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1、呼吸机治疗的肺保护策略 1 呼吸机相关性肺损伤 acute parenchymal lung injury and an acute inflammatory response in the lung cytokines alveoli and the systemic circulation multiple organ dysfunction mortality 2 呼吸机相关性肺损伤 ventilator induced lung injury 容量性损伤 Volutrauma large gas volumes 压力性损伤 Barotrauma high airway pressure
2、 不张性损伤 Atelectotrauma alveolar collapse and re expansion 生物性损伤 Biotrauma increased inflammation 3 肺 损 伤 病 理 alveolar structural damage pulmonary edema inflammation fibrosis surfactant dysfunction other organ dysfunction exacerbate the disturbance of lung development Semin Neonatol 2002 Oct 7 5 353 6
3、0 4 Approaches in the management of acute respiratory failure in children protective ventilatory and potential protective ventilatory modes lower tidal volume and PEEP permissive hypercapnia high frequency oscillatory ventilation airway pressure release ventilation partial liquid ventilation improve
4、 oxygenation recruitment maneuvers prone positioning kinetic therapy reduce FiO2 and facilitate gas exchange inhaled nitric oxide and surfactant Curr Opin Pediatr 2004 Jun 16 3 293 8 5 Can mechanical ventilation strategies reduce chronic lung disease continuous positive airway pressure permissive hy
5、percapnia patient triggered ventilation volume targeted ventilation proportional assist ventilation high frequency ventilation Semin Neonatol 2003 Dec 8 6 441 8 6 小潮气量和呼气末正压 lower tidal volume and PEEP 7 Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS
6、 1202 patients lower tidal volume 7ml kg low plateau pressure 30 cm H2O versus tidal volume 10 to 15 ml kg Mortality at day 28 long term mortality was uncertain low and conventional tidal volume with plateau pressure 31 cm H2O was not significantly different Cochrane Database Syst Rev 2004 2 CD00384
7、4 8 Higher versus lower positive end expiratory pressures in patients with the acute respiratory distress syndrome 549 patients acute lung injury and ARDS lower PEEP group 8 3 3 2cmH2O higher PEEP group 13 2 3 5cmH2O P 0 001 tidal volume 6ml kg end inspiratory plateau pressure 30cmH2O The rates of d
8、eath 24 9 27 5 p 0 48 From day 1 to day 28 breathing was unassisted 14 5 10 4 days 13 8 10 6 days p 0 5 clinical outcomes are similar whether lower or higher PEEP levels are used N Engl J Med 2004 Jul 22 351 4 327 36 9 Increasing inspiratory time exacerbates ventilator induced lung injury during hig
9、h pressure high volume mechanical ventilation Sprague Dawley rats negative control group low pressures PIP 12 cm H2O rate 30 iT 0 5 1 0 1 5secs experimental groups high pressures PIP 45 cm H2O rate 10 iT 0 5 1 0 1 5 secs lung compliance PaO2 FiO2 ratio wet dry lung weight and dry lung body weight as
10、 inspiratory time increased static lung compliance p 0002 and Pao2 Fio2 p 001 decreased Wet dry lung weights p 0001 and dry lung body weights p 0 05 0 05 0 05 0 05 0 05 14 对照组 NPM 应用人工呼吸机限压定时持续气流型 通气模 式为IMV 持续脉搏血氧饱和度监测使其维持 在85 95 每8h监测动脉血气一次 要求血 气维持在正常范围内 PaO2 40 70mmHg PaCO2 35 45mmHg 15 观察组 PM组 1
11、肺力学监测仪 Bicore CP100 每8 12h 监测 一次机械通气时肺力学参数 2 监测时要求患儿与呼吸机完全同步或无自 主呼吸状态 必要时通过药物抑制呼吸 3 肺力学监测仪的传感器置于近端接口 4 气管插管气漏率小于20 5 每监测一次持续0 5 1h至数据稳定后记录监 测的数据 16 NPM 组和PM组的评估指标 1 疾病极期 即生后24 48h时呼吸机要求最高值 包括FiO2 PIP PEEP Ti MAP VR 2 VE C20 C TC 限于PM组 3 记录血pH PaO2 PaCO2 氧合指数 OI OI FiO2 MAP PaO2 和心率 血压 4 呼吸机应用时间 用氧时间
12、 住院天数 病死 率 PDA IVH和呼吸机相关性肺损伤的发生 率 17 两组呼吸机参数比较 FiO2 PIP cmH2O PEEP cmH2O MAP cmH2O Ti sec VR 次 分 NPM60 1930 5 3 45 6 0 814 9 3 40 75 0 139 9 PM62 1826 7 1 75 4 0 611 9 2 00 45 0 142 10 t0 1847 5271 3395 81818 101 81 p 0 050 05 0 0010 05 18 19 两组血气监测结果比较 PHPaO2 mmHg PaCO2 mmHg HR 次 分 BP mmHg OI NPM7
13、31 0 157 1740 10144 840 4 619 13 PM7 3 0 0459 1648 6 3145 639 3 614 7 7 t0 2890 5164 6630 7980 9422 011 p 0 05 0 050 05 0 05 0 05 20 21 两组呼吸机相关性肺损伤 PDA IVH 呼吸机应用时间 用氧时间 住院天数 病死率比较 VALI PDA IVH IMV d 用氧时 间 d 住院天 数 d 病死率 NPM 3236423 9 1 811 719 1414 PM13 333 3404 2 1 713 722 118 3 t 0 8671 4741 22 5 5
14、70 090 05 0 9 p0 05 0 05 0 05 0 05 0 05 0 05 22 结论 肺力学监测能指导正确应用呼吸机 降低呼吸 机相关性肺损伤 从本研究结果推荐RDS呼吸机应用的参数为 PIP 25cmH2O左右 短Ti 0 3 0 5秒 应用适当 的PEEP 5 7cmH2O治疗RDS 不影响氧合 PaCO2的轻度增高 PaCO2 45 60 IVH的 发生未见增加 23 允许性高碳酸血症 Permissive hypercapnia 24 Permissive hypercapnia role in protective lung ventilatory strategie
15、s First we consider the evidence that protective lung ventilatory strategies improve survival and we explore current paradigms regarding the mechanisms underlying these effects Second we examine whether hypercapnic acidosis may have effects that are additive to the effects of protective ventilation
16、Third we consider whether direct elevation of CO2 in the absence of protective ventilation is beneficial or deleterious Fourth we address the current evidence regarding the buffering of hypercapnic acidosis 25 Lung protective ventilation in acute respiratory distress syndrome protection by reduced lung stress or by therapeutic hypercapnia hypercapnic acidosis lung protective ventilation respiratory acidosis protected the lung The protective effect of respiratory acidosis inhibition of xanthine o
