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1、ARDS呼吸功能监测呼吸功能监测与通气与通气(tng q)策略抉择策略抉择 邱海波邱海波(hi b)(hi b) 刘玲刘玲东南大学附属中大医院东南大学附属中大医院ICUICU第一页，共六十六页。ARDS呼吸功能监测与通气策略抉择内容提要(ni rn t yo) Physiopathologic course of ARDS and the dilemma in Mechanical ventilationOxygenation and ShuntRespiratory mechanicsCompliance (Elastance) and ResistanceStress indexEsoph
2、ageal PressureVd / Vt第二页，共六十六页。ARDS呼吸功能监测与通气策略抉择Therapeutic target of MV in ARDSBecome evident over the past two decadesMV itself can augment or cause pulmonary damageShift of therapeutic target of MV in ARDS 1970sNormal gas exchange1980-1990Protection of thelung from VILIN Engl J Med 1972;287:799-8
3、06.Lancet 1980;2:292-4.Am Rev Respir Dis 1987; 135:312-5.Intensive Care Med 1990;16:372-7.第三页，共六十六页。ARDS呼吸功能监测与通气策略抉择The lung-protection strategyLung recruitment-open the lung Use of higher PEEP-keep lung open (avoid collapse/recruitment) Low tidal volumes (Pplat 30cmH2O)- avoid overdistension Preve
4、nt regional and global stress and strain on the lung parenchymaAm J Respir Crit Care Med. 2022, 178: 346355.第四页，共六十六页。ARDS呼吸功能监测与通气策略抉择Same MV strategy sutiable for every ARDS pat ?May be No.Physiological effects of RM and PEEP associated with patients individual characteristics Inflamattion spreadi
5、ng from core diseasePercentage of potentially recruitable lungDifferent stages of ARDSN Engl J Med. 2006, 354; 1775-86 .JAMA. 1994, 271, 1772-79. 第五页，共六十六页。ARDS呼吸功能监测与通气策略抉择Inflamattion spreading from core diseasePossible modelLowerHigherHigher severity mortalityCore disease 24%Inflammation spreadin
6、g 1Lower severity mortality第六页，共六十六页。ARDS呼吸功能监测与通气策略抉择Potentially recruitable lungLower percentage of potentially recruitable lungHigher percentage of potentially recruitable lungN Engl J Med. 2006, 354; 1775-86第七页，共六十六页。ARDS呼吸功能监测与通气策略抉择Mortality in Relation to the Percentage of potentially Recruit
7、able Lung (Panel A) Pulmonary anatomy according to CT Findings in patients with Healthy Lungs, Patients with Unilateral Pneumonia,and Patients with Acute Lung Injury or ARDS (Panel B).N Engl J Med. 2006, 354; 1775-86第八页，共六十六页。ARDS呼吸功能监测与通气策略抉择Lower VS Higher percentage of potentially recruitable lun
8、gHigher percentage of potentially recruitable lungGreater total lung weights Poorer oxygenation Respiratory-system compliance Higher levels of dead spaceHigher rates of deathN Engl J Med. 2006, 354; 1775-86第九页，共六十六页。ARDS呼吸功能监测与通气策略抉择Different stages of ARDSPathologic stagesEarly exudative phase edem
9、a, bleeding, atelactasis, PMN and plt embolus, and microembolusProliferative phase proliferation of tive II epithelium cellFibrotic phase Proliferation of fibroblastHeterogeneity ：location, time courseVersatility : Pathologic changes第十页，共六十六页。ARDS呼吸功能监测与通气策略抉择Difficult to assessGattinoni L (1994)Ear
10、ly ARDS (MV up to 1 week): prevalent edemaIntermediate ARDS (between 12 weeks): a transition period during edema begins to be reabsorbed and proliferative processes begin to occurLate ARDS (more than 2 weeks): fibrous processesClinical stages of ARDSJAMA. 1994, 271, 1772-79. 第十一页，共六十六页。ARDS呼吸功能监测与通气
11、策略抉择Early VS Late ARDS 84 sever ARDS for underwent extracoresl support (1979-1992)JAMA. 1994, 271, 1772-79. 第十二页，共六十六页。ARDS呼吸功能监测与通气策略抉择Early VS Late ARDS JAMA. 1994, 271, 1772-79. 第十三页，共六十六页。ARDS呼吸功能监测与通气策略抉择CT scan, early VS late ARDS Gattinoni L Type 1Early ARDSWeek 1Intermediate ARDSWeek 2Late A
12、RDSWeek 7d)RM: PCV 2min at PIP 50cmH2O/PEEP PUIPAm J Respir Crit Care Med, 2002, 165:165170第十六页，共六十六页。ARDS呼吸功能监测与通气策略抉择Summary-Early and Late ARDSEarly ARDS is characterized by edema and intact lung structureRecruitability is function of the extent of edemaWith time lung structure is altered associa
13、ted with increased dead space and PCO2第十七页，共六十六页。ARDS呼吸功能监测与通气策略抉择Prognosis of ARDSInflammation spreadingPotentially recruitable lungLowerLower severity mortalityRM and higher PEEP may be harmfulHigherHigher severity mortalityRM and higher PEEP are neededCore diseaseAggravated Improved Early ARDSLat
14、e ARDSEffect of RM and higher PEEP?第十八页，共六十六页。ARDS呼吸功能监测与通气策略抉择QuestionsHow to know who will get benefit from RM and PEEPHow to set a suitable PEEP in ARDS patientCT scan may be one choiceBut not at bed sidePaO2 (P/F) may be another choiceBut our goal is not better gas exchangeHow about bedside resp
15、iratory mechanical monitoring Reduce VILI第十九页，共六十六页。ARDS呼吸功能监测与通气策略抉择内容提要(ni rn t yo) Physiopathologic course of ARDS and the dilemma in Mechanical ventilationOxygenation and ShuntRespiratory mechanicsCompliance (Elastance) and ResistanceStress indexEsophageal PressureVd / Vt第二十页，共六十六页。ARDS呼吸功能监测与通气
16、策略抉择Shunt is the fundamental cause of hypoxemia in ARDSRM and PEEPImprove oxygenation(P/F)Reduced Shunt Am J Respir Crit Care Med, 2001, 164:1701-1711第二十一页，共六十六页。ARDS呼吸功能监测与通气策略抉择肺泡(fipo)完全复张的临床标准-P/F1.PaO2/FiO2400 PaO2 + PaCO2 400 2.PaO2/FiO2 降低(jingd)5%第二十二页，共六十六页。ARDS呼吸功能监测与通气策略抉择lPaO2 + PaCO2 40
17、0 (at 100% oxygen): 维持肺开放(kifng)的可靠指标l到达PaO2 + PaCO2 400时： CT显示只有5% 的肺泡塌陷l PaO2 + PaCO2 400对塌陷肺泡的预测： ROC曲线下面积 0.943Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006肺泡完全复张的临床(ln chun)标准-CT第二十三页，共六十六页。ARDS呼吸功能监测与通气策略抉择肺泡完全(wnqun)复张的临床标准-CTBorges JB, , Amato MBP.Am J Respir Crit Ca
18、re Med Vol 174. pp 111, 2006l动脉氧合与塌陷肺组织重量(zhngling)明显呈负相关 (R = 0.91)第二十四页，共六十六页。ARDS呼吸功能监测与通气策略抉择Methods of Qs/Qt calculationQc: 经肺毛细血管回心的血量(已气体(qt)交换)Qs: 经短路回心的血量(未经体交换)Qt= Qc+Qs 总回心血量计算公式：太复杂但比较准确正常肺Qs/Qt 4-5%ARDS Qs/Qt常30%第二十五页，共六十六页。ARDS呼吸功能监测与通气策略抉择简化简化(jinhu)公式公式吸空气(kngq)时：吸纯氧时：应用条件吸纯氧10-20min
19、(最大限度(xind)纠正相对分流)PaO2150-200mmHg第二十六页，共六十六页。ARDS呼吸功能监测与通气策略抉择P/F and Qs/Qt change with lung recruitment Case 63 Y woman Guillain-Barre Syndrome, Pneumonia, ALIPEEPPEEP第二十七页，共六十六页。ARDS呼吸功能监测与通气策略抉择内容提要(ni rn t yo)Physiopathologic course of ARDS and the dilemma in Mechanical ventilationOxygenation an
20、d ShuntRespiratory mechanicsCompliance (Elastance) and ResistanceStress indexEsophageal PressureVd / Vt第二十八页，共六十六页。ARDS呼吸功能监测与通气策略抉择Respiratory mechanics -Compliance (Elastance) and Resistance第二十九页，共六十六页。ARDS呼吸功能监测与通气策略抉择Concepts and FormulaE=P / VolC= Vol / PCst=Vt / (Pplat-PEEPtot)Cdyn=Vt / (PIP-P
21、EEPtot)R= P / VC= 1 / E第三十页，共六十六页。ARDS呼吸功能监测与通气策略抉择Compliance and Resistance changes in ARDSCompliance decreased significantlyResistance may increase slightlyCompliance decreasedDue to alveolar collapse Resistance increased第三十一页，共六十六页。ARDS呼吸功能监测与通气策略抉择Compliance decreasedP-V curve Reduced range of v
22、olume excursion: Low complianceFlattening at low and high volumes: Lower and upper inflection pointsVolumePressureNORMALARDS顺应性曲线明显(mngxin)向右下移位第三十二页，共六十六页。ARDS呼吸功能监测与通气策略抉择six pigletsvenous infusion of oleic acidPEEP titration (from 26 to 0 cmH2Owith a Vt of 6 to 7 ml/kg) performed, following a RMC
23、ritical Care 2007, 11: R86.第三十三页，共六十六页。ARDS呼吸功能监测与通气策略抉择Ronitoring respiratory mechanics during a PEEP titration procedure may be a useful adjunct to optimize lung aerationCritical Care 2007, 11: R86.PEEP at min Ers corresponded to the greatest amount of normally aerated areas第三十四页，共六十六页。ARDS呼吸功能监测与
24、通气策略抉择%E2: Percentage of volume dependent elastancePercentage of non-linearity of the elastance of the Ers%E230%: tidal overdistensionIntensive Care Med. 2022, 34:22912299In non-injured animals第三十五页，共六十六页。ARDS呼吸功能监测与通气策略抉择Stress index and %E2 are useful in non-injured lungs onlyErs can be superior t
25、o the stress index and %E2 to guide PEEP titration in focal loss of lung aerationErs seems to be useful for guiding PEEP titration in non-injured and injured lungs第三十六页，共六十六页。ARDS呼吸功能监测与通气策略抉择Female pigsLung lavageCrs: computed using the occlusion techniqueRM: 45 cmH2O for 40 sPeep10 cmH2OPro and Po
26、st RM (CT scan)Gas exchange Lung mechanics Amount and the changes in aerated andCritical Care. 2005, 9: R471-R482第三十七页，共六十六页。ARDS呼吸功能监测与通气策略抉择Vpoor: volume of poorly aerated lung; Vhap: volume of hyperinflated lungPmcd: pressure of maximum compliance decrease on inflation curve 第三十八页，共六十六页。ARDS呼吸功能监
27、测与通气策略抉择Crs may be useful for guiding PEEP titrationChanges in aerated and nonaerated lung volumes were adequately represented by Crs Not by changes in oxygenation or shuntCritical Care. 2005, 9: R471-R482第三十九页，共六十六页。ARDS呼吸功能监测与通气策略抉择Case 79 y, man, 75 kg Pneumonia, ARDS, APACH II 27Sedation and ner
28、ve block Baiseline: VcV, Vt 500ml, PEEP 6cmH2O, RR 20 b/min, P/F Crs 56, Pplat 16cm H2O, PaCO2 35mmHg, P/F 121RM: SI 40cmH2O30s (P/F400 mm Hg or change1-b=1-b1RM again set the PEEP in b=1第四十七页，共六十六页。ARDS呼吸功能监测与通气策略抉择Case64 y, man, 70 kg Multiple trauma, ARDSBaiseline MV set: SIMV+PS (autoflow), Vt 4
29、20ml, PEEP10cmH2O, FiO2 50%, RR 20 b/minPplat 26cm H2O, PaCO2 47mmHg, P/F 155Change to VCV: VT 420ml, RR 20 b/minRM: SI 40cmH2O30s (P/F400 or change134151316122第四十九页，共六十六页。ARDS呼吸功能监测与通气策略抉择Respiratory mechanics -MV Guided by Esophageal Pressure第五十页，共六十六页。ARDS呼吸功能监测与通气策略抉择MV Guided by Esophageal Pres
30、surein ALIEsophageal pressurepleuralpressure pressureTranspulmonary pressure= pulmonary alveolar pressure -Esophageal pressure61 ARDS pats MVControl or esophagealpressureguided groupPrimary end pointimprovement in oxygenationSecondary end points:Respiratory-system compliancePatient outcomesN Engl J
31、Med. 2022, 359; 2095第五十一页，共六十六页。ARDS呼吸功能监测与通气策略抉择第五十二页，共六十六页。ARDS呼吸功能监测与通气策略抉择第五十三页，共六十六页。ARDS呼吸功能监测与通气策略抉择第五十四页，共六十六页。ARDS呼吸功能监测与通气策略抉择As compared with the current standard of careSignificantly improves oxygenation and complianceN Engl J Med. 2022, 359; 2095MV Guided by Esophageal Pressure第五十五页，共六十
32、六页。ARDS呼吸功能监测与通气策略抉择内容提要(ni rn t yo) Physiopathologic course of ARDS and the dilemma in Mechanical ventilationOxygenation and ShuntRespiratory mechanicsCompliance (Elastance) and ResistanceStress indexEsophageal PressureVd / Vt第五十六页，共六十六页。ARDS呼吸功能监测与通气策略抉择Vd/Vt VS PEEP生理死腔与潮气量比率(bl)Vd/Vt 是肺泡通气效率的指标过
33、高的PEEP可能导致肺泡过度膨胀(Vd/Vt增加)以往PEEP选择方法很少关注Vd/Vt问题Vd/Vt可能用于指导ARDS患者PEEP的选择 第五十七页，共六十六页。ARDS呼吸功能监测与通气策略抉择Vd/Vt测定方法测定方法 Douglas气囊法是最经典的方法VCV 镇静和肌松收集连续多个(du )呼吸周期的呼出气于Douglas囊内测定混合呼出气的CO2分压通过Enghoff改进后Bohr方程计算VDVT=(PaCO2PeCO2)PaCO2 第五十八页，共六十六页。ARDS呼吸功能监测与通气策略抉择Vd/Vt as a risk factor for death in ARDS179 in
34、tubated ARDS pats,Study outcomeMortality before hospital dischargeN Engl J Med. 2002, 346: 1281.第五十九页，共六十六页。ARDS呼吸功能监测与通气策略抉择第六十页，共六十六页。ARDS呼吸功能监测与通气策略抉择Increased Vd/Vt is a feature of the early phase of the ARDSElevated values are associated with an increased risk of deathN Engl J Med. 2002, 346: 1
35、281.第六十一页，共六十六页。ARDS呼吸功能监测与通气策略抉择Case 1Pat did not need higher PEEP75y ManPneumonia ARDS diabetesICU day 1第六十二页，共六十六页。ARDS呼吸功能监测与通气策略抉择Not routinely RMPEEP set 6 cmH2ORM 后逐步降低后逐步降低PEEP水平水平Douglas气囊气囊(qnng)法可计算法可计算 Vd/Vt第六十三页，共六十六页。ARDS呼吸功能监测与通气策略抉择Case 2Pat need higher PEEP47y Man TraumaICU day 1第六十四页，共六十六页。ARDS呼吸功能监测与通气策略抉择Routinely RM PEEP set 14 cmH2O第六十五页，共六十六页。ARDS呼吸功能监测与通气策略抉择内容(nirng)总结ARDS呼吸功能监测与通气策略抉择(juz)。Qt= Qc+Qs 总回心血量。E=P / Vol。Cdyn=Vt / (PIP-PEEPtot)。Compliance decreasedP-V curve。VDVT=(PaCO2PeCO2)PaCO2。Routinely RM第六十六页，共六十六页。ARDS呼吸功能监测与通气策略抉择
