ARDS患者的肺复张医学课件.ppt

1、北京协和医院杜斌幸运内容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 肺复张存在的问题幸运内容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 肺复张存在的问题幸运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 0.001Stewar

2、t60607.2 0.810.6 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 1.234550.041幸运ARDS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)幸运肺泡塌陷与复张造成的剪切力F=PL x(V0/V)2/3F:剪切力PL:

3、跨肺压V0:最初容积V:复张后容积如果: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幸运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 4n

4、.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幸运小潮气量通气的问题LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO

5、2/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 Recruitment:Respective Role o

6、f PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613幸运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 Respir Crit Care Med 2001;163:1609-1613幸运受

7、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(?)幸运内容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 肺复张存在的问题幸运肺泡的开放压与闭合压幸运PEEP不能使肺复张幸运LIP:仅仅是肺复张的开始Hickling KG.The pressure-volume curve is greatly modified by recruitment.A mathematical mo

8、del of ARDS lungs.Am J Respir Crit Care Med 1998:158:194-202.幸运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;159:1172-1178低位转折点低位转折点之上仍有肺之上仍

9、有肺组织复张组织复张幸运肺泡的开放压与闭合压幸运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 Respir Crit Care Med 2001:164:131-140.Clos

10、ing pressure幸运ARDS的肺开放幸运RM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

11、:1620-1626幸运肺复张能够改善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.幸运肺复张的各种方法w CPAP(SI)w incremental PEEPw PCVw Sigh(modified)w HFOVw 俯卧位w 幸运SI改善氧合0501

12、00150200250baseline15 min1 hr4 hrs6 hrsPaO2/FiO2ARDSpARDSexpTugrul S,Akinci 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 Car

13、e Med 2003;31:738-744Sustained Inflation:45 cmH2O x 30 s幸运SI改善氧合0100200300400baselinepre-RM2 min post-RM 20 min post-RM 40 min post-RM 60 min post-RMPaO2/FiO2Frank JA,McAuley DF,Gutierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar ep

14、ithelial and lung endothelial injury.Crit Care Med 2005;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval幸运叹气的设置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 respira

15、tory 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 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段幸运叹气改善氧合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 recruit

16、ment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260幸运叹气对氧合及呼吸力学的影响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;159:872-8

17、80Sigh:3 consecutive sighs/min at Pplat 45 cmH2O幸运叹气的设置Patroniti N,Foti G,Cortinovis 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;96:788-94Basel

18、ine:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,s=3 5 sf=1 bpm幸运叹气改善呼吸力学及氧合Patroniti N,Foti G,Cortinovis 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.Anesthesio

19、logy 2002;96:788-94幸运ARDS对RM的反应Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar 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幸运肺复张 CT的提示Henzler D,Mahnken AH,Wildberger JE,

20、Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359幸运肺复张 CT的提示Henzler D,Mahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determin

21、e the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359幸运内容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 肺复张存在的问题幸运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 M

22、aneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运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.Anesthesiology

23、 2003;99:71-80幸运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.Anesthesiology 2003;99:71-80幸运RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim

24、 WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运RM vs.PEEP0300600900lung recruitment正常通气组织增加正常通气组织增加过度膨胀组织增加过度膨胀组织增加RMPTLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effect

25、s of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80幸运内容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 肺复张存在的问题幸运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(m

26、mHg)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(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

27、in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5幸运为什么肺复张作用不能持久?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 Ear

28、ly Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5幸运RM+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

29、of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418幸运RM+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,etio

30、logical category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM only幸运RM后的PEEP幸运RM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

31、Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626幸运RM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 Prev

32、ents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626幸运肺泡稳定能够改善PaO2y=936.95x-0.9232R2=0.976902004006008001000051015202530I-E delta%PaO2,mmHgMcCann UG,Schiller HJ,Gatto LA,et al.Alveolar mechanics alter hypoxic ulmonary vasoconstriction.Crit Care med 2

33、002;30:1315-1321幸运RM后的PEEPLim 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幸运RM+PEEP vs.PEEP onlyLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,M

34、arini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377RM+PEEPPEEP only幸运PEEP的设置w RM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下降幸运PEEP的设置w 氧合下降前的PEEP水平防止大部分肺泡塌陷的

35、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 20 cmH2O幸运PEEP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PEEP幸运PEEP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

36、少,PaO2降低幸运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幸运总结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幸运幸运PEEP能否使肺复张?w PEEP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

37、 mmHg幸运幸运The P-V Curvew On the inflation limb of the curvew lower inflection point(Pflex)a region of changing slope in early inflation where lung recruitment beginsthe minimal PEEP necessaryto prevent partial derecruitment of the lung during exhalation幸运The P-V Curvew On the expiratory limbw the poi

38、nt of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during exhalationthe maximum PEEP requiredto prevent derecruitment幸运The P-V Curvew these two“points”identify the range of PEEP needed in ARDSPflex=the minimumPMCEX=the maximumw Ideally,a complete P-V should b

39、e preformed on all patients identifying these points to allow accurate setting of PEEP幸运幸运幸运幸运幸运RM后的PEEP影响PaO2Lim 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幸运幸运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.幸运