肺水測定及臨床應(yīng)用ppt課件

1、.,1,肺水測定及臨床應(yīng)用,浙江大學(xué)醫(yī)學(xué)院附屬邵逸夫醫(yī)院危重醫(yī)學(xué)科,潘孔寒,.,2,Preface,Pubmed Extravascular Lung Water 1295篇，1968年2006年6月,.,3,內(nèi)容,血管外肺水（EVLW）定義 EVLW的測定方法及原理 EVLW監(jiān)測的意義及臨床應(yīng)用,.,4,血管外肺水（EVLW）定義,Extravascular Lung Water， EVLW 正常37 ml/kg 7 ml/kg或10 ml/kg, 提示EVLW升高 絕對值意義值的變化的意義 The hallmark of sepsis is increased capillary perm

2、eability, which manifests in the lungs as altered alveolarcapillary barrier function and is characterized by accumulation of extravascular lung water (EVLW). Sepsis特征: 毛細(xì)血管滲漏。肺內(nèi)表現(xiàn)：肺泡毛細(xì)血管屏障功能改變及EVLW積聚,.,5,EVLW測定方法及原理,影像學(xué)法 比重法 雙指示劑稀釋法 單指示劑熱稀釋法 生物阻抗法,.,6,影像學(xué)法,胸片 Chest x-ray score Pistolesi M, Giuntini

3、C. Assessment of extravascular lung water. Radiol Clin North Am 1978;16:551574. CT MRI,.,7,影像學(xué)法,超聲 Transthoracic chest sonography A 4-step score of ultrasound Comet tail sign Semiquantitative The sensitivity and specificity of ultrasound was 97%, with a positive and negative predictive value of 94%

4、and 98%, respectively. The correlation between ultrasound and radiologic score was significant (0.90). Jambrik Z, et al. Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol 2004;93:12651270. Lichtenstein D, et al. The comet-tail artifact. An ultraso

5、und sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156: 16401646. Soldati G. Lung sonography artifact movement or echotexture. Italian J Ultrasound 2001;4: 329338.,.,8,比重法,常應(yīng)用于動物實(shí)驗(yàn)中 根據(jù)下列公式計(jì)算可得出EVLW 勻漿血紅蛋白濃度=上清液血紅蛋白濃度(勻漿含水百分比上清液含水百分比) 血重=勻漿重勻漿中血紅蛋白濃度血液血紅蛋白濃度 血液中水重=血重血液含水百分比 肺臟

6、中總的水含量(TPW)=勻漿含水百分比勻漿重-附加水(蒸餾水) EVLW=TPW-血液中水重,.,9,比重法,方法經(jīng)典，結(jié)果可靠 但多應(yīng)用于動物實(shí)驗(yàn)，且不能動態(tài)觀察EVLW變化，應(yīng)用范圍局限。,.,10,雙指示劑稀釋法(Double-indicator dilution method),基本裝置及操作 通過頸內(nèi)靜脈或鎖骨下靜脈放置中心靜脈(CV）導(dǎo)管，外接溫度探頭。 自中心靜脈注射兩種不同的指示劑，一種為熱稀釋指示劑，可滲透到毛細(xì)血管外，常用5GS或NS；另一種為染料稀釋指示劑，只能保留在血管內(nèi)，常用與白蛋白結(jié)合的吲哚綠（Indocyanine green, ICG, an intravasc

7、ular tracer） 股動脈放置一根尖端帶有熱敏電阻絲的導(dǎo)管檢測熱稀釋曲線，從股動脈導(dǎo)管中抽取股動脈血，分析得出染料稀釋曲線。根據(jù)各自的稀釋曲線分別得出稀釋曲線的平均傳送時(shí)間 (MTt)。根據(jù)史德華-漢密爾頓法(Stewart-Hamitonequation)，通過熱稀釋曲線計(jì)算出心輸出量(CO)。,.,11,雙指示劑稀釋法基本原理,染料稀釋指示劑不能滲透至毛細(xì)血管外，因此其所流經(jīng)的所有容積量為GEDV(全心舒張末期容積)和PBV(肺內(nèi)血容積)的總和，即ITBV(胸腔內(nèi)血容積) 熱稀釋指示劑能滲透至毛細(xì)血管外，因此其所流經(jīng)的所有容積量為EVLW和ITBV的總和，即 ITTV(胸腔內(nèi)熱容量)

8、,.,12,.,13,雙指示劑稀釋法,根據(jù)公式(1)：CO X MTt=指示劑所流經(jīng)的所有容積量，可得 ITTV=CO X MTt (熱稀釋指示劑) ITBV = CO X MTt (染料稀釋指示劑) 兩者之間的差值為EVLW，即EVLW=ITTV-ITBV,.,14,雙指示劑稀釋法,檢測染料指示劑的MTt準(zhǔn)確性不夠 操作復(fù)雜 費(fèi)用昂貴 近年來該法已為先進(jìn)的單指示劑熱稀釋法所替代。,.,15,單指示劑熱稀釋法,基本裝置及操作 與雙指示劑肺水測定法基本相同 放置中心靜脈導(dǎo)管用以注射熱稀釋指示劑，股動脈放置一根尖端帶有熱敏電阻絲的導(dǎo)管，檢測熱稀釋曲線。連接顯示屏后注射熱指示劑觀察其熱稀釋曲線。,.

9、,16,單指示劑熱稀釋法基本原理,心臟和肺可看成是由一系列序貫而獨(dú)立的容積腔組成，股動脈導(dǎo)管檢測到稀釋曲線可看成是每個(gè)容積腔稀釋曲線的組合，稀釋曲線中最長衰變曲線對應(yīng)的是其中的容積腔。將熱稀釋曲線取對數(shù)后進(jìn)行標(biāo)記，可得到稀釋曲線的指數(shù)下斜時(shí)間 (DSt)。,.,17,單指示劑熱稀釋法基本原理,CO DSt(熱稀釋指示劑)=PBV+EVLW CO MTt(熱稀釋指示劑)=ITTV 可得 CO (MTtDSt)(熱稀釋指示劑)=ITTV(PBV+EVLW)=GEDV ITBV和GEDV之差值為PBV(肺血容量),兩者之間有著較好的相關(guān)性，通過分析可計(jì)算出ITBV*。 根據(jù)ITTV=ITBV+EVL

10、W 得出EVLW*=ITTV-ITBV*,.,18,.,19,可靠性,Sakka等將57例患者的GEDV(單指示劑熱稀釋法測得)和ITBV(雙指示劑稀釋法測得)進(jìn)行分析得出方程：ITBV=125 X GEDV-28.4ml 進(jìn)一步運(yùn)用該方程計(jì)算出209例患者的ITBV*和EVLW*，并將其與由雙指示劑稀釋法則得ITBV和EVLW進(jìn)行比較，得出 ITBV*=106 X ITBV1243ml， 其回歸系數(shù)r=098(P00001) EVLW*：083XEVLW+1339ml， 其回歸系數(shù)r=096(P00001)。 由此可見，單指示劑熱稀釋法測定ITBV和EVLW結(jié)果準(zhǔn)確可靠。,.,20,脈波指示

11、劑連續(xù)心排血量(Pulse Indicator Continous Cardiac Output, PiCCO)原理,PiCCO采用相繼的三次的熱稀釋心排血量的平均值來獲得一個(gè)常數(shù)，以后只需連續(xù)測定主動脈壓力波形下收縮面積，分析與CO存在的關(guān)系,從而獲得病人的連續(xù)心排血量（CCO）。還可以測量心臟的前負(fù)荷容量和血管外肺水量。,.,21,PiCCO,與傳統(tǒng)熱稀釋導(dǎo)管不同的是，PiCCO從中心靜脈導(dǎo)管注射室溫水或冰水，在大動脈（通常是主動脈）內(nèi)測量溫度-時(shí)間變化曲線， 能夠測量全心的相關(guān)參數(shù)，而不是僅僅以右心來代表全心 由于同時(shí)測量動脈壓和CO，因此能夠連續(xù)反映血管阻力（SVR）的變化 此外，根據(jù)

12、溫度稀釋會受肺間質(zhì)液體量（即血管外肺水）的影響，而染料稀釋則不受其影響的特點(diǎn)（只受血管內(nèi)、不受血管外因素的影響）。 早期PiCCO采用雙指示劑法（溫度和染料）測量全心舒張末容積、血管外肺水等一系列參數(shù)，并在大量臨床數(shù)據(jù)的支持下總結(jié)了經(jīng)驗(yàn)公式，發(fā)展成為現(xiàn)在只需用溫度進(jìn)行測量就可得到這些參數(shù)的單指示劑法。,.,22,測量參數(shù),* 單次心輸出量（CO）及每次心臟搏動的心輸出量（PCCO）* 動脈壓（AP）* 全身循環(huán)阻力（SVR）* 全心舒張末期容積（GEDV, normal range 680800mL/m2）* 血管外肺水（EVLW, normal range 37 mL/kg） * 胸內(nèi)血容積

13、（ITBV, normal range 8501000mL/m2）* 不間斷容量反應(yīng)（SVV，PPV）* 全心射血分?jǐn)?shù)（GEF）* 心功能指數(shù)（CFI）* 肺血管通透性指數(shù)（PVPI),.,23,生物阻抗法,Transthoracic bioelectrical impedance analysis (BIA) An alternating electric current is passed through biologic tissue and the resistance to that current measured. This resistance is inversely pro

14、portional to the amount of water contained by the tissues within the electric field.,.,24,EVLW的意義及臨床應(yīng)用,防止和治療肺水腫 預(yù)后指標(biāo) 容量管理,.,25,肺水腫,高通透性肺水腫(如急性呼吸窘迫綜合征) 高靜水壓性肺水腫(如心源性肺水腫)，,.,26,CVP/PAWP不能反映肺水腫,對16例感染性休克導(dǎo)致肺水腫的患者研究發(fā)現(xiàn): EVLWI(血管外肺水含量指數(shù)變化)與 ITBVI(胸腔內(nèi)血容量指數(shù)變化)有著較好的相關(guān)性(r=06) 而與CVP和PAWP的變化無明顯相關(guān) Intensive Care

15、Med. 2002 Jun;28(6):712-8.,.,27,Significant negative correlation was found between EVLWi and PaO2/FiO2 (r = -0.53, CI -0.63 to -0.40, P 0.01) Critical Care 2005, 9(Suppl 1):P88,.,28,EVLW與Sepsis、肺損傷,A prospective cohort study in the Medical ICU at Grady Memorial Hospital (Atlanta, Georgia, USA) betwe

16、en July 2001 and March 2002 A total of 29 consecutive patients with severe sepsis from a medical intensive care unit in an urban university teaching hospital. A PICCO system Greg S Martin,et al. Extravascular lung water in patients with severe sepsis: a prospective cohort study. Critical Care 2005,

17、9:R74-R82,.,29,EVLW與Sepsis、肺損傷,Results Twenty-five of the 29 patients (86%) were mechanically ventilated, 15 of the 29 patients (52%) developed ARDS, and overall 28-day mortality was 41%. Eight out of 14 patients (57%) with non-ARDS severe sepsis had high EVLW with significantly greater hypoxemia th

18、an did those patient with low EVLW (mean arterial oxygen tension/fractional inspired oxygen ratio 230.7 36.1 mmHg versus 341.2 92.8 mmHg; P 0.001). Four out of 15 patients with severe sepsis with ARDS maintained a low EVLW and had better 28-day survival than did ARDS patients with high EVLW (100% ve

19、rsus 36%; P = 0.03). ARDS patients with a history of chronic alcohol abuse had greater EVLW than did nonalcoholic patients (19.9 ml/kg versus 8.7 ml/kg; P 0.0001). The arterial oxygen tension/fractional inspired oxygen ratio, lung injury score, and chest radiograph scores correlated with EVLW (r2 =

20、0.27, r2 = 0.18, and r2 = 0.28, respectively; all P 0.0001).,.,30,EVLW與Sepsis、肺損傷,Conclusions More than half of the patients with severe sepsis but without ARDS had increased EVLW,possibly representing subclinical lung injury.與亞臨床肺損傷有關(guān) EVLW correlated moderately with the severity of lung injury but

21、did not account for all respiratory derangements.與肺損傷程度有關(guān) EVLW may improve both risk stratification and management of patients with severe sepsis.監(jiān)測EVLW 有助于危險(xiǎn)度分層（可能為一預(yù)后指標(biāo)）及重度sepsis的管理,.,31,早期應(yīng)用PEEP有效降低肺水,Manuel等對18只高通透性肺水腫豬模型 研究發(fā)現(xiàn)，早期應(yīng)用PEEP可以明顯減少EVLW，同時(shí)獲得較高的氧合指數(shù)(Pa02Fi02) Colmenen等對21只高通透性肺水腫豬模型進(jìn)行研究

22、也發(fā)現(xiàn)類似的結(jié)果，進(jìn)一步提示EVLW可能是影響氧合指數(shù)的重要因素。,.,32,表1 不同PEEP 水平對ARDS 綿羊EVLW的影響(.x s) Tab 1 Effect of PEEP on EVLW in sheep with ARDS( .x s) 組別 時(shí)間點(diǎn) n EVLWPmlkg- 1 ITBVPml GEDVPml 5 cm H2O 組 0 h 7 15. 6 3. 2 1031. 8 425. 1 831. 9 343. 1 1 h 7 14. 8 3. 5 1043. 9 365. 0 841. 8 293. 8 2 h 7 14. 7 3. 2 974. 1 355. 6

23、786. 0 286. 7 10 cm H2O 組 0 h 8 16. 5 4. 7 963. 1 254. 2 798. 4 189. 3 1 h 8 16. 6 5. 0 843. 3 237. 4 677. 3 171. 5 2 h 8 14. 7 4. 5 * 803. 6 205. 1 648. 2 165. 1 15 cm H2O 組 0 h 6 18. 4 6. 0 1034. 8 466. 3 838. 0 380. 0 1 h 6 15. 7 2. 6* 911. 4 335. 5 741. 5 265. 1 2 h 6 15. 3 3. 7* 969. 3 401. 8 7

24、81. 7 323. 7 * 與組內(nèi)應(yīng)用PEEP 前比較, P 0. 05 東南大學(xué)學(xué)報(bào)(醫(yī)學(xué)版) 2004 年7 月,23 (4) 1995-2005 Tsinghua Tongfang Optical Disc Co., Ltd. All rights reserved.,.,33,肺水含量是ARDS的預(yù)后指標(biāo),Mortality as a function of EVLW. Patients were classified into four groups according to their highest EVLW value. The asterisk indicates stat

25、istical significance to the next higher EVLW group (2 test).,.,34,肺水含量是ARDS的預(yù)后指標(biāo),Sensitivity and specificity of ICU admission values for EVLW, SAPS II, APACHE II score, and SOFA score with respect to outcome according to ROC in 211 patients. The AUCs were 0.692 for APACHE II score, 0.766 for SAPS II

26、, 0.756 for SOFA score, and 0.639 for EVLW, respectively. The comparison between AUCs for EVLW with SOFA score (p = 0.012) and SAPS II (p = 0.008) showed a statistically significant difference.,.,35,評價(jià)危重病患者病死率,Sakka等對373例危重病患者回顧性研究發(fā)現(xiàn) 高EVLW患者的病死率顯著高于低EVLW患者 還發(fā)現(xiàn)EVLW與簡明急性生理評分(SAPS)和急性生理和慢性健康評分（APACHE)

27、一樣，是評價(jià)危重病患者病死率的獨(dú)立而可靠的因素。,.,36,容量管理,基本目標(biāo) 維持有效血容量 合適的心臟前負(fù)荷 預(yù)防和治療肺水腫,.,37,容量監(jiān)測現(xiàn)狀,臨床表現(xiàn)：BP, HR, 尿量, BUN/Cr 等 壓力監(jiān)測：飄浮導(dǎo)管（CVP/PAWP） 容量監(jiān)測：TEE, CT, MRI，核素掃描,.,38,壓力反映容量及肺水腫的局限性,心臟的順應(yīng)性 瓣膜功能 肺毛細(xì)血管通透性 機(jī)械通氣對循環(huán)的影響,.,39,CVP/PAWP,CVP和PAWP與心臟容量狀況之間相關(guān)性的可靠程度欠佳。 心肌順應(yīng)性降低的情況下，較少的容量增加會引起CVP和PAWP明顯增高，而ITBV 不受心肌順應(yīng)性影響。 因此，ITB

28、V比CVP和PAWP更能反映心臟容量負(fù)荷。,.,40,容量指標(biāo),胸腔內(nèi)血管容量（ITBV） 血管外肺水(EVLW) 全心舒張末期容積（GEDV） 搏出量變異率（SVV）,.,41,EVLW與CVP/PAWP,Mitchell等將101例放置肺動脈漂浮導(dǎo)管的肺水腫患者隨機(jī)分成兩組 分別通過PAWP和EVLW進(jìn)行液體管理，PAWP組將上限定為18 mmHg，EVLW組將上限定為7 mlKg，超過上限值就進(jìn)行限液并使用利尿劑。 結(jié)果，EVLW組機(jī)械通氣時(shí)間和住院時(shí)間較PAWP組明顯縮短 提示, 根據(jù)EVLW進(jìn)行肺水腫的液體管理可能比CVP和PAWP更為可靠。,.,42,胸腔內(nèi)血管容量（ITBV）,T

29、he accuracy of intrathoracic blood volume (ITBV) as a preload index, instead of central venous pressure and wedge pressure, has been demonstrated Lichtwark-Ashoff M, et al.: Intensive Care Med 1992, 18:142-147. Lichtwark-Ashoff M, et al.: J Crit Care 1996, 11:180-188 Joachim Boldt: Critical Care 200

30、2, 6:52-59,.,43,Fluid overload 透析與液體過負(fù)荷,To assess the dry weight of chronic hemodialysis (HD) patients The PiCCO system In 28 of the 42 patients (67%), elevated values of ELWI were found, indicating interstitial volume overload. 無液體過負(fù)荷的臨床表現(xiàn)并非意味著已達(dá)到理想的dry weight There were significant correlations be

31、tween ELWI and cardiac function index (p=0.003), global ejection fraction (p=0.012), ITBI (p=0.004), and GEDI (p=0.004) No significant relations among ELWI and mean arterial pressure (MAP), BNP, aldosterone, and renin were found. In conclusion, the use of ELWI is safe in chronic HD patients and identifies fluid-overloaded patients, who show no obvious signs of hypervolemia. The determination of ELWI is an excellent method to quantify the exact volume in chronic HD patients. Chris