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1、有创机械通气临床应用进展,2,乙胺碘呋酮致ARDS,2019/4/20,3,国内首例MDS继发PAP,4,胸腺瘤合并免疫缺陷疾病 Goods syndrome,5,丙基硫氧嘧啶相关血管炎继发肺泡出血综合征,6,细支气管肺泡癌（IV期）,7,双侧肺动脉主干栓塞,8,桥脑（呼吸调整中枢和长吸中枢）,延髓（节律呼吸控制中枢）,大脑皮层（随意呼吸控制中枢）,脊髓（神经信息传导与反馈通道）,呼吸系统,循环系统,通过气血屏障进行气体交换，排出二氧化碳，进行氧合,吸入氧，排出二氧化碳,9,Mortality rates of severe respiratory failure patients durin
2、g the past years,Ann Intern Med. 2004 ;140(5):338-345,10,正压机械通气的目的,正压机械通气能够解决肺的通气和部分换气功能 能够有效改善和维持最适氧合和促进二氧化碳排出，维持生命支持的氧的需要，为疾病的恢复赢得时机 在进行正压机械通气的同时，应采取有效的措施尽量减小机械通气相关副作用,11,机械通气为正压通气，与人体正常情况下的负压呼吸相违背，因而也可产生多种与机械通气的相关并发症,出血性肺损伤,Biotrauma,气胸,氧中毒,正压机械通气的并发症,12,呼吸机所致肺损伤(Ventilator induced lung injury, V
3、ILI),Concept of VILI 机械通气患者 机械通气过程中出现肺泡的反复萎陷/复张和/或肺的过度膨胀而继发的肺实质损伤 肺的基础疾病会增加发生VILI的几率，尤其是ARDS/ALI患者,Respir Care . 2005; 50(5):649,13,History of VILI,从基础到临床,Intensive Care Med. 2006; 32:2433,14,Risk factors of VILI,Baby lung: The “baby lung” concept originated as an offspring of computed tomography ex
4、aminations which showed in most patients with ALI/ARDS that the normally aerated tissue has the dimensions of the lung of a 5- to 6-year-old child,B: baby lung,Br J Anaesth 2004;92:261-70,15,Intensive Crit Care Nurs. 2004; 20: 358365,16,Aggravating Lung Injury Factors,Decreased Lung Volumes - effect
5、s on surfactant - recruitment/ de-recruitment,17,Respir Care . 2005; 50(5):649,18,Biological markers of VILI,CHEST 2006; 130:19061914,PBEF: preB-cell colony enhancing factor sTNFR: soluble tumor necrosis factor receptor,19,Low end expiratory pressure: Atelectrauma,3,Risk factors of VILI,20,Acute Res
6、piratory Failure Classification,ALI/ARDS Non ALI/ARDS: AECOPD, Asthma, Acute cardiogenic pulmonary edema, pulmonary fibrosis, pulmonary embolism,21,Respir Care. 2001;46(2):130-148,Low tidal volume ventilation,Should Tidal Volume Be 6 mL/kg Predicted Body Weight in Virtually All Patients With Acute R
7、espiratory Failure?,22,Crit Care Med.2008; 36:296327,Low tidal volume ventilation: ALI/ARDS,23,Low tidal volume ventilation: ALI/ARDS,24,ARDSNet. N Eng J Med 2000;342:1301-1308.,Low tidal volume ventilation: ALI/ARDS,2019/4/20,25,Mortality* - Low vs. Traditional Tidal Volume,VT:6.20.8ml/kg,VT:11.80.
8、8ml/kg,P=0.007,death before discharge home and breathing without assistance,ARDSNet. N Eng J Med 2000;342:1301-1308.,Low tidal volume ventilation: ALI/ARDS,2019/4/20,26,ARDSNet. N Eng J Med 2000;342:1301-1308. Eichacker PQ, et al. Am J Respir Crit Care Med. 2002 ; 166: 1510-1514.,Day 1,0,15,20,25,30
9、,35,40,Traditional VT,Low VT,Day 3,Day 7,Plateau pressure(cmH2O),Pplat- Low vs. Traditional Tidal Volume,339,257,349,267,379,267,Low tidal volume ventilation: ALI/ARDS,2019/4/20,27,Am J Respir Crit Care Med. 2005;172: 12411245 Respir Care. 2007;52(5):556 564,Low tidal volume ventilation: ALI/ARDS,AR
10、R： absolute risk reduction.,Control： Pplat:16-26cmH2O Low VT： Pplat:10-20cmH2O,Control： Pplat:26-31cmH2O Low VT： Pplat:20-25cmH2O,28,A,B,A: Patients of the more protected,B: Patients of the Less protected,Red: hyperinflated (between 901 and 1,000 HU) Blue: normally aerated (between 501 and 900 HU) Y
11、ellow: poorly aerated (between 101 and 500 HU) Green: nonaerated (between 100 and 100 HU),Am J Respir Crit Care Med.2007;175:160166,VT: 6.0ml/kg PEEP: 9-12cmH2O,Low tidal volume ventilation: ALI/ARDS,29,Am J Respir Crit Care Med.2007;175:160166,Low tidal volume ventilation: ALI/ARDS,30,Am J Respir C
12、rit Care Med.2007;175:160166,Low tidal volume ventilation: ALI/ARDS,31,Am J Respir Crit Care Med.2007;175:160166,Low tidal volume ventilation: ALI/ARDS,32,Am J Respir Crit Care Med.2007;175:160166,小潮气通气的情况下仍有大量肺泡处于萎陷状态和继发VILI的危险性 Pplat应限制在28 cm H2O以达到肺保护的目的,Low tidal volume ventilation: ALI/ARDS,33,
13、Am J Respir Crit Care Med. 2002 ; 166(11): 1510-1514,Optimal VT,Low tidal volume ventilation: ALI/ARDS,34,Crit Care Med . 2004; 32:18171824,Low tidal volume ventilation: Non-ALI/ARDS,VILI in patients without ALI at the onset of mechanical ventilation,35,Air Trapping,Inspiration,Expiration,Volume (ml
14、),Flow (L/min),Does not return to baseline,Normal Abnormal,Low tidal volume ventilation: AECOPD & Asthma,36,潮气量（VT）或气道压力（Paw） 目标潮气量达到6-8ml/kg即可，或使平台压不超过30cmH2O和/或气道峰压不超过35-40cmH2O，以避免DPH的进一步加重和气压伤的发生 同时要配合一定的通气频率以保证基本的分钟通气量，使PaCO2值逐渐恢复到缓解期水平，以避免PaCO2下降过快而导致的碱中毒的发生 通气频率（f） 需与潮气量配合以保证基本的分钟通气量，同时注意过高频率
15、可能导致DPH加重，一般10-15次/分即可 吸气流速（flow） 一般选择较高的峰流速（40-60L/min），使吸呼比（I:E）1:2，以延长呼气时间 同时满足AECOPD患者较强的通气需求，降低呼吸功耗，并改善气体交换,Low tidal volume ventilation: AECOPD,中华急诊医学杂志 2007; 16(4): 350-357,37,Low tidal volume ventilation: Asthma,Intensive Care Med .2006; 32:501510,*:适当的镇静与肌松是必要的,38,急性心源性肺水肿(ACPE)主要表现为肺间质水肿和氧
16、弥散障碍，致氧合受阻 有创正压机械通气应采取小潮气通气策略（VT:6-8ml/kg）,使Pplat 30cmH2O 维持胸腔内压保持较为稳定的水平对ACPE有创机械通气患者至关重要，因此治疗初期适当应用镇静药物以保持人机同步是必要的,Low tidal volume ventilation: -Acute cardiogenic pulmonary edema,Lancet. 2006;367:1155-1163 Thorax. 2002; 57:192-211,39,Low tidal volume ventilation,39,Respir Care 2007;52(5):556 564.,40,对于肺气体交换功能衰竭的患者来说，为限制气道平台压，不得不将潮气量降低，允许PaCO2高于正常，即所谓的允许性高碳酸血症,允许性高
