病理生理基礎(chǔ)課件

1、Stress index病理生理基礎(chǔ)Stress index病理生理基礎(chǔ)Ventilation in ALIBackgroundALI是ICU常見的危重病病理生理特點(diǎn) 肺容積明顯降低 肺順應(yīng)性明顯下降 通氣/血流比例失調(diào)肺組織分布“不均一”Ventilation in ALIBackgroundALTIDAL recruitment end-expiration end-inspirationTIDAL recruitment end-expiraTIDAL hyperinflation end-expiration end-inspirationTIDAL hyperinflation en

2、d-expbackgroundIntensive Care Med,2005, 31:776784backgroundIntensive Care Med,2非重力依賴區(qū)過度膨脹重力依賴區(qū)潮汐性塌陷復(fù)張Best Practice & Research Clinical Anaesthesiology 2010;24:171-182.VILI立項(xiàng)依據(jù)非重力依賴區(qū)過度膨脹重力依賴區(qū)潮汐性塌陷復(fù)張Best PrAlways opening and closingVILITidal collapseVT0 10 20 30 400 10 20 30 40 50%Paw(cmH2O)Closing pr

3、essureOpening pressureCrotti,et al Am J Respir Crit Care Med 2001;164:131-140Always opening and closingVIHEARTSPPEEP-Keep the lung openLow VtRM Open lung BackgroundARDS病理生理變化肺保護(hù)性通氣HEARTSPPEEP-Keep the lung ope機(jī)械通氣患者病死率仍高達(dá)37%Intensive Care Med 2009;35:816825.13,322 pats admitted to 299 ICUs from 35 c

4、ountriesBackground機(jī)械通氣患者病死率仍高達(dá)37%Intensive Care 6mlKg小潮氣量非重力依賴區(qū)肺泡依然過度膨脹 Background中大醫(yī)院重癥醫(yī)學(xué)科預(yù)試驗(yàn)6mlKg小潮氣量非重力依賴區(qū)肺泡依然過度膨脹 Ba重力依賴區(qū)通氣不良和塌陷肺泡明顯增加 Background中大醫(yī)院重癥醫(yī)學(xué)科預(yù)試驗(yàn)重力依賴區(qū)通氣不良和塌陷肺泡明顯增加 Background中HEARTSPAt present：Lung Protective Ventilation Strategies非重力依賴區(qū)肺泡過度膨脹 重力依賴區(qū)肺泡潮汐性塌陷復(fù)張 BackgroundVILI幾乎無處不在潮氣量和P

5、EEP的設(shè)定依然矛盾重重HEARTSPAt present：Lung Protect潮氣量設(shè)置困難個(gè)體化難！重癥ARDS大量肺泡塌陷即使“小”潮氣量仍然導(dǎo)致VILI潮氣量應(yīng)更小VILI塌陷肺泡少“小”潮氣量太小，肺泡通氣無法保證，導(dǎo)致肺泡塌陷顯然，6mlKg的“小”潮氣量不適合所有ARDS潮氣量設(shè)置困難個(gè)體化難！重癥ARDS大量肺泡塌陷The most controversial issue in ALI/ARDS pts The most controversial issue i維持肺開放(Keep Lung Open) -最佳PEEPPEEP水平不足肺泡反復(fù)塌陷、復(fù)張，產(chǎn)生剪切力 VIL

6、IPEEP水平過高肺泡過度膨脹，導(dǎo)致氣壓傷 VILI立項(xiàng)依據(jù)維持肺開放(Keep Lung Open) Methods to titrate PEEP in ALI/ARDSBest PEEP(Suter, NEJM, 1975)Super PEEP(Kirby, Chest, 1975)Pflex(Amato, Am J Respir Crit Care Med, 1995)Oxygenation scale(ARDSnet, NEJM, 2000)Stress index(Ranieri, Anesthesiology, 2000)Pmc(Goddon, Anesthesiology, 2

7、001)FRC+Cst(Lambermont, Critical Care, 2008)Pes(Talmor, NEJM, 2008)Increased recruitment strategy(Mercat, JAMA, 2008)EIT(Meier, ICM, 2008)Which one is best?Methods to titrate PEEP in ALI滴定PEEP的最佳方法簡(jiǎn)便、床邊快速安全可重復(fù)，為PEEP滴定提供可靠信息滴定PEEP的最佳方法簡(jiǎn)便、床邊Stress index-肺牽張指數(shù)容量控制通氣、恒定流速Stress index-肺牽張指數(shù)容量控制通氣、恒定流Stre

8、ss index-肺牽張指數(shù)P-t曲線吸氣支：曲線回歸方程P=a * tb + c b 值：肺牽張指數(shù)描述曲線的形狀，反映肺泡開放與塌陷程度的力學(xué)指標(biāo)Slutsky AS, Aneathiology, 2000,93: 1320-8 Grasso S, Crit Care Med, 2004, 32: 101827Stress index-肺牽張指數(shù)Slutsky ASRanieri VM et al Anesthesiology 2000Stress index-肺牽張指數(shù)Ranieri VM et al Anesthesiolostress index= 1 before RMstress

9、 index = 1 after RM 0.6 stress index 0.8 0.8 stress index 11.1 stress index 1.31.3 stress index 1.5End InspirationEnd Expirationstress index= 1 before RMstresb值與塌陷和過度膨脹b值與塌陷和過度膨脹b值與塌陷和過度膨脹b值與塌陷和過度膨脹肺牽張指數(shù)指導(dǎo)ARDS患者PEEP的選擇14例ARDS患者實(shí)施肺復(fù)張后容量控制通氣用回歸法求得方程: P=a*tb+c. b為肺牽張指數(shù)。復(fù)張后調(diào)整PEEP使b1(0.6b0.8)b=1(0.9b1(1.

10、1b1.3)與復(fù)張前比較，*P0.05; 與復(fù)張后b1比較，#P0.05; 與b=1比較，P0.05黃英姿，邱海波。中華醫(yī)學(xué)雜志。2009,89:2739肺復(fù)張后b=1時(shí)，氧合、順應(yīng)性和肺復(fù)張容積明顯改善肺牽張指數(shù)指導(dǎo)ARDS患者PEEP的選擇14例ARDS患者實(shí)與基礎(chǔ)狀態(tài)比較*P0.05；與氧合法比較P0.05；與肺牽張指數(shù)法比較P0.05；與順應(yīng)性法比較P0.05 *不同方法選擇最佳PEEP的比較 PEEP(cmH2O)與基礎(chǔ)狀態(tài)比較*P0.05；與氧合法比較P0.05；*PaO2/FiO2(mmHg)b值滴定PEEP對(duì)氧合的影響與基礎(chǔ)狀態(tài)比較，*P0.05*PaO2/FiO2(mmHg)

11、b值滴定PEEP對(duì)氧合的影響與*與基礎(chǔ)狀態(tài)比較，*P0.05復(fù)張容積(ml)Cst(ml/cmH2O )b值滴定PEEP對(duì)復(fù)張容積和Cst的影響*與基礎(chǔ)狀態(tài)比較，*P0.05復(fù)張容積(ml)Cst(mlTHE STRESS INDEX CONCEPT: experimental data0.0 0.5 1.0 1.5 2.0.Ranieri VM et al Anesthesiology 20000.0 0.5 1.0 1.5 2.0.THE STRESS INDEX CONCEPT: expTHE STRESS INDEX CONCEPT: experimental dataRanieri

12、VM, Slutsky AS Anesthesiology 2000THE STRESS INDEX CONCEPT: expBAL b=1 during SIventilationb=1 during SIventilationP 0.001b1 during NIHventilationb=1 during NIHventilationP 0.0541010IL-1 b=1，炎癥反應(yīng)降低BAL b=1 b=1 P 0.001b1 b=1 PB值滴定PEEPB值滴定PEEPB值反應(yīng)肺順應(yīng)性的動(dòng)態(tài)變化 btotal tot = 1.00 but the algorithm is still able to distinguish b1 = 0.91 b2 = 1.11KleisTEK - Advanced Electronic Systems, Bari - ItalyB值反應(yīng)肺順應(yīng)性的動(dòng)態(tài)變化 btotal tot = 1.First