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1、ARDS患者的肺复张北京协和医院内容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 0.211.9 0.53871 0.001Stewart60607.2 0.810
2、.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 1.234550.041ARDS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)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
3、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): 596-608小潮气量通气的问题LVt(n = 15)CVt(n = 15)P valueVt, ml411 55664 84 0.01Vt, ml/kg6 110 1 0.01setPEEP, cmH2O10 410 4n.s.PEEPtot, cmH2O11 411
4、 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: 1609-1613小潮气量通气的问题LVt(n = 15)CVt(n = 15)P valuePaO2, mmHg13
5、6 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 L. Influence of Tidal Volume on Alveolar
6、Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613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 PEEP and a Recruitment Maneuver. Am J Res
7、pir Crit Care Med 2001; 163: 1609-1613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(?)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肺复张存在的问题肺泡的开放压与闭合压PEEP不能使肺复张LIP: 仅仅是肺复张的开始Hickling KG. The pressure-volume curve is greatly modified by recruitmen
8、t. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998: 158: 194-202.Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. PressureVolume Curves and Compliance in Acute Lung Injury: Evidence of Recruitment Above the Lower Inflection Point. Am J Respir Crit Care Med 1999; 1
9、59: 1172-1178低位低位转折点转折点之上仍有肺之上仍有肺组织复张组织复张肺泡的开放压与闭合压肺泡开放压与闭合压0102030405005101520253035404550Opening pressurePaw (cmH2O)Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino M, Marini JJ, Gattinoni L. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Resp
10、ir Crit Care Med 2001: 164: 131-140.Closing pressureARDS的肺开放EditorialOpen up the lung and keep the lung openB. LachmannB. LachmannDept. of Anesthesiology, Erasmus University Rotterdam, The NetherlandsDept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands(1992) 18:319-321(1992) 18:319
11、-321RM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 Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-16
12、26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. Intensive Care Med 1999, 25: 1297-1301.肺复张的各种方法wCPAP (SI)wincremental PEEPwPCVwSigh (modified)wHFOVw俯卧位wSI改善氧合Tugrul S, Akinc
13、i 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 distress syndrome: Focusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744Sustained Inflation:45 cmH2O x 30 sSI改善氧合
14、Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Care Med 2005; 33: 181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval叹气的设置Lim CM, Koh Y, Par
15、k 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: 1255-1260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 c
16、mH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段叹气改善氧合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: 1255-1260叹气对氧合及呼
17、吸力学的影响Pelosi P, Cadringher P, Bottino N, Panigada M, Carrieri F, Riva E, Lissoni A, Gattinoni L. Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159: 872-880Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O叹气的设置Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, C
18、ereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-94Baseline:PSVSigh:BIPAPPEEPhigh =1.2 x PIPpsv or35 cmH2OTi,s = 3 5 sf = 1 bpm叹气改善呼吸力学及氧合Patroniti N, Foti G, Cort
19、inovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-94ARDS对RM的反应Villagra A, Ochagavia A, Vatus S, Murias G, Fernandez MF, Aguilar
20、 JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2002; 165: 165-170肺复张 CT的提示Henzler D, Mahnken AH, Wildberger JE, Rossaint R, Gnther RW, Kuhlen R. Multislice spiral computed tomography to determine
21、the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006; 16: 1351-1359肺复张 CT的提示Henzler D, Mahnken AH, Wildberger JE, Rossaint R, Gnther RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur R
22、adiol 2006; 16: 1351-1359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RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis.
23、Anesthesiology 2003; 99: 71-80RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, S
24、him TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recru
25、itment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic An
26、alysis. Anesthesiology 2003; 99: 71-80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肺复张存在的问题为什么肺复张作用不能持久?baseline3 min post-RM30 min post-RMPaO2/FiO2 (mmHg)139 46246 111138 39PaCO2 (mmHg)48.6 12.147.6 1346.4 12SvO2 (%)70.4 6.172.4 5.670 6.2Qs/Qt (%)30.8 5.821.5 9.729.2 7.4Crs
27、 (ml/cmH2O)34.1 12.636.9 15.135.7 13.5Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5为什么肺复张
28、作用不能持久?w肺复张的方法?SI: 50 cmH2O x 30 sw作者认为Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5RM +
29、PEEP vs. RM vs. PEEPLim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Cri
30、t Care Med 2003; 31: 411-418RM + PEEP vs. RM vs. PEEPLim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and
31、body position of the patient. Crit Care Med 2003; 31: 411-418RM + PEEPRM onlyRM后的PEEPRM后的PEEP能够稳定肺泡Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitme
32、nt. Am J Respir Crit Care Med 2003; 167: 1620-1626RM后的PEEP能够稳定肺泡RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEEP 10 cmH2OHalter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collaps
33、e and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626肺泡稳定能够改善PaO2McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic ulmonary vasoconstriction. Crit Care med 2002; 30: 1315-1321RM后的PEEPLim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR,
34、 Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377RM + PEEP vs. PEEP onlyLim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models o
35、f acute lung injury. Crit Care Med 2004; 32: 2371-2377RM + PEEPPEEP onlyPEEP的设置wRM之后通常将PEEP设置在能够维持PaO2 (防止塌陷)的水平w最初将PEEP设置为20 cmH2Ow然后将FiO2减小到最低水平维持SpO2 90 95%w每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降PEEP的设置w氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEPw一旦确认, 则需重复肺复张操作, 然后把PEEP和FiO2重新设置在上述水平对于多数ARDS患者, PEEP介于15 20 cmH2O之间某些患者
36、 20 cmH2OPEEP的设置w如果将PEEP设置于20 cmH2O后, 仍发现PaO2/FiO2显著下降按照最初的PEEP设置25 cmH2O重复肺复张然后按照上述方法调节FiO2和PEEPPEEP的设置w将PEEP从不必要的高水平逐渐降低w不要将PEEP由低水平增加到高水平如同P-V曲线所示, 根据设置方法不同, 同样水平的PEEP所维持的肺容积不同如果在肺泡塌陷后设置PEEP (增加PEEP), 则所设置的PEEP水平可以使肺容积减少, PaO2降低PEEP/FiO2的调整推荐意见w降低PEEP之前应当首先降低FiO2, 以避免肺泡塌陷w一般情况下FiO2应当减低到 5 min)时w如
37、果没有观察到氧合下降, 则需要每日进行一次或两次肺复张未知总结w肺复张是肺保护性通气策略的重要组成w开放肺并维持肺开放是其理论基础应用气道高压使塌陷肺泡开放应用足够的PEEP维持肺泡开放w肺复张对循环的影响w肺复张尚未解决的问题压力时间频率适应症PEEP能否使肺复张?wPEEP能够防止肺泡塌陷(derecruitment)w低水平的PEEP只能使很少的肺复张对于ARDS, 将压力持续维持在常用的PEEP水平( 300 mmHgThe P-V CurvewOn the inflation limb of the curvewlower inflection point (Pflex)a regi
38、on of changing slope in early inflation where lung recruitment beginsthe minimal PEEP necessaryto prevent partial derecruitment of the lung during exhalationThe P-V CurvewOn the expiratory limbwthe point of maximum curvature (PMCEX)the area where the maximum volume change/unit pressure occurs during
39、 exhalationthe maximum PEEP requiredto prevent derecruitmentThe P-V Curvewthese two “points” identify the range of PEEP needed in ARDSPflex= the minimumPMCEX= the maximumwIdeally, a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEPRM后的PEEP影响P
40、aO2Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377肺泡开放压与闭合压0102030405005101520253035404550Opening pressureClosing pressurePaw (cmH2O)Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino 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.
