1、ARDS肺复张的实施肺复张的实施科学与艺术的困惑内容提要内容提要肺保护性通气策略不能解决解决的问题肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺泡塌陷的病理生理后果肺复张的临床实施肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh RM ARDSnet:小潮气量通气小潮气量通气31.039.80.00765.755.00.001121110110.00710110.43151112110.006ARDS Net.N Engl J Med.2000 May 4;342(18):1301-8.Low tidal
2、volume:more alv collapse小小Vt不能复张塌陷肺泡，加重低氧血症不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略实施肺保护性通气策略至少至少1525%患者需提高患者需提高FiO2邱海波,刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205Collapsed airwayV1V2PressureVolumeV1V1+V2Opening pressureNormalARDSPEEP adjustmentPEEP not enough:more alv keep collapse30 kg PigPost LavagePCVPaw 13 cmH2O PEEP 5
3、cmH2OExperimental study-Pig with ARDS许红阳，邱海波许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较绵羊肺复张容积测定方法的比较.中国危重病急救医学，中国危重病急救医学，2004,16:413.邱海波邱海波.PEEP对对ARDS肺复张容积及氧合影响的临床研究肺复张容积及氧合影响的临床研究.中国危重病急救医学，中国危重病急救医学，2004,16:399.Clinical Trial11 ARDS patsConsolidation and alv collapseA.低氧血症低氧血症肺泡塌陷：肺泡塌陷：ARDS重力依赖区重力依赖区 炎症或不张区炎症或不张区
4、生理性低氧缩血管反应：障碍生理性低氧缩血管反应：障碍How Does Excessive Mechanical Stress Inflame the Lung?“Shear”Verbrugge et al.Crit Care Med 1999;27：779Purine:a marker of ATP breakdown and VILI42 SD ratsPCV 6minPCV Pre/PEEPBALF purine and proteinC.Surfactant 灭活灭活 Surfactant move away When lung regions collapse at end expir
5、ation,surfactant molecules move away from the alv surface toward terminal bronchioles and cannot be reused during next inflationRouby JJ.Am J Respir Crit Care Med,2001,165:1182 D.预防预防Biotrauma和和MODSMarini JJ,Gattinoni L.Ventilatory management of acute respiratory distress syndrome:a consensus of two
6、 Crit Care Med.2004 Jan;32(1):250-5.“Stretch”“Shear”Airway Trauma俯卧位通气的病理生理特征俯卧位通气的病理生理特征 改善通气过程改善通气过程 胸膜腔压力梯度胸膜腔压力梯度 顺应性顺应性胸壁胸壁 促进分泌物的清除促进分泌物的清除Time course of Prone on PaO2/FiO2 between ARDSp vs ARDSexp Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp 黄英姿,邱海波.肺内外源性ARDS实施俯卧位通气时间
7、的选择.中华内科杂志2004,43(12):883-887保留自主呼吸的优点保留自主呼吸的优点Paw cmH2O%Opening and Closing Pressures0510152025303540455001020304050 Opening pressureClosing pressure5 patients,ALI/ARDSFrom Crotti et alAJRCCM 2001.Some units cantbe kept open by any reasonable PEEP!Amato:CT+PV CurveHeartSpPVLIPUIPInsp recruitLarger
8、Vt/Sigh:Pressure must be high enoughEven up to UIP 许红阳，邱海波许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较绵羊肺复张容积测定方法的比较.中国危重病急救医学，中国危重病急救医学，2004,16:413.邱海波邱海波.PEEP对对ARDS肺复张容积及氧合影响的临床研究肺复张容积及氧合影响的临床研究.中国危重病急救医学，中国危重病急救医学，2004,16:399.Clinical Trial11 ARDS patsRecruitment is Time-Dependent 40 SECONDS Recruitment mannuvers
9、Basic Principles Methods for Recruitment Experimental Studies and Clinical Trials Efficacy HazardsMethods for Recruitment1.CPAP模式模式:PS 0,PEEP 30-40 cmH2O,20-50s 2.BIPAP:Ph/PL 30-40cmH2O,20-50s 3.Insp Hold:将吸气保持键按住，持续将吸气保持键按住，持续20-40sMultiple Maneuvers May Be Needed For Optimum RM EffectFujino et al,
10、Crit Care Med 2001;29(8):1579-1586Post-RM PEEP Determines PaO2Averaged data from three modelsRMS-C Lim,CCM 2004Transient BenefitPost-RM-PEEP肺开放效应持续时间的决定因素肺开放效应持续时间的决定因素CCM,2004,32:2371-2377l28 mixed-breed pigslModels of ARDS:OAVILIPneumonia(PNM)lRMSIIncreased PEEPPCV肺开放后的肺开放后的PEEP选择选择-PaO2/FiO21.RM后
11、后 PEEP:20cmH2O2.PEEP递减递减:2cmH2O/5min3.PEEP阈值阈值:PaO2/FiO25%4.PEEP:PEEP阈值阈值+2cmH2OBASELINE VENTILATIONTidal volume=6ml/kgPEEP=5cmH2OModify PEEP to get a1.10.9recruiting maneuverMeasure1.10.9Leave PEEP unchangedstress index 0.91.1Decrease PEEP until 1.1stress index 0.9Crit Care Med,2004,32:1018-1027肺开放
12、后的肺开放后的PEEP选择选择-Stress indexImplications RM 的有效性的有效性 ALI的病因的病因(direct vs in direct)Post RM PEEP Method in certain settings RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury PCV may be better tolerated than SIRecommendations Use PCV in preference to SI Safer,“multiple”,effective,maintains ventilation,simple Monitor hemodynamics during recruiting interval.以下情况需重复作以下情况需重复作RM:体位改变体位改变,管路断开管路断开,呼吸呼吸力学特征或力学特征或PaO2明显恶化明显恶化 对于顽固性难治性对于顽固性难治性ARDS患者患者,可考虑反复可考虑反复RM和和更高的压力更高的压力 Employ Prone Position and/or PEEP to consolidate RM benefit.
