ARDS呼吸功能监测与通气策略抉择课件

ARDS呼吸功能监测与通气策略抉择内容提要•

PhysiopathologiccourseofARDSandthedilemmainMechanicalventilationTherapeutictargetofMVinARDSShiftof

therapeutictargetofMVinARDS1970sNormalgasexchange1980-1990ProtectionofthelungfromVILILancet1980;2:292-4.NEnglJMed1972;287:799-806.AmRevRespirDis1987;135:312-5.IntensiveCareMed1990;16:372-7.Thelung-protectionstrategyAmJRespirCritCareMed.2008,178:346–355.SameMVstrategy

sutiableforeveryARDSpat??NEnglJMed.2006,354;1775-86.JAMA.1994,271,1772-79.Inflamattion

spreadingfromcorediseaseCoredisease

24%InflammationspreadingLowerHigherHigherseveritymortalityLowerseveritymortalityPotentially

recruitablelungLowerpercentageofpotentially

recruitable

lungHigherpercentageofpotentially

recruitable

lungNEnglJMed.2006,354;1775-86(PanelB).NEnglJMed.2006,354;1775-86LowerVSHigherpercentageofpotentiallyrecruitablelungNEnglJMed.2006,354;1775-86DifferentstagesofARDS•

Earlyexudative

phase•

Proliferativephase•

Fibroticphase•

Heterogeneity

：location,timecourse•

Versatility:PathologicchangesClinicalstagesofARDS–

EarlyARDS(MVupto1week):–

IntermediateARDS(between1~2weeks):–

LateARDS(morethan2weeks):JAMA.1994,271,1772-79.EarlyVSLateARDSJAMA.1994,271,1772-79.EarlyVSLateARDSJAMA.1994,271,1772-79.CTscan,earlyVSlateARDSType1EarlyARDSWeek1IntermediateARDSWeek2LateARDSWeek<=3GattinoniLType2Day1EarlyDay5inhomogeneousdiseaseandboththecraniocaudal

andsternovertebraldiffusegroundglassopacification,rightgreaterthanleftDay17LateDay12InterPartialclearingofboththediffusegroundglassopacification

andthegravity-dependent

atelectasisgroundglassopacification

hasamorereticularpattern.a

pneumatocele

intheleftmidlungandincreasingatelectasis

adjacenttoitAmJRespirCritCareMed.2001,164:1701–1711.EarlyandLate--

RecruitabilityAmJRespirCritCareMed,2002,165:165–170Summary-EarlyandLateARDSPrognosisofARDS•Inflammationspreading•Potentially

recruitable

lungEarlyARDSLateARDSEffectofRMandhigherPEEP?•Lower•Lowerseveritymortality•RMandhigherPEEPmaybeharmfulAggravatedCoredisease•HigherImproved•Higherseveritymortality•RMandhigherPEEPareneededQuestionsReduceVILI内容提要•

Oxygenation

andShuntShuntisthefundamentalcauseofhypoxemiainARDSAmJRespirCritCareMed,2001,164:1701-1711肺泡完全复张的临床标准----P/F1.

PaO2/FiO2>400PaO2+PaCO2>4002.PaO2/FiO2

降低>5%肺泡完全复张的临床标准--CTlPaO2+PaCO2>400(at100%oxygen):

维持肺开放的可靠指标l达到PaO2+PaCO2>400时：CT显示只有5%的肺泡塌陷l

PaO2+PaCO2>400对塌陷肺泡的预测：

ROC曲线下面积0.943BorgesJB,

…,AmatoMBP.AmJRespirCritCareMedVol174.pp1–11,2006肺泡完全复张的临床标准---CTl动脉氧合与塌陷肺组织重量明显呈负相关

(R=0.91)BorgesJB,

…,AmatoMBP.AmJRespirCritCareMedVol174.pp1–11,2006MethodsofQs/Qtcalculation简化公式：P/FandQs/QtchangewithlungrecruitmentPEEPPEEP内容提要•

Respiratorymechanics–

Compliance(Elastance)andResistance–

Stressindex–

EsophagealPressureRespiratorymechanics---Compliance(Elastance)andResistanceConceptsandFormulaC=1/EComplianceandResistancechangesinARDS•Compliancedecreased•Duetoalveolarcollapse•ResistanceincreasedCompliancedecreasedP-Vcurve顺应性曲线明显向右下移位VolumeNORMAL•ARDS•PressureCriticalCare2007,11:R86.PEEP

at

min

Ers

corresponded

to

thegreatest

amount

of

normally

aeratedareasCriticalCare2007,11:R86.Innon-injuredanimalsIntensiveCareMed.2008,34:2291–2299Ers

seems

to

be

useful

for

guiding

PEEPtitration

in

non-injured

and

injured

lungsCriticalCare.

2005,9:R471-R482•Vpoor:volumeofpoorlyaeratedlung;

Vhap:volumeofhyperinflatedlung•Pmcd:pressureofmaximumcompliancedecreaseoninflationcurveCrs

may

be

useful

for

guiding

PEEP

titrationCriticalCare.

2005,9:R471-R482CasePEEPPEEPNot

routinely

RM?;

PEEP

10

or

8

cmH2O?;

VT

500mlRespiratorymechanics---StressindexStressindexP=a*tb+cSlutskyAS,Aneathiology,2000,93:1320-8GrassoS,

CritCareMed,2004,32:1018–27CritCareMed,2004,32:1018–27PreconditionCritCareMed,2004,32:1018–27Howtodo

itatthebedsideCaseRespiratorymechanics---MVGuidedbyEsophagealPressureMVGuidedbyEsophagealPressureinALINEnglJMed.2008,359;2095MVGuidedbyEsophagealPre