醫(yī)學(xué)理論課件 體位療法在ICU-南通醫(yī)院

體位療法在ARDS中的應(yīng)用江蘇省南通市第一人民醫(yī)院ICU體位療法的歷史Useofextremepositionchangesinacuterespiratoryfailure.1976年第一次提示使用俯臥位可以改善ARDS患者的氧合。CritCareMed1976體位療法的研究非對(duì)照研究提示短期效果體位療法的研究ThepronepositioninARDSpatients.

13moderate-severeARDSpatientstwo-hourperiodofpronepositionLungCTwasobtainedinboththesupineandpronepositionsintwoofthesepatients.Chest1988Jul

體位療法的研究ResultAveragearterialoxygenationimprovedafterpronepositioning(p＜0.01).CTinthepronepositionshoweddisappearanceofposterobasaldensitiesandappearanceofnewdensitiesintheanteriorregions.Chest1988Jul

體位療法的研究Influenceofpositioningonventilation-perfusionrelationshipsinsevereARDS.n=122-hperiodofpressure-controlledmechanicalventilationwiththepatientintheproneposition.Ventilation-perfusionrelationships(VA/Q)wereassessedbyamultipleinertgaseliminationtechnique.Chest1994Nov體位療法的研究ResultPressure-controlledmechanicalventilationinthepronepositionresultedinanoverallincrease(p≤0.05)ofarterialoxygenationafter120min(98.4±50.3to146.2±94.9mmHg).Intherespondergrouppositioningcausedadecreaseofshuntperfusionof11±5%andaconcomitantincreaseofnormalVA/Qby12±4%after30min.Chest1994Nov體位療法的研究Short-termeffectsofpronepositionincriticallyillpatientswithARDSDESIGN:Open,prospectivestudy.SETTING:Generalintensivecareunits.PATIENTS:23patients[meanage56±17(SD)years]whometARDScriteriaandhadaLungInjuryScore>2.5(mean3.25±0.3).IntensiveCareMed1997

體位療法的研究ResultPaO2/FIO2ratioimprovedfrom78±37mmHgsupineto115±31mmHgprone(p<0.001),Intrapulmonaryshuntdecreasedfrom43±11to34±8%(p<0.001).Cardiacoutputandotherhemodynamicparameterswerenotaffected.IntensiveCareMed1997

體位療法的研究ResultRespiratorysystemcomplianceslightlyimprovedfrom24.7±10.2ml/cmH20supineto27.8±13.2ml/cmH20prone(p<0.05).[n=16]IntensiveCareMed1997

體位療法的研究俯臥位可以降低分流及增加正常VA/Q的區(qū)域體位療法的研究Pronepositioninmechanicallyventilatedpatientswithsevereacuterespiratoryfailure.n=32PaO2/FiO2<150After1hinaproneposition,improvementofPaO2/FiO2by20mmHgormorewasconsideredapositiveresponse.1hbefore,1and4hduringand1hafterplacinginaproneposition

AmJRespir

CritCareMed1997Feb體位療法的研究ResultSevenpatientsreferredtoasnonresponders(22%),and25hadapositiveresponse(78%)In10ofthe23responders(43%)whocompletedthe4hpronetrial,thePaO2/FiO2returnedtoitsstartingvaluewhenpatientswererepositionedsupine:117±24,164±44,156±55,and110±34,respectively(p<0.01).

AmJRespir

CritCareMed1997Feb體位療法的研究ResultIn13ofthe23(57%)improvementpersisted:105±27,187±58,189±49,and157±49,respectively(p<0.001)AmJRespir

CritCareMed1997Feb體位療法的研究對(duì)俯臥位時(shí)胸腹腔順應(yīng)性的研究體位療法的研究EffectsofthepronepositiononrespiratorymechanicsandgasexchangeduringALIn=16Before,during,andafter2hinthepronepositionAmJRespir

CritCareMed1998Feb

體位療法的研究Measuredtheend-expiratorylungvolume(EELV,heliumdilution),thetotalrespiratorysystem(Cst,rs),thelung(Cst,L)andthethoracoabdominalcage(Cst,w)compliances(end-inspiratoryocclusiontechniqueandesophagealballoon),thehemodynamics,andgasexchange.AmJRespir

CritCareMed1998Feb

體位療法的研究ResultIntheproneposition,PaO2increased(p<0.05)withoutsignificantchangesofCst,rsandEELV.Cst,wdecreased(p<0.01)andthedecreasewascorrelatedwiththeoxygenationincrease(r=0.62,p<0.05).AmJRespir

CritCareMed1998Feb

體位療法的研究ResultReturningtothesupinepositionCst,rsincreasedcomparedwithbaseline(p<0.01),mainlybecauseofthelungcomponent(p<0.01).

AmJRespir

CritCareMed1998Feb

體位療法的研究ConculsionThepronepositionimprovesCst,rsandCst,Lwhenthesupinepositionisresumed.

體位療法的研究長(zhǎng)時(shí)間應(yīng)用效果的前瞻非對(duì)照研究體位療法的研究EffectsofthepronepositionongasexchangeandhemodynamicsinsevereARDS

PATIENTS:Nineteenconsecutive,mechanicallyventilatedpatients(age45±20yrs,mean±SD)withARDSandseverehypoxemia,definedasPaO2/FiO2of≤150withFiO2of≥0.6persistingfor≤24hrs,andapulmonaryarteryocclusionpressureof<18mmHg.CritCareMed1998Dec體位療法的研究Patientswereturnedpronefor2hrs.Nonresponderswerereturnedsupine,butrespondersweremaintainedpronefor12hrsbeforebeingreturnedtothesupineposition.Measurementswereperformedatthefollowingtimepoints:a)baselinesupine;b)after30minsprone;c)after120minsprone.Forresponders,additionalmeasurementsweretakenafter12hrsproneand30minssupine.

CritCareMed1998Dec體位療法的研究Result11(57%)patientsrespondedtotheproneposition.After12hrsprone,meanFiO2hadbeenlowered(p<.05).30minafterthepatientswerereturnedsupine,PaO2,PaO2/FiO2,andQva/Qtwerenotdifferentfrom12-hrpronevalues,andwereimprovedincomparisonwithbaselinesupinevalues.CritCareMed1998Dec體位療法的研究Theeffectsoflong-termpronepositioninginpatientswithtrauma-inducedARDSn=20aftermultipletrauma(InjurySeverityScore[ISS]27.3±10,ARDSscore2.84±0.42).PaO2/FiO2<200mmHgatinverseratioventilationwithPEEP>8mmHgformorethan24h)wereturnedtothepronepositionatnoonandwereturnedbacktothesupinepositionat8:00AMonthenextday.Twoturnsperday.Anesth

Analg1996Dec體位療法的研究n=20aftermultipletrauma(InjurySeverityScore[ISS]27.3±10,ARDSscore2.84±0.42).PaO2/FiO2<200mmHgatinverseratioventilationwithPEEP>8mmHgformorethan24h)Allpatientswereturnedtothepronepositionatnoonandwereturnedbacktothesupinepositionat8:00AMonthenextday.Anesth

Analg1996Dec體位療法的研究ResultOxygenationvariablesimprovedsignificantlyeachtimethepatientswereplacedprone.PaO2increased,intrapulmonaryshunt(Qva/Qt)decreased,andthealveolar-arterialoxygendifferencedecreased.Anesth

Analg1996Dec體位療法的研究ResultMostoftheseimprovementswerelostwhenthepatientswereturnedsupine,butcouldbereproducedwhenpronepositioningwasrepeatedafterashortperiod(4h)inthesupineposition.Noposition-dependentchangesofsystemichemodynamicvariableswereobserved.Anesth

Analg1996Dec體位療法的研究ConclusionIntraumapatientswithARDSundergoinglong-termpositioningtreatment,lungfunctionimprovessignificantlyduringpronepositioncomparedtoshortphasesofconventionalsupineposition.Anesth

Analg1996Dec體位療法的研究一個(gè)大型，前瞻對(duì)照研究體位療法的研究Effectofpronepositioningonthesurvivalofpatientswithacuterespiratoryfailure.comparedconventionaltreatment(inthesupineposition)ofpatientswithALIorARDSwithapredefinedstrategyofplacingpatientsinapronepositionforsixormorehoursdailyfor10days.304patients,152ineachgroup.NEnglJMed2001Aug

體位療法的研究ResultTherelativeriskofdeathinthepronegroupascomparedwiththesupinegroupwas0.84attheendofthestudyperiod(95％confidenceinterval,0.56to1.27).1.05atthetimeofdischargefromtheintensivecareunit(95％confidenceinterval,0.84to1.32).1.06atsixmonths(95％confidenceinterval,0.88to1.28).NEnglJMed2001Aug

體位療法的研究ResultDuringthestudyperiodthemean(±SD)increaseintheratioofPaO2/FiO2measuredeachmorningwhilepatientsweresupine,wasgreaterinthepronethanthesupinegroup(63.0±66.8vs.44.6±68.2,P=0.02).NEnglJMed2001Aug

體位療法的研究ResultTheincidenceofcomplicationsrelatedtopositioning(suchaspressuresoresandaccidentalextubation)wassimilarinthetwogroups.NEnglJMed2001Aug

Conclusion

Thestudyconfirmsthattheuseofthepronepositionimprovesarterialoxygenation.However,routineuseofthepronepositioninpatientswithacuterespiratoryfailureisnotjustified.Thepronepositionmightbeconsideredusefulforpatientswithseverehypoxemia.NEnglJMed2001Aug

體位療法的研究

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