ARDS通氣策略宋立強(qiáng)復(fù)習(xí)過程課件

ARDS通氣策略宋立強(qiáng)ARDS通氣策略宋立強(qiáng)

ARDS的發(fā)生機(jī)制？ARDS的發(fā)生機(jī)制？1肺間質(zhì)2肺泡ARDS是一種水循環(huán)障礙的“肺水腫”1肺間質(zhì)ARDS是一種水循環(huán)障礙的“肺水腫”①血流動(dòng)力性肺水腫(hemodynamicpulmonaryedema)毛細(xì)血管靜水壓升高，流入肺間質(zhì)液體增多所形成的肺水腫，但蛋白質(zhì)分子的滲透性，或液體的傳遞方面均無任何變化②通透性肺水腫(permeability

pulmonaryedema

)

不僅肺水通過肺毛細(xì)血管內(nèi)皮細(xì)胞劇增，且蛋白質(zhì)滲透過內(nèi)皮細(xì)胞也增加“肺水腫”分類(按照病因及發(fā)生機(jī)制)ARDS！①血流動(dòng)力性肺水腫(hemodynamicpulmo1.感染性肺水腫(pulmonaryedemaduetoinfection)2.毒素吸入性肺水腫(pulmonaryedemaduetopoison)3.淹溺性肺水腫(pulmonaryedemaduetodrowning)4.尿毒癥性肺水腫(pulmonaryedemainuremia)5.氧中毒肺水腫(pulmonaryedemaduetooxygentoxicity)②通透性肺水腫——病因及分類1.感染性肺水腫(pulmonaryedemadueARDS肺水腫的成分：富含蛋白細(xì)胞碎片未激活的PS中性粒細(xì)胞巨噬細(xì)胞炎癥介質(zhì)......參與反應(yīng)的細(xì)胞——中性粒細(xì)胞巨噬細(xì)胞上皮細(xì)胞內(nèi)皮細(xì)胞參與反應(yīng)的介質(zhì)——氧自由基蛋白溶解酶花生四烯酸代謝物補(bǔ)體系統(tǒng)凝血和纖溶系統(tǒng)PAFTNFIL......ARDS發(fā)病的炎癥機(jī)制ARDS肺水腫的參與反應(yīng)的細(xì)胞——AApexHilumBase病變分布有重力依賴性，從肺前部到背部——

1.正常區(qū)30%

2.陷閉區(qū)20~30%

3.實(shí)變區(qū)40~50%病理生理變化——間歇性分流切變力損傷肺循環(huán)阻力增加病理生理變化——持續(xù)性分流肺循環(huán)阻力增加力學(xué)曲線變化——ApexHilumBase病變分布有重力依賴性，病理生理變化

ARDS的臨床診斷？ARDS的臨床診斷？臨床診斷標(biāo)準(zhǔn)的變遷——AECC定義1967年，Ashbaugh等首先描述“成人中的急性呼吸窘迫”1971年，Petty等正式命名“成人呼吸窘迫綜合征（ARDS）”1992年，美歐共識(shí)會(huì)（American-EuropeanConsensusConference,AECC）

急性呼吸窘迫綜合征（AcuteRespiratoryDiseaseSyndrome，ARDS）

首次提出ALI

提出AECC標(biāo)準(zhǔn)臨床診斷標(biāo)準(zhǔn)的變遷——AECC定義1967年，AshbauAECC標(biāo)準(zhǔn)局限性病程急性起病無具體時(shí)間ALIPaO2/FiO2≤300mmHg誤解201-300mmHg為ALI氧合指數(shù)PaO2/FiO2≤200mmHg，未考慮PEEP水平不同的PEEP及FiO2，PaO2/FiO2也不同胸片雙肺彌漫性浸潤(rùn)缺乏客觀評(píng)價(jià)指標(biāo)PAWPPAWP≤18mmHg，無左心房高壓ARDS及高水平PAWP可同時(shí)存在，PAWP有不確定性AECC診斷標(biāo)準(zhǔn)的局限AECC標(biāo)準(zhǔn)局限性病程急性起病無具體時(shí)間ALIPaO2/FiAnearlyPEEP/FIO2trialidentifiesdifferentdegreesoflunginjuryinpatientswithacuterespiratorydistresssyndrome.AmJRespirCritCareMed.

2007；15;176(8):795-804.例：ARDS患者在不同通氣條件下的變化在（day1）時(shí)間點(diǎn)FiO2≥0.5+PEEP≥10，

30min條件下——重新分類為ARDS,ALI,ARFAnearlyPEEP/FIO2trialident29%ARDS患者PAWP≥18mmHg（或CVP升高）,而其中97%PAWP升高的ARDS患者中有正常的心臟功能。結(jié)論：PAWP或CVP升高不能作為ARDS的排除標(biāo)準(zhǔn)。Pulmonary-arteryversuscentralvenouscathetertoguidetreatmentofacutelunginjury.NEnglJMed.

2006May25;354(21):2213-24.CVPPAWP例：ARDS與PAWP、CVP81829%ARDS患者PAWP≥18mmHg（或CVP升高）,BerlinDefinition2012柏林定義ARDS的診斷及病情分級(jí)發(fā)病時(shí)間1周以內(nèi)起病、或新發(fā)、或惡化的呼吸癥狀2.胸部影像學(xué)雙肺模糊影——不能完全由滲出、肺塌陷或結(jié)節(jié)來解釋3.肺水腫起因不能完全由心力衰竭或容量過負(fù)荷解釋的呼吸衰竭，沒有發(fā)現(xiàn)危險(xiǎn)因素時(shí)可行超聲心動(dòng)圖等檢查排除血流源性肺水腫4.氧合指數(shù)輕度200mmHg<PaO2/FiO2≤300mmHgwithPEEP≥5cmH2O中度100mmHg<PaO2/FiO2≤200mmHgwithPEEP≥5cmH2O重度PaO2/FiO2≤100mmHgwithPEEP≥5cmH2OBerlinDefinition2012柏林定義ARD

傳統(tǒng)機(jī)械通氣的肺損傷？傳統(tǒng)機(jī)械通氣的肺損傷？VentilatorInducedLungInjury，VILIOverdistention過度擴(kuò)張

Barotrauma壓力傷Volutrauma容量傷Recruitment/DerecruitmentInjury

（Atlectrauma）剪切傷/萎陷傷

TranslocationofCells細(xì)胞形態(tài)移位Biotrauma生物傷

OxidantInjury氧中毒

VentilatorInducedLungInjuryOverdistentionBarotrauma&VolutraumaOverdistentionBarotrauma&Vol“Shear”Recruitment/DerecruitmentInjury跨肺壓若用30cmH2O的正壓通氣，則跨肺壓約35cmH2O。兩個(gè)肺單位之間產(chǎn)生高達(dá)140cmH2O的切變力。“Shear”Recruitment/DerecruitTranslocationofCellsByBUBBLEBilek,A.M....D.P.GaverIIIJApplPhysiol94:770-783,2003

DisruptingthealveolarepitheliumTearingincapillaryendotheliumTranslocationofCellsByBUBBBiotruamaIncitingEventPMNs/MacsEndotheliumEpitheliumAdhesionProteasesO2radicalsCoagulationProteinsCytokinesIL-6IL-8IL-10IL-8-RATNF-aENA-78MIP-1aTransferrinPAFComplementLPBLTB4LTC4BiotruamaIncitingEventPMNs/M②BiophysicalInjuryshearoverdistentioncyclicstretchDintrathoracicpressurealveolar-capillarypermeabilitycardiacoutputorganperfusion①BiochemicalInjury(Biotrauma)mfcytokines,complement,PGs,LTs,ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistalOrganDysfunctionMechanicalVentilationSlutsky,TremblayAmJRespCritCareMed.1998;157:1721-5DEATH②Biophysicalshearalveolar-c

ARDS的保護(hù)性通氣策略？ARDS的保護(hù)性通氣策略？Oxidantinjury-keepFiO2<60Barotrauma-keepalveolarinflationpressures<35cmH2OVolutrauma-BabylungconceptorstretchinjuryAtelectrauma-repeatedopeningandclosingBiotrauma-releaseofinflammatorymediatorsandbacterialtranslocationOPENGENTLYANDKEEPTHEMOPEN溫柔的打開肺泡，并保持開放Principle原則WhiteheadT,SlutskyAS.Thorax.2002;57:636Oxidantinjury-keepFiO2<60傳統(tǒng)的肺保護(hù)性通氣策略①

小潮氣量（6ml／kg理想體重）②允許性高碳酸血癥③控制氣道平臺(tái)壓<30cmH2O④使用合適的PEEP是迄今為止少有的被大規(guī)模隨機(jī)對(duì)照研究證實(shí)，能降低ARDS患者死亡率的治療措施。傳統(tǒng)的肺保護(hù)性通氣策略①小潮氣量（6ml／kg理想體提高治療干預(yù)強(qiáng)度輕度ARDS中度ARDS嚴(yán)重ARDS小潮氣量通氣更高水平PEEP無創(chuàng)通氣低-中水平PEEP俯臥位通氣神經(jīng)肌肉阻滯劑高頻振蕩通氣ECCO2-RECMO30025020015010050提輕度ARDS中度ARDS嚴(yán)重ARDS小潮氣量通氣更高水平P提綱：臨床探討的通氣模式與參數(shù)TidalvolumePlateaupressurespHPEEPVCvsPCVRecruitmentmaneuversHigh-frequencyoscillatoryPronepositioningECMO潮氣量平臺(tái)壓允許性高碳酸血癥呼氣末正壓定容與定壓手法復(fù)張高頻振蕩通氣俯臥位通氣體外膜氧合提綱：臨床探討的通氣模式與參數(shù)肺通氣保護(hù)策略在兒童ARDS中的應(yīng)用2000年《NEJM》，861名成人ARDS患者治療組：小潮氣量（4-6ml/kg）,限制壓力（平臺(tái)壓<30cmH2O），允許性高碳酸血癥但保持pH大于7.3顯著改善預(yù)后病死率39.8%―→31%自主呼吸天數(shù)10天―→12天首次為小潮氣量通氣模式提供可靠的循證醫(yī)學(xué)證據(jù)小潮氣量LowTidalVolumeARDSNet.2000肺通氣保護(hù)策略在兒童ARDS中的應(yīng)用2000年《NEJM》PLATEAUPRESSURES低平臺(tái)壓HagerDNetal.TidalVolumeReductioninPatientswithAcuteLungInjuryWhenPlateauPressuresAreNotHigh.AJRCCM2005.Vol1721241-1245多個(gè)研究比較***死亡率PLATEAUPRESSURES低平臺(tái)壓HagerDN787patientsfromARDSNetworkstudy平臺(tái)壓死亡率787patientsfromARDSNetwork平臺(tái)壓的調(diào)整策略平臺(tái)壓的調(diào)整策略PEEP：較高的呼氣末正壓(Meta)BrielM,MeadeM,MercatA,etal.Highervslowerpositiveend-expiratorypressureinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome.JAMA2010;303(9):865–73.醫(yī)院死亡率ICU死亡率氣胸氣胸后死亡脫機(jī)時(shí)間PEEP：較高的呼氣末正壓(Meta)BrielM,M允許性高碳酸血癥的通氣策略允許性高碳酸血癥的通氣策略pH值的調(diào)整策略pH值的調(diào)整策略流程圖起始選擇與設(shè)置流程圖起始選擇與設(shè)置ARDS通氣策略宋立強(qiáng)復(fù)習(xí)過程課件小潮氣量+高PEEP

潮氣量：VTof8mL/kgvsVTof10~15mL/kgPEEP：titratingPEEPashighaspossiblewithoutincreasingthemaximalPEItogreaterthan30cmH2OPurpose:Todeterminewhetherventilationwithlowtidalvolume(VT)andlimitedairwaypressureorhigherpositiveend-expiratorypressure(PEEP)improvesoutcomesforpatientswithARDSoracutelunginjury小潮氣量+高PEEP潮氣量：VTof8mL/kgv住院死亡率住院死亡率隨訪死亡率隨訪死亡率氣壓傷氣壓傷因嚴(yán)重低氧所致?lián)尵刃灾委煹膽?yīng)用率搶救性治療的死亡率因嚴(yán)重低氧所致?lián)尵刃灾委煹乃劳雎实?天的PaO2第1天的PaO2研究結(jié)論

routineuseoflowVTtendstobebene?cialinallpatientswithacutelunginjuryorARDSbecausethisventilationstrategyimprovedhospitalmortality.

HigherPEEPstrategiesduringlowerVTventilationdidnotimprovehospitalmortalityandcannotberecommendedinunselectedpatientswithacutelunginjuryorARDS.HigherPEEPstrategiesduringlowerVTventilationmaypreventlife-threateninghypoxemia.研究結(jié)論

routineuseoflowVTtenVCVvsPCV定容與定壓

PCV的優(yōu)點(diǎn):variableflowsomorecomfortableifdys-synchrony,prolongitimeforoxygenation,controlpeakpressuresVCVvsPCV定容與定壓PCV的優(yōu)點(diǎn):variRCTmulticenter,79patientswithARDSPCV(n-37)versusVCV(n=42).Pplat≤35cmH2ONodifferenceinmortalitytrendtomorerenalfailureinVCVgroupBUTpatientsinVCVgrouphadahigherin-housemortalityrelatedtohighernumberofextra-pulmonaryorganfailures(78%vs51%)

（TV8cc/kgofweight）RCTmulticenter,79patientswRECRUITMENT肺復(fù)張Arecentsystematicreviewanalyzed40studiesthatevaluatedRMs;（4wereRCTs,32prospectivestudies,and4retrospectivecohortstudies）Thesustainedinflationmethod——45%：CPAPof35–50cmH2Ofor20–40seconds23%：highpressurecontrol20%：incrementalPEEP10%：highVT/sighFanE,WilcoxME,BrowerRG,etal.Recruitmentmaneuversforacutelunginjury.AmJRespirCritCareMed2008;178(11):1156–63.RECRUITMENT肺復(fù)張ArecentsystemCurrentevidencesuggeststhatthatRMsshouldnotberoutinelyusedonallARDSpatientsunlessseverehypoxemiapersistsorasarescuemaneuvertoovercomeseverehypoxemia,toopenthelungwhensettingPEEP,orfollowingevidenceofacutelungderecruitmentsuchasaventilatorcircuitdisconnect結(jié)論：RM不常規(guī)用在所有的ARDS患者，除非持續(xù)的嚴(yán)重低氧血癥，或者做為嚴(yán)重低氧血癥的一種肺開放手段（設(shè)置PEEP），或者由于管路斷開出現(xiàn)急性肺陷閉FanE,WilcoxME,BrowerRG,etal.Recruitmentmaneuversforacutelunginjury.AmJRespirCritCareMed2008;178(11):1156–63.CurrentevidencesuggeststhatPRONEPOSITIONING俯臥位通氣PRONEPOSITIONING俯臥位通氣ComputedtomographyscanofthelungsshowingARDSwhenthepatientislyingsupine(left)andprone(right).GattinoniL,ProttiA.Ventilationintheproneposition:forsomebutnotforall?CMAJ2008;178(9):1174–6)ComputedtomographyscanofthTheProne-SupineIIStudyisthelargestclinicaltrial(N5342)inadultARDSpatients,conductedin23centersinItalyand2inSpain20hours/daySimilar28-daymortality-31.0%vs32.8%;RR0.97;(95%CI0.84–1.13;P=0.72)Mortalityinseverehypoxemiawasdecreasedinthepronegroup-37.8%inthepronegroupand46.1%inthesupinegroup(RR,0.87;95%CI,0.66–1.14P=0.31)TacconeP,PesentiA,LatiniR,etal.Pronepositioninginpatientswithmoderateandsevereacuterespiratorydistresssyndrome:arandomizedcontrolledtrial.JAMA2009;302:1977–84.TheProne-SupineIIStudyistMortalityEffectofmechanicalventilationinthepronepositiononclinicaloutcomesinpatientswithacutehypoxemicrespiratoryfailure:asystematicreviewandmeta-analysis.CMAJ2008;178(8):1153–61短時(shí)間長(zhǎng)時(shí)間P=0.32P=0.68MortalityEffectofmechanicalOxygenationSudS,SudM,FriedrichJO,etal.Effectofmechanicalventilationinthepronepositiononclinicaloutcomesinpatientswithacutehypoxemicrespiratoryfailure:asystematicreviewandmeta-analysis.CMAJ2008;178(8):1153–61第1天第2天第3天P<0.001P<0.001P<0.001OxygenationSudS,SudM,FriedrComplications鎮(zhèn)靜肌松氣道阻塞短暫SpO2下降嘔吐低血壓心律失常深靜脈脫落氣管插管移位氣管切開移位Complications鎮(zhèn)靜肌松High-frequencyoscillatoryventilation,HFOV高頻振蕩通氣

High-frequencyoscillatoryvenMeta分析結(jié)論——維持高平均氣道壓以保持肺復(fù)張，避免肺泡周期性開放、閉合。均為小樣本研究。2010《BMJ》meta-analysis：系統(tǒng)分析多項(xiàng)隨機(jī)對(duì)照臨床研究，HFOV提高氧合指數(shù)、顯著降低死亡率。SudS,SudM,FriedrichJO,etal.Highfrequencyoscillationinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome(ARDS):systematicreviewandmeta-analysis.BMJ2010;340:c2327.Meta分析結(jié)論——SudS,SudM,FriedECMO體外膜氧合ECMO體外膜氧合ECMOissupportivecareandisnotintendedasaprimaryARDStreatmentCESARtrial-Patientswererandomizedtoeitherconventionalcareat1of68tertiarycarecentersortoasinglecenterusingatreatmentprotocolthatincludedECMOThetrialwasstoppedforefficacyafter180patientsSurvivalwithoutseveredisabilityat6monthswas47%vs63%at6monthsPeekGJ,MugfordM,TiruvoipatiR,etal.Efficacyandeconomicassessmentofconventionalventilatorysupportversusextracorporealmembraneoxygenationforsevereadultrespiratoryfailure(CESAR):amulticentrerandomisedcontrolledtrial.Lancet2009;374(9698):1351–63.ECMOissupportivecareandisARDS通氣策略宋立強(qiáng)復(fù)習(xí)過程課件57NPPV無創(chuàng)通氣中國(guó)危重病急救醫(yī)學(xué).2006;18(12):706-710

預(yù)計(jì)病情能夠短期緩解的早期ALI/ARDS患者可考慮應(yīng)用NIV。(B級(jí))合并免疫功能低下的ALI/ARDS患者早期可首先試用NIV。(B級(jí))應(yīng)用NIV治療ALI/ARDS應(yīng)嚴(yán)密監(jiān)測(cè)患者的生命體征及治療反應(yīng)。意識(shí)不清、休克、氣道自潔能力障礙的ALI/ARDS患者不宜應(yīng)用NIV。(C級(jí))57NPPV無創(chuàng)通氣中國(guó)危重病急救醫(yī)學(xué).2006;18(1NPPV被推薦的適應(yīng)癥及強(qiáng)度高中低AECOPD急性心源性肺水腫免疫力低下呼衰COPD脫機(jī)術(shù)后呼衰拔管失敗的預(yù)防拒絕插管ARDS創(chuàng)傷肺間質(zhì)纖維化NPPV被推薦的適應(yīng)癥及強(qiáng)度高中低AECOPD術(shù)后呼衰ARD1.感染性肺水腫(pulmonaryedemaduetoinfection)2.毒素吸入性肺水腫(pulmonaryedemaduetopoison)3.淹溺性肺水腫(pulmonaryedemaduetodrowning)4.尿毒癥性肺水腫(pulmonaryedemainuremia)5.氧中毒肺水腫(pulmonaryedemaduetooxygentoxicity)不能忽視：針對(duì)ARDS病因的治療1.感染性肺水腫(pulmonaryedemadue1.經(jīng)驗(yàn)性抗感染治療的原則：

早期、廣譜、聯(lián)合、強(qiáng)效、足量

2.48-72小時(shí)做出評(píng)價(jià)，有效的表現(xiàn)：

體溫下降癥狀改善臨床狀態(tài)穩(wěn)定白細(xì)胞趨于正常、下降或升高（降低者）胸片吸收常較晚些

1.經(jīng)驗(yàn)性抗感染治療的原則：延誤使用有效抗生素增加重癥肺炎死亡率

KumaretalCritCareMed2006;34:1589-1596延誤使用有效抗生素1小時(shí)，死亡率增加12%延誤使用有效抗生素增加重癥肺炎死亡率Kumaretal中華醫(yī)學(xué)會(huì)《社區(qū)獲得性肺炎診斷和治療指南》中華醫(yī)學(xué)會(huì)《社區(qū)獲得性肺炎診斷和治療指南》ATS2005年醫(yī)院獲得性肺炎治療指南AmJRespirCritCare.2005,17I(4)：388-416.美平?ATS2005年醫(yī)院獲得性肺炎治療指南AmJResp小結(jié)：常規(guī)通氣方式選擇與設(shè)定無創(chuàng)通氣有創(chuàng)通氣定壓、自主通氣及允許性高碳酸血癥，肺開放策略PEEP：經(jīng)驗(yàn)設(shè)置為8～12cmH2O，或10～15cmH2O平臺(tái)壓：<30cmH2O潮氣量：8～12mL/Kg，或6～8mL/Kg（PHC）吸氣流量：遞減波，60～90L/min頻率：20～25次/分吸呼比：1：1.5觸發(fā)靈敏度：-2～-4cmH2OFiO2：<0.6（二）肺開放策略小結(jié)：常規(guī)通氣方式選擇與設(shè)定無創(chuàng)通氣提高治療干預(yù)強(qiáng)度輕度ARDS中度ARDS嚴(yán)重ARDS小潮氣量通氣更高水平PEEP無創(chuàng)通氣低-中水平PEEP俯臥位通氣神經(jīng)肌肉阻滯劑高頻振蕩通氣ECCO2-RECMO30025020015010050小結(jié)提輕度ARDS中度ARDS嚴(yán)重ARDS小潮氣量通氣更高水平P感謝專家的批評(píng)指正！感謝專家的批評(píng)指正！感謝專家的批評(píng)指正！感謝專家的批評(píng)指正！此課件下載可自行編輯修改，僅供參考！

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感謝您的支持，我們努力ARDS通氣策略宋立強(qiáng)ARDS通氣策略宋立強(qiáng)

ARDS的發(fā)生機(jī)制？ARDS的發(fā)生機(jī)制？1肺間質(zhì)2肺泡ARDS是一種水循環(huán)障礙的“肺水腫”1肺間質(zhì)ARDS是一種水循環(huán)障礙的“肺水腫”①血流動(dòng)力性肺水腫(hemodynamicpulmonaryedema)毛細(xì)血管靜水壓升高，流入肺間質(zhì)液體增多所形成的肺水腫，但蛋白質(zhì)分子的滲透性，或液體的傳遞方面均無任何變化②通透性肺水腫(permeability

pulmonaryedema

)

不僅肺水通過肺毛細(xì)血管內(nèi)皮細(xì)胞劇增，且蛋白質(zhì)滲透過內(nèi)皮細(xì)胞也增加“肺水腫”分類(按照病因及發(fā)生機(jī)制)ARDS！①血流動(dòng)力性肺水腫(hemodynamicpulmo1.感染性肺水腫(pulmonaryedemaduetoinfection)2.毒素吸入性肺水腫(pulmonaryedemaduetopoison)3.淹溺性肺水腫(pulmonaryedemaduetodrowning)4.尿毒癥性肺水腫(pulmonaryedemainuremia)5.氧中毒肺水腫(pulmonaryedemaduetooxygentoxicity)②通透性肺水腫——病因及分類1.感染性肺水腫(pulmonaryedemadueARDS肺水腫的成分：富含蛋白細(xì)胞碎片未激活的PS中性粒細(xì)胞巨噬細(xì)胞炎癥介質(zhì)......參與反應(yīng)的細(xì)胞——中性粒細(xì)胞巨噬細(xì)胞上皮細(xì)胞內(nèi)皮細(xì)胞參與反應(yīng)的介質(zhì)——氧自由基蛋白溶解酶花生四烯酸代謝物補(bǔ)體系統(tǒng)凝血和纖溶系統(tǒng)PAFTNFIL......ARDS發(fā)病的炎癥機(jī)制ARDS肺水腫的參與反應(yīng)的細(xì)胞——AApexHilumBase病變分布有重力依賴性，從肺前部到背部——

1.正常區(qū)30%

2.陷閉區(qū)20~30%

3.實(shí)變區(qū)40~50%病理生理變化——間歇性分流切變力損傷肺循環(huán)阻力增加病理生理變化——持續(xù)性分流肺循環(huán)阻力增加力學(xué)曲線變化——ApexHilumBase病變分布有重力依賴性，病理生理變化

ARDS的臨床診斷？ARDS的臨床診斷？臨床診斷標(biāo)準(zhǔn)的變遷——AECC定義1967年，Ashbaugh等首先描述“成人中的急性呼吸窘迫”1971年，Petty等正式命名“成人呼吸窘迫綜合征（ARDS）”1992年，美歐共識(shí)會(huì)（American-EuropeanConsensusConference,AECC）

急性呼吸窘迫綜合征（AcuteRespiratoryDiseaseSyndrome，ARDS）

首次提出ALI

提出AECC標(biāo)準(zhǔn)臨床診斷標(biāo)準(zhǔn)的變遷——AECC定義1967年，AshbauAECC標(biāo)準(zhǔn)局限性病程急性起病無具體時(shí)間ALIPaO2/FiO2≤300mmHg誤解201-300mmHg為ALI氧合指數(shù)PaO2/FiO2≤200mmHg，未考慮PEEP水平不同的PEEP及FiO2，PaO2/FiO2也不同胸片雙肺彌漫性浸潤(rùn)缺乏客觀評(píng)價(jià)指標(biāo)PAWPPAWP≤18mmHg，無左心房高壓ARDS及高水平PAWP可同時(shí)存在，PAWP有不確定性AECC診斷標(biāo)準(zhǔn)的局限AECC標(biāo)準(zhǔn)局限性病程急性起病無具體時(shí)間ALIPaO2/FiAnearlyPEEP/FIO2trialidentifiesdifferentdegreesoflunginjuryinpatientswithacuterespiratorydistresssyndrome.AmJRespirCritCareMed.

2007；15;176(8):795-804.例：ARDS患者在不同通氣條件下的變化在（day1）時(shí)間點(diǎn)FiO2≥0.5+PEEP≥10，

30min條件下——重新分類為ARDS,ALI,ARFAnearlyPEEP/FIO2trialident29%ARDS患者PAWP≥18mmHg（或CVP升高）,而其中97%PAWP升高的ARDS患者中有正常的心臟功能。結(jié)論：PAWP或CVP升高不能作為ARDS的排除標(biāo)準(zhǔn)。Pulmonary-arteryversuscentralvenouscathetertoguidetreatmentofacutelunginjury.NEnglJMed.

2006May25;354(21):2213-24.CVPPAWP例：ARDS與PAWP、CVP81829%ARDS患者PAWP≥18mmHg（或CVP升高）,BerlinDefinition2012柏林定義ARDS的診斷及病情分級(jí)發(fā)病時(shí)間1周以內(nèi)起病、或新發(fā)、或惡化的呼吸癥狀2.胸部影像學(xué)雙肺模糊影——不能完全由滲出、肺塌陷或結(jié)節(jié)來解釋3.肺水腫起因不能完全由心力衰竭或容量過負(fù)荷解釋的呼吸衰竭，沒有發(fā)現(xiàn)危險(xiǎn)因素時(shí)可行超聲心動(dòng)圖等檢查排除血流源性肺水腫4.氧合指數(shù)輕度200mmHg<PaO2/FiO2≤300mmHgwithPEEP≥5cmH2O中度100mmHg<PaO2/FiO2≤200mmHgwithPEEP≥5cmH2O重度PaO2/FiO2≤100mmHgwithPEEP≥5cmH2OBerlinDefinition2012柏林定義ARD

傳統(tǒng)機(jī)械通氣的肺損傷？傳統(tǒng)機(jī)械通氣的肺損傷？VentilatorInducedLungInjury，VILIOverdistention過度擴(kuò)張

Barotrauma壓力傷Volutrauma容量傷Recruitment/DerecruitmentInjury

（Atlectrauma）剪切傷/萎陷傷

TranslocationofCells細(xì)胞形態(tài)移位Biotrauma生物傷

OxidantInjury氧中毒

VentilatorInducedLungInjuryOverdistentionBarotrauma&VolutraumaOverdistentionBarotrauma&Vol“Shear”Recruitment/DerecruitmentInjury跨肺壓若用30cmH2O的正壓通氣，則跨肺壓約35cmH2O。兩個(gè)肺單位之間產(chǎn)生高達(dá)140cmH2O的切變力?！癝hear”Recruitment/DerecruitTranslocationofCellsByBUBBLEBilek,A.M....D.P.GaverIIIJApplPhysiol94:770-783,2003

DisruptingthealveolarepitheliumTearingincapillaryendotheliumTranslocationofCellsByBUBBBiotruamaIncitingEventPMNs/MacsEndotheliumEpitheliumAdhesionProteasesO2radicalsCoagulationProteinsCytokinesIL-6IL-8IL-10IL-8-RATNF-aENA-78MIP-1aTransferrinPAFComplementLPBLTB4LTC4BiotruamaIncitingEventPMNs/M②BiophysicalInjuryshearoverdistentioncyclicstretchDintrathoracicpressurealveolar-capillarypermeabilitycardiacoutputorganperfusion①BiochemicalInjury(Biotrauma)mfcytokines,complement,PGs,LTs,ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistalOrganDysfunctionMechanicalVentilationSlutsky,TremblayAmJRespCritCareMed.1998;157:1721-5DEATH②Biophysicalshearalveolar-c

ARDS的保護(hù)性通氣策略？ARDS的保護(hù)性通氣策略？Oxidantinjury-keepFiO2<60Barotrauma-keepalveolarinflationpressures<35cmH2OVolutrauma-BabylungconceptorstretchinjuryAtelectrauma-repeatedopeningandclosingBiotrauma-releaseofinflammatorymediatorsandbacterialtranslocationOPENGENTLYANDKEEPTHEMOPEN溫柔的打開肺泡，并保持開放Principle原則WhiteheadT,SlutskyAS.Thorax.2002;57:636Oxidantinjury-keepFiO2<60傳統(tǒng)的肺保護(hù)性通氣策略①

小潮氣量（6ml／kg理想體重）②允許性高碳酸血癥③控制氣道平臺(tái)壓<30cmH2O④使用合適的PEEP是迄今為止少有的被大規(guī)模隨機(jī)對(duì)照研究證實(shí)，能降低ARDS患者死亡率的治療措施。傳統(tǒng)的肺保護(hù)性通氣策略①小潮氣量（6ml／kg理想體提高治療干預(yù)強(qiáng)度輕度ARDS中度ARDS嚴(yán)重ARDS小潮氣量通氣更高水平PEEP無創(chuàng)通氣低-中水平PEEP俯臥位通氣神經(jīng)肌肉阻滯劑高頻振蕩通氣ECCO2-RECMO30025020015010050提輕度ARDS中度ARDS嚴(yán)重ARDS小潮氣量通氣更高水平P提綱：臨床探討的通氣模式與參數(shù)TidalvolumePlateaupressurespHPEEPVCvsPCVRecruitmentmaneuversHigh-frequencyoscillatoryPronepositioningECMO潮氣量平臺(tái)壓允許性高碳酸血癥呼氣末正壓定容與定壓手法復(fù)張高頻振蕩通氣俯臥位通氣體外膜氧合提綱：臨床探討的通氣模式與參數(shù)肺通氣保護(hù)策略在兒童ARDS中的應(yīng)用2000年《NEJM》，861名成人ARDS患者治療組：小潮氣量（4-6ml/kg）,限制壓力（平臺(tái)壓<30cmH2O），允許性高碳酸血癥但保持pH大于7.3顯著改善預(yù)后病死率39.8%―→31%自主呼吸天數(shù)10天―→12天首次為小潮氣量通氣模式提供可靠的循證醫(yī)學(xué)證據(jù)小潮氣量LowTidalVolumeARDSNet.2000肺通氣保護(hù)策略在兒童ARDS中的應(yīng)用2000年《NEJM》PLATEAUPRESSURES低平臺(tái)壓HagerDNetal.TidalVolumeReductioninPatientswithAcuteLungInjuryWhenPlateauPressuresAreNotHigh.AJRCCM2005.Vol1721241-1245多個(gè)研究比較***死亡率PLATEAUPRESSURES低平臺(tái)壓HagerDN787patientsfromARDSNetworkstudy平臺(tái)壓死亡率787patientsfromARDSNetwork平臺(tái)壓的調(diào)整策略平臺(tái)壓的調(diào)整策略PEEP：較高的呼氣末正壓(Meta)BrielM,MeadeM,MercatA,etal.Highervslowerpositiveend-expiratorypressureinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome.JAMA2010;303(9):865–73.醫(yī)院死亡率ICU死亡率氣胸氣胸后死亡脫機(jī)時(shí)間PEEP：較高的呼氣末正壓(Meta)BrielM,M允許性高碳酸血癥的通氣策略允許性高碳酸血癥的通氣策略pH值的調(diào)整策略pH值的調(diào)整策略流程圖起始選擇與設(shè)置流程圖起始選擇與設(shè)置ARDS通氣策略宋立強(qiáng)復(fù)習(xí)過程課件小潮氣量+高PEEP

潮氣量：VTof8mL/kgvsVTof10~15mL/kgPEEP：titratingPEEPashighaspossiblewithoutincreasingthemaximalPEItogreaterthan30cmH2OPurpose:Todeterminewhetherventilationwithlowtidalvolume(VT)andlimitedairwaypressureorhigherpositiveend-expiratorypressure(PEEP)improvesoutcomesforpatientswithARDSoracutelunginjury小潮氣量+高PEEP潮氣量：VTof8mL/kgv住院死亡率住院死亡率隨訪死亡率隨訪死亡率氣壓傷氣壓傷因嚴(yán)重低氧所致?lián)尵刃灾委煹膽?yīng)用率搶救性治療的死亡率因嚴(yán)重低氧所致?lián)尵刃灾委煹乃劳雎实?天的PaO2第1天的PaO2研究結(jié)論

routineuseoflowVTtendstobebene?cialinallpatientswithacutelunginjuryorARDSbecausethisventilationstrategyimprovedhospitalmortality.

HigherPEEPstrategiesduringlowerVTventilationdidnotimprovehospitalmortalityandcannotberecommendedinunselectedpatientswithacutelunginjuryorARDS.HigherPEEPstrategiesduringlowerVTventilationmaypreventlife-threateninghypoxemia.研究結(jié)論

routineuseoflowVTtenVCVvsPCV定容與定壓

PCV的優(yōu)點(diǎn):variableflowsomorecomfortableifdys-synchrony,prolongitimeforoxygenation,controlpeakpressuresVCVvsPCV定容與定壓PCV的優(yōu)點(diǎn):variRCTmulticenter,79patientswithARDSPCV(n-37)versusVCV(n=42).Pplat≤35cmH2ONodifferenceinmortalitytrendtomorerenalfailureinVCVgroupBUTpatientsinVCVgrouphadahigherin-housemortalityrelatedtohighernumberofextra-pulmonaryorganfailures(78%vs51%)

（TV8cc/kgofweight）RCTmulticenter,79patientswRECRUITMENT肺復(fù)張Arecentsystematicreviewanalyzed40studiesthatevaluatedRMs;（4wereRCTs,32prospectivestudies,and4retrospectivecohortstudies）Thesustainedinflationmethod——45%：CPAPof35–50cmH2Ofor20–40seconds23%：highpressurecontrol20%：incrementalPEEP10%：highVT/sighFanE,WilcoxME,BrowerRG,etal.Recruitmentmaneuversforacutelunginjury.AmJRespirCritCareMed2008;178(11):1156–63.RECRUITMENT肺復(fù)張ArecentsystemCurrentevidencesuggeststhatthatRMsshouldnotberoutinelyusedonallARDSpatientsunlessseverehypoxemiapersistsorasarescuemaneuvertoovercomeseverehypoxemia,toopenthelungwhensettingPEEP,orfollowingevidenceofacutelungderecruitmentsuchasaventilatorcircuitdisconnect結(jié)論：RM不常規(guī)用在所有的ARDS患者，除非持續(xù)的嚴(yán)重低氧血癥，或者做為嚴(yán)重低氧血癥的一種肺開放手段（設(shè)置PEEP），或者由于管路斷開出現(xiàn)急性肺陷閉FanE,WilcoxME,BrowerRG,etal.Recruitmentmaneuversforacutelunginjury.AmJRespirCritCareMed2008;178(11):1156–63.CurrentevidencesuggeststhatPRONEPOSITIONING俯臥位通氣PRONEPOSITIONING俯臥位通氣ComputedtomographyscanofthelungsshowingARDSwhenthepatientislyingsupine(left)andprone(right).GattinoniL,ProttiA.Ventilationintheproneposition:forsomebutnotforall?CMAJ2008;178(9):1174–6)ComputedtomographyscanofthTheProne-SupineIIStudyisthelargestclinicaltrial(N5342)inadultARDSpatients,conductedin23centersinItalyand2inSpain20hours/daySimilar28-daymortality-31.0%vs32.8%;RR0.97;(95%CI0.84–1.13;P=0.72)Mortalityinseverehypoxemiawasdecreasedinthepronegroup-37.8%inthepronegroupand46.1%inthesupinegroup(RR,0.87;95%CI,0.66–1.14P=0.31)TacconeP,PesentiA,LatiniR,etal.Pronepositioninginpatientswithmoderateandsevereacuterespiratorydistresssyndrome:arandomizedcontrolledtrial.JAMA2009;302:1977–84.TheProne-SupineIIStudyistMortalityEffectofmechanicalventilationinthepronepositiononclinicaloutcomesinpatientswithacutehypoxemicrespiratoryfailure:asystematicreviewandmeta-analysis.CMAJ2008;178(8):1153–61短時(shí)間長(zhǎng)時(shí)間P=0.32P=0.68MortalityEffectofmechanicalOxygenationSudS,SudM,FriedrichJO,etal.Effectofmechanicalventilationinthepronepositiononclinicaloutcomesinpatientswithacutehypoxemicrespiratoryfailure:asystematicreviewandmeta-analysis.CMAJ2008;178(8):1153–61第1天第2天第3天P<0.001P<0.001P<0.001OxygenationSudS,SudM,FriedrComplications鎮(zhèn)靜肌松氣道阻塞短暫SpO2下降嘔吐低血壓心律失常深靜脈脫落氣管插管移位氣管切開移位Complications鎮(zhèn)靜肌松High-frequencyoscillatoryventilation,HFOV高頻振蕩通氣

High-frequencyoscillatoryvenMeta分析結(jié)論——維持高平均氣道壓以保持肺復(fù)張，避免肺泡周期性開放、閉合。均為小樣本研究。2010《BMJ》meta-analysis：系統(tǒng)分析多項(xiàng)隨機(jī)對(duì)照臨床研究，HFOV提高氧合指數(shù)、顯著降低死亡率。SudS,SudM,FriedrichJO,etal.Highfrequencyoscillationinpatientswithacutelunginjuryandacuterespiratorydistresssyndrome(ARDS):systematicr