ARDS肺复张的实施课件

邱海波东南大学附属中大医院ICU东南大学急诊与危重病医学研究所ARDS肺复张的实施科学与艺术的困惑邱海波ARDS肺复张的实施科学与艺术的困惑内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM内容提要肺保护性通气策略不能解决解决的问题ARDSnet:小潮气量通气LowTidalVolumesTraditionalTidalVolumesP-valueDeathbeforedischargehomeandbreathingwithoutassistant(%)31.039.80.007Breathingwithoutassistancebydays(%)65.755.0<0.001NOofventilatorfreedaysDay1-2812±1110±110.007Boratrauma,Day1-28(%)10110.43NOofdayswithoutfailureofnonpulmonaryorgansorsystemsDay1-2815±1112±110.006ARDSNet.NEnglJMed.2000May4;342(18):1301-8.ARDSnet:小潮气量通气LowTidalVolumLowtidalvolume:morealvcollapse小Vt不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略至少15~25%患者需提高FiO2邱海波,刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205Lowtidalvolume:morealvcoCollapsedairwayV1V2PressureVolumeV1V1+V2OpeningpressureNormalARDSPEEPadjustmentLIP：塌陷肺泡开始复张的压力

不是全部塌陷肺泡复张的压力PEEPnotenough:morealvkeepcollapseCollapsedV1V2PressureVolumeV130kgPigPostLavagePCVPaw13cmH2OPEEP5cmH2OExperimentalstudy-PigwithARDS30kgPigExperimentalstudy-Pi许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.ClinicalTrial－11ARDSpats许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM内容提要肺保护性通气策略不能解决解决的问题A.HypoxamiaB.ShearforcesC.SurfactantsinactivateD.BiotraumaandMODSPathophysiologyConsolidationandalvcollapseA.HypoxamiaPathophysiologyA.低氧血症肺泡塌陷：ARDS重力依赖区 炎症或不张区生理性低氧缩血管反应：障碍 A.低氧血症肺泡塌陷：ARDS重力依赖区HowDoesExcessiveMechanicalStressInflametheLung?“Shear”HowDoesExcessiveMechanicalVerbruggeetal.CritCareMed1999;27：779Ventilator-associatedlunginjuryPurine:amarkerofATPbreakdownandVILI42SDratsPCV6minPCVPre/PEEPBALFpurineandproteinVerbruggeetal.CritCareMedLachmann.ICM,1994;20:6-11Intra-alveolarproteinsinactivatealvsurfactantinadose-dependentway

1mgsurfactant=

inhibitoryeffectof1mgplasmaproteinC.Surfactant灭活Lachmann.ICM,1994;20:6-11InSurfactantmoveawayWhenlungregionscollapseatend–expiration,surfactantmoleculesmoveawayfromthealvsurfacetowardterminalbronchiolesandcannotbereusedduringnextinflationRoubyJJ.AmJRespirCritCareMed,2001,165:1182SurfactantmoveawayWhenlungD.预防Biotrauma和MODSMariniJJ,GattinoniL.Ventilatorymanagementofacuterespiratorydistresssyndrome:aconsensusoftwoCritCareMed.2004Jan;32(1):250-5.“Stretch”“Shear”AirwayTraumaD.预防Biotrauma和MODSMariniJJ,内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM内容提要肺保护性通气策略不能解决解决的问题俯卧位通气的病理生理特征改善通气过程胸膜腔压力梯度顺应性胸壁促进分泌物的清除ClosingpressureClosingpressure俯卧位通气的病理生理特征改善通气过程ClosingClosiTimecourseofProneonPaO2/FiO2betweenARDSpvsARDSexpTimeresponseofPronepositiononPaO2/FiO2betweenARDSpvsARDSexp黄英姿,邱海波.肺内外源性ARDS实施俯卧位通气时间的选择.中华内科杂志2004,43(12):883-887TimecourseofProneonPaO2/F内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM内容提要肺保护性通气策略不能解决解决的问题保留自主呼吸的优点保留自主呼吸的优点内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM内容提要肺保护性通气策略不能解决解决的问题Paw[cmH2O]

%OpeningandClosingPressures0510152025303540455001020304050

OpeningpressureClosingpressure5patients,ALI/ARDSFromCrottietalAJRCCM2001.Someunitscan’tbekeptopenbyanyreasonablePEEP!Paw[cmH2O]%OpeningandClosiAmato:CT+PVCurveHeartSpPVLIPUIPInsprecruitLargerVt/Sigh:PressuremustbehighenoughEvenuptoUIPAmato:CT+PVCurveHeartSpPV内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighHighPEEPRM内容提要肺保护性通气策略不能解决解决的问题许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.ClinicalTrial－11ARDSpats许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.RecruitmentisTime-Dependent~40SECONDSRecruitmentisTime-Dependent~内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighHighPEEPRM内容提要肺保护性通气策略不能解决解决的问题

RecruitmentmannuversBasicPrinciplesMethodsforRecruitmentExperimentalStudiesandClinicalTrialsEfficacyHazardsRecruitmentmannuversBasicPr1.控制性肺膨胀(SI)法2.PEEP递增法3.压力控制(PCV)法MethodsforRecruitment1.控制性肺膨胀(SI)法MethodsforRecrCPAP模式:

PS0,PEEP30-40cmH2O,20-50s

2.BIPAP:

Ph/PL30-40cmH2O,20-50s

3.InspHold:

将吸气保持键按住，持续20-40s控制性肺膨胀(SI)法CPAP模式:

PS0,PEEP30-40cmHMultipleManeuversMayBeNeededForOptimumRMEffectFujinoetal,CritCareMed2001;29(8):1579-1586MultipleManeuversMayBeNeedPost-RMPEEPDeterminesPaO2AverageddatafromthreemodelsRMS-CLim,CCM2004TransientBenefitPost-RM-PEEP－

肺开放效应持续时间的决定因素CCM,2004,32:2371-237728mixed-breedpigsModelsofARDS:OAVILIPneumonia(PNM)RMSIIncreasedPEEPPCVPost-RMPEEPDeterminesPaO2Av肺开放后的PEEP选择----PaO2/FiO21.RM后PEEP:20cmH2O2.PEEP递减:2cmH2O/5min3.PEEP阈值:PaO2/FiO2<400的PEEP或PaO2/FiO2

降低>5%4.PEEP:PEEP阈值+2cmH2O肺开放后的PEEP选择----PaO2/FiO21.RM后BASELINEVENTILATIONTidalvolume=6ml/kgPEEP=5cmH2OMod