1、Treatment of Hypercapnia in ARDS Bin DuARDS机械通气：如何应对高碳酸血症机械通气：如何应对高碳酸血症Treatment of Hypercapnia in ARDS Bin Du利益冲突 Carefusion Drger Medical Hamiltion Maquet Medtronic(former Covidien)TaemaTreatment of Hypercapnia in ARDS Bin Du病例摘要 男性，70岁，2001年1月9日入院 IBW 60 kg 咳嗽，咳痰12天，发热4天，呼吸困难1天 12天前咳嗽,咳黄粘痰,伴全身乏力
2、4天前 寒战高热，体温39.5C CXR：肺部感染，右上肺膨胀不全 头孢呋肟治疗无效 1天前呼吸困难，紫绀，伴血压下降(50/20 mmHg)Treatment of Hypercapnia in ARDS Bin Du病例摘要入ICU时 BT 37.2C HR 130 bpm BP 84/40 mmHg(DA 10 g/kg/min)SpO2 78%RA 双肺散在湿罗音Treatment of Hypercapnia in ARDS Bin Du病例摘要Treatment of Hypercapnia in ARDS Bin Du病例摘要 呼吸支持(CMV)FiO2100%PEEP15 cm
3、H2O Vt360 ml RR20 bpm ABG pH7.15 PaCO265 mmHg PaO260 mmHg HCO322 mmol/L如何有效降低PaCO2Treatment of Hypercapnia in ARDS Bin Du降低PaCO2的方法 增加MinVent 增加Vt 加快RR 减少Vd/Vt 减少VCO2PaCO2 VCO2MinVent(1 Vd/Vt)Treatment of Hypercapnia in ARDS Bin Du增加Vt伴随Pplat升高延长Tins增加FlowPplatPplatPplatTreatment of Hypercapnia in A
4、RDS Bin Du增加Vt伴随Pplat升高pH 7.15,PaCO2 65 mmHgPplat 30 cmH2O?增加Vt至7 ml/kgPplat 35 cmH2O?YN气压伤风险增加Treatment of Hypercapnia in ARDS Bin Du降低PaCO2的方法 增加MinVent 增加Vt视Pplat而定 加快RR 减少Vd/Vt 减少VCO2PaCO2 VCO2MinVent(1 Vd/Vt)Treatment of Hypercapnia in ARDS Bin Du增加RR提高MinVent低RR高RRRR,bpm17 330 3 0.01MinVent,lp
5、m7.4 2.113.4 2.7 0.01PaCO2,mmHg61 1943 15 0.01pH7.26 0.087.39 0.11 0.01Richard JC,Brochard L,Breton L,et al.Influence of respiratory rate on gas trapping during low volume ventilation of patients with acute lung injury.Intensive Care Med 2002;28:1078-1083Treatment of Hypercapnia in ARDS Bin Du增加RR提高
6、MinVentRR 15 bpmRR 30 bpmVt,ml596 60464 56 0.05Texp,sec2.7 0.21.0 0.1 0.05PaO2,mmHg95 3599 40 0.05Vieillard-Baron A,Prin S,Augarde R,et al.Increasing respiratory rate to improve CO2 clearance during mechanical ventilation is not a panacea in acute respiratory failure.Crit Care Med 2002;30:1407-1412T
7、reatment of Hypercapnia in ARDS Bin Du增加RR提高MinVentTexpTreatment of Hypercapnia in ARDS Bin Du增加RR提高MinVentTexpTreatment of Hypercapnia in ARDS Bin Du增加RR提高MinVentTexpTreatment of Hypercapnia in ARDS Bin Du增加RR提高MinVentRR 15 bpmRR 30 bpmPEEPi,cmH2O0.3 0.26.4 2.7 0.05FRC,ml329 100493 146 0.05MinVent,
8、lpm9.2 0.913.9 1.7 0.05Vd/Vt0.14 0.090.21 0.08 0.05MinVentalv,lpm4.3 1.34.4 1.9 I.sedation,ventilation,and metabolic rate.Anesthesiology 1992;77:1125-1133Treatment of Hypercapnia in ARDS Bin Du降低PaCO2的方法 增加MinVent 增加Vt视Pplat而定 加快RR视呼气流量时间曲线而定 减少Vd/Vt视HME和延长管使用情况而定 减少VCO2视患者自主呼吸及躁动情况而定PaCO2 VCO2MinVe
9、nt(1 Vd/Vt)Treatment of Hypercapnia in ARDS Bin Du病例摘要 呼吸支持(CMV)FiO2100%PEEP15 cmH2O Vt360 ml RR20 bpm ABG pH7.15 PaCO265 mmHg PaO260 mmHg HCO322 mmol/L增加MinVent 增加VtPplat 35 cmH2O 加快RR呼气流量时间曲线提示无法增加RR减少Vd/Vt没有使用HME和延长管减少VCO2患者深度镇静，无自主呼吸Treatment of Hypercapnia in ARDS Bin DuARDS患者的俯卧位通气改善氧合Gattinon
10、i L,Tognoni G,Pesenti A,et al.Effect of prone positioning on the survival of patients with acute respiratory failure.N Engl J Med 2001;345:568-573Treatment of Hypercapnia in ARDS Bin DuARDS患者的俯卧位通气改善氧合Sud S,Friedrich JO,Adhikari NKJ,et al.Effect of prone positioning during mechanical ventilation on
11、mortality among patients with acute respiratory distress syndrome:a systematic review and meta-analysis.CMAJ 2014;186:E381-E390Treatment of Hypercapnia in ARDS Bin DuARDS患者的俯卧位通气改善氧合俯卧位改善PaO2/FiO2PEEP降低Pplat降低增加VtTreatment of Hypercapnia in ARDS Bin Du病例摘要 呼吸支持(CMV)FiO2100%PEEP15 cmH2O Pplat35 cmH2O
12、 Vt360 ml RR20 bpm ABG pH7.15 PaCO265 mmHg PaO260 mmHg HCO322 mmol/L假设：俯卧位后PaO2 150 mmHg，顺应性从18 ml/cmH2O增加到25 ml/cmH2O措施：调整PEEP 10 cmH2O，此时Pplat 24.5 cmH2O(Vt 360 ml)若允许Pplat 30 cmH2O，则Vt可增加至500 mlTreatment of Hypercapnia in ARDS Bin DuARDS患者的俯卧位通气Gattinoni L,Vagginelli F,Carlesso E,et al.Decrease i
13、n PaCO2 with prone position is predictive of improved outcome in acute respiratory distress syndrome.Crit Care Med 2003;31:2727-273345%的患者(94/209)俯卧位后PaCO2下降-6.0 5.6 mmHg(p 0.0001)Treatment of Hypercapnia in ARDS Bin Du病例摘要 呼吸支持(CMV)FiO2100%PEEP15 cmH2O Pplat35 cmH2O Vt360 ml RR20 bpm ABG pH7.15 PaC
14、O265 mmHg PaO260 mmHg HCO322 mmol/L若俯卧位后PaO2没有任何改善，还有什么措施降低PaCO2?Treatment of Hypercapnia in ARDS Bin Du降低PaCO2的其他措施 碳酸氢钠?高频振荡通气(HFOV)?体外膜氧合(ECMO)体外CO2清除(ECCO2R)允许性低氧血症?Treatment of Hypercapnia in ARDS Bin Du906025Treatment of Hypercapnia in ARDS Bin Du珠峰攀登者的动脉氧合Grocott MP,Martin DS,Levett DZ,et al.
15、Arterial blood gases and oxygen content in climbers on Mount Everest.N Engl J Med 2009;360:140-149Treatment of Hypercapnia in ARDS Bin Du珠峰攀登者的动脉氧合Grocott MP,Martin DS,Levett DZ,et al.Arterial blood gases and oxygen content in climbers on Mount Everest.N Engl J Med 2009;360:140-149Treatment of Hyper
16、capnia in ARDS Bin Du机械通气患者的保守性氧疗Suzuki S,Eastwood GM,Glassford NJ,et al.Conservative oxygen therapy in mechanically ventilated patients:a pilot before-and-after trial.Crit Care Med 2014;42:1414-1422Treatment of Hypercapnia in ARDS Bin Du机械通气患者的保守性氧疗Suzuki S,Eastwood GM,Glassford NJ,et al.Conservati
17、ve oxygen therapy in mechanically ventilated patients:a pilot before-and-after trial.Crit Care Med 2014;42:1414-1422事件数（传统氧疗:保守氧疗）校正后OR新发非呼吸器官功能衰竭22:160.32(0.12 0.83)0.019心律失常24:160.56(0.22 1.43)0.2328天病死率16:90.35(0.12 1.06)0.062Treatment of Hypercapnia in ARDS Bin Du危重病患者的高氧Damiani E,Adrario E,Gira
18、rdis M,et al.Arterial hyperoxia and mortalidy in critically ill patients:a systematic review and meta-analysis.Crit Care 2014;18:711事件数（传统氧疗:保守氧疗）异质性I2心跳骤停后1.42(1.04 1.92)67.73%0.0280.015卒中1.23(1.06 1.43)0%0.0050.844颅脑创伤1.41(1.03 1.94)64.54%0.0320.024Treatment of Hypercapnia in ARDS Bin Du早产儿的保守性氧疗S
19、chmidt B,Whyte RK,Asztalos EV,et al.Effects of targeting higher vs lower arterial oxygen saturations on death or disability in extremely preterm infants:a randomized clinical trial.JAMA 2013;309:2111-21201201名早产儿孕周23+0周至27+6周调整FiO2以维持SpO2 88 92%602名早产儿随机分至SpO2 85 89%599名早产儿随机分至SpO2 91 95%显示显示SpO2 88
20、 92%SpO2 高于实际值高于实际值3%实际实际SpO2 85 89%显示显示SpO2 88 92%SpO2 低于实际值低于实际值3%实际实际SpO2 91 95%Treatment of Hypercapnia in ARDS Bin Du早产儿的保守性氧疗Schmidt B,Whyte RK,Asztalos EV,et al.Effects of targeting higher vs lower arterial oxygen saturations on death or disability in extremely preterm infants:a randomized cl
21、inical trial.JAMA 2013;309:2111-2120Treatment of Hypercapnia in ARDS Bin Du早产儿的保守性氧疗Schmidt B,Whyte RK,Asztalos EV,et al.Effects of targeting higher vs lower arterial oxygen saturations on death or disability in extremely preterm infants:a randomized clinical trial.JAMA 2013;309:2111-2120SpO2 85%89%
22、SpO2 91%95%死亡或残疾51.6%(298/578)49.7%(283/569)aOR 1.06(0.83 1.37)18个月内死亡16.6%(97/585)15.3%(88/577)GMFCS 2 56.1%(30/488)6.4%(31/488)认知或语言延迟40.0%(190/475)39.9%(191/479)严重听力丧失3.7%(18/487)2.5%(12/489)双眼盲1.0%(5/487)0.6%(3/488)Treatment of Hypercapnia in ARDS Bin Du氧代谢的生理学DO2I=10 x CI x CaO2 =10 x CI x(0.00
23、31 x PaO2+1.34 x Hb x SaO2)如果如果PaO2 49 mmHg,SaO2 83.7%,Hb 100 g/LCaO2=0.0031 x 49+1.34 x 10 x 83.7%=11.4 ml/dL相比之下，相比之下，PaO2 159 mmHg,SaO2 100%CaO2=0.0031 x 159+1.34 x 10 x 100%=13.9 ml/dL即即CaO2 较基础值降低较基础值降低18%Treatment of Hypercapnia in ARDS Bin Du氧代谢的生理学DO2I=10 x CI x CaO2 =10 x CI x(0.0031 x PaO2
24、+1.34 x Hb x SaO2)当当CaO2降低降低18%时时从13.9 ml/dL下降到11.4 ml/dL只要只要CO至少增加至少增加22%，那么氧输送即可维持不变，那么氧输送即可维持不变Treatment of Hypercapnia in ARDS Bin Du低氧血症的血流动力学Adachi H,Strauss W,Ochi H,et al.The effect of hypoxia on the regional distribution of cardiac output in the dog.Cir Res 1976;39:314-319对照轻度缺氧PaO2,mmHg80.
25、5 6.541.2 5.3 0.01HR,bpm141 32170 34 0.10CO,ml/min/kg86.8 14.2101.3 14.1 0.05Treatment of Hypercapnia in ARDS Bin Du低氧血症的血流动力学Adachi H,Strauss W,Ochi H,et al.The effect of hypoxia on the regional distribution of cardiac output in the dog.Cir Res 1976;39:314-319对照重度缺氧PaO2,mmHg83.1 8.224.3 5.8 0.01HR,
26、bpm148 21179 13 0.10CO,ml/min/kg72.9 11.7120.4 23.5 0.01Treatment of Hypercapnia in ARDS Bin Du允许性低氧血症适应症 心血管储备功能良好 ACS风险低 恶性心律失常风险低Treatment of Hypercapnia in ARDS Bin DuARDS的高碳酸血症 根据生理原则确定个体化治疗措施 增加分钟通气量 减少死腔 降低氧耗及代谢率 根据具体情况确定个体化治疗目标 允许性低氧血症Treatment of Hypercapnia in ARDS Bin Du福州市福州海峡国际会展中心2015年9月17日至20日Treatment of Hypercapnia in ARDS Bin Du欢迎参加中国危重病医学大会中国危重病医学大会2015日期：2015年9月17日至20日地点：福建省福州市详情请关注中国病理生理学会危重病医学专业委员会官方网站http:/中国病理生理学会危重病医学专业委员会微信平台CSCCM_official
