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1、呼吸机治疗的肺保护策略,浙江大学医学院附属儿童医院 施丽萍,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,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（hig
2、h airway pressure ） 不张性损伤 Atelectotrauma（alveolar collapse and re-expansion） 生物性损伤 Biotrauma（increased inflammation ）,肺 损 伤 病 理,alveolar structural damage pulmonary edema、 inflammation、 fibrosis surfactant dysfunction other organ dysfunction exacerbate the disturbance of lung development Semin Neona
3、tol. 2002 Oct;7(5):353-60.,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 liq
4、uid ventilation improve 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.,Can mechanical ventilation strategies reduce chronic lung disease? continuous positive airw
5、ay pressure permissive hypercapnia patient-triggered ventilation volume-targeted ventilation proportional assist ventilation high-frequency ventilation Semin Neonatol. 2003 Dec;8(6):441-8,小潮气量和呼气末正压 lower tidal volume and PEEP,Ventilation with lower tidal volumes versus traditional tidal volumes in
6、adults for ALI and ARDS 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 Databas
7、e Syst Rev. 2004;(2):CD003844,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 8.33.2cmH2O higher-PEEP group 13.23.5cmH2O (P0.001). tidal-volume 6ml/kg end-inspiratory plateau-press
8、ure30cmH2O The rates of death 24.9 % 27.5 % (p=0.48) From day 1 to day 28, breathing was unassisted 14.510.4 days 13.810.6 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.,Increasing inspiratory time exacerbates ventila
9、tor-induced lung injury during high-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, Pa
10、O2 /FiO2 ratio, wet/dry lung weight, and dry lung/body weight as 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 .0001) increased Light microscopy revealed evidence of intra-alveolar edema an
11、d hemorrhage in the iT = 1.0 and iT = 1.5 animals but not the LoP and iT = 0.5 animals. Crit Care Med. 2002 Oct;30(10):2295-9.,新生儿呼吸窘迫综合征 呼吸机治疗的肺保护性策略研究,施丽萍 孙眉月 杜立中 中华儿科杂志2003,本项目研究的目的 通过肺力学参数的监测（PM）指导呼吸机参数的调节来降低呼吸机相关性肺损伤的发生 探讨新生儿RDS最合适的呼吸机参数 允许性高碳酸血症对新生儿的影响,非肺力学监测组（NPM）：19941997年, RDS 50例，作为对照组 肺力学
12、监测组(PM): 19982001年，RDS 60例，作为观察组 肺力学监测仪(Bicore CP100）,两组胎龄、体重、病情严重程度比较,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8595%，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,观察组（PM组）： 1、肺力学监测仪(Bicore CP100)每812h 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
13、管插管气漏率小于20% 5、每监测一次持续0.51h至数据稳定后记录监测的数据,NPM 组和PM组的评估指标 1. 疾病极期，即生后2448h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=FiO2MAP/PaO2）和心率、血压 4. 呼吸机应用时间，用氧时间，住院天数，病死率，PDA，IVH和呼吸机相关性肺损伤的发生率。,两组呼吸机参数比较,两组血气监测结果比较,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,结论
14、,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 0.30.5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。,允许性高碳酸血症 Permissive hypercapnia,Permissive hypercapnia-role in protective lung ventilatory strategies First, we consider the evidence that protective lung ve
15、ntilatory 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 Third, we consider whether direct elevation of CO2, in
16、the absence of protective ventilation, is beneficial or deleterious Fourth, we address the current evidence regarding the buffering of hypercapnic acidosis,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 xan
