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1、ARDS与肺血管通透性,杨从山 东南大学附属中大医院ICU 东南大学急诊与危重病医学研究所,内容概要,ARDS诊断的困惑 肺血管通透性相关指标的测定 肺血管通透性指标对ARDS诊治的临床评估,pH 7.359 PO2 76.4 mmHg (FiO2 50%) CVP 15mmHg Lac 6.5mmol/L,ARDS/ALI诊断,急性呼吸窘迫综合征(ARDS)： 急性起病；PaO2/FiO2200 mmHg(不管PEEP水平)；正位X线胸片显示双肺均有斑片状阴影；肺动脉嵌顿压18 mmHg，或无左心房压力增高的临床证据。 急性肺损伤(ALI)： 如PaO2/FiO2300 mmHg且满足上述其
2、它标准 Bernard GR, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med, 1994, 149:818,PAWP18 mmHg is common of ARDS,N Engl J Med， 2006,354:2213-24,29 pats ：PAWP 18 mmHg 97% pats with PAWP 18 mm
3、Hg had a normal or elevated cardiac index.,1001 patients, 513 assigned to PAC, 488 to CVC,CVP/PAWP增高不一定就是左心衰,高水平PEEP或气道平台压 针对休克的早期大量液体复苏 感染对心肌的抑制 腹内压的增高 肺血管阻力的增加(如COPD) 测量不当,ARDS与心源性肺水肿的鉴别诊断,对于有基础心脏病史，合并感染、休克时鉴别诊断非常困难,肺水肿机制,Cardiogenic pulmonary edema(CPE),ALI/ARDS,The definition of ALI/ARDS should
4、include the functional feature of lung injury, i.e. an increased pulmonary microvascular permeability.,Normal lung,N Engl J Med, 2005, 353:2788-96,Starling定律与肺水肿,Starling公式 Qf=K(Pmv-Ppmv)-(mv-Pmv) P=(Pmv-Ppmv)-(mv-Pmv) 注：Qf 水分转移量； K 毛细血管滤过系数 Pmv 毛细血管内压；Ppmv 肺间质压 蛋白质通过屏障系数 mv 毛细血管内胶体渗透压 Pmv 肺间质胶体渗透压
5、P 毛细血管内外静水压与胶体渗透压差,肺泡毛细血管膜,ARDS 液体和蛋白,肺血管通透性(PVR)的测定,伊文思蓝(EBD)染料 荧光比色法 用于动物实验，它是经静脉注射伊文思蓝染料，30 min后，开胸取出肺，用甲酸胺提取伊文蓝并用荧光光度计定量测定伊文思蓝含量，并通过伊文蓝甲酞胺溶液的荧光光谱和标准曲线来计算伊文思蓝含量来反映PVP,肺血管通透性(PVR)的测定,双核素体内标记技术 (67Ga-labeled transferrin and 99mTc-labeled red blood cells) Intensive Care Med, 2006，32(9): 1315-21 BALF
6、蛋白含量(/血浆蛋白) PiCCO,Central Venous Catheter,Arterial thermodilution catheter,Injectate temperature sensor cable,PCCI,AP,13.03 16.28 TB37.0,AP 140 117 92 (CVP) 5 SVRI 2762 PC CI 3.24 HR 78 SVI 42 SVV 5% dPmx 1140 (GEDI) 625,Temperature interface cable,Pressure cable,PiCCO反映肺水肿及通透性指标,Extravascular Lung
7、Water: EVLW Pulmonary Vascular Permeability Index: PVPI (EVLW/PBV),Pulmonary Vascular Permeability Index (PVPI),Hydrostatic pulmonary edema,Permeability pulmonary edema,PVPI =,PBV,EVLW,normal,elevated,elevated,PVPI =,PBV,EVLW,elevated,elevated,normal,PVPI =,PBV,EVLW,normal,normal,normal,PBV,EVLW,PBV
8、,EVLW,PBV,EVLW,Normal Lung,EVLW/ITBV Katzenelson P, et al. Crit Care Med, 2004, 32(7):1550-4 Groeneveld AB . Intensive Care Med,2006, 32(9):1315-21 EVLWi/GEDVi,Intensive Care Med,2000,26:180-187,Increased pulmonary capillary permeability and extravascular lung water after major vascular surgery,Sixt
9、een mechanically ventilated patients without heart failure were studied, within 3 h after major abdominal surgery. Extravascular lung water, intrathoracic, global end-diastolic and pulmonary blood volumes, 67Ga-transferrin pulmonary leak index and ventilatory and radiographic variables The pulmonary
10、 leak index was elevated in 11 patients and a supranormal extravascular lung water was associated with a high pulmonary leak index,European Journal of Anaesthesiology 2006, 23: 3641,European Journal of Anaesthesiology 2006, 23: 3641,Accurate characterization of extravascular lung water in ARDS,Desig
11、n: Prospective, observational cohort study Setting: Medical and surgical ICUs at two academic hospitals,Crit Care Med 2008; 36:18031809,Indexing EVLW to PBW or AdjBW reduces the number of ARDS patients with normal EVLW,Crit Care Med 2008; 36:18031809,Design: Retrospective review of cases Patients: 4
12、8 critically ill pats ventilated for ARF Bilateral infiltrates on chest radiograph PaO2/FiO2 300 mm Hg EVLWI 12 ml/kg,Intervention: Pulmonary permeability：PVPI and EVLWi/GEDVi Cause of pulmonary edema：determined by 3 experts Measurements and results:,EVLWi/GEDVi 3.01021.2102 1.41020.4102*,PVPI can b
13、e helpful for distinguishing hydrostatic pulmonary edema and ARDS,Cut-off value = 3 Se=85% Sp=100%,ROC-PVPI: 0.920.04,Underlying etiologies of ARDSp and ARDSexp,Eur Respir J, 2003, 22: Suppl.42, 48s56s,Do the data obtained by PiCCO system enable to differentiate direct/indirect ALI/ARDS?,Ten patient
14、s, four with direct ALI/ARDS (two aspiration and two pneumonia) and six with indirect ALI/ARDS (sepsis induced). All patients were mechanically ventilated. One hundred and twenty measurements were available for analysis,Critical Care 2006, 10(Suppl 1):P326,PI(permeability index) =EVLW/ITBV,Clinical
15、investigation of EVLWI and PVPI in diagnosis of lung edema,Objective: To study the clinical value of EVLWI and PVPI in the diagnosis and continuous monitoring of lung edema. Methods: To retrospectively analyze PiCCO monitoring in 40 patients with lung edema(ARDS group, 25 cases; ACPE group, 15 cases). PVPI was calculated at 0, 24, and 72 hours after tracheal intubation.,Zhongguo Wei Zhong Bing Ji Jiu Yi Xue, 2008; 20(2): 111-4,Results: (1) PVPI in ARDS group was significantly higher than that in ACPE patients (P0.01) at 0 hour after tracheal intubatton, significant correl
