机械通气患者的压力容积曲线协和杜斌课件

北京协和医院杜斌机械通气患者的压力容积曲线北京协和医院机械通气患者的压力容积曲线呼吸系统压力容积曲线反映肺和胸廓的静态机械力学特征了解患者的病理生理学改变设置机械通气参数呼吸系统压力容积曲线反映肺和胸廓的静态机械力学特征静态法(staticmethod)准静态法(quasistatic)超大注射器法(super-syringetechnique)吸气阻断法(inspiratoryocclusiontechnique)低流量法(continuousinflationataconstantflow)PV曲线的测定方法静态法(staticmethod)准静态法(quasist静态PV曲线的测定方法(I):超大注射器法测定前的准备工作镇静+肌松测定前15分钟预氧合FiO21.0PEEP0准备好1.5或3.0L超大注射器充满经过湿化的氧气MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法测定前的准备工作静态PV曲线的测定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法Matamis静态PV曲线的测定方法(I):超大注射器法将患者脱离呼吸机数秒钟使得肺完全排空，恢复至FRC将超大注射器连接气管插管从FRC开始进行充气每次向肺内注入50–100mL气体等待3秒钟以使压力稳定通过压力传感器测定气道压力再次充气50–100mL直至Paw达到40–50cmH2O，或注入气体达到1.5L整个过程通常不超过90秒钟MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法将患者脱离呼吸机静态PV曲线的测定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法Matamis静态PV曲线的测定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66通常重复测定4次第1次结果舍弃对volumehistory进行校正后3次结果取平均值静态PV曲线的测定方法(I):超大注射器法Matamis优点缺点测定PV曲线的经典方法1980s的金标准可以测定吸气支及呼气支PV曲线测定时须脱离呼吸机充气过程中肺容积减少充气过程延长(>45s)消耗氧气导致肺容积减少仅部分被生成的CO2代偿注射器中氧气的温度和湿度影响测定结果使用未经加温加湿的气体导致曲线左移静态PV曲线的测定方法(I):超大注射器法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare2000;4:91-100优点缺点测定PV曲线的经典方法测定时须脱离呼吸机静态PV曲线静态PV曲线的测定方法(II):吸气阻断法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89测定原理吸气末平台压力反映肺泡压力使用不同潮气量可以得到相应的肺泡压力静态PV曲线的测定方法(II):吸气阻断法LevyP,静态PV曲线的测定方法(II):吸气阻断法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89测定前的准备工作镇静+肌松呼吸机须具备的功能吸气末暂停呼气末暂停平台压及呼气末压力显示设置基础通气模式容量控制通气模式恒定流量校正volumehistory静态PV曲线的测定方法(II):吸气阻断法LevyP,静态PV曲线的测定方法(II):吸气阻断法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89每次测定平台压力前应当恢复基础通气模式及设置使用呼气末暂停测定PEEPi保证肺容积及呼气末压力恒定(volumehistory)每次测定时改变潮气量通过改变呼吸频率即吸气时间增加或减少潮气量保持吸气流量不变随机选择潮气量吸气末阻断数秒钟后测定平台压力得到不同潮气量所对应的肺泡压力并作图静态PV曲线的测定方法(II):吸气阻断法LevyP,静态PV曲线的测定方法(II):吸气阻断法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed2003;29:130-134静态PV曲线的测定方法(II):吸气阻断法Barberis静态PV曲线的测定方法(II):吸气阻断法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed2003;29:130-134静态PV曲线的测定方法(II):吸气阻断法Barberis静态PV曲线的测定方法(II):吸气阻断法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed2003;29:130-134静态PV曲线的测定方法(II):吸气阻断法BarberisVolumehistory对PV曲线测定的影响TakeuchiM,SedeekKA,SchettinoGPP,etal.Peakpressureduringvolumehistoryandpressure-volumecurvemeasurementaffectsanalysis.AmJRespirCritCareMed2001;164:1225-1230Volumehistory对PV曲线测定的影响TakeucVolumehistory对PV曲线测定的影响NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed2004;32:1358-1364Volumehistory对PV曲线测定的影响NishidVolumehistory对PV曲线测定的影响NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed2004;32:1358-1364Volumehistory对PV曲线测定的影响NishidVolumehistory对PV曲线测定的影响NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed2004;32:1358-1364Volumehistory对PV曲线测定的影响Nishid优点缺点患者无需脱离呼吸机可以忽略氧气消耗每次测定仅3秒钟可以在不同PEEP下测定PV曲线所有呼吸机均可使用耗时较长(约15分钟)恢复基础通气设置测定PEEPi不能测定呼气支PV曲线静态PV曲线的测定方法(II):吸气阻断法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare2000;4:91-100优点缺点患者无需脱离呼吸机耗时较长(约15分钟)静态PV曲线准静态PV曲线的测定方法(I):低流量法测定原理:顺应性计算公式准静态PV曲线的测定方法(I):低流量法测定原理:顺应性准静态PV曲线的测定方法(I):低流量法测定原理:顺应性计算公式若V(t)恒定则克服阻力的压力差恒定此时气道压力与呼吸系统顺应性呈负相关准静态PV曲线的测定方法(I):低流量法测定原理:顺应性准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲线:历史演变Surattetal(JAP1980;Chest1981)吸气流量0.60±0.10(0.40–0.65)L/secPV曲线的顺应性与静态法相同Ranierietal(AmJRespirCritCareMed1994)低流量法PV曲线有助于确定PEEP导致的肺泡复张及过度膨胀Servilloetal(AmJRespirCritCareMed1997); Luetal(AmJRespirCritCareMed1999)吸气流量20–60lpm时,PV曲线斜率测定准确,但高估UIP和LIP准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲准静态PV曲线的测定方法(I):低流量法SurattPM,OwensDH,KilgoreWT,HarryRR,HsiaoHS:Apulsemethodofmeasuringrespiratorysystemcompliance.JApplPhysiol1980,49:1116-1121SurattPM,OwensDH:Apulsemethodofmeasuringrespiratorysystemcomplianceinventilatedpatients.Chest1981,80:34-38RanieriVM,GiulianiR,FloreT,DambrosioM,Milic-EmiliJ:Volume–pressurecurveoftherespiratorysystempredictseffectsofPEEPinARDS:‘occlusion’versus‘constantflow’technique.AmJRespirCritCareMed1994,149:19-27ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法SurattPM准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲线:历史演变Mankikianetal(CritCaremed1983)吸气流量1.7lpm准静态PV曲线与静态法(超大注射器法)相同吸气时间长达60sServilloetal(AmJRespirCritCareMed1997);吸气流量15lpm时,准静态PV曲线右移,但斜率不变高估UIP和LIPMankikianB,LemaireF,BenitoS,etal:Anewdeviceformeasurementofpulmonarypressure-volumecurvesinpatientsonmechanicalventilation.CritCareMed1983；11:897-901ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-163准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所需压力进一步降低吸气流量Ptot=Ptrach+Pres(tube)Ptrach=Pel+Pres与吸气阻断法相比呼吸系统顺应性,UIP和LIP均相同Paw=ΔPressure+PelΔPressure=FlowxRaw当吸气流量≈0ΔPressure≈0Paw≅Pel如何提高准静态PV曲线的准确性ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所准静态PV曲线的测定方法(I):低流量法JonsonB,RichardJC,StrausC,etal:Pressure–volumecurvesandcomplianceinacutelunginjury.AmJRespirCritCareMed1999,159:1172-1178准静态PV曲线的测定方法(I):低流量法JonsonB,准静态PV曲线的测定方法(I):低流量法KárasonS,SöndergaardS,LundinS,WiklundJ,StenqvistO.Evaluationofpressure/volumeloopsbasedonintratrachealpressuremeasurementsduringdynamicconditions.ActaAnaesthesiolScand2000;44:571-577准静态PV曲线的测定方法(I):低流量法KárasonS准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所需压力进一步降低吸气流量Ptot=Ptrach+Pres(tube)Ptrach=Pel+Pres与吸气阻断法相比呼吸系统顺应性,UIP和LIP均相同Paw=ΔPressure+PelΔPressure=FlowxRaw当吸气流量≈0ΔPressure≈0Paw≈Pel如何提高准静态PV曲线的准确性ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282呼吸机设置容量控制通气模式吸气流量恒定呼吸频率 5lpmI:E 4:1VtFlow设置1500mL3lpm设置21500mL9lpm准静态PV曲线的测定方法(I):低流量法LuQ,Vie准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法LuQ,Vie准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282PEEPi呼气流量从呼气末数值下降至0克服气道阻力所需压力(Pres):吸气流量开始恒定时所对应的气道压力与PEEPi的差值吸气流量开始恒定LIP:初始阶段顺应性曲线与PV曲线斜率的交点准静态PV曲线的测定方法(I):低流量法LuQ,Vie准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282当吸气流量设置为9lpm时PV曲线因阻力因素的影响向右侧移动高估LIP(统计学无差异)PV曲线斜率无差异准静态PV曲线的测定方法(I):低流量法LuQ,Vie优点缺点患者无需脱离呼吸机不影响肺容积测定时间较短每次测定仅需10秒钟整个操作包括曲线分析仅需2分钟可以在不同PEEP下测定PV曲线需要特殊的呼吸机吸气流量较高时影响准确性PV曲线右移不能测定呼气支PV曲线准静态PV曲线的测定方法(I):低流量法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare2000;4:91-100优点缺点患者无需脱离呼吸机需要特殊的呼吸机准静态PV曲线的测DraegerEvitaXLHamiltonGalileoGold/G5低流量法吸气支和呼气支PV曲线改良低流量法压力改变速度很慢吸气支和呼气支PV曲线准静态PV曲线的测定方法(II):改良低流量法DraegerEvitaXLHamiltonGalil准静态PV曲线的测定方法(II):改良低流量法/.../PN%20689213_PV-Tool_WP_01-Validation_of_New_Method.pdfPV-Tool_WP_01-Validation_of_New_Method.pdfPiacentiniE,WysockiM,BlanchL.Anewautomatedmethodversuscontinuouspositiveairwaypressuremethodformeasuringpressure-volumecurvesinpatientswithacutelunginjury.IntensiveCareMed2009;35:565-570HamiltonGalileoGold采用的改良低流量法测定吸气与呼气PV曲线与CPAP方法相同与低流量法相同准静态PV曲线的测定方法(II):改良低流量法www.in低流量:HowLowisLow?目的:评价不同吸气流量下测定的准静态PV曲线,其LIP,UIP,最大斜率及WOB是否存在差异研究对象:7名接受机械通气的ARDS患者方法:容量控制通气模式吸气流量1,2,5,10lpm吸气时间从73±1.6sec到8.8±0.69sec结论:LIP无差异UIP和顺应性有统计学差异GamaAM,MeyerEC,GaudencioAM,etal.Differentlowconstantflowscanequallydeterminethelowerinfectionpointinacuterespiratorydistresssyndromepatients.ArtifOrgans2001;25:882-889低流量:HowLowisLow?目的:评价不同吸气低流量:HowLowisLow?Figure1.Effectofinspiratoryflowonairwaypressuretraces.Thecurveontheleftwasobtainedbyusinga30L/minflow,thecurveontherightwith6L/min.Thecomponentrelatedtotheresistanceofflowthroughairwaysandtrachealcannula(ΔP1=Pmax−Pi)increaseswithhigherflows,whereasthecomponentrelatedtotheviscoelasticpropertiesoflungparenchyma(ΔP2=Pi−Pplat)remainsconstantinbothtracings.Thegoalinthelow-flowtechniqueforacquisitionofPVcurvesistouseaflowthatmakesΔP1negligible.Paw=airwaypressure,Pmax=maximumairwaypressure,Pi=pressureatthebeginningoftheinspiratorypause,Pplat=plateaupressureorpressureattheendoftheinspiratorypause.BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg2003;97:145-150低流量:HowLowisLow?Figure1.低流量:HowLowisLow?BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg2003;97:145-150低流量:HowLowisLow?BensenorF低流量:HowLowisLow?BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg2003;97:145-150低流量:HowLowisLow?BensenorF低流量:HowLowisLow?BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg2003;97:145-150低流量:HowLowisLow?BensenorF呼吸系统静态PV曲线:WhatElse?(B)ThetrachealpressurePtrach(innerloop,dashedarea)iscalculatedpointbypoint.ThepressuredifferencebetweentheouterPAW/V-loopandtheinnerPtrach/V-loopmainlyrepresentstheflow-dependentresistivepressuredropacrosstheETT.ThePtrach/V-loopissubdividedintoeightslices(indicatedbyhorizontallines)andrespiratorymechanicsareanalysedseparatelyforeachslice.Theupperandlower5%ofthetidalvolume(VT)(i.e.slices1and8,respectively)areexcludedfromanalysis.Theremaining90%ofVTaredividedinto6slices.Onevolume-dependentdynamiccomplianceandresistanceoftherespiratorysystem(Crs,dynandRrs,dyn)arecalculatedperslice.(C)Qualitycheck:Ptrachisrecalculatedpointbypointforeachslice,usingthecalculatedvaluesforCrs,dynandRrs,dynandthemeasuredvolumeandflow.ThisrecalculatedPtrach/V-loopissuperimposedonthemeasuredPtrach/V-loop,andthepressuredifferencebetweenbothloopsreflectstheaccuracyofthecalculatedmechanicalparameters.ThemeasuredandrecalculatedloopsinCarebarelydistinguishable.Paw-VolumeCurveLichtwarck-AschoffM,KesslerV,SjostrandUH,etal.Staticversusdynamicrespiratorymechanicsforsettingtheventilator.BrJAnaesth2000;85:577-586呼吸系统静态PV曲线:WhatElse?(B)The呼吸系统静态PV曲线:WhatElse?多元线性回归模型(multiplelinearregressionmodel)Paw=Vt/Crs,st+RrsxV+PEEPtot多元非线性回归模型(multiplenonlinearregressionmodel)Paw=Vt/Crs,st+k1xV+k2xV2+PEEPtotVassiliouMP,PetriL,AmgdalouA,etal.Linearandnonlinearanalysisofpressureandflowduringmechanicalventilation.IntensiveCareMed2000;26:1057-1064呼吸系统静态PV曲线:WhatElse?多元线性回归模型静态PV曲线:多元线性回归模型MolsG,BrandesI,KesslerV,etal.Volume-dependentcomplianceinARDS:proposalofanewdiagnosticconcept.IntensiveCareMed10999;25:1084-1091静态PV曲线:多元线性回归模型MolsG,Brande静态PV曲线:多元线性回归模型Lichtwarck-AschoffM,KesslerV,SjostrandUH,etal.Staticversusdynamicrespiratorymechanicsforsettingtheventilator.BrJAnaesth2000;85:577-586静态PV曲线:多元线性回归模型Lichtwarck-Asc静态PV曲线:总结临床可行的测定方法吸气阻断法和准静态法操作要求和影响因素临床意义有待确定静态PV曲线:总结临床可行的测定方法北京协和医院杜斌机械通气患者的压力容积曲线北京协和医院机械通气患者的压力容积曲线呼吸系统压力容积曲线反映肺和胸廓的静态机械力学特征了解患者的病理生理学改变设置机械通气参数呼吸系统压力容积曲线反映肺和胸廓的静态机械力学特征静态法(staticmethod)准静态法(quasistatic)超大注射器法(super-syringetechnique)吸气阻断法(inspiratoryocclusiontechnique)低流量法(continuousinflationataconstantflow)PV曲线的测定方法静态法(staticmethod)准静态法(quasist静态PV曲线的测定方法(I):超大注射器法测定前的准备工作镇静+肌松测定前15分钟预氧合FiO21.0PEEP0准备好1.5或3.0L超大注射器充满经过湿化的氧气MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法测定前的准备工作静态PV曲线的测定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法Matamis静态PV曲线的测定方法(I):超大注射器法将患者脱离呼吸机数秒钟使得肺完全排空，恢复至FRC将超大注射器连接气管插管从FRC开始进行充气每次向肺内注入50–100mL气体等待3秒钟以使压力稳定通过压力传感器测定气道压力再次充气50–100mL直至Paw达到40–50cmH2O，或注入气体达到1.5L整个过程通常不超过90秒钟MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法将患者脱离呼吸机静态PV曲线的测定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66静态PV曲线的测定方法(I):超大注射器法Matamis静态PV曲线的测定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66通常重复测定4次第1次结果舍弃对volumehistory进行校正后3次结果取平均值静态PV曲线的测定方法(I):超大注射器法Matamis优点缺点测定PV曲线的经典方法1980s的金标准可以测定吸气支及呼气支PV曲线测定时须脱离呼吸机充气过程中肺容积减少充气过程延长(>45s)消耗氧气导致肺容积减少仅部分被生成的CO2代偿注射器中氧气的温度和湿度影响测定结果使用未经加温加湿的气体导致曲线左移静态PV曲线的测定方法(I):超大注射器法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare2000;4:91-100优点缺点测定PV曲线的经典方法测定时须脱离呼吸机静态PV曲线静态PV曲线的测定方法(II):吸气阻断法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89测定原理吸气末平台压力反映肺泡压力使用不同潮气量可以得到相应的肺泡压力静态PV曲线的测定方法(II):吸气阻断法LevyP,静态PV曲线的测定方法(II):吸气阻断法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89测定前的准备工作镇静+肌松呼吸机须具备的功能吸气末暂停呼气末暂停平台压及呼气末压力显示设置基础通气模式容量控制通气模式恒定流量校正volumehistory静态PV曲线的测定方法(II):吸气阻断法LevyP,静态PV曲线的测定方法(II):吸气阻断法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89每次测定平台压力前应当恢复基础通气模式及设置使用呼气末暂停测定PEEPi保证肺容积及呼气末压力恒定(volumehistory)每次测定时改变潮气量通过改变呼吸频率即吸气时间增加或减少潮气量保持吸气流量不变随机选择潮气量吸气末阻断数秒钟后测定平台压力得到不同潮气量所对应的肺泡压力并作图静态PV曲线的测定方法(II):吸气阻断法LevyP,静态PV曲线的测定方法(II):吸气阻断法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed2003;29:130-134静态PV曲线的测定方法(II):吸气阻断法Barberis静态PV曲线的测定方法(II):吸气阻断法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed2003;29:130-134静态PV曲线的测定方法(II):吸气阻断法Barberis静态PV曲线的测定方法(II):吸气阻断法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed2003;29:130-134静态PV曲线的测定方法(II):吸气阻断法BarberisVolumehistory对PV曲线测定的影响TakeuchiM,SedeekKA,SchettinoGPP,etal.Peakpressureduringvolumehistoryandpressure-volumecurvemeasurementaffectsanalysis.AmJRespirCritCareMed2001;164:1225-1230Volumehistory对PV曲线测定的影响TakeucVolumehistory对PV曲线测定的影响NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed2004;32:1358-1364Volumehistory对PV曲线测定的影响NishidVolumehistory对PV曲线测定的影响NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed2004;32:1358-1364Volumehistory对PV曲线测定的影响NishidVolumehistory对PV曲线测定的影响NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed2004;32:1358-1364Volumehistory对PV曲线测定的影响Nishid优点缺点患者无需脱离呼吸机可以忽略氧气消耗每次测定仅3秒钟可以在不同PEEP下测定PV曲线所有呼吸机均可使用耗时较长(约15分钟)恢复基础通气设置测定PEEPi不能测定呼气支PV曲线静态PV曲线的测定方法(II):吸气阻断法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare2000;4:91-100优点缺点患者无需脱离呼吸机耗时较长(约15分钟)静态PV曲线准静态PV曲线的测定方法(I):低流量法测定原理:顺应性计算公式准静态PV曲线的测定方法(I):低流量法测定原理:顺应性准静态PV曲线的测定方法(I):低流量法测定原理:顺应性计算公式若V(t)恒定则克服阻力的压力差恒定此时气道压力与呼吸系统顺应性呈负相关准静态PV曲线的测定方法(I):低流量法测定原理:顺应性准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲线:历史演变Surattetal(JAP1980;Chest1981)吸气流量0.60±0.10(0.40–0.65)L/secPV曲线的顺应性与静态法相同Ranierietal(AmJRespirCritCareMed1994)低流量法PV曲线有助于确定PEEP导致的肺泡复张及过度膨胀Servilloetal(AmJRespirCritCareMed1997); Luetal(AmJRespirCritCareMed1999)吸气流量20–60lpm时,PV曲线斜率测定准确,但高估UIP和LIP准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲准静态PV曲线的测定方法(I):低流量法SurattPM,OwensDH,KilgoreWT,HarryRR,HsiaoHS:Apulsemethodofmeasuringrespiratorysystemcompliance.JApplPhysiol1980,49:1116-1121SurattPM,OwensDH:Apulsemethodofmeasuringrespiratorysystemcomplianceinventilatedpatients.Chest1981,80:34-38RanieriVM,GiulianiR,FloreT,DambrosioM,Milic-EmiliJ:Volume–pressurecurveoftherespiratorysystempredictseffectsofPEEPinARDS:‘occlusion’versus‘constantflow’technique.AmJRespirCritCareMed1994,149:19-27ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法SurattPM准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲线:历史演变Mankikianetal(CritCaremed1983)吸气流量1.7lpm准静态PV曲线与静态法(超大注射器法)相同吸气时间长达60sServilloetal(AmJRespirCritCareMed1997);吸气流量15lpm时,准静态PV曲线右移,但斜率不变高估UIP和LIPMankikianB,LemaireF,BenitoS,etal:Anewdeviceformeasurementofpulmonarypressure-volumecurvesinpatientsonmechanicalventilation.CritCareMed1983；11:897-901ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-163准静态PV曲线的测定方法(I):低流量法低流量法测定PV曲准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所需压力进一步降低吸气流量Ptot=Ptrach+Pres(tube)Ptrach=Pel+Pres与吸气阻断法相比呼吸系统顺应性,UIP和LIP均相同Paw=ΔPressure+PelΔPressure=FlowxRaw当吸气流量≈0ΔPressure≈0Paw≅Pel如何提高准静态PV曲线的准确性ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所准静态PV曲线的测定方法(I):低流量法JonsonB,RichardJC,StrausC,etal:Pressure–volumecurvesandcomplianceinacutelunginjury.AmJRespirCritCareMed1999,159:1172-1178准静态PV曲线的测定方法(I):低流量法JonsonB,准静态PV曲线的测定方法(I):低流量法KárasonS,SöndergaardS,LundinS,WiklundJ,StenqvistO.Evaluationofpressure/volumeloopsbasedonintratrachealpressuremeasurementsduringdynamicconditions.ActaAnaesthesiolScand2000;44:571-577准静态PV曲线的测定方法(I):低流量法KárasonS准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所需压力进一步降低吸气流量Ptot=Ptrach+Pres(tube)Ptrach=Pel+Pres与吸气阻断法相比呼吸系统顺应性,UIP和LIP均相同Paw=ΔPressure+PelΔPressure=FlowxRaw当吸气流量≈0ΔPressure≈0Paw≈Pel如何提高准静态PV曲线的准确性ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法减去克服气道阻力所准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282呼吸机设置容量控制通气模式吸气流量恒定呼吸频率 5lpmI:E 4:1VtFlow设置1500mL3lpm设置21500mL9lpm准静态PV曲线的测定方法(I):低流量法LuQ,Vie准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282准静态PV曲线的测定方法(I):低流量法LuQ,Vie准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282PEEPi呼气流量从呼气末数值下降至0克服气道阻力所需压力(Pres):吸气流量开始恒定时所对应的气道压力与PEEPi的差值吸气流量开始恒定LIP:初始阶段顺应性曲线与PV曲线斜率的交点准静态PV曲线的测定方法(I):低流量法LuQ,Vie准静态PV曲线的测定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282当吸气流量设置为9lpm时PV曲线因阻力因素的影响向右侧移动高估LIP(统计学无差异)PV曲线斜率无差异准静态PV曲线的测定方法(I):低流量法LuQ,Vie优点缺点患者无需脱离呼吸机不影响肺容积测定时间较短每次测定仅需10秒钟整个操作包括曲线分析仅需2分钟可以在不同PEEP下测定PV曲线需要特殊的呼吸机吸气流量较高时影响准确性PV曲线右移不能测定呼气支PV曲线准静态PV曲线的测定方法(I):低流量法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare2000;4:91-100优点缺点患者无需脱离呼吸机需要特殊的呼吸机准静态PV曲线的测DraegerEvitaXLHamiltonGalileoGold/G5低流量法吸气支和呼气支PV曲线改良低流量法压力改变速度很慢吸气支和呼气支PV曲线准静态PV曲线的测定方法(II):改良低流量法DraegerEvitaXLHamiltonGalil准静态PV曲线的测定方法(II):改良低流量法/.../PN%20689213_PV-Tool_WP_01-Validation_of_New_Method.pdfPV-Tool_WP_01-Validation_of_New_Method.pdfPiacentiniE,WysockiM,BlanchL.Anewautomatedmethodversuscontinuouspositiveairwaypressuremethodformeasuringpressure-volumecurvesinpatientswithacutelunginjury.IntensiveCareMed2009;35:565-570HamiltonGalileoGold采用的改良低流量法测定吸气与呼气PV曲线与CPAP方法相同与低流量法相同准静态PV曲线的测定方法(II):改良低流量法www.in低流量:HowLowisLow?目的:评价不同吸气流量下测定的准静态PV曲线,其LIP,UIP,最大斜率及WOB是否存在差异研究对象:7名接受机械通气的ARDS患者方法:容量控制通气模式吸气流量1,2,5,10lpm吸气时间从73±1.6sec到8.8±0.69sec结论:LIP无差异UIP和顺应性有统计学差异GamaAM,MeyerEC,GaudencioAM,etal.Differentlowconstantflowscanequallydeterminethelowerinfectionpointinacuterespiratorydistresssyndromepatients.ArtifOrgans2001;25:882-889低流量:HowLowisLow?目的:评价不同吸气低流量:HowLowisLow?Figure1.Effectofinspiratoryflowonairwaypressuretraces.Thecurveontheleftwasobtainedbyusinga30L/minflow,thecurveontherightwith6L/min.Thecomponentrelatedtotheresistanceofflowthroughairwaysandtrachealcannula(ΔP1=Pmax−Pi)increaseswithhigherflows,whereasthecomponentrelatedtotheviscoelasticpropertiesoflungparenchyma(ΔP2=Pi−Pplat)remainsconstantinbothtracings.Thegoalinthelow-flowtechniqueforacquisitionofPVcurves