1、北京协和医院杜斌内容w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题内容w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题ARDS的肺保护性通气策略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、.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041ARDS的肺保护性通气策略w 小潮气量(6 ml/kg IBW)避免过度膨胀造成的容积伤(volutrauma)w 足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma)肺泡塌陷与复张造成的剪切力F=PL x(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积
3、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 distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):596-608小潮气量通气的问题LVt(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,cmH
4、2O23 830 10 0.01Richard 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;163:1609-1613小潮气量通气的问题LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,mmHg165
5、 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,mmHg125 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 R
6、ecruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613小潮气量通气的问题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;163:1609-1613小潮气量通气的问题Richard JC
7、,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;163:1609-1613受损的肺组织如何复张w 俯卧位w 足够的PEEPw 足够的潮气量和(或)叹气?w 肺复张手法肺复张手法w 减少水肿(?)w 最低可接受的FiO2(?)w 自主呼吸(?)内容w 小潮气量通气的问题w 肺复张
8、的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题肺泡的开放压与闭合压PEEP不能使肺复张LIP:仅仅是肺复张的开始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
9、,Brochard L.PressureVolume Curves and Compliance in Acute Lung Injury:Evidence of Recruitment Above 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肺泡的开放压与闭合压肺泡开放压与闭合压0102030405005101520253035404550Opening pressurePaw(cmH2O)Crotti S,Mascheroni D,Cai
10、roni 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.Closing pressureARDS的肺开放RM能够使肺开放RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minHalter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto
11、 LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626肺复张能够改善ARDS氧合Lapinsky SE,Aubin M,Mehta S,Boiteau P,Slutsky AS:Safety and efficacy of a sustained inflation fo
12、r alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.肺复张的各种方法w CPAP(SI)w incremental PEEPw PCVw Sigh(modified)w HFOVw 俯卧位w SI改善氧合050100150200250baseline15 min1 hr4 hrs6 hrsPaO2/FiO2ARDSpARDSexpTugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L,Akpir K,Cakar N.
13、Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome:Focusing on pulmonary and extrapulmonary forms.Crit Care Med 2003;31:738-744Sustained Inflation:45 cmH2O x 30 sSI改善氧合0100200300400baselinepre-RM2 min post-RM 20 min post-RM 40 min
14、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 epithelial and lung endothelial injury.Crit Care Med 2005;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval叹
15、气的设置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 patients with acute respiratory distress 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,PE
16、EP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段叹气改善氧合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 patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260叹气对氧合及呼吸力学的影响
17、Pelosi 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 Pplat 45 cmH2O叹气的设置Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh
18、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 cmH2OTi,s=3 5 sf=1 bpm叹气改善呼吸力学及氧合Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Ce
19、reda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94ARDS对RM的反应Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar JL,Fernandez R,Blanch L.Recruitment Maneuvers d
20、uring Lung Protective Ventilation in Acute Respiratory Distress Syndrome.Am J Respir Crit Care Med 2002;165:165-170肺复张 CT的提示Henzler 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 i
21、njury.Eur Radiol 2006;16:1351-1359肺复张 CT的提示Henzler 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;16:1351-1359内容w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEPw 肺复张后的PEEPw
22、不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题RM vs.PEEPLim 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;99:71-80RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee
23、 SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80RM vs.PEEPLim 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-lav
24、aged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80RM vs.PEEPLim 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;99:71-80RM vs.PEE
25、P0300600900lung 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内容w 小潮气量通气的问题w 肺复张的理论与实践w 肺复张与PEEP
26、w 肺复张后的PEEPw 不同复张方法的差异w 肺复张的临床适应症w 肺复张的副作用w 肺复张存在的问题为什么肺复张作用不能持久?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,Lo
27、renzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5为什么肺复张作用不能持久?w 肺复张的方法?SI:50 cmH2O x 30 sw 作者认为Oczenski W,Hrmann C,Keller C,Lorenzl N,
28、Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of
29、 alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,K
30、im WD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM onlyRM后的PEEPRM后的PEEP能够稳定肺泡Halter JM,Steinberg JM,Schi
31、ller HJ,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626RM后的PEEP能够稳定肺泡RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEEP 10 cmH2OHalter JM,
32、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/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626肺泡稳定能够改善PaO2y=936.95x-0.9232R2=0.976902004006008001000051015202530I-E
33、 delta%PaO2,mmHgMcCann UG,Schiller HJ,Gatto LA,et al.Alveolar mechanics alter hypoxic ulmonary vasoconstriction.Crit Care med 2002;30:1315-1321RM后的PEEPLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lun
34、g injury.Crit Care Med 2004;32:2371-2377RM+PEEP vs.PEEP onlyLim CM,Adams 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;32:2371-2377RM+PEEPPEEP only肺复张的操作w 镇静 肌松患者能否耐受较高的PEEPw 预氧合避免肺复
35、张过程中的缺氧通常维持原来的FiO2 便于评价肺复张效果肺复张的操作CPAP(SI)w 初始CPAP设定为30 cmH2OPCVw PC恒定为15或20 cmH2Ow 初始PEEP设定为30 cmH2Ow 呼吸频率10 20w I/E 1:1两种方法开放压力不同,相差15 20 cmH2O肺复张的操作w 定压通气方式而非定容通气方式更好地控制气道压力w 压力控制模式而非压力支持模式更好地控制复张时间肺复张的操作时间压力闭合压开放压肺复张的操作开放压时间压力闭合压15+30 30+15肺复张的操作w 持续时间40 120 sec视复张压力与循环状态而不同压力越高,时间越短评价肺复张的效果w Fi
36、O2维持1.0w 判断肺开放标准(塌陷肺泡 400PaO2/FiO2 300PaO2+PaCO2 400w 需要频繁复查血气评价肺复张的效果w 维持FiO2在原有水平w 通过观察SpO2的变化评价肺复张w 避免频繁复查血气w 没有一致的判断标准肺复张的操作w 如复张效果不明显,可以逐步增加PEEP通常每次增加5 cmH2O开放压力 60 cmH2O是安全的w 持续时间40 120 sec视复张压力与循环状态而不同压力越高,时间越短PEEP的设置w RM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平w 最初将PEEP设置为20 cmH2Ow 然后将FiO2减小到最低水平维持SpO2
37、90 95%w 每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降PEEP的设置w 氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEPw 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 cmH2OPEEP的设置w 如果将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PEEPPEEP的设置w 将PEEP从不必要的高水平逐渐降低w 不要将PEEP由低水平增加到高水平如同P-V曲线所示,根
38、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PEEP/FiO2的调整推荐意见w 降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷w 一般情况下FiO2应当减低到 5 min)时w 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总结w 肺复张是肺保护性通气策略的重要组成w 开放肺并维持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w 肺复张对循环的影响w 肺复张尚未解决的问题压力时间频率适应症PEEP能否使肺复张?w PEEP能够防止肺泡塌陷(d
39、erecruitment)w 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 mmHgThe P-V Curvew On the inflation limb of the curvew lower inflection point(Pflex)a region of changing slope in early inflation where lung recruitment beginsthe minimal PEEP necessary to prevent partial derecruitment of the lung during e
40、xhalationThe P-V Curvew On the expiratory limbw the point of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during exhalationthe maximum PEEP required to prevent derecruitmentThe P-V Curvew these two“points”identify the range of PEEP needed in ARDSPflex=the min
41、imumPMCEX=the maximumw Ideally,a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEPRM后的PEEP影响PaO2Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute
42、lung injury.Crit Care Med 2004;32:2371-2377肺泡开放压与闭合压0102030405005101520253035404550Opening 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.
