肺保護(hù)機(jī)械通氣2009seminar-課件

1、Lung Protective Mechanical Ventilation肺保護(hù)性機(jī)械通氣Adoption & discussion張翔宇急救重癥科上海同濟(jì)大學(xué)上海市第十人民醫(yī)院Lung protective strategy Ventilator Induced Lung Injury, VILILung protective strategy PEEP VT Recruitment Maneuver, RM PIP=? Pplateau=? Mode ?Ventilator Induced Lung InjuryVILI Overdistention Barotrauma Volutra

2、uma Recruitment/Derecruitment Injury Translocation of Cells BiotraumaVILI： Recruitment/Derecruitment Injury PIP=14, PEEP=0PIP= 45, PEEP=10PIP= 45, PEEP = 0Webb&Tierney ARRD 1974;110;556Ventilation Strategies & BAL CytokinesTremblay, Valenza, Ribeiro, Li, Slutsky J Clinical Investigation 99:944-52, 1

3、99773MVHP1510HVZPCcontrol40identical dV/dtVT(cc/kg)PEEP cm H2O15MVZP1002001,2001,400*CMVHPMVZPHVZPTNF-a, pg/ml50倍！Serum Cytokines in Acid Aspiration ModelChiumello, Pristine, Slutsky AJRCCM 1999;160:109-16Vt, ml/kgPEEP, cmH2OHVZPHVPLVZPLVP16165555Cytokines in HumansStuber et al Int Care Med 2002;28:

4、834-841JAMA 289:2104-2112,2003Systemic Effects of VILIImai et al JAMA 289:2104-2112,2003BiophysicalInjury shear overdistention cyclic stretch D intrathoracicpressure alveolar-capillarypermeability cardiac output organ perfusionBiochemical Injury (Biotrauma)mfcytokines, complement,PGs, LTs, ROS,prote

5、asesbacteriaEpithelium/interstitiumneutrophilsDistal Organ DysfunctionMechanical VentilationSlutsky, Tremblay Am J Resp Crit Care Med. 1998;157:1721-5DEATHProtect the lungs? PEEP=? VT=? PIP=? Pplateau=? RM ?PEEP=? PEEP/FiO2 combination? X! ARDSnet, 2000, NEJM, 2000; 18: 1301中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)分會(huì)急性肺損傷/急性呼吸窘迫綜合

6、征診斷與治療指南2006推薦意見7：對(duì)ARDS患者實(shí)施機(jī)械通氣時(shí)應(yīng)采用肺保護(hù)性通氣策略，氣道平臺(tái)壓不應(yīng)超過30-35cmH2O推薦級(jí)別：B級(jí)推薦意見8：可采用肺復(fù)張手法促進(jìn)ARDS患者塌陷肺泡復(fù)張，改善氧合推薦級(jí)別：E級(jí)ALI/ARDS指南： 中華內(nèi)科雜志,2007, 46(5):430-435推薦意見9：應(yīng)使用能防止肺泡塌陷的最低PEEP，有條件情況下，應(yīng)根據(jù)靜態(tài)P-V曲線低位轉(zhuǎn)折點(diǎn)壓力+2cmH2O來確定PEEP推薦級(jí)別：C級(jí)推薦意見10：ARDS患者機(jī)械通氣時(shí)應(yīng)盡量保存自主呼吸推薦級(jí)別：C級(jí)推薦意見11：假設(shè)無禁忌證，機(jī)械通氣的ARDS患者應(yīng)采用30-45度半臥位推薦級(jí)別：B級(jí)推薦意見1

7、2：常規(guī)機(jī)械通氣治療無效的重度ARDS患者，假設(shè)無禁忌證，可考慮采用俯臥位通氣推薦級(jí)別：DSSC 2021Crit Care Med 2021 Vol. 36, No. 1SSC 2021推薦對(duì)ALI/ARDS病人應(yīng)用6ml/kg預(yù)測(cè)體重的目標(biāo)潮氣量。1B推薦對(duì)ALI/ARDS病人進(jìn)行平臺(tái)壓監(jiān)測(cè)，對(duì)于被動(dòng)通氣的病人初始平臺(tái)壓目標(biāo)設(shè)定在30cmH2O;檢測(cè)平臺(tái)壓時(shí)應(yīng)當(dāng)考慮到胸廓的順應(yīng)性。1C推薦對(duì)ALI/ARDS病人在必要降低平臺(tái)壓或減少潮氣量時(shí)施行允許性高碳酸血癥PaCO2水平高于病前。1CSSC 20214. 推薦設(shè)定PEEP以阻止張開的肺在呼氣末塌陷。1C5. 建議在有經(jīng)驗(yàn)的單位，對(duì)于需要

8、可能有害的FiO2和平臺(tái)壓的ALI/ARDS病人在沒有不良后果高風(fēng)險(xiǎn)的條件下應(yīng)用俯臥位通氣。2C6a. 除非有禁忌，推薦機(jī)械通氣的病人床頭抬高減少誤吸風(fēng)險(xiǎn)，防止呼吸機(jī)相關(guān)性肺炎 。1B6b. 建議床頭抬高3045.2C7. 建議無創(chuàng)通氣NIV只能在少數(shù)輕中度低氧的、血流動(dòng)力學(xué)穩(wěn)定的、易于喚醒的、能夠自我呼吸道保護(hù)的、能自主咳痰的、能很快恢復(fù)的ALI/ARDS病人考慮應(yīng)用。SSC 20218. 推薦制定一套適當(dāng)?shù)拿摍C(jī)方案，當(dāng)患者還須滿足以下條件時(shí)常規(guī)對(duì)機(jī)械通氣患者施行自主呼吸試驗(yàn)以評(píng)估脫離機(jī)械通氣的能力，：可喚醒，血流動(dòng)力學(xué)穩(wěn)定不用升壓藥，沒有新的潛在嚴(yán)重疾患，只需低通氣量和低PEEP，面罩或鼻

9、導(dǎo)管給氧可滿足吸氧濃度要求。應(yīng)選擇低水平壓力支持、持續(xù)氣道正壓CPAP，5cmH2O或T管進(jìn)行自主呼吸試驗(yàn)1A。9. 不推薦對(duì)ALI/ARDS患者常規(guī)應(yīng)用肺動(dòng)脈導(dǎo)管1A。10. 對(duì)已有ALI且無組織低灌注證據(jù)的患者，推薦保守補(bǔ)液策略，以減少機(jī)械通氣和住ICU天數(shù)1C。潮氣量 VT 6 ml/kg Pplateau Puip Pplateau 30cmH2O肺復(fù)張術(shù)Lung recruitment maneuver, RM SI PC Stepwise RMRecruitment ManeuverMassachusetts General HospitalPerformance of RM MG

10、H30 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 35 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 secAllow 15 to 20 minutes between RMPerformance of RM MGHSet FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple RMsM

11、onitoring during RM (MGH)The RM should be aborted if:MAP 20 mmHgSpO2 130 or 400 mmHgAmatoARDS protocolRecruitFIO2 = 1Titrate PEEPTitrate PdrivingWAIT( 15 )FIO2 30%( High PEEP + PSV )WAITFIO2 30%( High PEEP + PSV )Decrease PS down to 8Decrease PEEP down to 12NIMV(CPAP = 12, PS = 8)PEEP / FIO2 target

12、( 814 cmH2O)PEEP at PFLEX ( 1418 cmH2O)PEEP enough to fully avoid airway collapse ( 1626 cmH2O)Amato: 2004 China張翔宇的 方 法 所有患者均行有創(chuàng)動(dòng)脈壓持續(xù)監(jiān)測(cè) SpO2持續(xù)監(jiān)測(cè) CVP持續(xù)監(jiān)測(cè) 清醒患者適當(dāng)鎮(zhèn)靜 復(fù)張術(shù)RM前排除氣壓傷 排除肺氣腫患者 Protocol Mode: PEEP+PCV or PEEP+PSV PEEP: increment 2 cmH2O Interval: 2 min PEEP target: 16/1st RM, 20/2nd RM, 2630/3

13、rd RM PIPmax: 45 cmH2O Abort if ABP or SpO2 start fall Rest interval: 1530 min May repeat twice a day結(jié) 果心臟外科術(shù)后低氧患者 有效：100% PaO2/FiO2 improve：110%36% 無并發(fā)癥多發(fā)傷并發(fā)ALI/ARDS患者有效：92% PaO2/FiO2 improve：86%32%無并發(fā)癥 軍團(tuán)菌病1例，無效，出現(xiàn)氣壓傷 RM一次，PEEPmax: 22, PIPmax: 32縱隔氣腫臨床觀察252例次RM有93次血壓短暫降低37%出現(xiàn)血壓下降的PEEP水平為623cmH2O,平

14、均13.9cmH2OPEEP降低之后動(dòng)脈恢復(fù)到原來水平所有病人有創(chuàng)持續(xù)血壓監(jiān)測(cè)1例經(jīng)心超證實(shí)卵圓孔未閉，在PEEP=6時(shí)發(fā)生右向左分流，同時(shí)SpO2下降張翔宇，等，中國(guó)危重病急救醫(yī)學(xué)，2007，199Crit Care Med 2007 Vol. 35, No. 1Fernando Suarez-Sipmann, et al Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental studyEight healthy pigsLung lavage

15、sCT slices were obtained 2 cm cranial of the right diaphragmatic domeProtocolResultSuarez-Sipmanns clusiondynamic compliance identified the beginning of lung collapse in a pig model.the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying the level

16、of PEEP that prevents end-expiratory lung collapse？Bobs new protocol 2007Performance of RMSet FIO2 at 1.0Allow time for stabilizationInsure appropriate sedationInsure hemodynamic stabilityBobs new protocolPerformance of RM - PCVPressure control ventilation:PEEP 20-30 cmH2OPeak Inspir Press 40-50 cmH

17、2OInspir Time: 1 to 3 secRate: 8 to 20/ minTime 1 to 3 minSet PEEP at 20, ventilate VC, VT 4 to 6 ml/kg PBW, increase rate, avoid auto-PEEPMeasure dynamic complianceDecrease PEEP 2 cm H2OBobs new protocolPerformance of RM - PCVMeasure dynamic complianceRepeat until max compliance determinedOptimal P

18、EEP max comp PEEP+2 to 3 cm H2ORepeat recruitment maneuver and set PEEP at the identified settings, adjust ventilationAfter PEEP and ventilation set and stabilized, decrease FIO2 until PO2 in target rangeIf response is poor, repeat RM, PEEP 25, Peak Pressure 45If response is poor, repeat RM, PEEP 30

19、, Peak Pressure 50Bobs new protocol 2007Lung RecruitmentPerform early in ARDSIdeal approach to RM most likely PC, limited patient data available using PC!Works better in extra pulmonary than primary ARDS?More difficult to recruit the lung the stiffer the chest wall!Start with low pressure, increase

20、as tolerated and needed!If benefit lost after RM, PEEP inadequate!Bobs new protocolA comparison of methods to identify open-lung PEEP.Caramez MP, Kacmarek RM, et al In this animal model of ARDS, dynamic tidal respiratory compliance, maximum PaO2, maximum PaO2 + PaCO2, minimum shunt, inflation lower

21、Pflex and Pmci,i yield similar values for PEEP following a recruitment maneuver.Intensive Care Med. 2009 Apr;35(4):740-7. Patients ( n=549 ) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 12.9 4 8.4 4 RR (b/min) 30 TV ( ml /Kg ) 6 The NIH randomized multicenter study assessing the effect on mortality of l

22、ow vs high PEEP in ARDS New Engl J Med 2004; 351: 327-336NIHPEEP selected according to a Table to achieve minimal physiological oxygenation (88-95%) Patients ( n=983) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 16.3 3 RR (b/min) 30 TV ( ml /Kg ) 6 9.1 4The LOVS: Lung Open Ventilation Canadian Study Can

23、adianTrial Oxygenation was better in High PEEP Compliance was better in High PEEP Less rescue therapies in High PEEP0,40,50,60,70,80,910102030405060Days after randomizationProbability of survivalLow PEEPHigh PEEPPEEP selected according to a table to achieve minimal physiological oxygenation + RMStew

24、art T et al JAMA. 2021;299(6):637-645 Patients ( n=752 ) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 14.9 4 RR (b/min) 30 TV ( ml /Kg ) 6 7.4 4French Trial“ExpressPEEP selected to avoid overdistension or to achieve maximal recruitmentPEEP set for PEEP tot 5-9 cmH2O PEEP set for Plat 28-30 cmH2O Oxygena

25、tion was better in Max distension Higher ventilation free days in Max distension Higher organ failure free days in Max distensionMercat A et al JAMA. 2021;299(6):646-655The Express Study: randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDS Critical Care 2021, 1

26、3:R22 Younsuck Koh, et alEfficacy of positive end-expiratory pressure titration after thealveolar recruitment manoeuvre in patients with acute respiratorydistress syndromeCritical Care 2021, 13:R22 Younsuck Koh, et alEfficacy of positive end-expiratory pressure titration after thealveolar recruitmen

27、t manoeuvre in patients with acute respiratorydistress syndrome. Younsuck Koh, et alCritical Care 2009, 13:R22MARCELO AMATO, M.D.,et al. (N Engl J Med 1998;338:347-54.)EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROMEMechanical Ventilation Guided by Esophageal Pressure in Acute Lung InjuryN Engl J Med 2008;359:2095-104.N Engl J Med 2021;359:2095-104N Engl J Med 2021;359:2095-104N Engl J Med 360;8 February 19, 2021N Engl J Med 359;20, november 13, 2021Effect of the chest wall on pressurevolume curve analysis