1、ARDS患者肺复张小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题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 0.001Stewart60607.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.
2、247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041小潮气量(6 ml/kg IBW)避免过度膨胀造成的容积伤(volutrauma)足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma)F=PL x(V0/V)2/3F:剪切力PL: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
3、distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):596-608LVt(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.s.Pplat,cmH2O23 830 10 0.01Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influenc
4、e of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/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,mm
5、Hg125 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 of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613Richard JC,Maggiore SM,Jonson B,
6、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俯卧位足够的PEEP足够的潮气量和(或)叹气?肺复张手法肺复张手法减少水肿(?)最低可接受的FiO2(?)自主呼吸(?)小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存
7、在的问题Hickling KG.The pressure-volume curve is greatly modified by recruitment.A mathematical model of ARDS lungs.Am J Respir Crit Care Med 1998:158:194-202.Jonson B,Richard JC,Straus C,Mancebo J,Lemaire F,Brochard L.PressureVolume Curves and Compliance in Acute Lung Injury:Evidence of Recruitment Abo
8、ve 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有肺组织复张组织复张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 fai
9、lure:a clinical study.Am J Respir Crit Care Med 2001:164:131-140.Closing pressureRM: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
10、/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626Lapinsky 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.CPAP(SI)incremental PEEPPCVSigh(modified)HFOV俯卧位05
11、0100150200250baseline15 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 C
12、are Med 2003;31:738-744Sustained Inflation:45 cmH2O x 30 s0100200300400baselinepre-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 epitheli
13、al and lung endothelial injury.Crit Care Med 2005;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min intervalLim 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 respiratory distress
14、 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 pati
15、ents with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260Pelosi 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;159:872-880Sigh:3 consecutive sighs/min at Pp
16、lat 45 cmH2OPatroniti 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;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35
17、 cmH2OTi,s=3 5 sf=1 bpmPatroniti 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;96:788-94Villagra A,Ochagavia A,Vatus S,Murias
18、 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;165:165-170Henzler D,Mahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determin
19、e the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359Henzler D,Mahnken AH,Wildberger JE,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;16:135
20、1-1359小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题Lim 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;99:71-80Lim CM,Lee SS,Lee JS,Ko
21、h 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;99:71-80Lim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Salin
22、e-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80Lim 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;99:71-800300600900lung
23、 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 Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临
24、床适应症肺复张的副作用肺复张存在的问题baseline3 min post-RM30 min post-RMPaO2/FiO2(mmHg)139 46246 111138 39PaCO2(mmHg)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.Recrui
25、tment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5肺复张的方法?SI:50 cmH2O x 30 s作者认为Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a P
26、ositive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5Lim 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 accordin
27、g to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418Lim 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 a
28、ntiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM onlyHalter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveo
29、lar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626RM: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 Prevents Both Al
30、veolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626y=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 2002;30:1315-1321Lim CM,Ada
31、ms 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;32:2371-2377Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy
32、in three models of acute lung injury.Crit Care Med 2004;32:2371-2377RM+PEEPPEEP onlyRM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平最初将PEEP设置为20 cmH2O然后将FiO2减小到最低水平维持SpO2 90 95%每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP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如果将
33、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将PEEP从不必要的高水平逐渐降低不要将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少,PaO2降低推荐意见降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷一般情况下FiO2应当减低到 5 min)时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肺复张是肺保护性通气策略的重要组成开放肺并维持
34、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维持肺泡开放肺复张对循环的影响肺复张尚未解决的问题压力时间频率适应症PEEP能够防止肺泡塌陷(derecruitment)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 mmHgOn the inflation limb of the curvelower inflection point(Pflex)a region of changing slope in early inflation where lung recruitment beginsthe minimal PEEP nec
35、essaryto prevent partial derecruitment of the lung during exhalationOn the expiratory limbthe point of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during exhalationthe maximum PEEP requiredto prevent derecruitmentthese two“points”identify the range of PEEP n
36、eeded in ARDSPflex=the minimumPMCEX=the maximumIdeally,a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEPLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models
37、 of acute lung injury.Crit Care Med 2004;32:2371-23770102030405005101520253035404550Opening 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.
