機械通氣患者的壓力容積曲線學(xué)習(xí)課件

1、機械通氣患者的壓力容積曲線機械通氣患者的壓力容積曲線 呼吸系統(tǒng)壓力容積曲線呼吸系統(tǒng)壓力容積曲線 反映肺和胸廓的靜態(tài)機械力學(xué)特征 了解患者的病理生理學(xué)改變 設(shè)置機械通氣參數(shù) 靜態(tài)法(static method)準(zhǔn)靜態(tài)法(quasistatic) 超大注射器法(super-syringe technique) 吸氣阻斷法(inspiratory occlusion technique) 低流量法(continuous inflation at a constant flow) PV曲線的測定方法曲線的測定方法 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 測定前的準(zhǔn)備

2、工作 鎮(zhèn)靜+肌松 測定前15分鐘預(yù)氧合 FiO2 1.0 PEEP 0 準(zhǔn)備好1.5或3.0 L超大注射器 充滿經(jīng)過濕化的氧氣 Matamis D, Lemaire F, Harf A, et al: Total respiratory pressure volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 58-66 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 Matamis D, Lemaire F, Harf A, et al: Total respiratory

3、 pressure volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 58-66 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 將患者脫離呼吸機數(shù)秒鐘 使得肺完全排空，恢復(fù)至FRC 將超大注射器連接氣管插管 從FRC開始進行充氣 每次向肺內(nèi)注入50 100 mL氣體 等待3秒鐘以使壓力穩(wěn)定 通過壓力傳感器測定氣道壓力 再次充氣50 100 mL 直至Paw達到40 50 cmH2O，或注入氣體達到1.5 L 整個過程通常不超過90秒鐘 Matamis D, Lemai

4、re F, Harf A, et al: Total respiratory pressure volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 58-66 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 Matamis D, Lemaire F, Harf A, et al: Total respiratory pressure volume curves in the adult respiratory distress syndrome. Chest 1984;

5、86: 58-66 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 Matamis D, Lemaire F, Harf A, et al: Total respiratory pressure volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 58-66 通常重復(fù)測定4次 第1次結(jié)果舍棄 對volume history進行校正 后3次結(jié)果取平均值 優(yōu)點缺點 測定PV曲線的經(jīng)典方法 1980s的金標(biāo)準(zhǔn) 可以測定吸氣支及呼氣支PV曲線 測定時須脫離呼吸機 充氣過程中肺容積

6、減少 充氣過程延長( 45 s) 消耗氧氣導(dǎo)致肺容積減少 僅部分被生成的CO2代償 注射器中氧氣的溫度和濕度影響測定 結(jié)果 使用未經(jīng)加溫加濕的氣體導(dǎo)致曲 線左移 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 Lu Q, Rouby JJ. Measurement of pressure-volume curves in patients on mechanical ventilation: methods and significance. Crit Care 2000; 4: 91-100 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法

7、 Levy P, Similowski T, Corbeil C, et al: A method for studying the static volume-pressure curves of the respiratory system during mechanical ventilation. J Crit Care 1989, 4: 83-89 測定原理 吸氣末平臺壓力反映肺泡壓力 使用不同潮氣量可以得到相應(yīng)的 肺泡壓力 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Levy P, Similowski T, Corbeil C, et al: A m

8、ethod for studying the static volume-pressure curves of the respiratory system during mechanical ventilation. J Crit Care 1989, 4: 83-89 測定前的準(zhǔn)備工作 鎮(zhèn)靜+肌松 呼吸機須具備的功能 吸氣末暫停 呼氣末暫停 平臺壓及呼氣末壓力顯示 設(shè)置基礎(chǔ)通氣模式 容量控制通氣模式 恒定流量 校正volume history 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Levy P, Similowski T, Corbeil C, et a

9、l: A method for studying the static volume-pressure curves of the respiratory system during mechanical ventilation. J Crit Care 1989, 4: 83-89 每次測定平臺壓力前應(yīng)當(dāng) 恢復(fù)基礎(chǔ)通氣模式及設(shè)置 使用呼氣末暫停測定PEEPi 保證肺容積及呼氣末壓力恒定(volume history) 每次測定時改變潮氣量 通過改變呼吸頻率即吸氣時間增加或減少潮氣量 保持吸氣流量不變 隨機選擇潮氣量 吸氣末阻斷數(shù)秒鐘后測定平臺壓力 得到不同潮氣量所對應(yīng)的肺泡壓力并作圖 靜態(tài)靜

10、態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Barberis L, Manno E, Guerin C. Effect of end-inspiratory pause duration on plateau pressure in mechanically ventilated patients. Intensive Care Med 2003; 29: 130-134 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Barberis L, Manno E, Guerin C. Effect of end-inspiratory pause

11、duration on plateau pressure in mechanically ventilated patients. Intensive Care Med 2003; 29: 130-134 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Barberis L, Manno E, Guerin C. Effect of end-inspiratory pause duration on plateau pressure in mechanically ventilated patients. Intensive Care Med 2003; 29: 13

12、0-134 Volume history對對PV曲線測定的影響曲線測定的影響 Takeuchi M, Sedeek KA, Schettino GPP, et al. Peak pressure during volume history and pressure-volume curve measurement affects analysis. Am J Respir Crit Care Med 2001; 164: 1225-1230 Volume history對對PV曲線測定的影響曲線測定的影響 Nishida T, Suchodolski K, Schettino GPP, et

13、al. Peak volume history and peak pressure-volume curve pressures independently affect the shape of the pressure-volume curve of the respiratory system. Crit Care Med 2004; 32: 1358-1364 Volume history對對PV曲線測定的影響曲線測定的影響 Nishida T, Suchodolski K, Schettino GPP, et al. Peak volume history and peak pres

14、sure-volume curve pressures independently affect the shape of the pressure-volume curve of the respiratory system. Crit Care Med 2004; 32: 1358-1364 Volume history對對PV曲線測定的影響曲線測定的影響 Nishida T, Suchodolski K, Schettino GPP, et al. Peak volume history and peak pressure-volume curve pressures independe

15、ntly affect the shape of the pressure-volume curve of the respiratory system. Crit Care Med 2004; 32: 1358-1364 優(yōu)點缺點 患者無需脫離呼吸機 可以忽略氧氣消耗 每次測定僅3秒鐘 可以在不同PEEP下測定PV曲線 所有呼吸機均可使用 耗時較長(約15分鐘) 恢復(fù)基礎(chǔ)通氣設(shè)置 測定PEEPi 不能測定呼氣支PV曲線 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Lu Q, Rouby JJ. Measurement of pressure-volume cur

16、ves in patients on mechanical ventilation: methods and significance. Crit Care 2000; 4: 91-100 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 測定原理: 順應(yīng)性計算公式 Compliance volume presssure Compliance volume/time presssure/time 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 測定原理: 順應(yīng)性計算公式 Compliance V presssure/time 若V(t)恒定 則克服

17、阻力的壓力差恒定 此時氣道壓力與呼吸系統(tǒng)順應(yīng)性呈負相關(guān) 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 低流量法測定PV曲線: 歷史演變 Suratt et al (JAP 1980; Chest 1981) 吸氣流量0.60 0.10 (0.40 0.65) L/sec PV曲線的順應(yīng)性與靜態(tài)法相同 Ranieri et al (Am J Respir Crit Care Med 1994) 低流量法PV曲線有助于確定PEEP導(dǎo)致的肺泡復(fù)張及過度膨脹 Servillo et al (Am J Respir Crit Care Med 1997); Lu et al (

18、Am J Respir Crit Care Med 1999) 吸氣流量20 60 lpm時, PV曲線斜率測定準(zhǔn)確, 但高估UIP和LIP 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Suratt PM, Owens DH, Kilgore WT, Harry RR, Hsiao HS: A pulse method of measuring respiratory system compliance. J Appl Physiol 1980, 49: 1116-1121 Suratt PM, Owens DH: A pulse method of measuri

19、ng respiratory system compliance in ventilated patients. Chest 1981, 80: 34-38 Ranieri VM, Giuliani R, Flore T, Dambrosio M, Milic-Emili J: Volumepressure curve of the respiratory system predicts effects of PEEP in ARDS: occlusion versus constant flow technique. Am J Respir Crit Care Med 1994, 149:

20、19-27 Servillo G, Svantesson C, Beydon L, et al: Pressurevolume curves in acute respiratory failure. Automated low flow inflation versus occlusion. Am J Respir Crit Care Med 1997, 155: 1629-1636 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measuring pressure-volume curve during

21、 mechanical ventilation. Am J Respir Crit Care Med 1999, 159: 275-282 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 低流量法測定PV曲線: 歷史演變 Mankikian et al (Crit Care med 1983) 吸氣流量1.7 lpm 準(zhǔn)靜態(tài)PV曲線與靜態(tài)法(超大注射器法)相同 吸氣時間長達60 s Servillo et al (Am J Respir Crit Care Med 1997); 吸氣流量15 lpm時, 準(zhǔn)靜態(tài)PV曲線右移, 但斜率不變 高估UIP和LIP Mankik

22、ian B, Lemaire F, Benito S, et al: A new device for measurement of pulmonary pressure-volume curves in patients on mechanical ventilation. Crit Care Med 1983； 11: 897-901 Servillo G, Svantesson C, Beydon L, et al: Pressurevolume curves in acute respiratory failure. Automated low flow inflation versu

23、s occlusion. Am J Respir Crit Care Med 1997, 155: 1629-163 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 減去克服氣道阻力所需壓力減去克服氣道阻力所需壓力進一步降低吸氣流量進一步降低吸氣流量 Ptot = Ptrach + Pres(tube) Ptrach = Pel + Pres 與吸氣阻斷法相比 呼吸系統(tǒng)順應(yīng)性, UIP和LIP均相同 Paw = Pressure + Pel Pressure = Flow x Raw 當(dāng)吸氣流量0 Pressure 0 Paw Pel 如何提高準(zhǔn)靜態(tài)PV曲線的準(zhǔn)確性 S

24、ervillo G, Svantesson C, Beydon L, et al: Pressurevolume curves in acute respiratory failure. Automated low flow inflation versus occlusion. Am J Respir Crit Care Med 1997, 155: 1629-1636 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measuring pressure-volume curve during mechan

25、ical ventilation. Am J Respir Crit Care Med 1999, 159: 275-282 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Jonson B, Richard JC, Straus C, et al: Pressurevolume curves and compliance in acute lung injury. Am J Respir Crit Care Med 1999, 159: 1172-1178 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Krason S, Sndergaard

26、 S, Lundin S, Wiklund J, Stenqvist O. Evaluation of pressure/volume loops based on intratracheal pressure measurements during dynamic conditions. Acta Anaesthesiol Scand 2000; 44: 571-577 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 減去克服氣道阻力所需壓力減去克服氣道阻力所需壓力進一步降低吸氣流量進一步降低吸氣流量 Ptot = Ptrach + Pres(tube) Ptrach

27、 = Pel + Pres 與吸氣阻斷法相比 呼吸系統(tǒng)順應(yīng)性, UIP和LIP均相同 Paw = Pressure + Pel Pressure = Flow x Raw 當(dāng)吸氣流量0 Pressure 0 Paw Pel 如何提高準(zhǔn)靜態(tài)PV曲線的準(zhǔn)確性 Servillo G, Svantesson C, Beydon L, et al: Pressurevolume curves in acute respiratory failure. Automated low flow inflation versus occlusion. Am J Respir Crit Care Med 1997

28、, 155: 1629-1636 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measuring pressure-volume curve during mechanical ventilation. Am J Respir Crit Care Med 1999, 159: 275-282 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measu

29、ring pressure-volume curve during mechanical ventilation. Am J Respir Crit Care Med 1999, 159: 275-282 呼吸機設(shè)置 容量控制通氣模式 吸氣流量恒定 呼吸頻率5 lpm I:E4:1 VtFlow 設(shè)置1500 mL3 lpm 設(shè)置21500 mL9 lpm 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measuring pressur

30、e-volume curve during mechanical ventilation. Am J Respir Crit Care Med 1999, 159: 275-282 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measuring pressure-volume curve during mechanical ventilation. Am J Respir Crit Care Med 1999, 159: 275-28

31、2 PEEPi 呼氣流量從呼氣末數(shù)值 下降至0 克服氣道阻力所需壓力 (Pres): 吸氣流量開始恒 定時所對應(yīng)的氣道壓力 與PEEPi的差值 吸氣流量開始恒定 LIP: 初始階段順應(yīng)性曲 線與PV曲線斜率的交點 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Lu Q, Vieira S, Richecoeur J, et al: A simple automated method for measuring pressure-volume curve during mechanical ventilation. Am J Respir Crit Care Med 1

32、999, 159: 275-282 當(dāng)吸氣流量設(shè)置為9 lpm時 PV曲線因阻力因素的影響向 右側(cè)移動 高估LIP (統(tǒng)計學(xué)無差異) PV曲線斜率無差異 優(yōu)點缺點 患者無需脫離呼吸機 不影響肺容積 測定時間較短 每次測定僅需10秒鐘 整個操作包括曲線分析僅需2分 鐘 可以在不同PEEP下測定PV曲線 需要特殊的呼吸機 吸氣流量較高時影響準(zhǔn)確性 PV曲線右移 不能測定呼氣支PV曲線 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 低流量法低流量法 Lu Q, Rouby JJ. Measurement of pressure-volume curves in patients on mec

33、hanical ventilation: methods and significance. Crit Care 2000; 4: 91-100 Draeger Evita XLHamilton Galileo Gold/G5 低流量法 吸氣支和呼氣支PV曲線 改良低流量法 壓力改變速度很慢 吸氣支和呼氣支PV曲線 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 改改良良低流量法低流量法 準(zhǔn)靜態(tài)準(zhǔn)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 改改良良低流量法低流量法 /./PN%20689213_PV-Tool_WP_01-

34、Validation_of_New_Method.pdf Piacentini E, Wysocki M, Blanch L. A new automated method versus continuous positive airway pressure method for measuring pressure-volume curves in patients with acute lung injury. Intensive Care Med 2009; 35: 565-570 Hamilton Galileo Gold采用的改良低流量法 測定吸氣與呼氣PV曲線 與CPAP方法相同

35、與低流量法相同 低流量低流量: How Low is Low? 目的: 評價不同吸氣流量下測 定的準(zhǔn)靜態(tài)PV曲線, 其LIP, UIP, 最大斜率及WOB是否存 在差異 研究對象: 7名接受機械通氣的 ARDS患者 方法: 容量控制通氣模式 吸氣流量1, 2, 5, 10 lpm 吸氣時間從73 1.6 sec到 8.8 0.69 sec 結(jié)論: LIP無差異 UIP和順應(yīng)性有統(tǒng)計學(xué)差異 Gama AM, Meyer EC, Gaudencio AM, et al. Different low constant flows can equally determine the lower inf

36、ection point in acute respiratory distress syndrome patients. Artif Organs 2001; 25: 882-889 低流量低流量: How Low is Low? Figure 1. Effect of inspiratory flow on airway pressure traces. The curve on the left was obtained by using a 30 L/min flow, the curve on the right with 6 L/min. The component related

37、 to the resistance of flow through airways and tracheal cannula (P1 = Pmax Pi) increases with higher flows, whereas the component related to the viscoelastic properties of lung parenchyma (P2 = Pi Pplat) remains constant in both tracings. The goal in the low-flow technique for acquisition of PV curv

38、es is to use a flow that makes P1 negligible. Paw = airway pressure, Pmax = maximum airway pressure, Pi = pressure at the beginning of the inspiratory pause, Pplat = plateau pressure or pressure at the end of the inspiratory pause. Bensenor FE, Vieira JE, Auler JOC. Guidelines for inspiratory flow s

39、etting when measuring the pressure-volume relationship. Anesth Analg 2003; 97: 145-150 低流量低流量: How Low is Low? Bensenor FE, Vieira JE, Auler JOC. Guidelines for inspiratory flow setting when measuring the pressure-volume relationship. Anesth Analg 2003; 97: 145-150 低流量低流量: How Low is Low? Bensenor F

40、E, Vieira JE, Auler JOC. Guidelines for inspiratory flow setting when measuring the pressure-volume relationship. Anesth Analg 2003; 97: 145-150 低流量低流量: How Low is Low? Bensenor FE, Vieira JE, Auler JOC. Guidelines for inspiratory flow setting when measuring the pressure-volume relationship. Anesth

41、Analg 2003; 97: 145-150 呼吸系統(tǒng)靜態(tài)呼吸系統(tǒng)靜態(tài)PV曲線曲線: What Else? (B) The tracheal pressure Ptrach (inner loop, dashed area) is calculated point by point. The pressure difference between the outer PAW/V-loop and the inner Ptrach/V-loop mainly represents the flow-dependent resistive pressure drop across the ETT

42、. The Ptrach/V- loop is subdivided into eight slices (indicated by horizontal lines) and respiratory mechanics are analysed separately for each slice. The upper and lower 5% of the tidal volume (VT) (i.e. slices 1 and 8, respectively) are excluded from analysis. The remaining 90% of VT are divided i

43、nto 6 slices. One volume-dependent dynamic compliance and resistance of the respiratory system (Cr s,dyn and Rr s,dyn) are calculated per slice. (C) Quality check: Ptrach is recalculated point by point for each slice, using the calculated values for Cr s,dyn and Rr s,dyn and the measured volume and

44、flow. This recalculated Ptrach/V-loop is superimposed on the measured Ptrach/V-loop, and the pressure difference between both loops reflects the accuracy of the calculated mechanical parameters. The measured and recalculated loops in C are barely distinguishable. Paw-Volume Curve Lichtwarck-Aschoff

45、M, Kessler V, Sjostrand UH, et al. Static versus dynamic respiratory mechanics for setting the ventilator. Br J Anaesth 2000; 85: 577-586 呼吸系統(tǒng)靜態(tài)呼吸系統(tǒng)靜態(tài)PV曲線曲線: What Else? 多元線性回歸模型(multiple linear regression model) Paw = Vt/Crs,st + Rrs x V + PEEPtot 多元非線性回歸模型(multiple nonlinear regression model) Paw =

46、 Vt/Crs,st + k1 x V + k2 x V2 + PEEPtot Vassiliou MP, Petri L, Amgdalou A, et al. Linear and nonlinear analysis of pressure and flow during mechanical ventilation. Intensive Care Med 2000; 26: 1057-1064 靜態(tài)靜態(tài)PV曲線曲線: 多元線性回歸模型多元線性回歸模型 Mols G, Brandes I, Kessler V, et al. Volume-dependent compliance in

47、ARDS: proposal of a new diagnostic concept. Intensive Care Med 10999; 25: 1084-1091 靜態(tài)靜態(tài)PV曲線曲線: 多元線性回歸模型多元線性回歸模型 Lichtwarck-Aschoff M, Kessler V, Sjostrand UH, et al. Static versus dynamic respiratory mechanics for setting the ventilator. Br J Anaesth 2000; 85: 577-586 靜態(tài)靜態(tài)PV曲線曲線: 總結(jié)總結(jié) 臨床可行的測定方法 吸氣阻

48、斷法和準(zhǔn)靜態(tài)法 操作要求和影響因素 臨床意義有待確定 呼吸系統(tǒng)壓力容積曲線呼吸系統(tǒng)壓力容積曲線 反映肺和胸廓的靜態(tài)機械力學(xué)特征 了解患者的病理生理學(xué)改變 設(shè)置機械通氣參數(shù) 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(I): 超大注射器法超大注射器法 Matamis D, Lemaire F, Harf A, et al: Total respiratory pressure volume curves in the adult respiratory distress syndrome. Chest 1984; 86: 58-66 靜態(tài)靜態(tài)PV曲線的測定方法曲線的測定方法(II): 吸氣阻斷法吸氣阻斷法 Barberis L, Man