心脏病患者的正压通气─心肺相互作用-课件

心脏病患者的正压通气:

心肺相互作用1ppt课件心脏病患者的正压通气:

心肺相互作用1ppt课件利益冲突无2ppt课件利益冲突无2ppt课件机械通气是心脏病患者常用的治疗手段美国6个州共6,469,674名住院患者180,326(2.8%)接受机械通气AMI 1.7%心脏功能不全 18.4%全球20个国家361个ICU中15,757名患者5,183(33%)接受机械通气急性呼衰 68.8%原因术后 20.8%肺炎 13.9%充血性心衰 10.4%全身性感染 8.8%创伤 7.9%WunschH,Linde-ZwirbleWT,AngusDC,etal.TheepidemiologyofmechanicalventilationintheUnitedStates.CritCareMed2010;38:1947-1953EstebanA,AnzuetoA,FrutosF,etal.Characteristicsandoutcomesinadultpatientsreceivingmechanicalventilation.A28-dayinternationalstudy.JAMA2002;287:345-3553ppt课件机械通气是心脏病患者常用的治疗手段美国6个州共6,469,6自主呼吸及机械通气对心血管的影响ShekerdemianL,BohnD.Cardiovasculareffectsofmechanicalventilation.ArchDisChild1999;80:475-480正压通气胸腔内压肺容积前负荷后负荷心率心肌收缩力4ppt课件自主呼吸及机械通气对心血管的影响ShekerdemianL正压通气对心血管的影响ScharfSM,CaldiniP,IngramRH.Cardiovasculareffectsofincreasingairwaypressureinthedog.AmJPhysiol1977;232:H35-H435ppt课件正压通气对心血管的影响ScharfSM,Caldini胸腔内压改变的血流动力学影响ThoraxVenousReturnLVEjection6ppt课件胸腔内压改变的血流动力学影响ThoraxVenousLV6p自主呼吸对LV充盈的影响Lemaire,etal.Anesthesiol1988;69:171-1797ppt课件自主呼吸对LV充盈的影响Lemaire,etal.An胸腔内负压的剧烈波动可导致肺水肿哮喘持续状态上气道梗阻肺水肿StalcupandMellins.NEnglJMed1977;297:592-596KanterandWatchko.AmJDisChil1984;138:356-358Lukeetal.Pediatrics1966;37:762-768Oswaltetal.JAMA1977;238:1833-1835Miroetal.Chest1989;96:1430-14318ppt课件胸腔内负压的剧烈波动可导致肺水肿哮喘持续状态StalcupNPPE的发病机制UpperAirwayObstructionMullerManeuverITPmorenegative

Pulm.bloodvolume

Pulm.arterialpressureTransudationPulmonaryEdema

CapillarypermeabilityPulm.capillarydamagePulm.arterialconstrictionSystemicvasoconstrictionCNSHypoxia

LVafterload

Pulm.venouspressure

Pericapillaryhydrostaticpressure

CO9ppt课件NPPE的发病机制UpperAirwayObstructITP升高能够降低LV后负荷，增加心输出量β-受体阻滞剂诱导的急性心功能衰竭（犬模型）Pinskyetal.JApplPhysiol1983;54:950-955Pinskyetal.JApplPhysiol1985;58:1189-1198合并CHF的心肌病患者Pinsky&Summer.Chest1983;84:370-375急性心功能衰竭犬模型心动周期特异性ITP增加Pinskyetal.JApplPhysiol1986;60:604-612预防低血容量下CO下降Matuschaketal.JApplPhysiol1986;61:44-53急性二尖瓣返流的犬模型Steinetal.JApplPhysiol1990;69:2120-212510ppt课件ITP升高能够降低LV后负荷，增加心输出量β-受体阻滞剂诱导ITP改变对LV射血的影响ITP下降能够增加LV射血压，增加LV后负荷ITP升高能够降低LV射血压，降低LV后负荷Buda,Pinsky,etal.NEnglJMed1979;301:453-459Pinsky,etal.JApplPhysiol1983;54:950-95511ppt课件ITP改变对LV射血的影响ITP下降能够Buda,Pins呼吸周期对左室每搏输出量的影响JallonJF,AbdulhayE,CalabreseP,etal.Amodelofmechanicalinteractionsbetweenheartandlungs.PhilTransRSocA2009;367:4741-475712ppt课件呼吸周期对左室每搏输出量的影响JallonJF,AbduLVPV曲线，MVO2和心脏做功的关系StrokeWorkElastance-DefinedPotentialWorkThehiddenmechanicalworkoftheLVSugaH,HayashiT,ShirahataM.Ventricularsystolicpressure-volumeareaaspredictorofcardiacoxygenconsumption.AmJPhysiol1981;240:H39-H4413ppt课件LVPV曲线，MVO2和心脏做功的关系StrokeElasLV压力─容积面积(PVA)VendelinM,BovendeerdPHM,EngelbrechtJ,etal.Optimizingventricularfibers:uniformstrainorstress,butnotATPconsumption,leadstohighefficiency.AmJPhysiol2002;283:H1072-H1081LVVolumeStrokeWorkPELVVolumePVALVPressureATP/MVO2PVA14ppt课件LV压力─容积面积(PVA)VendelinM,BoveLVPV曲线，MVO2和心脏做功的关系LVVolumeLVPressureABLVVolumeLVPressureABMVO2A>>MVO2B两个P/V环：每搏功相同PVA及MVO2不同15ppt课件LVPV曲线，MVO2和心脏做功的关系LVVolumeL正压通气对LV前负荷和后负荷的影响DenaultAY,GorcsanJ,PinskyMR.Dynamiceffectsofpositive-pressureventilationoncanineleftventricularpressure-volumerelations.JApplPhysiol2001;91:298-30816ppt课件正压通气对LV前负荷和后负荷的影响DenaultAY,G正压通气对LV前负荷和后负荷的影响DenaultAY,GorcsanJ,PinskyMR.Dynamiceffectsofpositive-pressureventilationoncanineleftventricularpressure-volumerelations.JApplPhysiol2001;91:298-30817ppt课件正压通气对LV前负荷和后负荷的影响DenaultAY,G正压通气对LV前负荷和后负荷的影响DhainautJF,DevauxJY,MonsallierJF,etal.MechanismsofdecreasedleftventricularpreloadduringcontinuouspositivepressureventilationinARDS.Chest1986;90:74-8018ppt课件正压通气对LV前负荷和后负荷的影响DhainautJF,LV收缩力正常时

ITP

ITPIncreasedLVEjectionPressureIncreasedLVPreloadDecreasedLVEjectionPressureDecreasedLVPreloadESPVRPinskyMR.Thehemodynamicconsequencesofmechanicalventilation:anevolvingstory.IntensiveCareMed1997;23:493-50319ppt课件LV收缩力正常时ITPITPIncreasedLVELV收缩力降低时

ITP

ITPIncreasedLVEjectionPressureIncreasedLVPreloadDecreasedLVEjectionPressureDecreasedLVPreloadESPVRPinskyMR.Thehemodynamicconsequencesofmechanicalventilation:anevolvingstory.IntensiveCareMed1997;23:493-50320ppt课件LV收缩力降低时ITPITPIncreasedLVE无创CPAP和BiPAP能够减轻心脏应激CPAP能够减轻急性心源性肺水肿(ACPE)患者的心脏缺血Rasanenetal.AmJCardiol55:296-300,1985如果CPAP能够消除ACPE患者的胸腔内负压，才能发挥有益作用Rasanenetal.Chest87:158-62,1985面罩CPAP可避免ACPE患者气管插管Berstenetal.NEnglJMed325:1825-30,1991面罩BiPAP以及PSV可改善ACPE患者氧合，避免气管插管Massipetal.Lancet356:2126-32,2000Giacominietal.Chest123:2057-61,2003Navaetal.AmJRespirCritCareMed168:1432-7,2003Ferreretal.AmJRespirCritCareMed168:1438-44,2003CPAP和BiPAP对ACPE具有相似的有益作用Parketal.CritCareMed32:2407-15,2005面罩BiPAP能够改善OSA患者的左心室功能Kanekoetal.NEnglJMed348:1233-41,200321ppt课件无创CPAP和BiPAP能够减轻心脏应激CPAP能够减轻急性急性心梗时的CPAPRasanenetal.Chest1985；87:158-16222ppt课件急性心梗时的CPAPRasanenetal.ChestCPAP对CHF患者ITP的影响NaughtonMT,RahmanA,HaraK,etal.Effectofcontinuouspositiveairwaypressureonintrathoracicandleftventriculartransmuralpressuresinpatientswithcongestiveheartfailure.Circ1995;91:1725-173123ppt课件CPAP对CHF患者ITP的影响NaughtonMT,RCPAP对CHF患者ITP的影响NaughtonMT,RahmanA,HaraK,etal.Effectofcontinuouspositiveairwaypressureonintrathoracicandleftventriculartransmuralpressuresinpatientswithcongestiveheartfailure.Circ1995;91:1725-173124ppt课件CPAP对CHF患者ITP的影响NaughtonMT,RCPAP改善CHF患者的LV功能24名合并CHF的OSA患者夜间CPAPx1mthvs.对照组夜间CPAP组病情改善OSA发作减少收缩压降低(126to116mmHg)心率减慢(68to63bpm)LV射血分数改善(25to34%)LV收缩末内径减小(55to53mm)Kanekoetal.NEnglJMed2003;348:1233-124125ppt课件CPAP改善CHF患者的LV功能24名合并CHF的OSA患者CPAP改善CHF患者的LV功能Kanekoetal.NEnglJMed2003;348:1233-124126ppt课件CPAP改善CHF患者的LV功能Kanekoetal.ACPE时的面罩CPAP39名ACPE患者随机分为面罩CPAP组或氧疗组(FiO20.4)研究持续24h30分钟后呼吸频率及PaCO2下降24h时两组患者生理指标相似气管插管比例CPAP组 0/20对照组 7/19Berstenetal.NEnglJMed1991;325:1825-183027ppt课件ACPE时的面罩CPAP39名ACPE患者随机分为面罩CPAACPE时的面罩CPAPBerstenetal.NEnglJMed1991;325:1825-1830CPAPO228ppt课件ACPE时的面罩CPAPBerstenetal.NEACPE的无创通气Masip,etal.Lancet2000;356:2126-2132Control(n=18)NIPSV(n=19)29ppt课件ACPE的无创通气Masip,etal.LancetACPE的无创通气