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1、“围术期单肺与双肺通气的肺保护策略 ASA 2015 知识更新“读书报告Perioperative Lung Protection Strategiesin One-lung and Two-lung Ventilation Peter Slinger, MD, FRCPC Department of Anesthesia University of Toronto and Toronto General Hospital Toronto, Ontario, Canada提纲1.COPD :呼吸驱动力、肺大泡、气流受限、auto- peep2、机械通气:ALI、VILI(呼吸机相关肺损伤)3、
2、围术期管理：外科相关因素、挥发性麻醉药在肺 保护中的作用、超保护性肺通气(Ultraprotective Lung Ventilation)、液体和细胞外被、其它肺保护 治疗4、总结COPD所有3期（FEV1 3049%预期值）及4期（ FEV130%预期值）COPD患者都需要进行动脉血 气分析检查通常的病史采集、体格检查以及肺功能 检查难以将这类“CO2潴留”与其他非潴留情况相 鉴别。此类患者术后必须补充给氧，以预防与术后不可避免 的功能残气量减少有关的低氧血症发生，同时要预料 到可能会伴随有PaCO2升高，密切监测PaCO2变化 。2.Parot S, Saunier C, Gauthie
3、r H, Milic-Emile J, Sadoul P: Breathing pattern and hypercapnia in patients with obstructive pulmonary disease. Am Rev Respir Dis 1980; 121:98591. Perioperative Lung Protection Strategiesin One-lung and Two-lung Ventilation Peter Slinger, MD, FRCPC Department of Anesthesia University of Toronto and
4、Toronto General Hospital Toronto, Ontario, Canada呼吸驱动力 COPD患者濒临呼衰时，予高浓度氧气诱发高碳 酸血症性昏迷?之前的理论认为，慢性高碳酸血症的患者有赖于低氧刺激以保证呼吸 驱动，而对PaCO2敏感性降低。3.Aubier M, Murciano D, Milic-Emili J, et al.: Effects of the administration of O2 on ventilation and blood gases in patients with chronic obstructive pulmonary disease
5、 during acute respiratory failure. Am Rev Respir Dis 1980; 122:74754. 4.Simpson SQ: Oxygen-induced acute hypercapnia in chronic obstructive pulmonary disease: Whats the problem? Crit Care Med 2002; 30:25860. 5.Hanson CW. III, Marshall BE, Frasch HF, Marshall C: Causes of hypercarbia in patients with
6、 chronic obstructive pulmonary disease. Crit Care Med 1996; 24:238.肺大泡正压通气破裂、张力性气胸、支气管胸膜瘘在维持低气道压力的情况下，肺大泡患者可以安全地 应用正压通气；但应保证配备合适的专业人员和设备 ，以便必要时可以及时置入胸腔引流管和进行肺隔离 。Perioperative Lung Protection Strategiesin One-lung and Two-lung Ventilation Peter Slinger, MD, FRCPC Department of Anesthesia University
7、of Toronto and Toronto General Hospital Toronto, Ontario, Canada气流受限由于肺的动力性高度膨胀，严重气流受限的患者接受 正压通气时存在血流动力学崩溃的风险：他们吸入阻 力没有增加，但是存在明显的呼气阻塞，所以面罩手 动通气时即使轻微的正压通气也可引起患者出现低血 压。“Lazarus拉撒路综合征”抢救措施和正压通气停止 后，心跳骤停的患者却复苏过来的现象的原因。9.Ben-David B, Stonebraker VC, Hershman R, Frost CL,Williams HK: Survival after failed
8、 intraoperative resuscitation: A case of Lazarus syndrome. Anesth Analg 2001; 92:6904.AUTO-PEEP10. Slinger P, Hickey D: The interaction between applied PEEP and auto- PEEP during one-lung ventilation. J Cardiothorac Vasc Anesth 1998; 12:1337. 11. Caramez MP, Borges JB, Tucci MR, et al.: Paradoxical
9、responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation. Crit Care Med 2005; 33:151928. 12. Slinger P, Kruger M, McRae K, Winton T: The relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one- lung
10、 ventilation. Anesthesiology 2002; 95: 1096102.机械通气15. Gajic O, Dara SI, Mendez JL, et al.: Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med 2004; 32:181724. 16. Gajic O, Frutos-Vivar F, Esteban A, Hubmayr RD, Anzueto A: Ve
11、ntilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated atients. ntensive Care Med 2005; 31:92226. 17. Michelet P, DJourno X-B, Roch A, et al.: Protective ventilation influences systemic inflammation after esophagectomy: A randomized controlled study. An
12、esthesiology 2006; 105:91119. 18. Pinheiro de Oliveira R, Hetzel MP, Silva M, Dallegrave D, Friedman G: Mechanical ventilation with high tidal volume induces inflammation in patients without lung disease. Crit Care 2010; 14:R39. 19. Choi G, Wolthuis EK, Bresser P, et al.: Mechanical ventilation with
13、 lower tidal volumes and positive end-expiratory pressure prevents alveolar coagulation in patients without lung injury. Anesthesiology 2006; 105:68995. 20. Determann R, Royakkers A, Wolthuis EK, et al.: Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients wi
14、thout acute lung injury: A preventive andomized controlled trial. Crit Care 2010; 14:R1.非伤害性或所谓保护性的通气设定仍可能使原本健康 的肺形成肺损伤小鼠 “单次打击”所致VILI模型进行的动物研究显示： 即使是最小的伤害性肺通气设置仍可引起符合肺损伤 的生化和组织病理学改变。【21】对啮齿动物模型进行机械通气的另一项研究显示：仅 仅90分钟的保护性通气后就会出现显著的基因表达 （包括参与免疫和炎症反应的基因）。这些改变是否 对临床转归有影响，目前还不确定。【22】ALI是术后发生呼吸衰竭最常见的病因且与降
15、低的术 后生存率有关。【23】21. Wolthuis EK, Vlaar APJ, Choi G, et al.: Mechanical ventilation using non-injurious ventilation settings causes lung injury in the absence of pre- existing lung injury in healthy mice. Crit Care 2009; 13:R1. 22. Ng CSH, Song Wan Ho AMH, Underwood MJ: Gene expression changes with a
16、non-injurious ventilation strategy. Crit Care 2009; 13:40310. 23. Fernandez-Perez ER, Sprung J, Alessa B, et al.: Intraoperative ventilator settings and acute lung injury after elective surgery: A nested case control study. Thorax 2009; 64:12127.围术期肺损伤围术期 肺损伤Q:ALI的主要危险因素？Fernandez-Perez等，4000名患者，前瞻性病例对照研究，观察术中 呼吸机设定与择期手术后发生ALI的情况。研究显示：高危择期手术后 ALI的发生率为3%。与对照组相比，发生ALI的患者术后生存率明显降 低且住院时间延长。 有趣的是，ALI的发生与术中气道峰压有关，而 与潮气量、PEEP或吸入氧浓度无关。一项特别观察危
