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1、邱海波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ARDS肺复张的实施肺复张的实施科学与艺术的困惑内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM ARDSnet: 小潮气量通气小潮气量通气Low Tidal Low Tidal VolumesVolumesTraditional Tidal Traditional Tidal VolumesVolumesP-P-va
2、luevalueDeath before discharge home and Death before discharge home and breathing without assistant (%)breathing without assistant (%)31.039.80.007Breathing without assistance by Breathing without assistance by days (%)days (%)65.755.00.001NO of ventilator free days NO of ventilator free days Day1-2
3、8Day1-28121110110.007BoratraumaBoratrauma, Day1-28(%), Day1-28(%)10110.43NO of days without failure of NO of days without failure of nonpulmonarynonpulmonary organs or systems organs or systems Day1-28Day1-28151112110.006ARDS Net. N Engl J Med. 2000 May 4;342(18):1301-8.Low tidal volume: more alv co
4、llapse小小Vt不能复张塌陷肺泡，加重低氧血症不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略实施肺保护性通气策略至少至少1525%患者需提高患者需提高FiO2邱海波, 刘大为, 陈德昌等. 中华麻醉学杂志, 1998, 18: 202-205Collapsed airwayV1V2PressureVolumeV1V1 + V2Opening pressureNormalARDSPEEP adjustmentLIPLIP：塌陷肺泡开始复张的压力塌陷肺泡开始复张的压力塌陷肺泡开始复张的压力塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力不是全部塌陷肺泡复张的压力不是全部塌陷肺泡复张的压力
5、不是全部塌陷肺泡复张的压力PEEP not enough: more alv keep collapse30 kg PigPost LavagePCVPaw 13 cmH2O PEEP 5 cmH2OExperimental study-Pig with ARDS许红阳，邱海波许红阳，邱海波. ARDS绵羊肺复张容积测定方法的比较绵羊肺复张容积测定方法的比较. 中国危重病急救医学，中国危重病急救医学， 2004, 16: 413.邱海波邱海波. PEEP对对ARDS肺复张容积及氧合影响的临床研究肺复张容积及氧合影响的临床研究. 中国危重病急救医学，中国危重病急救医学，2004, 16: 399
6、.Clinical Trial11 ARDS pats内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM A. Hypoxamia B. Shear forcesC. Surfactants inactivate D. Biotrauma and MODSPathophysiology Consolidation and alv collapseA .低氧血症低氧血症肺泡塌陷：肺泡
7、塌陷：ARDS重力依赖区重力依赖区 炎症或不张区炎症或不张区生理性低氧缩血管反应：障碍生理性低氧缩血管反应：障碍How Does Excessive Mechanical Stress Inflame the Lung?“Shear”Verbrugge et al. Crit Care Med 1999;27：779Ventilator-associated lung injuryPurine: a marker of ATP breakdown and VILI42 SD ratsPCV 6minPCV Pre/PEEPBALF purine and proteinLachmannLachm
8、ann. ICM, 1994; 20:6-11. ICM, 1994; 20:6-11Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way1mg surfactant = inhibitory effect of 1mg plasma proteinC. Surfactant 灭活灭活 Surfactant move away When lung regions collapse at end expiration, surfactant molecules move away from the al
9、v surface toward terminal bronchioles and cannot be reused during next inflationRouby JJ. Am J Respir Crit Care Med, 2001, 165: 1182 D. 预防预防Biotrauma和和MODSMarini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two Crit Care Med. 2004 Jan;32(1):250-5.“St
10、retch”“Shear”Airway Trauma内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM 俯卧位通气的病理生理特征俯卧位通气的病理生理特征改善通气过程改善通气过程 胸膜腔压力梯度胸膜腔压力梯度 顺应性顺应性胸壁胸壁促进分泌物的清除促进分泌物的清除ClosingClosingpressurepressureClosing Closing pressurepressure
11、Time course of Prone on PaO2/FiO2 between ARDSp vs ARDSexp Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp 黄英姿, 邱海波. 肺内外源性ARDS实施俯卧位通气时间的选择.中华内科杂志2004, 43(12):883-887内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathi
12、ngHigh VT and sighRM 保留自主呼吸的优点保留自主呼吸的优点内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighRM Paw cmH2O %Opening and Closing Pressures0510152025303540455001020304050 Opening pressureClosing pressure5 patients,ALI / ARDSFr
13、om Crotti et alAJRCCM 2001.Some units cantbe kept open by any reasonable PEEP!Amato: CT + PV CurveHeartSpPVLIPUIPInsp recruitLarger Vt/Sigh: Pressure must be high enoughEven up to UIP 内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathingH
14、igh VT and sighHigh PEEPRM 许红阳，邱海波许红阳，邱海波. ARDS绵羊肺复张容积测定方法的比较绵羊肺复张容积测定方法的比较. 中国危重病急救医学，中国危重病急救医学， 2004, 16: 413.邱海波邱海波. PEEP对对ARDS肺复张容积及氧合影响的临床研究肺复张容积及氧合影响的临床研究. 中国危重病急救医学，中国危重病急救医学，2004, 16: 399.Clinical Trial11 ARDS patsRecruitment is Time-Dependent 40 SECONDS内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解
15、决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM Recruitment mannuversBasic PrinciplesMethods for RecruitmentExperimental Studies and Clinical TrialsEfficacyHazards1. 控制性肺膨胀控制性肺膨胀(SI)法法2. PEEP递增法递增法3. 压力控制压力控制(PCV)法法Methods for Recruitment1.CPA
16、P模式模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续将吸气保持键按住，持续20- 40s控制性肺膨胀控制性肺膨胀(SI)法法Multiple Maneuvers May Be Needed For Optimum RM EffectFujino et al, Crit Care Med 2001; 29(8):1579-1586Post-RM PEEP Determines PaO2Averaged data from three modelsRMS
17、-C Lim, CCM 2004Transient BenefitPost-RM-PEEP肺开放效应持续时间的决定因素肺开放效应持续时间的决定因素CCM, 2004, 32: 2371-2377l28 mixed-breed pigslModels of ARDS:OAVILIPneumonia(PNM)lRMSIIncreased PEEPPCV肺开放后的肺开放后的PEEP选择选择-PaO2/FiO21. RM后后 PEEP: 20cmH2O2. PEEP递减递减: 2cmH2O/5min3. PEEP阈值阈值: PaO2/FiO25%4. PEEP: PEEP阈值阈值 +2cmH2OBAS
18、ELINE VENTILATIONTidal volume=6ml/kgPEEP=5cmH2OModify PEEP to get a1.10.9recruiting maneuverMeasure1.10.9Leave PEEP unchangedstress index 0.91.1Decrease PEEP until 1.1stress index 0.9Crit Care Med, 2004, 32: 1018-1027肺开放后的肺开放后的PEEP选择选择- Stress indexImplicationsRM 的有效性的有效性ALI的病因的病因 (direct vs in dire
19、ct)Post RM PEEPMethod in certain settingsRM hazards are greatest and effectiveness least in pneumonia-caused acute lung injuryPCV may be better tolerated than SIRecommendationsUse PCV in preference to SISafer, “multiple”, effective, maintains ventilation, simpleMonitor hemodynamics during recruiting interval.以下情况需重复作以下情况需重复作RM: 体位改变体位改变, 管路断开管路断开, 呼吸呼吸力学特征或力学特征或PaO2明显恶化明显恶化对于顽固性难治性对于顽固性难治性ARDS患者患者, 可考虑反复可考虑反复RM和和更高的压力更高的压力Employ Prone Position and/or PEEP to consolidate RM benefit.
