1、Recruitment Maneuver & PEEP Titration 肺复张术与PEEP调定 Overdistention Barotrauma Volutrauma Recruitment/Derecruitment Injury Translocation of Cells BiotraumaVt too highPplateau too highPIP=14, PEEP=0PIP= 45, PEEP=10PIP= 45, PEEP = 0Webb&Tierney ARRD 1974;110;556 PEEP=? RM ? Pplateau=? VT=? PIP=? Mode ?Re
2、cruitment Maneuver and PV curve hysteresisAirway Pressure cmH2O %Opening and Closing Pressures0510152025303540455001020304050 Opening pressureClosing pressure5 patients,ALI / ARDSAm J Respir Crit Care Med Vol 164. pp 131140,2001 Methodology Sustained inflation Stepwise Recruitment Strategy Pressure
3、control with prone position, with HFOV, et al Titrating PEEPdeflex after RM PV curve (looking for Pdeflex) Oxygenation (PaO2 drop 10%)FULL RECRUITMENT: PaO2 + PaCO2 400 mmHgFiO2=100%Lung protective ventilation in ARDS:Lung protective ventilation in ARDS:the open lung maneuverthe open lung maneuver 4
4、50 mmHg on pure oxygen. When a lung is “open” Pdeflex + 2cmH2O, (PV curve) Super-syringe Low-flow Multiple occlusion Linear ramping (Hamilton Galilio Gold) Oxygenation PaO2 drop 10% Recognizable? And percentage of them? Is this Pdeflex constant over time? Or RM? Is Pdeflex after RM repeatable? Is PE
5、EP on Pdeflex clinically practical? Not answered yet“maximum difference of “maximum difference of 11 cm H11 cm H2 2O O for for the same patient”the same patient”AM J RESPIR CRIT CARE MED AM J RESPIR CRIT CARE MED 2000;161:4324392000;161:432439. .R. SCOTT HARRIS, DEAN R. HESS, and R. SCOTT HARRIS, DE
6、AN R. HESS, and JOS G. VENEGASJOS G. VENEGASAmato: 2004 ChinaTitrating PEEP fellowing RMTitrating PEEP fellowing RMAccording to oxygenationAccording to oxygenation Is it practical for clinical? Possible. Is continuous PaO2 practical? Not yet. SpO2 is probably a useful tool Hickling K. AJRCCM 2001;16
7、3:69-78.Conclusions: Conclusions: In this experimental model, the In this experimental model, the continuous monitoring of dynamic compliance continuous monitoring of dynamic compliance identified the beginning of collapse after identified the beginning of collapse after lung recruitment.lung recrui
8、tment. These findings were These findings were confirmed by oxygenation and computed confirmed by oxygenation and computed tomography scans. This method might become tomography scans. This method might become a a valuable bedside tool for identifying the valuable bedside tool for identifying the lev
9、el of PEEP that prevents end-expiratory level of PEEP that prevents end-expiratory collapse.collapse. Use of dynamic compliance for open Use of dynamic compliance for open lung positive end-expiratory pressure lung positive end-expiratory pressure titration in an experimental studytitration in an ex
10、perimental studyEight healthy pigsLung lavagesCT slices were obtained 2 cm cranial of the right diaphragmatic domedynamic compliance identified the beginning of lung collapse in a pig model.the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying th
11、e level of PEEP that prevents end-expiratory lung collapse？推荐意见8：可采用肺复张手法促进ARDS患者塌陷肺泡复张，改善氧合。（E级） 中国危重病急救医学，2006；18（12）：706Massachusetts General HospitalSet FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple RMs30 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated wel
12、l 35 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 secAllow 15 to 20 minutes between RMThe RM should be aborted if:MAP 20 mmHgSpO2 130 or 20%) PaO2/FiO2 improve：92%27% No barotraumaTrauma or sepsis ARDS (early ARDS) Responsive: (18/22) 81.8% PaO2/FiO2 impro
13、ve: 71%26% No barotrauma Legionnaires Disease 1 pt, nonresponsive, RM only one timeRM only one time Severe subcutaneous emphysemaHypoxia after CPB & open heart surgery All pts appeared obvious ABP drop in 1st RM SpO2 drop together with ABP drop ABP drop occurred at PEEP1216 at 1st RM Pts tolerance improved in later RMsTrauma or sepsis ARDS 12/22（54.5%）appeared ABP drop at 1st RM SpO2drop with ABP drop Pts tolerance improved in later RMs
