1、心脏病患者的正压通气心脏病患者的正压通气: :心肺相互作用心肺相互作用1 1ppt课件利益冲突利益冲突无2 2ppt课件机械通气是心脏病患者常用的治疗手段机械通气是心脏病患者常用的治疗手段美国6个州共6,469,674名住院患者180,326 (2.8%)接受机械通气AMI1.7%心脏功能不全18.4%全球20个国家361个ICU中15,757名患者5,183 (33%)接受机械通气急性呼衰 68.8%原因 术后20.8% 肺炎13.9% 充血性心衰 10.4% 全身性感染 8.8% 创伤7.9%Wunsch H, Linde-Zwirble WT, Angus DC, et al. The
2、epidemiology of mechanical ventilation in the United States. Crit Care Med 2010; 38: 1947-1953Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-day international study. JAMA 2002; 287: 345-3553 3ppt课件自主呼吸及机械通气对心血管的影响自主呼吸及机械通气
3、对心血管的影响Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ventilation. Arch Dis Child 1999; 80: 475-480正压通气胸腔内压肺容积前负荷后负荷心率心肌收缩力4 4ppt课件正压通气对心血管的影响正压通气对心血管的影响Scharf SM, Caldini P, Ingram RH. Cardiovascular effects of increasing airway pressure in the dog. Am J Physiol 1977; 232: H35-H435 5p
4、pt课件胸腔内压改变的血流动力学影响胸腔内压改变的血流动力学影响Thorax6 6ppt课件自主呼吸对自主呼吸对LVLV充盈的影响充盈的影响Lemaire, et al. Anesthesiol 1988; 69: 171-1797 7ppt课件胸腔内负压的剧烈波动可导致肺水肿胸腔内负压的剧烈波动可导致肺水肿哮喘持续状态上气道梗阻肺水肿Stalcup and Mellins. N Engl J Med 1977; 297: 592-596 Kanter and Watchko. Am J Dis Chil 1984; 138: 356-358Luke et al. Pediatrics 196
5、6; 37: 762-768Oswalt et al. JAMA 1977; 238: 1833-1835Miro et al. Chest 1989; 96: 1430-14318 8ppt课件NPPENPPE的发病机制的发病机制Upper Airway ObstructionMuller ManeuverITP more negativePulm. blood volumePulm. arterial pressureTransudationPulmonary EdemaCapillary permeabilityPulm. capillary damagePulm. arterial c
6、onstrictionSystemic vasoconstrictionCNSHypoxiaLV afterloadPulm. venous pressurePericapillary hydrostatic pressureCO9 9ppt课件ITPITP升高能够降低升高能够降低LVLV后负荷，增加心输出量后负荷，增加心输出量-受体阻滞剂诱导的急性心功能衰竭（犬模型）Pinsky et al. J Appl Physiol 1983; 54: 950-955Pinsky et al. J Appl Physiol 1985; 58: 1189-1198合并CHF的心肌病患者Pinsky &
7、Summer. Chest 1983; 84: 370-375急性心功能衰竭犬模型心动周期特异性ITP增加Pinsky et al. J Appl Physiol 1986; 60: 604-612预防低血容量下CO下降Matuschak et al. J Appl Physiol 1986; 61: 44-53急性二尖瓣返流的犬模型Stein et al. J Appl Physiol 1990; 69: 2120-21251010ppt课件ITPITP改变对改变对LVLV射血的影响射血的影响ITP下降能够 增加LV射血压，增加LV后负荷ITP升高能够 降低LV射血压，降低LV后负荷Buda
8、, Pinsky, et al. N Engl J Med 1979; 301: 453-459Pinsky, et al. J Appl Physiol 1983; 54: 950-9551111ppt课件呼吸周期对左室每搏输出量的影响呼吸周期对左室每搏输出量的影响Jallon JF, Abdulhay E, Calabrese P, et al. A model of mechanical interactions between heart and lungs. Phil Trans R Soc A 2009; 367: 4741-47571212ppt课件LV PVLV PV曲线，曲线
9、，MVO2MVO2和心脏做功的关系和心脏做功的关系StrokeWorkElastance-DefinedPotentialWorkThe hidden mechanical work of the LVSuga H, Hayashi T, Shirahata M. Ventricular systolic pressure-volume area as predictor of cardiac oxygen consumption. Am J Physiol 1981; 240: H39-H441313ppt课件LVLV压力压力容积面积容积面积(PVA)(PVA)Vendelin M, Bov
10、endeerd PHM, Engelbrecht J, et al. Optimizing ventricular fibers: uniform strain or stress, but not ATP consumption, leads to high efficiency. Am J Physiol 2002; 283: H1072-H1081StrokeWorkPEPVA1414ppt课件LV PVLV PV曲线，曲线，MVO2MVO2和心脏做功的关系和心脏做功的关系LV VolumeLV PressureABLV VolumeLV PressureABMVO2A MVO2B两个P
11、/V环：每搏功相同PVA及MVO2不同1515ppt课件正压通气对正压通气对LVLV前负荷和后负前负荷和后负荷的影响荷的影响Denault AY, Gorcsan J, Pinsky MR. Dynamic effects of positive-pressure ventilation on canine left ventricular pressure-volume relations. J Appl Physiol 2001; 91: 298-3081616ppt课件正压通气对正压通气对LVLV前负荷和后负前负荷和后负荷的影响荷的影响Denault AY, Gorcsan J, Pin
12、sky MR. Dynamic effects of positive-pressure ventilation on canine left ventricular pressure-volume relations. J Appl Physiol 2001; 91: 298-3081717ppt课件正压通气对正压通气对LVLV前负荷和后负前负荷和后负荷的影响荷的影响Dhainaut JF, Devaux JY, Monsallier JF, etal. Mechanisms of decreased left ventricular preload during continuous po
13、sitive pressure ventilation in ARDS. Chest 1986; 90:74-801818ppt课件LVLV收缩力正常时收缩力正常时ITPITPIncreased LV Ejection PressureIncreased LV PreloadDecreased LV Ejection PressureDecreased LV PreloadESPVRPinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 19
14、97; 23: 493-5031919ppt课件LVLV收缩力降低时收缩力降低时ITPITPIncreased LV Ejection PressureIncreased LV PreloadDecreased LV Ejection PressureDecreased LV PreloadESPVRPinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-5032020ppt课件无创无创CPAPCPAP和和BiPA
15、PBiPAP能够能够减轻减轻心脏应激心脏应激CPAP能够减轻急性心源性肺水肿(ACPE)患者的心脏缺血Rasanen et al. Am J Cardiol 55:296-300, 1985Rasanen et al. Am J Cardiol 55:296-300, 1985如果CPAP能够消除ACPE患者的胸腔内负压，才能发挥有益作用Rasanen et al. Chest 87:158-62, 1985Rasanen et al. Chest 87:158-62, 1985面罩CPAP可避免ACPE患者气管插管Bersten et al. N Engl J Med 325:1825-30
16、, 1991Bersten et al. N Engl J Med 325:1825-30, 1991面罩BiPAP以及PSV可改善ACPE患者氧合，避免气管插管Massip et al. Lancet 356:2126-32, 2000Massip et al. Lancet 356:2126-32, 2000Giacomini et al. Chest 123:2057-61, 2003Giacomini et al. Chest 123:2057-61, 2003Nava et al. Am J Respir Crit Care Med 168:1432-7, 2003Nava et a
17、l. Am J Respir Crit Care Med 168:1432-7, 2003Ferrer et al. Am J Respir Crit Care Med 168:1438-44, 2003Ferrer et al. Am J Respir Crit Care Med 168:1438-44, 2003CPAP和BiPAP对ACPE具有相似的有益作用Park et al. Crit Care Med 32:2407-15, 2005Park et al. Crit Care Med 32:2407-15, 2005面罩BiPAP能够改善OSA患者的左心室功能Kaneko et a
18、l. N Engl J Med 348:1233-41, 2003Kaneko et al. N Engl J Med 348:1233-41, 20032121ppt课件急性心梗时的急性心梗时的CPAPCPAPRasanen et al. Chest 1985； 87: 158-1622222ppt课件CPAPCPAP对对CHFCHF患者患者ITPITP的影响的影响Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventr
19、icular transmural pressures in patients with congestive heart failure. Circ 1995; 91: 1725-17312323ppt课件CPAPCPAP对对CHFCHF患者患者ITPITP的影响的影响Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with cong
20、estive heart failure. Circ 1995; 91: 1725-17312424ppt课件CPAPCPAP改善改善CHFCHF患者的患者的LVLV功能功能24名合并CHF的OSA患者夜间CPAP x 1 mth vs. 对照组夜间CPAP组病情改善 OSA发作减少 收缩压降低 (126 to 116 mmHg) 心率减慢 (68 to 63 bpm) LV射血分数改善 (25 to 34%) LV收缩末内径减小 (55 to 53 mm)Kaneko et al. N Engl J Med 2003; 348: 1233-12412525ppt课件CPAPCPAP改善改善C
21、HFCHF患者的患者的LVLV功能功能Kaneko et al. N Engl J Med 2003; 348: 1233-12412626ppt课件ACPEACPE时的面罩时的面罩CPAPCPAP39名ACPE患者随机分为面罩CPAP组或氧疗组(FiO2 0.4)研究持续24 h30分钟后呼吸频率及PaCO2下降24 h时两组患者生理指标相似气管插管比例 CPAP组0/20 对照组7/19Bersten et al. N Engl J Med 1991; 325: 1825-18302727ppt课件ACPEACPE时的面罩时的面罩CPAPCPAPBersten et al. N Engl
22、J Med 1991; 325: 1825-1830CPAPO22828ppt课件ACPEACPE的无创通气的无创通气Masip, et al. Lancet 2000; 356: 2126-2132Control(n = 18)NIPSV(n = 19)2929ppt课件ACPEACPE的无创通气的无创通气Masip, et al. Lancet 2000; 356: 2126-21323030ppt课件ACPEACPE的无创机械通气的无创机械通气Ferrer M,Esquinas A, Leon M et al. Noninvasive ventilation in severe hypo
23、xemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168: 1438-14443131ppt课件ACPEACPE的无创机械通气的无创机械通气Ferrer M,Esquinas A, Leon M et al. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168: 1438-14443232ppt课件CPAPCPAP和和BiPAPBiPAP同样改善同样改善ACPEACPE的存活率的存活率Park et al. Crit Care Med 2005; 32: 2407-2415BiPAPCPAPO23333ppt课件总结总结正压通气升高胸腔内压 LV前负荷降低 LV后负荷降低 心输出量改变受心脏收缩功能的影响有助于减少心脏病患者心肌氧耗改善临床预后3434ppt课件
