醫(yī)學資料ARDS患者的肺復(fù)張

1、ARDS患者的肺復(fù)張北京協(xié)和醫(yī)院杜斌2021/7/19 星期一內(nèi)容小潮氣量通氣的問題肺復(fù)張的理論與實踐肺復(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)張存在的問題2021/7/19 星期一內(nèi)容小潮氣量通氣的問題肺復(fù)張的理論與實踐肺復(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)張存在的問題2021/7/19 星期一ARDS的肺保護性通氣策略患者數(shù)潮氣量病死率作者小潮氣量對照小潮氣量對照小潮氣量對照P值A(chǔ)mato29246.1 0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.

2、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 1.234550.0412021/7/19 星期一ARDS的肺保護性通氣策略小潮氣量(6 ml/kg IBW)避免過度膨脹造成的容積傷(volutrauma)足夠的PEEP防止肺泡復(fù)張造成的剪切力損傷(atelectrauma)2021/7/19 星期一肺泡塌陷與復(fù)張造成的剪切力F = PL x (V0/V)2/3F:剪切力P

3、L:跨肺壓V0:最初容積V:復(fù)張后容積如果:PL = 30 cmH2O, V0/V = 1/10則:F = 140 cmH2OMead J, Takishima T, Leith D. Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 1970; 28(5): 596-6082021/7/19 星期一小潮氣量通氣的問題LVt(n = 15)CVt(n = 15)P valueVt, ml411 55664 84 0.01Vt, ml/kg6 110 1 0.01setPEEP, cmH2O

4、10 410 4n.s.PEEPtot, cmH2O11 411 4n.s.Pplat, cmH2O23 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: 1609-16132021/7/19 星期一小潮氣量通

5、氣的問題LVt(n = 15)CVt(n = 15)P valuePaO2, mmHg136 80156 82n.s.PaO2/FiO2, mmHg165 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, Broch

6、ard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-16132021/7/19 星期一小潮氣量通氣的問題Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Re

7、spective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-16132021/7/19 星期一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(?)2021/7/19 星期一內(nèi)容小潮氣量通氣的問題肺復(fù)張的理論與實踐肺復(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)張存在的問題2021/7/19 星期一肺泡的開放壓與閉合壓2021/7/19 星期一PEEP不能

8、使肺復(fù)張2021/7/19 星期一LIP: 僅僅是肺復(fù)張的開始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: 194-202.2021/7/19 星期一Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. PressureVolume Curves and Complian

9、ce in Acute Lung Injury: Evidence of Recruitment Above the Lower Inflection Point. Am J Respir Crit Care Med 1999; 159: 1172-1178低位轉(zhuǎn)折點之上仍有肺組織復(fù)張2021/7/19 星期一肺泡的開放壓與閉合壓2021/7/19 星期一肺泡開放壓與閉合壓0102030405005101520253035404550Opening pressurePaw (cmH2O)Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G

10、, 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 pressure2021/7/19 星期一ARDS的肺開放EditorialOpen up the lung and keep the lung openB. LachmannDept. of Anesthesiology, Erasmus Univers

11、ity Rotterdam, The Netherlands(1992) 18:319-3212021/7/19 星期一RM能夠使肺開放RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 minHalter JM, 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/Der

12、ecruitment. Am J Respir Crit Care Med 2003; 167: 1620-16262021/7/19 星期一肺復(fù)張能夠改善ARDS氧合Lapinsky SE, Aubin M, Mehta S, Boiteau P, Slutsky AS: Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure. Intensive Care Med 1999, 25: 1297-1301.2021/7/19 星期一肺復(fù)張的

13、各種方法CPAP (SI)incremental PEEPPCVSigh (modified)HFOV俯臥位2021/7/19 星期一SI改善氧合Tugrul S, Akinci O, Ozcan PE, Ince, S, Esen F, Telci L, Akpir K, Cakar N. Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome: Focusing on pulmonary and extrap

14、ulmonary forms. Crit Care Med 2003; 31: 738-744Sustained Inflation:45 cmH2O x 30 s2021/7/19 星期一SI改善氧合Frank 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

15、 2005; 33: 181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval2021/7/19 星期一嘆氣的設(shè)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 pr

16、eliminary study. Crit Care Med 2001; 29: 1255-1260充氣階段, 每30秒PEEP增加5 cmH2OVt減少2 ml/kg前2次呼吸除外直至Vt 2 ml/kg, PEEP 25 cmH2O暫停階段CPAP 30 cmH2Ofor 30 s放氣階段2021/7/19 星期一嘆氣改善氧合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 recruitme

17、nt maneuver in patients with acute respiratory distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-12602021/7/19 星期一嘆氣對氧合及呼吸力學的影響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 C

18、are Med 1999; 159: 872-880Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O2021/7/19 星期一嘆氣的設(shè)置Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ven

19、tilation. Anesthesiology 2002; 96: 788-94Baseline:PSVSigh:BIPAPPEEPhigh =1.2 x PIPpsv or35 cmH2OTi,s = 3 5 sf = 1 bpm2021/7/19 星期一嘆氣改善呼吸力學及氧合Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory

20、 Distress Syndrome Undergoing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-942021/7/19 星期一ARDS對RM的反應(yīng)Villagra A, Ochagavia A, Vatus S, Murias G, Fernandez MF, Aguilar JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndro

21、me. Am J Respir Crit Care Med 2002; 165: 165-1702021/7/19 星期一肺復(fù)張 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: 1351-13592021/7/19 星

22、期一肺復(fù)張 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: 1351-13592021/7/19 星期一內(nèi)容小潮氣量通氣的問題肺復(fù)張的理論與實踐肺復(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)

23、張的副作用肺復(fù)張存在的問題2021/7/19 星期一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: 71-802021/7/19 星期一RM vs. PEEPLim CM, Lee SS, Lee JS,

24、 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: 71-802021/7/19 星期一RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometri

25、c Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-802021/7/19 星期一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 Cani

26、ne Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-802021/7/19 星期一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 20

27、03; 99: 71-802021/7/19 星期一內(nèi)容小潮氣量通氣的問題肺復(fù)張的理論與實踐肺復(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)張存在的問題2021/7/19 星期一為什么肺復(fù)張作用不能持久?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/cm

28、H2O)34.1 12.636.9 15.135.7 13.5Oczenski W, Hrmann C, Keller C, Lorenzl 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: 620-52021/7/19 星期一

29、為什么肺復(fù)張作用不能持久?肺復(fù)張的方法?SI: 50 cmH2O x 30 s作者認為Oczenski W, Hrmann C, Keller C, Lorenzl 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: 620-52

30、021/7/19 星期一RM + PEEP vs. RM vs. PEEPLim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim 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

31、 the patient. Crit Care Med 2003; 31: 411-4182021/7/19 星期一RM + PEEP vs. RM vs. PEEPLim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological categor

32、y of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418RM + PEEPRM only2021/7/19 星期一RM后的PEEP2021/7/19 星期一RM后的PEEP能夠穩(wěn)定肺泡Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Pre

33、vents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-16262021/7/19 星期一RM后的PEEP能夠穩(wěn)定肺泡RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEEP 10 cmH2OHalter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory

34、 Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-16262021/7/19 星期一肺泡穩(wěn)定能夠改善PaO2McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic ulmonary vasoconstriction. Crit Care med 2002; 30: 13

35、15-13212021/7/19 星期一RM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 lung injury. Crit Care Med 2004; 32: 2371-23772021/7/19 星期一RM + PEEP vs. PEEP onlyLim CM, Adams AB, Simonson DA, Dries

36、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 only2021/7/19 星期一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20 cmH2O然后將FiO2減小到最低水平維持SpO2 90 95%每20 30分鐘降低PEEP 2 cmH2O直

37、至患者SpO2下降2021/7/19 星期一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, 則需重復(fù)肺復(fù)張操作, 然后把PEEP和FiO2重新設(shè)置在上述水平對于多數(shù)ARDS患者, PEEP介于15 20 cmH2O之間某些患者 20 cmH2O2021/7/19 星期一PEEP的設(shè)置如果將PEEP設(shè)置于20 cmH2O后, 仍發(fā)現(xiàn)PaO2/FiO2顯著下降按照最初的PEEP設(shè)置25 cmH2O重復(fù)肺復(fù)張然后按照上述方法調(diào)節(jié)FiO2和PEEP2021/7/19 星期一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

38、, 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2021/7/19 星期一PEEP/FiO2的調(diào)整推薦意見降低PEEP之前應(yīng)當首先降低FiO2, 以避免肺泡塌陷一般情況下FiO2應(yīng)當減低到 5 min)時如果沒有觀察到氧合下降, 則需要每日進行一次或兩次肺復(fù)張未知2021/7/19 星期一總結(jié)肺復(fù)張是肺保護性通氣策略的重要組成開放肺并維持肺開放是其理論基礎(chǔ)應(yīng)用氣道高壓使塌陷肺泡開放應(yīng)用足夠的PEEP維持肺泡開放肺復(fù)張對循環(huán)的影響肺復(fù)張尚未解決的問題壓力時間頻率適應(yīng)癥2021/7/19 星期一2021/7/19 星期一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)張對于ARDS, 將壓力持續(xù)維持在常用的PEEP水平( 300 mmHg2021/7/19 星期一2021/7/19 星期一The P-V CurveOn the inflatio