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1、Stress index 病理生理基础,Ventilation in ALI,Background,ALI是ICU常见的危重病 病理生理特点 肺容积明显降低 肺顺应性明显下降 通气/血流比例失调 肺组织分布“不均一”,TIDAL recruitment,end-expiration end-inspiration,TIDAL hyperinflation,end-expiration end-inspiration,background,Intensive Care Med,2005, 31:776784,非重力依赖区过度膨胀 重力依赖区潮汐性塌陷复张,Best Practice 24:171
2、-182.,VILI,立项依据,Always opening and closingVILI,Tidal collapse,VT,0 10 20 30 40,0 10 20 30 40 50,%,Paw(cmH2O),Closing pressure,Opening pressure,Crotti,et al Am J Respir Crit Care Med 2001;164:131-140,HEART,SP,PEEP-Keep the lung open,Low Vt,RM Open lung,Background,ARDS病理生理变化 肺保护性通气,机械通气患者病死率仍高达37%,Int
3、ensive Care Med 2009;35:816825.,13,322 pats admitted to 299 ICUs from 35 countries,Background,6mlKg小潮气量 非重力依赖区肺泡依然过度膨胀,Background,中大医院重症医学科预试验,重力依赖区通气不良和塌陷肺泡明显增加,Background,中大医院重症医学科预试验,HEART,SP,At present：Lung Protective Ventilation Strategies,Background,VILI几乎无处不在 潮气量和PEEP的设定依然矛盾重重,潮气量设置困难个体化难！,重症
4、ARDS大量肺泡塌陷 即使“小”潮气量仍然导致VILI 潮气量应更小 VILI塌陷肺泡少 “小”潮气量太小，肺泡通气无法保证，导致肺泡塌陷 显然，6mlKg的“小”潮气量不适合所有ARDS,The most controversial issue in ALI/ARDS pts,维持肺开放(Keep Lung Open) -最佳PEEP,PEEP水平不足,肺泡反复塌陷、复张，产生剪切力 VILI,PEEP水平过高,肺泡过度膨胀，导致气压伤 VILI,立项依据,Methods to titrate PEEP in ALI/ARDS,Best PEEP(Suter, NEJM, 1975) Sup
5、er PEEP(Kirby, Chest, 1975) Pflex(Amato, Am J Respir Crit Care Med, 1995) Oxygenation scale(ARDSnet, NEJM, 2000) Stress index(Ranieri, Anesthesiology, 2000) Pmc(Goddon, Anesthesiology, 2001) FRC+Cst(Lambermont, Critical Care, 2008) Pes(Talmor, NEJM, 2008) Increased recruitment strategy(Mercat, JAMA,
6、 2008) EIT(Meier, ICM, 2008) ,Which one is best?,滴定PEEP的最佳方法,简便、床边 快速 安全 可重复，为PEEP滴定提供可靠信息,Stress index-肺牵张指数,容量控制通气、恒定流速,Stress index-肺牵张指数,P-t曲线吸气支：曲线回归方程P=a * tb + c b 值：肺牵张指数 描述曲线的形状，反映肺泡开放与塌陷程度的力学指标,Slutsky AS, Aneathiology, 2000,93: 1320-8 Grasso S, Crit Care Med, 2004, 32: 101827,Ranieri VM e
7、t al Anesthesiology 2000,Stress index-肺牵张指数,stress index= 1 before RM,stress index = 1 after RM,0.6 stress index 0.8,0.8 stress index 1,1.1 stress index 1.3,1.3 stress index 1.5,b值与塌陷和过度膨胀,b值与塌陷和过度膨胀,肺牵张指数指导ARDS患者PEEP的选择,14例ARDS患者实施肺复张后容量控制通气 用回归法求得方程: P=a*tb+c. b为肺牵张指数。 复张后调整PEEP使 b1(1.1b1.3),与复张前比
8、较，*P0.05; 与复张后b1比较，#P0.05; 与b=1比较，P0.05,黄英姿，邱海波。中华医学杂志。2009,89:2739,肺复张后b=1时，氧合、顺应性和肺复张容积明显改善,与基础状态比较*P0.05；与氧合法比较P0.05； 与肺牵张指数法比较P0.05；与顺应性法比较P0.05,*,*,*,*,不同方法选择最佳PEEP的比较,PEEP(cmH2O),PaO2/FiO2(mmHg),b值滴定PEEP对氧合的影响,与基础状态比较，*P0.05,*,*,*,*,*,与基础状态比较，*P0.05,复张容积(ml),Cst(ml/cmH2O ),b值滴定PEEP对 复张容积和Cst的影
9、响,THE STRESS INDEX CONCEPT: experimental data,0.0 0.5 1.0 1.5 2.0.,Ranieri VM et al Anesthesiology 2000,0.0 0.5 1.0 1.5 2.0.,THE STRESS INDEX CONCEPT: experimental data,Ranieri VM, Slutsky AS Anesthesiology 2000,BAL,4,b=1，炎症反应降低,B值滴定PEEP,B值反应肺顺应性的动态变化,btotal tot = 1.00 but the algorithm is still able to distinguish b1 = 0.91 b2 = 1.11,KleisTEK - Advanced Electronic Systems, Bari - Italy,First phase: b1 = 0.91,Second phase: b2 = 1.11,KleisTEK - Advanced Electronic Systems, Bari - Italy,B值反应肺顺应性的动态变化,B值滴定PEEP是最佳方法？,简便、床边 快速 安全 可重复，为PEEP滴定提供可靠信息,谢谢,选择=结果,汇报结束 谢谢观看！ 欢迎提出您的宝贵意见！,
