mmHg136 80156 82n.s.PaO2/FiO2, mmHg165 84183 8

5、3n.s.SaO2, %94.8 5.097.6 2.1 0.05PaCO2, mmHg60 3538 21 0.001pH7.21 0.17.36 0.1 0.001SBP, mmHg125 25121 20n.s.DBP, mmHg60 960 10n.s.HR, bpm101 1593 15n.s.Richard JC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolume on Alveolar Recruitment:Respective RoleofPEEPandaRecruitmentManeuv

6、er.AmJRespirCritCare Med2001;163: 1609-1613小潮气量量通气的的问题Richard JC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolume on Alveolar Recruitment:Respective RoleofPEEPandaRecruitmentManeuver.AmJRespirCritCare Med2001;163: 1609-1613受损的肺肺组织如如何复张张俯卧位足够的PEEP足够的潮潮气量和(或或)叹叹气?肺复张手手法减少水肿肿(?)最低可

7、接接受的FiO2(?)自主呼吸吸(?)内容小潮气量量通气的的问题肺复张的的理论与与实践肺复张与与PEEP肺复张后后的PEEP不同复张张方法的的差异肺复张的的临床适适应症肺复张的的副作用用肺复张存存在的问问题肺泡的开开放压与与闭合压压PEEP不能使使肺复张张LIP: 仅仅仅是肺复复张的开开始HicklingKG.The pressure-volumecurveisgreatly modified by recruitment.A mathematicalmodelofARDS lungs.AmJRespirCritCare Med1998:158: 194-202.JonsonB,Richard

8、 JC,StrausC,ManceboJ,LemaireF,BrochardL.PressureVolumeCurves andCompliance in Acute LungInjury:EvidenceofRecruitmentAbovetheLowerInflectionPoint.AmJRespirCritCare Med1999;159: 1172-1178低位转折折点之上上仍有肺肺组织复复张肺泡的开开放压与与闭合压压肺泡开放放压与闭闭合压0102030405005101520253035404550Opening pressurePaw(cmH2O)CrottiS,Maschero

9、niD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCare Med2001:164: 131-140.Closing pressureARDS的肺开开放EditorialOpen up thelung andkeep thelung openB.LachmannDept.ofAnesthesiology,ErasmusUniversity Rotterdam,

10、The Netherlands(1992)18:319-321RM能够够使肺开开放RM:PIP 45 cmH2O,PEEP 35 cmH2O x1minHalterJM, SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBoth Alveolar Collapse andRecruitment/Derecruitment. Am JRespirCritCare Med2003;167: 1620-1626

11、肺复张能能够改善善ARDS氧合合LapinskySE,AubinM,MehtaS,BoiteauP,SlutskyAS:Safety andefficacyofa sustainedinflationfor alveolar recruitment in adultswith respiratory failure.IntensiveCareMed1999,25:1297-1301.肺复张的的各种方方法CPAP (SI)incrementalPEEPPCVSigh (modified)HFOV俯卧位SI改善善氧合TugrulS,AkinciO,OzcanPE,Ince, S,EsenF,Tel

12、ciL,AkpirK,CakarN.Effects of sustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonary andextrapulmonaryforms.CritCare Med2003;31:738-744SustainedInflation:45cmH2O x30sSI改善善氧合FrankJA,McAuleyDF,Gutierrez JA,DanielBM, Dobbs L,MatthayMA.Differ

13、ential effectsofsustained inflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCare Med2005;33:181-188SustainedInflation:30cmH2O x30sTwicewith 1min interval叹气的设设置LimCM,KohY,Park W, ChinJY, ShimTS, LeeSD,Kim WS,KimDS, KimWD:Mechanisticscheme andeffectofextendedsighasa recruit

14、ment maneuver in patients withacuterespiratorydistresssyndrome: Apreliminarystudy.CritCare Med2001;29:1255-1260充气阶段段,每每30秒秒PEEP增加5 cmH2OVt减少少2ml/kg前2次呼呼吸除外外直至Vt 2ml/kg, PEEP25cmH2O暂停阶段段CPAP 30 cmH2Ofor30s放气阶段段叹气改善善氧合LimCM,KohY,Park W, ChinJY, ShimTS, LeeSD,Kim WS,KimDS, KimWD:Mechanisticscheme andef

15、fectofextendedsighasa recruitment maneuver in patients withacuterespiratorydistresssyndrome: Apreliminarystudy.CritCare Med2001;29:1255-1260叹气对氧氧合及呼呼吸力学学的影响响PelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,Riva E,LissoniA,GattinoniL.Sigh in acute respiratory distress syndrome.AmJRespirCritCare Med19

16、99;159: 872-880Sigh:3 consecutive sighs/minatPplat45cmH2O叹气的设设置PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.Sigh Improves GasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoing Pressure SupportVentilation. Anesthesiology 2002; 96:788-94Baseline:PSVSig

17、h:BIPAPPEEPhigh=1.2xPIPpsvor35cmH2OTi,s =3 5sf =1bpm叹气改善善呼吸力力学及及氧合PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.Sigh Improves GasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoing Pressure SupportVentilation. Anesthesiology 2002; 96:788-94ARDS对RM的反应应V

18、illagraA,OchagaviaA,VatusS,MuriasG,FernandezMF, AguilarJL, FernandezR,BlanchL.RecruitmentManeuvers duringLung ProtectiveVentilationinAcuteRespiratoryDistressSyndrome. Am JRespirCritCare Med2002;165: 165-170肺复张CT的提提示HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GntherRW,KuhlenR.Multislicespiralcomputedto

19、mographytodeterminethe effectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359肺复张CT的提提示HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminethe effectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359

20、内容小潮气量量通气的的问题肺复张的的理论与与实践肺复张与与PEEP肺复张后后的PEEP不同复张张方法的的差异肺复张的的临床适适应症肺复张的的副作用用肺复张存存在的问问题RMvs.PEEPLimCM, LeeSS,Lee JS,KohY,Shim TS,LeeSD, KimWS,Kim DS,KimWD.MorphometricEffects of theRecruitmentManeuveronSaline-lavagedCanineLungs: AComputedTomographicAnalysis.Anesthesiology2003;99: 71-80RMvs.PEEPLimCM, L

21、eeSS,Lee JS,KohY,Shim TS,LeeSD, KimWS,Kim DS,KimWD.MorphometricEffects of theRecruitmentManeuveronSaline-lavagedCanineLungs: AComputedTomographicAnalysis.Anesthesiology2003;99: 71-80RMvs.PEEPLimCM, LeeSS,Lee JS,KohY,Shim TS,LeeSD, KimWS,Kim DS,KimWD.MorphometricEffects of theRecruitmentManeuveronSal

22、ine-lavagedCanineLungs: AComputedTomographicAnalysis.Anesthesiology2003;99: 71-80RMvs.PEEPLimCM, LeeSS,Lee JS,KohY,Shim TS,LeeSD, KimWS,Kim DS,KimWD.MorphometricEffects of theRecruitmentManeuveronSaline-lavagedCanineLungs: AComputedTomographicAnalysis.Anesthesiology2003;99: 71-80RMvs.PEEPLimCM, LeeS

23、S,Lee JS,KohY,Shim TS,LeeSD, KimWS,Kim DS,KimWD.MorphometricEffects of theRecruitmentManeuveronSaline-lavagedCanineLungs: AComputedTomographicAnalysis.Anesthesiology2003;99: 71-80内容小潮气量量通气的的问题肺复张的的理论与与实践肺复张与与PEEP肺复张后后的PEEP不同复张张方法的的差异肺复张的的临床适适应症肺复张的的副作用用肺复张存存在的问问题为什么肺肺复张作作用不能能持久?baseline3 min post-RM

24、30 min post-RMPaO2/FiO2 (mmHg)139 46246 111138 39PaCO2 (mmHg)48.6 12.147.6 1346.4 12SvO2 (%)70.4 6.172.4 5.670 6.2Qs/Qt (%)30.8 5.821.5 9.729.2 7.4Crs (ml/cmH2O)34.1 12.636.9 15.135.7 13.5OczenskiW,HrmannC,KellerC,LorenzlN,KepkaA,Schwarz S, FitzgeraldRD. Recruitment Maneuversaftera Positive End-expi

25、ratory Pressure Trial Do NotInduceSustained EffectsinEarlyAdultRespiratoryDistressSyndrome. Anesthesiology 2004; 101:620-5为什么肺肺复张作作用不能能持久?肺复张的的方法?SI:50cmH2O x30s作者认为为OczenskiW,HrmannC,KellerC,LorenzlN,KepkaA,Schwarz S, FitzgeraldRD. Recruitment Maneuversaftera Positive End-expiratory Pressure Trial

26、Do NotInduceSustained EffectsinEarlyAdultRespiratoryDistressSyndrome. Anesthesiology 2004; 101:620-5RM+ PEEPvs. RM vs.PEEPLimCM, JungH,KohY,LeeJS, ShimTS, LeeSD,Kim WS,KimDS, KimWD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome accordingtoantiderecruitmentstrate

27、gy,etiologicalcategoryofdiffuselung injury,and bodypositionofthe patient.CritCare Med2003;31:411-418RM+ PEEPvs. RM vs.PEEPLimCM, JungH,KohY,LeeJS, ShimTS, LeeSD,Kim WS,KimDS, KimWD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome accordingtoantiderecruitmentstrate

28、gy,etiologicalcategoryofdiffuselung injury,and bodypositionofthe patient.CritCare Med2003;31:411-418RM+ PEEPRMonlyRM后的的PEEPRM后的的PEEP能够够稳定肺肺泡HalterJM, SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBoth Alveolar Collapse andRecr

29、uitment/Derecruitment. Am JRespirCritCare Med2003;167: 1620-1626RM后的的PEEP能够够稳定肺肺泡RM:PIP 45 cmH2O,PEEP 35 cmH2O x1minPEEP 5cmH2OPEEP 10 cmH2OHalterJM, SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBoth Alveolar Collapse andRecr

30、uitment/Derecruitment. Am JRespirCritCare Med2003;167: 1620-1626肺泡稳定定能够改改善PaO2McCannUG, Schiller HJ,GattoLA,etal. Alveolar mechanicsalterhypoxiculmonaryvasoconstriction.CritCare med2002;30:1315-1321RM后的的PEEPLimCM, Adams AB,SimonsonDA,DriesDJ,BroccardAF,Hotchkiss JR,MariniJJ.Intercomparisonofrecruitm

31、entmaneuverefficacyinthreemodelsofacutelunginjury.CritCare Med2004;32:2371-2377RM+ PEEPvs. PEEPonlyLimCM, Adams AB,SimonsonDA,DriesDJ,BroccardAF,Hotchkiss JR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCare Med2004;32:2371-2377RM+ PEEPPEEP onlyPEEP的设置置RM之后

32、后通常将将PEEP设置置在能够够维持PaO2(防止塌塌陷)的的水平最初将PEEP设置为为20cmH2O然后将FiO2减小到最最低水平平维持SpO290 95%每2030分钟钟降低PEEP 2cmH2O直至患者者SpO2下降PEEP的设置置氧合下降降前的PEEP水平防止大部部分肺泡泡塌陷的的PEEP一旦确认认,则则需重复复肺复张张操作, 然后后把PEEP和和FiO2重新新设置在在上述水水平对于多数数ARDS患者者,PEEP介于15 20 cmH2O之间某些患者者20cmH2OPEEP的设置置如果将PEEP设置于于20cmH2O后,仍仍发现现PaO2/FiO2显著下降降按照最初初的PEEP设设置2

33、5 cmH2O重复肺肺复张然后按照照上述方方法调节节FiO2和PEEPPEEP的设置置将PEEP从不不必要的的高水平平逐渐降降低不要将PEEP由低水水平增加加到高水水平如同P-V曲线线所示, 根据据设置方方法不同同,同同样水平平的PEEP所所维持的的肺容积积不同如果在肺肺泡塌陷陷后设置置PEEP(增加PEEP),则则所设设置的PEEP水平可可以使肺肺容积减减少,PaO2降低PEEP/FiO2的调整推荐意见见降低PEEP之之前应当当首先降降低FiO2, 以避避免肺泡泡塌陷一般情况况下FiO2应当减低低到5min)时如果没有有观察到到氧合下下降,则则需要要每日进进行一次次或两次次肺复张张未知总结肺复张是是肺保护护性通气气策略的的重要组组成开放肺并并维持肺肺开放是是其理论论基础应用气道道高压使使塌陷肺肺泡开放放应用足够够的PEEP维维持肺泡泡开放肺复张对对循环的的影响肺复张尚尚未解决决的问题题压力时间频率适应症PEEP能否使使肺复张张?PEEP能够防防止肺泡泡塌陷(derecruitment)