心脏病患者的正压通气─心肺相互作用.ppt

1、北京协和医院 杜斌,心脏病患者的正压通气:心肺相互作用,利益冲突,无,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 AMI1.7% 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%,Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilati

2、on in the United States. Crit Care Med 2010; 38: 1947-1953 Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-day international study. JAMA 2002; 287: 345-355,自主呼吸及机械通气对心血管的影响,Shekerdemian L, Bohn D. Cardiovascular effects of

3、mechanical ventilation. Arch Dis Child 1999; 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,正压通气对心血管的影响,Scharf SM, Caldini P, Ingram RH. Cardiovascular effects of increasing airway pressure in the dog. Am J Physiol 1977; 232: H35-H43,胸腔内压改变的血流动力学影响,Thorax,Venous Return,LV Ejection,自主呼吸对LV充盈的影响,Lemaire,

4、et al. Anesthesiol 1988; 69: 171-179,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,Stalcup and Mellins. N Engl J Med 1977; 297: 592-596,Kanter and Watchko. Am J Dis Chil 1984; 138: 356-358,Luke et al. Pediatrics 1966; 37: 762-768 Oswalt et al. JAMA 1977; 238: 1833-1835 Miro et al. Chest 1989; 96: 1430-1431,NPPE

5、的发病机制,Upper Airway Obstruction,Muller Maneuver,ITP more negative,Pulm. blood volume,Pulm. arterial pressure,Transudation,Pulmonary Edema,Capillary permeability,Pulm. capillary damage,Pulm. arterial constriction,Systemic vasoconstriction,CNS,Hypoxia,LV afterload,Pulm. venous pressure,Pericapillary hy

6、drostatic pressure,CO,ITP升高能够降低LV后负荷，增加心输出量,-受体阻滞剂诱导的急性心功能衰竭（犬模型） Pinsky et al. J Appl Physiol 1983; 54: 950-955 Pinsky et al. J Appl Physiol 1985; 58: 1189-1198 合并CHF的心肌病患者 Pinsky 69: 2120-2125,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, et al. N Engl J Med 1979; 301

7、: 453-459,Pinsky, et al. J Appl Physiol 1983; 54: 950-955,呼吸周期对左室每搏输出量的影响,Jallon JF, Abdulhay E, Calabrese P, et al. A model of mechanical interactions between heart and lungs. Phil Trans R Soc A 2009; 367: 4741-4757,LV PV曲线，MVO2和心脏做功的关系,Stroke Work,Elastance-Defined Potential Work,The hidden mechan

8、ical work of the LV,Suga H, Hayashi T, Shirahata M. Ventricular systolic pressure-volume area as predictor of cardiac oxygen consumption. Am J Physiol 1981; 240: H39-H44,LV压力容积面积(PVA),Vendelin M, Bovendeerd PHM, Engelbrecht J, et al. Optimizing ventricular fibers: uniform strain or stress, but not A

9、TP consumption, leads to high efficiency. Am J Physiol 2002; 283: H1072-H1081,LV Volume,Stroke Work,PE,LV Volume,PVA,LV Pressure,LV PV曲线，MVO2和心脏做功的关系,LV Volume,LV Pressure,A,B,LV Volume,LV Pressure,A,B,MVO2A MVO2B,两个P/V环：每搏功相同 PVA及MVO2不同,正压通气对LV前负荷和后负荷的影响,Denault AY, Gorcsan J, Pinsky MR. Dynamic ef

10、fects of positive-pressure ventilation on canine left ventricular pressure-volume relations. J Appl Physiol 2001; 91: 298-308,正压通气对LV前负荷和后负荷的影响,Denault AY, Gorcsan J, Pinsky MR. Dynamic effects of positive-pressure ventilation on canine left ventricular pressure-volume relations. J Appl Physiol 2001

11、; 91: 298-308,正压通气对LV前负荷和后负荷的影响,Dhainaut JF, Devaux JY, Monsallier JF, etal. Mechanisms of decreased left ventricular preload during continuous positive pressure ventilation in ARDS. Chest 1986; 90:74-80,LV收缩力正常时,ITP,ITP,Increased LV Ejection Pressure,Increased LV Preload,Decreased LV Ejection Press

12、ure,Decreased LV Preload,ESPVR,Pinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-503,LV收缩力降低时,ITP,ITP,Increased LV Ejection Pressure,Increased LV Preload,Decreased LV Ejection Pressure,Decreased LV Preload,ESPVR,Pinsky MR. The hemo

13、dynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-503,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 Rasanen et al. Am J Cardiol 55:296-300, 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 Rasanen et al. Chest 87:158-62, 1985 面罩CPAP可避免ACPE患者气管插管 Bersten et

14、al. N Engl J Med 325:1825-30, 1991 面罩BiPAP以及PSV可改善ACPE患者氧合，避免气管插管 Massip et al. Lancet 356:2126-32, 2000 Giacomini et al. Chest 123:2057-61, 2003 Nava et al. Am J Respir Crit Care Med 168:1432-7, 2003 Ferrer et al. Am J Respir Crit Care Med 168:1438-44, 2003 CPAP和BiPAP对ACPE具有相似的有益作用 Park et al. Crit

15、 Care Med 32:2407-15, 2005 面罩BiPAP能够改善OSA患者的左心室功能 Kaneko et al. N Engl J Med 348:1233-41, 2003,急性心梗时的CPAP,Rasanen et al. Chest 1985； 87: 158-162,CPAP对CHF患者ITP的影响,Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural press

16、ures in patients with congestive heart failure. Circ 1995; 91: 1725-1731,CPAP对CHF患者ITP的影响,Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Circ 1995; 91: 1725-1731

17、,CPAP改善CHF患者的LV功能,24名合并CHF的OSA患者 夜间CPAP x 1 mth vs. 对照组 夜间CPAP组病情改善 OSA发作减少 收缩压降低 (126 to 116 mmHg) 心率减慢 (68 to 63 bpm) LV射血分数改善 (25 to 34%) LV收缩末内径减小 (55 to 53 mm),Kaneko et al. N Engl J Med 2003; 348: 1233-1241,CPAP改善CHF患者的LV功能,Kaneko et al. N Engl J Med 2003; 348: 1233-1241,ACPE时的面罩CPAP,39名ACPE患者

18、随机分为面罩CPAP组或氧疗组(FiO2 0.4) 研究持续24 h 30分钟后呼吸频率及PaCO2下降 24 h时两组患者生理指标相似 气管插管比例 CPAP组0/20 对照组7/19,Bersten et al. N Engl J Med 1991; 325: 1825-1830,ACPE时的面罩CPAP,Bersten et al. N Engl J Med 1991; 325: 1825-1830,CPAP,O2,ACPE的无创通气,Masip, et al. Lancet 2000; 356: 2126-2132,Control (n = 18),NIPSV (n = 19),ACPE的无创通气,Masip, et al. Lancet 2000; 356: 2126-2132,ACPE的无创机械通气,Ferrer M,Esquinas A, Leon M et al. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168: 1438-1444,ACPE的无创机械通气,Ferrer M,Esquinas A, Leon M et