ards肺復(fù)的實(shí)施

1、邱海波東南大學(xué)附屬中大醫(yī)院ICU東南大學(xué)急診與危重病醫(yī)學(xué)研究所,,,ARDS肺復(fù)張的實(shí)施,科學(xué)與藝術(shù)的困惑,內(nèi)容提要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM,ARDSnet: 小潮氣量通氣,ARDS Net. N Engl J Med. 2000 May 4;342(18):13

2、01-8.,Low tidal volume: more alv collapse,小Vt不能復(fù)張塌陷肺泡，加重低氧血癥實(shí)施肺保護(hù)性通氣策略至少15~25%患者需提高FiO2,邱海波, 劉大為, 陳德昌等. 中華麻醉學(xué)雜志, 1998, 18: 202-205,LIP：塌陷肺泡開始復(fù)張的壓力 不是全部塌陷肺泡復(fù)張的壓力,PEEP not enough: more alv keep collapse,30 kg PigPo

3、st LavagePCVPaw 13 cmH2O PEEP 5 cmH2O,,Experimental study-Pig with ARDS,許紅陽(yáng)，邱海波. ARDS綿羊肺復(fù)張容積測(cè)定方法的比較. 中國(guó)危重病急救醫(yī)學(xué)， 2004, 16: 413.邱海波. PEEP對(duì)ARDS肺復(fù)張容積及氧合影響的臨床研究. 中國(guó)危重病急救醫(yī)學(xué)，2004, 16: 399.,Clinical Trial－11 ARDS pats,內(nèi)容提

4、要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM,A. Hypoxamia B. Shear forcesC. Surfactants inactivate D. Biotrauma and MODS,Pathophysiology Consolidation and alv coll

5、apse,A .低氧血癥,肺泡塌陷：ARDS重力依賴區(qū) 炎癥或不張區(qū)生理性低氧縮血管反應(yīng)：障礙,,How Does Excessive Mechanical Stress Inflame the Lung?,“Shear”,,Verbrugge et al. Crit Care Med 1999;27：779,Ventilator-associated lung injury,Purine: a marker

6、 of ATP breakdown and VILI42 SD ratsPCV 6minPCV Pre/PEEPBALF purine and protein,Lachmann. ICM, 1994; 20:6-11,Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way1mg surfactant

7、 = inhibitory effect of 1mg plasma protein,C. Surfactant 滅活,Surfactant move away,When lung regions collapse at end –expiration, surfactant molecules move away from the alv surface toward terminal bronchioles and ca

8、nnot be reused during next inflation,Rouby JJ. Am J Respir Crit Care Med, 2001, 165: 1182,,,D. 預(yù)防Biotrauma和MODS,Marini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two

9、 Crit Care Med. 2004 Jan;32(1):250-5.,,“Stretch”,“Shear”,,Airway Trauma,內(nèi)容提要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM,俯臥位通氣的病理生理特征,改善通氣過(guò)程? 胸膜腔壓力梯度? 順應(yīng)性胸壁促進(jìn)分泌物的清除,

10、,,Closingpressure,Closing pressure,Time course of Prone on PaO2/FiO2 between ARDSp vs ARDSexp,Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp,黃英姿, 邱海波. 肺內(nèi)外源性ARDS實(shí)施俯臥位通氣時(shí)間的選擇.中華內(nèi)科雜志2004, 43(12

11、):883-887,內(nèi)容提要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM,保留自主呼吸的優(yōu)點(diǎn),內(nèi)容提要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighR

12、M,,Paw [cmH2O],%,Opening and Closing Pressures,,,,,,,,,,,,,0,5,10,15,20,25,30,35,40,45,50,,,,,,,,0,10,20,30,40,50,5 patients,ALI / ARDS,From Crotti et alAJRCCM 2001.,,Some units can’tbe kept open by any reasonable PE

13、EP!,Amato: CT + PV Curve,,,,,,Heart,Sp,,,,,,,,,,,,,,,,,,,,,,,,,P,V,LIP,UIP,Insp recruit,,,,,,Larger Vt/Sigh: Pressure must be high enoughEven up to UIP,內(nèi)容提要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontan

14、eous breathingHigh VT and sighHigh PEEPRM,許紅陽(yáng)，邱海波. ARDS綿羊肺復(fù)張容積測(cè)定方法的比較. 中國(guó)危重病急救醫(yī)學(xué)， 2004, 16: 413.邱海波. PEEP對(duì)ARDS肺復(fù)張容積及氧合影響的臨床研究. 中國(guó)危重病急救醫(yī)學(xué)，2004, 16: 399.,Clinical Trial－11 ARDS pats,,Recruitment is Time-Dependent,,

15、,,,~ 40 SECONDS,內(nèi)容提要,肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM,Recruitment mannuvers,Basic PrinciplesMethods for RecruitmentExperimental Studies and Clini

16、cal TrialsEfficacyHazards,1. 控制性肺膨脹(SI)法2. PEEP遞增法3. 壓力控制(PCV)法,Methods for Recruitment,CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 將吸氣保持鍵按住，持續(xù)20- 40s,控制性肺膨脹

17、(SI)法,Multiple Maneuvers May Be Needed For Optimum RM Effect,Fujino et al, Crit Care Med 2001; 29(8):1579-1586,,,,Post-RM PEEP Determines PaO2,Post-RM-PEEP－肺開放效應(yīng)持續(xù)時(shí)間的決定因素,CCM, 2004, 32: 2371-2377,28 mixed-breed pigsMod

18、els of ARDS:OAVILIPneumonia(PNM)RMSIIncreased PEEPPCV,,肺開放后的PEEP選擇----PaO2/FiO2,1. RM后 PEEP: 20cmH2O2. PEEP遞減: 2cmH2O/5min3. PEEP閾值: PaO2/FiO25%4. PEEP: PEEP閾值 +2cmH2O,BASELINE VENTILATIONTidal volu

19、me=6ml/kgPEEP=5cmH2O,Modify PEEP to get a1.1>ｂ>0.9,recruiting maneuver,Measureｂ,,,,,,,1.1>ｂ>0.9Leave PEEP unchanged,ｂstress index >0.9,ｂ>1.1Decrease PEEP until 1.1>stress index >0.9,Crit Care

20、Med, 2004, 32: 1018-1027,肺開放后的PEEP選擇---- Stress index,Implications,RM 的有效性ALI的病因 (direct vs in direct)Post RM PEEPMethod in certain settingsRM hazards are greatest and effectiveness least in pneumonia-caused acute lu

21、ng injuryPCV may be better tolerated than SI,Recommendations,Use PCV in preference to SISafer, “multiple”, effective, maintains ventilation, simpleMonitor hemodynamics during recruiting interval.以下情況需重復(fù)作RM: 體位改變, 管路斷