aecopdpaco2的治療目標和機械通氣策略

1、AECOPD：PaCO2的治療目標和機械通氣策略 (mini ECMO),,,F/42 COPD and asthma壓力控制通氣PEEPi 20 cmH2O從眼眶到肚臍都是皮下氣腫PaCO2 55mmHg,下一步應該做什么？,ASAIO Journal 2009; 55:420–422.,,18 F 雙腔右頸內(nèi)置管血流速 800ml/min氣流速 10l/min,,,Venovenous carbon dioxide r

2、emoval was maintained for 88 hours. Subcutaneous emphysema was almost completely resolved at this time. She was extubated 48 hours after decannulation and discharged on hospital day 13.,,M/74，既往有哮喘病史，無常規(guī)治療窒息、休克pH 7.0

3、8, PaO2/FIO2 158.2mmHg,PaCO2 106.5mmHg.對沙丁胺醇、茶堿、激素等無反應,鎮(zhèn)靜鎮(zhèn)痛肌松低PEEP低頻率、延長呼氣時間,收入ICU，采取重癥哮喘通氣策略,VT<200mlPaCO2 147.52mmHg, pH 6.87嚴重休克,,左股動靜脈置管分別15及17-Fr血流速1.5 L/min初始的最大氣流速15L/min,,After the PaCO2 had remained

4、 stable for 93 hrs between 45 and 60 mm Hg and signs of bronchospasm had resolved, oxygen flow to the Novalung was reduced to zero. The extracorporeal circuit was kept in place for a further 28 hrs and then disconnected.

5、,NPPV 治療 COPD,NIPPV的禁忌,嚴重呼吸性酸中毒意識狀態(tài)改變面部創(chuàng)傷血流動力學不穩(wěn)定喀血,64例COPD，40例NIV失敗，要求有創(chuàng)通氣,AECOPD時的呼吸機制,氣流阻力升高氣流受限PEEPi and hyperinflation 呼吸淺快,,肌無力高碳酸呼吸泵衰竭分鐘通氣量升高,AECOPD時的通氣策略,Pmus + Pappl = (flow x R,RS) + (volume x E,R

6、S) + PEEPiPaCO2= VCO2/VE*(1-VD/VT)UNLOAD Pmus BY INCREASING VEUNLOAD Pmus BY DECREASING VE,低肺牽張策略,低潮氣量低呼吸頻率減低吸呼比,Gattinoni L. JAMA 1986;256:881–886.,LFPPV-ECCO2R,動物實驗呼吸頻率每分鐘0.66、1、2、4次潮氣量3、10、15ml/kg最小頻率及10-

7、15ml/kg,能維持生命7小時,Gattinoni。Anesth Analg. 1978 Jul-Aug;57(4):470-7.,,43例嚴重急性呼衰患者非對照研究肺靜息頻率3-5次/分PEEP：15-25cmH2O“低”峰壓35-45cmH2O,JAMA 1986;256:881-886,,結(jié)果：改善肺功能71%，存活48.8%,,Lung function improvedin thirty-one patien

8、ts (72.8%) .Improvement in lung function, when present, always occurred within 48 hours 21 patients (48.8%) eventually survivedThe mean time on bypass for the survivors was 5.4 ±3.5 daysBlood loss averaged 180

9、0 ± 850mL/d,ECCO2R的隨機對照研究,40例重癥ARDS患者30天生存率：MV（42%）vs.EC(33%)嚴重并發(fā)癥：出血、溶血、神經(jīng)系統(tǒng)損害,Am J Respir Crit Care Med. 1994；149(2 Pt 1):295-305.,Extracorporeal support for ARDS should be restricted to controlled clinical tr

10、ials,,與6 mL/kg 潮氣量相比，3 mL/kg的潮氣量結(jié)合體外CO2 清除是否減輕呼吸機相關性肺損傷14只豬評價器官功能和組織病理學,Crit Care Med 2007; 35,,organ function and organ injury assessment didnot reveal significant improvements when comparedwith conventional strat

11、egy,,,,whether VT lower than 6 ml/kg may enhance lung protection and that consequent respiratory acidosis may be managed by extracorporeal carbon dioxide removal.32 patients ventilated with a VT of 6ml/kgMeasurements

12、: lung morphology computed tomography,and pulmonary inflammatory cytokines,Anesthesiology 2009; 111:826–35,,高平臺壓組VT逐步減少以每4小時降低1ml/kg以高PEEP策略進行通氣,低流量的體外CO2清除,MiniECMO對呼吸機制的影響,,,,從“完全”到“部分”的體外生命支持技術,,血流速度膜面積通路選擇抗凝,

13、體外CO2清除的臨床研究,體外CO2清除的并發(fā)癥,常見技術,LFPPV-ECCO2Rinterventional lung assist (iLA),,Extracorporeal CO2 removal in patients with severe COPD exacerbation failing noninvasive ventilationLorenzo Del SorboStefano NavaV. Marco

14、RanieriDECOPD Study http://decopd.ddmc.unito.it,,Inclusion criteria Patients with COPD, severe acute respiratory failure and hypercapnia with persistence, despite full NIV, for at least 2 hrs of:- Moderated to severe