ARDS患者的肺復(fù)張課件

ARDS患者的肺復(fù)張 1 ARDS患者的肺復(fù)張 ARDS患者的肺復(fù)張 2 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 3 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 4 ARDS的肺保護(hù)性通氣策略 ARDS患者的肺復(fù)張 5 ARDS的肺保護(hù)性通氣策略 小潮氣量 6ml kgIBW 避免過(guò)度膨脹造成的容積傷 volutrauma 足夠的PEEP防止肺泡復(fù)張?jiān)斐傻募羟辛p傷 atelectrauma ARDS患者的肺復(fù)張 6 肺泡塌陷與復(fù)張?jiān)斐傻募羟辛?F PLx V0 V 2 3F 剪切力PL 跨肺壓V0 最初容積V 復(fù)張后容積如果 PL 30cmH2O V0 V 1 10則 F 140cmH2O MeadJ TakishimaT LeithD Stressdistributioninlungs amodelofpulmonaryelasticity JApplPhysiol1970 28 5 596 608 ARDS患者的肺復(fù)張 7 小潮氣量通氣的問(wèn)題 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 ARDS患者的肺復(fù)張 8 小潮氣量通氣的問(wèn)題 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 ARDS患者的肺復(fù)張 9 小潮氣量通氣的問(wèn)題 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 ARDS患者的肺復(fù)張 10 受損的肺組織如何復(fù)張 俯臥位足夠的PEEP足夠的潮氣量 和 或 嘆氣 肺復(fù)張手法減少水腫 最低可接受的FiO2 自主呼吸 ARDS患者的肺復(fù)張 11 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 12 肺泡的開(kāi)放壓與閉合壓 ARDS患者的肺復(fù)張 13 PEEP不能使肺復(fù)張 ARDS患者的肺復(fù)張 14 LIP 僅僅是肺復(fù)張的開(kāi)始 HicklingKG Thepressure volumecurveisgreatlymodifiedbyrecruitment AmathematicalmodelofARDSlungs AmJRespirCritCareMed1998 158 194 202 ARDS患者的肺復(fù)張 15 JonsonB RichardJC StrausC ManceboJ LemaireF BrochardL Pressure VolumeCurvesandComplianceinAcuteLungInjury EvidenceofRecruitmentAbovetheLowerInflectionPoint AmJRespirCritCareMed1999 159 1172 1178 低位轉(zhuǎn)折點(diǎn)之上仍有肺組織復(fù)張 ARDS患者的肺復(fù)張 16 肺泡的開(kāi)放壓與閉合壓 ARDS患者的肺復(fù)張 17 肺泡開(kāi)放壓與閉合壓 Paw cmH2O CrottiS MascheroniD CaironiP PelosiP RonzoniG MondinoM MariniJJ GattinoniL Recruitmentandderecruitmentduringacuterespiratoryfailure aclinicalstudy AmJRespirCritCareMed2001 164 131 140 ARDS患者的肺復(fù)張 18 ARDS的肺開(kāi)放 EditorialOpenupthelungandkeepthelungopenB LachmannDept ofAnesthesiology ErasmusUniversityRotterdam TheNetherlands 1992 18 319 321 ARDS患者的肺復(fù)張 19 RM能夠使肺開(kāi)放 RM PIP45cmH2O PEEP35cmH2Ox1min HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 ARDS患者的肺復(fù)張 20 肺復(fù)張能夠改善ARDS氧合 LapinskySE AubinM MehtaS BoiteauP SlutskyAS Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure IntensiveCareMed1999 25 1297 1301 ARDS患者的肺復(fù)張 21 肺復(fù)張的各種方法 CPAP SI incrementalPEEPPCVSigh modified HFOV俯臥位 ARDS患者的肺復(fù)張 22 SI改善氧合 TugrulS AkinciO OzcanPE Ince S EsenF TelciL AkpirK CakarN Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome Focusingonpulmonaryandextrapulmonaryforms CritCareMed2003 31 738 744 SustainedInflation 45cmH2Ox30s ARDS患者的肺復(fù)張 23 SI改善氧合 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 SustainedInflation 30cmH2Ox30sTwicewith1mininterval ARDS患者的肺復(fù)張 24 嘆氣的設(shè)置 LimCM KohY ParkW ChinJY ShimTS LeeSD KimWS KimDS KimWD Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome Apreliminarystudy CritCareMed2001 29 1255 1260 充氣階段 每30秒PEEP增加5cmH2OVt減少2ml kg前2次呼吸除外直至Vt2ml kg PEEP25cmH2O暫停階段CPAP30cmH2Ofor30s放氣階段 ARDS患者的肺復(fù)張 25 嘆氣改善氧合 LimCM KohY ParkW ChinJY ShimTS LeeSD KimWS KimDS KimWD Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome Apreliminarystudy CritCareMed2001 29 1255 1260 ARDS患者的肺復(fù)張 26 嘆氣對(duì)氧合及呼吸力學(xué)的影響 PelosiP CadringherP BottinoN PanigadaM CarrieriF RivaE LissoniA GattinoniL Sighinacuterespiratorydistresssyndrome AmJRespirCritCareMed1999 159 872 880 Sigh 3consecutivesighs minatPplat45cmH2O ARDS患者的肺復(fù)張 27 嘆氣的設(shè)置 PatronitiN FotiG CortinovisB MaggioniE BigatelloLM CeredaM PesentiA SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation Anesthesiology2002 96 788 94 Baseline PSVSigh BIPAPPEEPhigh 1 2xPIPpsvor35cmH2OTi s 3 5sf 1bpm ARDS患者的肺復(fù)張 28 嘆氣改善呼吸力學(xué)及氧合 PatronitiN FotiG CortinovisB MaggioniE BigatelloLM CeredaM PesentiA SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation Anesthesiology2002 96 788 94 ARDS患者的肺復(fù)張 29 ARDS對(duì)RM的反應(yīng) VillagraA OchagaviaA VatusS MuriasG FernandezMF AguilarJL FernandezR BlanchL RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome AmJRespirCritCareMed2002 165 165 170 ARDS患者的肺復(fù)張 30 肺復(fù)張 CT的提示 HenzlerD MahnkenAH WildbergerJE RossaintR G ntherRW KuhlenR Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury EurRadiol2006 16 1351 1359 ARDS患者的肺復(fù)張 31 肺復(fù)張 CT的提示 HenzlerD MahnkenAH WildbergerJE RossaintR G ntherRW KuhlenR Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury EurRadiol2006 16 1351 1359 ARDS患者的肺復(fù)張 32 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 33 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復(fù)張 34 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復(fù)張 35 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復(fù)張 36 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復(fù)張 37 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復(fù)張 38 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 39 為什么肺復(fù)張作用不能持久 OczenskiW H rmannC KellerC LorenzlN KepkaA SchwarzS FitzgeraldRD RecruitmentManeuversafteraPositiveEnd expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome Anesthesiology2004 101 620 5 ARDS患者的肺復(fù)張 40 為什么肺復(fù)張作用不能持久 肺復(fù)張的方法 SI 50cmH2Ox30s作者認(rèn)為 OczenskiW H rmannC KellerC LorenzlN KepkaA SchwarzS FitzgeraldRD RecruitmentManeuversafteraPositiveEnd expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome Anesthesiology2004 101 620 5 ARDS患者的肺復(fù)張 41 RM PEEPvs RMvs PEEP LimCM JungH KohY LeeJS ShimTS LeeSD KimWS KimDS KimWD Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy etiologicalcategoryofdiffuselunginjury andbodypositionofthepatient CritCareMed2003 31 411 418 ARDS患者的肺復(fù)張 42 RM PEEPvs RMvs PEEP LimCM JungH KohY LeeJS ShimTS LeeSD KimWS KimDS KimWD Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy etiologicalcategoryofdiffuselunginjury andbodypositionofthepatient CritCareMed2003 31 411 418 RM PEEP RMonly ARDS患者的肺復(fù)張 43 RM后的PEEP ARDS患者的肺復(fù)張 44 RM后的PEEP能夠穩(wěn)定肺泡 HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 ARDS患者的肺復(fù)張 45 RM后的PEEP能夠穩(wěn)定肺泡 RM PIP45cmH2O PEEP35cmH2Ox1min PEEP5cmH2O PEEP10cmH2O HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 ARDS患者的肺復(fù)張 46 肺泡穩(wěn)定能夠改善PaO2 McCannUG SchillerHJ GattoLA etal Alveolarmechanicsalterhypoxiculmonaryvasoconstriction CritCaremed2002 30 1315 1321 ARDS患者的肺復(fù)張 47 RM后的PEEP LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 ARDS患者的肺復(fù)張 48 RM PEEPvs PEEPonly LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 RM PEEP PEEPonly ARDS患者的肺復(fù)張 49 PEEP的設(shè)置 RM之后通常將PEEP設(shè)置在能夠維持PaO2 防止塌陷 的水平最初將PEEP設(shè)置為20cmH2O然后將FiO2減小到最低水平維持SpO290 95 每20 30分鐘降低PEEP2cmH2O直至患者SpO2下降 ARDS患者的肺復(fù)張 50 PEEP的設(shè)置 氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP一旦確認(rèn) 則需重復(fù)肺復(fù)張操作 然后把PEEP和FiO2重新設(shè)置在上述水平對(duì)于多數(shù)ARDS患者 PEEP介于15 20cmH2O之間某些患者20cmH2O ARDS患者的肺復(fù)張 51 PEEP的設(shè)置 如果將PEEP設(shè)置于20cmH2O后 仍發(fā)現(xiàn)PaO2 FiO2顯著下降按照最初的PEEP設(shè)置25cmH2O重復(fù)肺復(fù)張然后按照上述方法調(diào)節(jié)FiO2和PEEP ARDS患者的肺復(fù)張 52 PEEP的設(shè)置 將PEEP從不必要的高水平逐漸降低不要將PEEP由低水平增加到高水平如同P V曲線所示 根據(jù)設(shè)置方法不同 同樣水平的PEEP所維持的肺容積不同如果在肺泡塌陷后設(shè)置PEEP 增加PEEP 則所設(shè)置的PEEP水平可以使肺容積減少 PaO2降低 ARDS患者的肺復(fù)張 53 PEEP FiO2的調(diào)整 推薦意見(jiàn)降低PEEP之前應(yīng)當(dāng)首先降低FiO2 以避免肺泡塌陷一般情況下FiO2應(yīng)當(dāng)減低到 0 45如果降低PEEP導(dǎo)致氧合下降應(yīng)當(dāng)重新設(shè)定PEEP肺泡塌陷時(shí)不應(yīng)增加FiO2 ARDS患者的肺復(fù)張 54 肺復(fù)張后氧合穩(wěn)定所需時(shí)間 TugrulS CakarN AkinciO OzcanPE DisciR EsenF TelciL TAkpir Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend expiratorypressureinacuterespiratorydistresssyndrome CritCareMed2005 33 995 1000 LIP 2 ARDS患者的肺復(fù)張 55 肺復(fù)張后氧合穩(wěn)定所需時(shí)間 TugrulS CakarN AkinciO OzcanPE DisciR EsenF TelciL TAkpir Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend expiratorypressureinacuterespiratorydistresssyndrome CritCareMed2005 33 995 1000 ARDS患者的肺復(fù)張 56 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 57 不同RM方法的比較 基礎(chǔ)通氣方式VCV Vt10ml kg f20bpm I E1 2 FiO20 5肺復(fù)張 OdenstedtH LindgrenS OlegardC ErlandssonK LethvallS AnemanA StenqvistO LundinS Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復(fù)張 58 不同RM方法的比較 OdenstedtH LindgrenS OlegardC etal Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復(fù)張 59 不同RM方法的比較 OdenstedtH LindgrenS OlegardC ErlandssonK LethvallS AnemanA StenqvistO LundinS Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復(fù)張 60 不同RM方法的比較 對(duì)于灌洗造成的急性肺損傷模型緩慢低壓復(fù)張操作可以促進(jìn)肺泡復(fù)張減少對(duì)循環(huán)系統(tǒng)的抑制避免對(duì)呼吸力學(xué)的不良影響 OdenstedtH LindgrenS OlegardC ErlandssonK LethvallS AnemanA StenqvistO LundinS Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復(fù)張 61 不同RM方法的比較 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 Sustainedinflation45for40s IncrementalPEEPPIP35 PEEP8 35 PCVPIP45 PEEP16I E1 2 2min ARDS患者的肺復(fù)張 62 對(duì)于VILI模型PCV是最佳的RM方法其他模型結(jié)果相似 PEEP8 PEEP12 PEEP16 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 ARDS患者的肺復(fù)張 63 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 64 RM保護(hù)肺內(nèi)皮而非肺泡上皮 試驗(yàn)動(dòng)物 大鼠模型制備 酸 pH1 5 吸入機(jī)械通氣 Vt6ml kgPEEP5cmH2OFiO21 0F60 70bpm復(fù)張操作 30cmH2Ox30sx2間隔1分鐘 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 ARDS患者的肺復(fù)張 65 RM保護(hù)肺內(nèi)皮而非肺泡上皮 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 ARDS患者的肺復(fù)張 66 RM ARDS早期vs 晚期 VillagraA OchagaviaA VatusS MuriasG FernandezMF AguilarJL FernandezR BlanchL RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome AmJRespirCritCareMed2002 165 165 170 ARDS患者的肺復(fù)張 67 原發(fā)性ARDS對(duì)RM反應(yīng)不佳 Salinelavage Oleicacidinjury Pneumonia VanderKlootTE BlanchL YoungbloodAM WeinertC AdamsAB MariniJJ ShapiroRS NahumA RecruitmentManeuversinThreeExperimental ModelsofAcuteLungInjuryEffectonLungVolumeandGasExchange AmJRespirCritCareMed2000 161 1485 1494 SustainedinflationCPAP40 30CPAP60 30CPAP60 30 ARDS患者的肺復(fù)張 68 油酸損傷模型RM作用短暫 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 PEEP8 PEEP12 PEEP16 ARDS患者的肺復(fù)張 69 不同病因?qū)M的反應(yīng) LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 RM PEEP PEEPonly ARDS患者的肺復(fù)張 70 RM ARDSp與ARDSexp LimCM JungH KohY LeeJS ShimTS LeeSD KimWS KimDS KimWD Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy etiologicalcategoryofdiffuselunginjury andbodypositionofthepatient CritCareMed2003 31 411 418 ARDS患者的肺復(fù)張 71 SI改善氧合 TugrulS AkinciO OzcanPE Ince S EsenF TelciL AkpirK CakarN Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome Focusingonpulmonaryandextrapulmonaryforms CritCareMed2003 31 738 744 SustainedInflation 45cmH2Ox30s ARDS患者的肺復(fù)張 72 嘆氣 ARDSp與ARDSexp PelosiP CadringherP BottinoN PanigadaM CarrieriF RivaE LissoniA GattinoniL Sighinacuterespiratorydistresssyndrome AmJRespirCritCareMed1999 159 872 880 Sigh 3consecutivesighs minatPplat45cmH2O ARDS患者的肺復(fù)張 73 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 74 RM不增加肺泡過(guò)度膨脹 BugedoG BruhnA HernandezG etal Lungcomputedtomographyduringalungrecruitmentmaneuverinpatientswithacutelunginjury IntensiveCareMed2003 29 218 225 ARDS患者的肺復(fù)張 75 ARDS患者的肺復(fù)張 76 肺復(fù)張對(duì)內(nèi)臟血流的影響 NunesS RothenHU BranderL TakalaJ JakobSM ChangesinSplanchnicCirculationDuringanAlveolarRecruitmentManeuverinHealthyPorcineLungs AnesthAnalg2004 98 1432 8 ARDS患者的肺復(fù)張 77 肺復(fù)張對(duì)胃腸道血流的影響 ClaessonJ LehtipaloS WinsoD Dolungrecruitmentmaneuversdecreasegastricmucosalperfusion IntensiveCareMed2003 29 1314 1321 ARDS患者的肺復(fù)張 78 肺復(fù)張對(duì)腦氧代謝的影響 BeinT KuhrLP BeleS PlonerF KeylC TaegerK Lungrecruitmentmaneuverinpatientswithcerebralinjury effectsonintracranialpressureandcerebralmetabolism IntensiveCareMed2002 28 554 558 ARDS患者的肺復(fù)張 79 內(nèi)容 小潮氣量通氣的問(wèn)題肺復(fù)張的理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后的PEEP不同復(fù)張方法的差異肺復(fù)張的臨床適應(yīng)癥肺復(fù)張的副作用肺復(fù)張存在的問(wèn)題 ARDS患者的肺復(fù)張 80 肺泡開(kāi)放壓與閉合壓 Paw cmH2O CrottiS MascheroniD CaironiP PelosiP RonzoniG MondinoM MariniJJ GattinoniL Recruitmentandderecruitmentduringacuterespiratoryfailure aclinicalstudy AmJRespirCritCareMed2001 164 131 140 即使使用足夠的PEEP也不能使所有肺單位開(kāi)放 ARDS患者的肺復(fù)張 81 RM對(duì)哪些患者療效好 尚不清楚肺復(fù)張對(duì)哪類患者療效更好肺復(fù)張對(duì)早期ARDS ALI患者的效果更顯著隨著ARDS的進(jìn)展 肺進(jìn)入纖維增殖期肺復(fù)張就無(wú)法有效改善氧合氣壓傷的危險(xiǎn)反而增加 ARDS患者的肺復(fù)張 82 RM對(duì)哪些患者療效好 ARDS的病因繼發(fā)性ARDS 全身性感染 創(chuàng)傷等 比原發(fā)性ARDS 肺炎 更容易復(fù)張目前的推薦意見(jiàn)在ARDS ALI病程早期進(jìn)行肺復(fù)張無(wú)論ARDS的病因如何 ARDS患者的肺復(fù)張 83 肺復(fù)張操作的頻率 尚不清楚對(duì)某一患者進(jìn)行肺復(fù)張操作的適宜頻率以下情況應(yīng)進(jìn)行肺復(fù)張操作病程早期當(dāng)肺泡塌陷時(shí)例如呼吸機(jī)脫開(kāi) ARDS患者的肺復(fù)張 84 肺復(fù)張操作的頻率 對(duì)于ARDS患者脫離呼吸機(jī)能夠?qū)е路闻菅杆偎?從而發(fā)生嚴(yán)重的低氧血癥為避免呼吸機(jī)脫開(kāi) 建議采用密閉吸痰裝置特殊霧化裝置 ARDS患者的肺復(fù)張 85 肺復(fù)張操作的頻率 肺復(fù)張操作當(dāng)觀察到SpO2持續(xù)降低 5min 時(shí)如果沒(méi)有觀察到氧合下降 則需要每日進(jìn)行一次或兩次肺復(fù)張未知 ARDS患者的肺復(fù)張 86 總結(jié) 肺復(fù)張是肺保護(hù)性通氣策略的重要組成開(kāi)放肺并維持肺開(kāi)放是其理論基礎(chǔ)應(yīng)用氣道高壓使塌陷肺泡開(kāi)放應(yīng)用足夠的PEEP維持肺泡開(kāi)放肺復(fù)張對(duì)循環(huán)的影響肺復(fù)張尚未解決的問(wèn)題壓力時(shí)間頻率適應(yīng)癥 ARDS患者的肺復(fù)張 87 ARDS患者的肺復(fù)張 88 PEEP能否使肺復(fù)張 PEEP能夠防止肺泡塌陷 derecruitment 低水平的PEEP只能使很少的肺復(fù)張對(duì)于ARDS 將壓力持續(xù)維持在常用的PEEP水平 20cmH2O 只能使小部分肺組織復(fù)張 ARDS患者的肺復(fù)張 89 PEEP能否使肺復(fù)張 ARDS患者的肺復(fù)張貫穿于整個(gè)吸氣過(guò)程byHicklingAJRCCM1998TidalrecruitmentoccursbelowoptimalPEEP PEEPattheoptimallevelgenerallyresultsinadecreasedquasi staticcompliancewhenmeasuredontheventilatorbyJonsonetalAJRCCM1999 ARDS患者的肺復(fù)張 90 肺復(fù)張所需的壓力 正常潮氣量通氣也能使肺組織復(fù)張但是 大部分肺組織可能仍未充分復(fù)張?jiān)谟邢薜奈鼩鈺r(shí)間內(nèi)在目標(biāo)氣道峰壓水平由于塌陷肺泡表面液體的粘滯性這些肺單位較高的表面張力間質(zhì)組織的限制塌陷的肺組織需要較高的氣道壓力和較長(zhǎng)的時(shí)間才能復(fù)張 ARDS患者的肺復(fù)張 91 Howhighapressure Howlongatime healthylung transpulmonarypressureof30cmH2OtorecruitatelectatichealthylungsGreavesetalJAP1990peakalveolarpressuresof40cmH2Ofor7to15secondstorecruitlungsofpreviouslyhealthynormalpatientsfollowing20minutesofgeneralanesthesiabyRothenetalBrJAnaesth1993 1998resolutionofatelectasisduringa40cmH2ORMhasatimeconstantof2 6secRothenetalBrJAnaesth1999 ARDS患者的肺復(fù)張 92 Howhighapressure Howlongatime healthylung Asaresultinpreviouslyhealthyindividualsthevastmajorityofatelectasiswouldberecruitedwithinabout7 8sec ARDS患者的肺復(fù)張 93 Howhighapressure Howlongatime animal peakairwaypressuresof55cmH2Ofor5 10mintoopencollapsedlunginaporcinemodelofARDSSjosrandetalICM1995tomaximallyrecruitlunginasheepsalinelavagelunginjuredmodel40cmH2OPEEP 20cmH2OPC Ppeak60cmH2O I Eof1 1 andarateof10bpmfor2minutesFujinoetalAJRCCM1999 ARDS患者的肺復(fù)張 94 Howhighapressure Howlongatime animal animalsrecruitedwith40cmH2OCPAPfor60secnotmaximallyrecruitedtofullyrecruitthelungmultiple 2 3 RMsrequiredevenatpeakpressuresof60cmH2O ARDS患者的肺復(fù)張 95 Howhighapressure Howlongatime patient peakairwaypressureof46cmH2OtorecruitcollapsedlunginARDSpatientsGattinonietalAJRCCM198635 40cmH2OCPAPfor30 40secpriortoestablishingalungprotectiveventilatorystrategywhenevermechanicalventilationwasdisruptedAmatoetalNEJM1998 ARDS患者的肺復(fù)張 96 Howhighapressure Howlongatime patient InapatientwithsepticARDSinitialrecruitmentmaneuverswith40cmH2OCPAPfor40secfailedPEEP40cmH2OPEEPandPCV20cmH2OatanI Eratioof1 1witharateof10bpmfor2minutestofullyrecruitthelungMedoffetalCCM2000 ARDS患者的肺復(fù)張 97 Howhighapressure Howlongatime patient ThesuccessofPCvsCPAPintheexamplesemphasizetherelationshipbetweenpressureandtimeFujinoetalAJRCCM1999MedoffetalCCM2000Theoptimalrelationshipbetweenthesetwovariablestomaximizeefficacyandmaintainsafetyremainsunclear ARDS患者的肺復(fù)張 98 Mechanismoflungrecruitment First theairwaysmustbeo