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1、ARDS患者的肺复张北京协和医院杜斌2021/7/19 星期一内容w小潮气量通气的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题2021/7/19 星期一内容w小潮气量通气的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题2021/7/19 星期一ARDS的肺保护性通气策略患者数患者数潮气量潮气量病死率病死率作者作者小潮气量小潮气量对照对照小潮气量小潮气量对照对照小潮气量小潮气量对照对照P值值Amato29246.1
2、0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.0412021/7/19 星期一ARDS的肺保护性通气策略w小潮气量(6 ml/kg IBW)避免过度膨胀造成的容积伤(volutrauma)w足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma)20
3、21/7/19 星期一肺泡塌陷与复张造成的剪切力F=PL x(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积V:复张后容积如果:PL=30 cmH2O,V0/V=1/10则:F=140 cmH2OMead J,Takishima T,Leith D.Stress distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):596-6082021/7/19 星期一小潮气量通气的问题LVt(n=15)CVt(n=15)P valueVt,ml411 55664 84 0.01Vt,ml/kg6
4、 110 1 0.01setPEEP,cmH2O10 410 4n.s.PEEPtot,cmH2O11 411 4n.s.Pplat,cmH2O23 830 10 0.01Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-16132021/7
5、/19 星期一小潮气量通气的问题LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,mmHg165 84183 83n.s.SaO2,%94.8 5.097.6 2.1 0.05PaCO2,mmHg60 3538 21 0.001pH7.21 0.17.36 0.1 0.001SBP,mmHg125 25121 20n.s.DBP,mmHg60 960 10n.s.HR,bpm101 1593 15n.s.Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard
6、L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-16132021/7/19 星期一小潮气量通气的问题Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of
7、 PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-16132021/7/19 星期一受损的肺组织如何复张w俯卧位w足够的PEEPw足够的潮气量和(或)叹气?w肺复张手法肺复张手法w减少水肿(?)w最低可接受的FiO2(?)w自主呼吸(?)2021/7/19 星期一内容w小潮气量通气的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题2021/7/19 星期一肺泡的开放压与闭合压2021/7/19 星期一PEEP不能
8、使肺复张2021/7/19 星期一LIP:仅仅是肺复张的开始Hickling KG.The pressure-volume curve is greatly modified by recruitment.A mathematical model of ARDS lungs.Am J Respir Crit Care Med 1998:158:194-202.2021/7/19 星期一Jonson B,Richard JC,Straus C,Mancebo J,Lemaire F,Brochard L.PressureVolume Curves and Compliance in Acute
9、Lung Injury:Evidence of Recruitment Above the Lower Inflection Point.Am J Respir Crit Care Med 1999;159:1172-1178低位转折点低位转折点之上仍有肺之上仍有肺组织复张组织复张2021/7/19 星期一肺泡的开放压与闭合压2021/7/19 星期一肺泡开放压与闭合压0102030405005101520253035404550Opening pressurePaw(cmH2O)Crotti S,Mascheroni D,Caironi P,Pelosi P,Ronzoni G,Mondin
10、o M,Marini JJ,Gattinoni L.Recruitment and derecruitment during acute respiratory failure:a clinical study.Am J Respir Crit Care Med 2001:164:131-140.Closing pressure2021/7/19 星期一ARDS的肺开放EditorialOpen up the lung and keep the lung openB.LachmannB.LachmannDept.of Anesthesiology,Erasmus University Rott
11、erdam,The NetherlandsDept.of Anesthesiology,Erasmus University Rotterdam,The Netherlands(1992)18:319-321(1992)18:319-3212021/7/19 星期一RM能够使肺开放RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minHalter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitm
12、ent Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-16262021/7/19 星期一肺复张能够改善ARDS氧合Lapinsky SE,Aubin M,Mehta S,Boiteau P,Slutsky AS:Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.I
13、ntensive Care Med 1999,25:1297-1301.2021/7/19 星期一肺复张的各种方法wCPAP(SI)wincremental PEEPwPCVwSigh(modified)wHFOVw俯卧位w2021/7/19 星期一SI改善氧合Tugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L,Akpir K,Cakar N.Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory di
14、stress syndrome:Focusing on pulmonary and extrapulmonary forms.Crit Care Med 2003;31:738-744Sustained Inflation:45 cmH2O x 30 s2021/7/19 星期一SI改善氧合Frank JA,McAuley DF,Gutierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and
15、 lung endothelial injury.Crit Care Med 2005;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval2021/7/19 星期一叹气的设置Lim CM,Koh Y,Park W,Chin JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respirat
16、ory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260充气阶段,每30秒PEEP增加5 cmH2OVt减少2 ml/kg前2次呼吸除外直至Vt 2 ml/kg,PEEP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段2021/7/19 星期一叹气改善氧合Lim CM,Koh Y,Park W,Chin JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-12602021/7/19 星期一叹气对氧合及呼吸力学的影响Pelosi P,Cadringher P,Bottino N,Panigada M,Car
