ARDS機械通氣：怎樣應(yīng)對高碳酸血癥MechanicalventilationinARDS

1、ARDS機械通氣：怎樣應(yīng)對高碳酸血癥MechanicalventilationinARDS Carefusion Drger Medical Hamiltion Maquet Medtronic (former Covidien) Taema病例摘要 男性，70歲，2001年1月9日入院 IBW 60 kg 咳嗽，咳痰12天，發(fā)熱4天，呼吸困難1天 12天前咳嗽, 咳黃粘痰, 伴全身乏力 4天前 寒戰(zhàn)高熱，體溫39.5C CXR：肺部感染，右上肺膨脹不全 頭孢呋肟治療無效 1天前呼吸困難，紫紺，伴血壓下降(50/20 mmHg)病例摘要入ICU時 BT 37.2C HR 130 bpm BP

2、84/40 mmHg (DA 10 g/kg/min) SpO2 78% RA 雙肺散在濕羅音病例摘要病例摘要 呼吸支持(CMV) FiO2100% PEEP15 cmH2O Vt360 ml RR20 bpm ABG pH7.15 PaCO265 mmHg PaO260 mmHg HCO322 mmol/L如何有效降低PaCO2降低PaCO2的方法 增加MinVent 增加Vt 加快RR 減少Vd/Vt 減少VCO2PaCO2 VCO2MinVent (1 Vd/Vt)增加Vt伴隨Pplat升高延長Tins增加FlowPplatPplatPplat增加Vt伴隨Pplat升高pH 7.15,

3、PaCO2 65 mmHgPplat 30 cmH2O?增加Vt至7 ml/kgPplat 35 cmH2O?YN氣壓傷風(fēng)險增加降低PaCO2的方法 增加MinVent 增加Vt視Pplat而定 加快RR 減少Vd/Vt 減少VCO2PaCO2 VCO2MinVent (1 Vd/Vt)增加RR提高MinVent低RR高RRRR, bpm17 330 3 0.01MinVent, lpm7.4 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,

4、et al. Influence of respiratory rate on gas trapping during low volume ventilation of patients with acute lung injury. Intensive Care Med 2002; 28: 1078-1083增加RR提高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

5、, 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: 1407-1412增加RR提高MinVentTexp增加RR提高MinVentTexp增加RR提高MinVentTexp增加RR提高MinVentRR 15 bpmRR 30 bpmPEEPi, cmH2O0.3 0.26.4 2.7 0.05FRC, ml329 1004

6、93 146 0.05MinVent, 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: 1125-1133降低PaCO2的方法 增加MinVent 增加Vt視Pplat而定 加快RR視呼氣流量時間曲線而定 減少Vd/Vt視HME和延長管使用情況而定 減少VCO2視患者自主呼吸及躁動情況而定PaCO2 VCO2MinVent (1 Vd/Vt)

7、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呼氣流量時間曲線提示無法增加RR減少Vd/Vt沒有使用HME和延長管減少VCO2患者深度鎮(zhèn)靜，無自主呼吸ARDS患者的俯臥位通氣改善氧合Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone positioning on the survival of patients

8、 with acute respiratory failure. N Engl J Med 2001; 345: 568-573ARDS患者的俯臥位通氣改善氧合Sud S, Friedrich JO, Adhikari NKJ, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ 2014;

9、186: E381-E390ARDS患者的俯臥位通氣改善氧合俯臥位改善PaO2/FiO2PEEP降低Pplat降低增加Vt病例摘要 呼吸支持(CMV) FiO2100% PEEP15 cmH2O Pplat35 cmH2O Vt360 ml RR20 bpm ABG pH7.15 PaCO265 mmHg PaO260 mmHg HCO322 mmol/L假設(shè)：俯臥位后PaO2 150 mmHg，順應(yīng)性從18 ml/cmH2O增加到25 ml/cmH2O措施：調(diào)整PEEP 10 cmH2O，此時Pplat 24.5 cmH2O (Vt 360 ml)若允許Pplat 30 cmH2O，則Vt可

10、增加至500 mlARDS患者的俯臥位通氣Gattinoni L, Vagginelli F, Carlesso E, et al. Decrease in 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)俯臥位后PaCO2下降-6.0 5.6 mmHg(p 0.0001)病例摘要 呼吸支持(CMV) FiO2100% PEEP15 cmH2O Ppl

11、at35 cmH2O Vt360 ml RR20 bpm ABG pH7.15 PaCO265 mmHg PaO260 mmHg HCO322 mmol/L若俯臥位后PaO2沒有任何改善，還有什么措施降低PaCO2?降低PaCO2的其他措施 碳酸氫鈉? 高頻振蕩通氣(HFOV)? 體外膜氧合(ECMO) 體外CO2清除(ECCO2R) 允許性低氧血癥?906025珠峰攀登者的動脈氧合Grocott MP, Martin DS, Levett DZ, et al. Arterial blood gases and oxygen content in climbers on Mount Evere

12、st. N Engl J Med 2009; 360: 140-149珠峰攀登者的動脈氧合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: 140-149機械通氣患者的保守性氧療Suzuki S, Eastwood GM, Glassford NJ, et al. Conservative oxygen therapy in mechanically ventilated pa

13、tients: a pilot before-and-after trial. Crit Care Med 2014; 42: 1414-1422機械通氣患者的保守性氧療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: 1414-1422事件數(shù)（傳統(tǒng)氧療 : 保守氧療）校正后OR新發(fā)非呼吸器官功能衰竭22 : 160.

14、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)0.062危重病患者的高氧Damiani E, Adrario E, Girardis M, et al. Arterial hyperoxia and mortalidy in critically ill patients: a systematic review and meta-analysis. Crit Care 2014; 18: 711事件數(shù)（傳統(tǒng)氧療 : 保守氧療）異質(zhì)性I2心跳驟停后1.42 (1.04 1.92)67.

15、73%0.0280.015卒中1.23 (1.06 1.43)0%0.0050.844顱腦創(chuàng)傷1.41 (1.03 1.94)64.54%0.0320.024早產(chǎn)兒的保守性氧療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: 2111-212

16、01201名早產(chǎn)兒孕周23+0周至27+6周調(diào)整FiO2以維持SpO2 88 92%602名早產(chǎn)兒隨機分至SpO2 85 89%599名早產(chǎn)兒隨機分至SpO2 91 95%顯示顯示SpO2 88 92%SpO2 高于實際值高于實際值3%實際實際SpO2 85 89%顯示顯示SpO2 88 92%SpO2 低于實際值低于實際值3%實際實際SpO2 91 95%早產(chǎn)兒的保守性氧療Schmidt B, Whyte RK, Asztalos EV, et al. Effects of targeting higher vs lower arterial oxygen saturations on de

17、ath or disability in extremely preterm infants: a randomized clinical trial. JAMA 2013; 309: 2111-2120早產(chǎn)兒的保守性氧療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. J

18、AMA 2013; 309: 2111-2120SpO2 85% 89%SpO2 91% 95%死亡或殘疾51.6% (298/578)49.7% (283/569)aOR 1.06 (0.83 1.37)18個月內(nèi)死亡16.6% (97/585)15.3% (88/577)GMFCS 2 56.1% (30/488)6.4% (31/488)認(rèn)知或語言延遲40.0% (190/475)39.9% (191/479)嚴(yán)重聽力喪失3.7% (18/487)2.5% (12/489)雙眼盲1.0% (5/487)0.6% (3/488)氧代謝的生理學(xué)DO2I= 10 x CI x CaO2 = 1

19、0 x CI x (0.0031 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 較基礎(chǔ)值降低較基礎(chǔ)值降低18%氧代謝的生理學(xué)DO2I= 10 x CI x CaO2 = 10 x CI x (0.0031 x PaO2 + 1.34 x Hb x SaO2)當(dāng)當(dāng)CaO2降低降低18%時時從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%，那么氧輸送即可維持不變，那么氧輸送