醫(yī)學(xué)資料ARDS肺復(fù)張的實(shí)施(邱海波)

1、邱海波東南大學(xué)附屬中大醫(yī)院ICU東南大學(xué)急診與危重病醫(yī)學(xué)研究所ARDS肺復(fù)張的實(shí)施科學(xué)與藝術(shù)的困惑2021/7/19 星期一內(nèi)容提要肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM 2021/7/19 星期一ARDSnet: 小潮氣量通氣Low Tidal VolumesTraditional Tidal VolumesP-valueDeath before discharge home and breathing without assistant (%)31.0

2、39.80.007Breathing without assistance by days (%)65.755.00.001NO of ventilator free days Day1-28121110110.007Boratrauma, Day1-28(%)10110.43NO of days without failure of nonpulmonary organs or systems Day1-28151112110.006ARDS Net. N Engl J Med. 2000 May 4;342(18):1301-8.2021/7/19 星期一Low tidal volume:

3、 more alv collapse小Vt不能復(fù)張塌陷肺泡，加重低氧血癥實(shí)施肺保護(hù)性通氣策略至少1525%患者需提高FiO2邱海波, 劉大為, 陳德昌等. 中華麻醉學(xué)雜志, 1998, 18: 202-2052021/7/19 星期一Collapsed airwayV1V2PressureVolumeV1V1 + V2Opening pressureNormalARDSPEEP adjustmentLIP：塌陷肺泡開始復(fù)張的壓力 不是全部塌陷肺泡復(fù)張的壓力PEEP not enough: more alv keep collapse2021/7/19 星期一30 kg PigPost Lava

4、gePCVPaw 13 cmH2O PEEP 5 cmH2OExperimental study-Pig with ARDS2021/7/19 星期一許紅陽(yáng)，邱海波. ARDS綿羊肺復(fù)張容積測(cè)定方法的比較. 中國(guó)危重病急救醫(yī)學(xué)， 2004, 16: 413.邱海波. PEEP對(duì)ARDS肺復(fù)張容積及氧合影響的臨床研究. 中國(guó)危重病急救醫(yī)學(xué)，2004, 16: 399.Clinical Trial11 ARDS pats2021/7/19 星期一內(nèi)容提要肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHi

5、gh VT and sighRM 2021/7/19 星期一A. Hypoxamia B. Shear forcesC. Surfactants inactivate D. Biotrauma and MODSPathophysiology Consolidation and alv collapse2021/7/19 星期一A .低氧血癥肺泡塌陷：ARDS重力依賴區(qū) 炎癥或不張區(qū)生理性低氧縮血管反應(yīng)：障礙2021/7/19 星期一How Does Excessive Mechanical Stress Inflame the Lung?“Shear”2021/7/19 星期一Verbrugg

6、e et al. Crit Care Med 1999;27：779Ventilator-associated lung injuryPurine: a marker of ATP breakdown and VILI42 SD ratsPCV 6minPCV Pre/PEEPBALF purine and protein2021/7/19 星期一Lachmann. ICM, 1994; 20:6-11Intra-alveolar proteins inactivate alv surfactant in a dose-dependent way1mg surfactant = inhibit

7、ory effect of 1mg plasma proteinC. Surfactant 滅活 2021/7/19 星期一Surfactant move away When lung regions collapse at end expiration, 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: 1

8、182 2021/7/19 星期一D. 預(yù)防Biotrauma和MODSMarini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two Crit Care Med. 2004 Jan;32(1):250-5.“Stretch”“Shear”Airway Trauma2021/7/19 星期一內(nèi)容提要肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh

9、VT and sighRM 2021/7/19 星期一俯臥位通氣的病理生理特征改善通氣過(guò)程 胸膜腔壓力梯度 順應(yīng)性胸壁促進(jìn)分泌物的清除ClosingpressureClosing pressure2021/7/19 星期一Time course of Prone on PaO2/FiO2 between ARDSp vs ARDSexp Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp 黃英姿, 邱海波. 肺內(nèi)外源性ARDS實(shí)施俯臥位通氣時(shí)間的選擇.中華內(nèi)科雜志2004, 43(12):883-88720

10、21/7/19 星期一內(nèi)容提要肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM 2021/7/19 星期一保留自主呼吸的優(yōu)點(diǎn)2021/7/19 星期一內(nèi)容提要肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighRM 2021/7/19 星期一Paw cmH2O %Opening and Closing Pressures0510152025303

11、540455001020304050 Opening pressureClosing pressure5 patients,ALI / ARDSFrom Crotti et alAJRCCM 2001.Some units cantbe kept open by any reasonable PEEP!2021/7/19 星期一Amato: CT + PV CurveHeartSpPVLIPUIPInsp recruitLarger Vt/Sigh: Pressure must be high enoughEven up to UIP 2021/7/19 星期一內(nèi)容提要肺保護(hù)性通氣策略不能解決

12、解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM 2021/7/19 星期一許紅陽(yáng)，邱海波. ARDS綿羊肺復(fù)張容積測(cè)定方法的比較. 中國(guó)危重病急救醫(yī)學(xué)， 2004, 16: 413.邱海波. PEEP對(duì)ARDS肺復(fù)張容積及氧合影響的臨床研究. 中國(guó)危重病急救醫(yī)學(xué)，2004, 16: 399.Clinical Trial11 ARDS pats2021/7/19 星期一Recruitment is Time-Dependent 40 SECONDS2021/7/19 星期

13、一內(nèi)容提要肺保護(hù)性通氣策略不能解決解決的問(wèn)題肺泡塌陷的病理生理后果肺復(fù)張的臨床實(shí)施Prone positionSpontaneous breathingHigh VT and sighHigh PEEPRM 2021/7/19 星期一 Recruitment mannuversBasic PrinciplesMethods for RecruitmentExperimental Studies and Clinical TrialsEfficacyHazards2021/7/19 星期一1. 控制性肺膨脹(SI)法2. PEEP遞增法3. 壓力控制(PCV)法Methods for Recru

14、itment2021/7/19 星期一CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 將吸氣保持鍵按住，持續(xù)20- 40s控制性肺膨脹(SI)法2021/7/19 星期一Multiple Maneuvers May Be Needed For Optimum RM EffectFujino et al, Crit Care Med 2001; 29(8):1579-15862021/7/19 星期一Post-RM PEEP Determines PaO2Averag

15、ed data from three modelsRMS-C Lim, CCM 2004Transient BenefitPost-RM-PEEP肺開放效應(yīng)持續(xù)時(shí)間的決定因素CCM, 2004, 32: 2371-237728 mixed-breed pigsModels of ARDS:OAVILIPneumonia(PNM)RMSIIncreased PEEPPCV2021/7/19 星期一肺開放后的PEEP選擇-PaO2/FiO21. RM后 PEEP: 20cmH2O2. PEEP遞減: 2cmH2O/5min3. PEEP閾值: PaO2/FiO25%4. PEEP: PEEP閾值

16、+2cmH2O2021/7/19 星期一BASELINE 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肺開放后的PEEP選擇- Stress index2021/7/19 星期一ImplicationsRM 的有效性ALI的病因 (direct vs in direct)Post RM PEEPMethod in certain settingsRM hazards are greatest and effectiveness least in pneumonia-caused acute lung injuryPCV may be better tolerated than SI2021/7/19 星期一RecommendationsUse PCV in p