呼吸治療肺保護(hù)施麗萍指南

1、1呼吸機(jī)相關(guān)性肺損傷呼吸機(jī)相關(guān)性肺損傷acute parenchymal lung injury and an acute inflammatory response in the lung. cytokines alveoli and the systemic circulation multiple organ dysfunction mortality1容量性損傷容量性損傷 Volutrauma（large gas volumes ）壓力性損傷壓力性損傷 Barotrauma（high airway pressure ）不張性損傷不張性損傷 Atelectotrauma（alveolar

2、 collapse and re-expansion）生物性損傷生物性損傷 Biotrauma（increased inflammation ）1alveolar structural damagepulmonary edema、 inflammation、 fibrosis surfactant dysfunctionother organ dysfunctionexacerbate the disturbance of lung development Semin Neonatol. 2002 Oct;7(5):353-60.1 Approaches in the management o

3、f acute respiratory failure in childrenprotective ventilatory and potential protectiveventilatory modes lower tidal volume and PEEP permissive hypercapnia high-frequency oscillatory ventilation airway pressure release ventilation partial liquid ventilationimprove oxygenation recruitment maneuvers pr

4、one positioning kinetic therapy reduce FiO2 and facilitate gas exchange inhaled nitric oxide and surfactant Curr Opin Pediatr. 2004 Jun;16(3):293-8.1Can mechanical ventilation strategies reduce chronic lung disease?continuous positive airway pressurepermissive hypercapnia patient-triggered ventilati

5、on volume-targeted ventilation proportional assist ventilation high-frequency ventilation Semin Neonatol. 2003 Dec;8(6):441-81小潮氣量和呼氣末正壓小潮氣量和呼氣末正壓 lower tidal volume and PEEP1Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS1202 patientslower tidal volu

6、me (7ml/kg) low plateau pressure 30 cm H2O versus tidal volume 10 to 15 ml/kgMortality at day 28 long-term mortality was uncertainlow and conventional tidal volume with plateau pressure 31 cm H2O was not significantly different Cochrane Database Syst Rev. 2004;(2):CD0038441549 patients acute lung in

7、jury and ARDSlower-PEEP group 8.33.2cmH2O higher-PEEP group 13.23.5cmH2O (P0.001). tidal-volume 6ml/kg end-inspiratory plateau-pressure30cmH2OThe rates of death 24.9 % 27.5 % (p=0.48) From day 1 to day 28, breathing was unassisted 14.510.4 days 13.810.6 days (p=0.5)clinical outcomes are similar whet

8、her lower or higher PEEP levels are used. N Engl J Med. 2004 Jul 22;351(4):327-36.1Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilationSprague-Dawley rats negative control group low pressures (PIP = 12 cm H2O), rate = 30, iT =

9、 0.5, 1.0, 1.5secs experimental groups high pressures (PIP = 45 cm H2O), rate = 10, iT = 0.5 , 1.0 , 1.5 secslung compliance, PaO2 /FiO2 ratio, wet/dry lung weight, and dry lung/body weightas inspiratory time increased ,static lung compliance (p =.0002) and Pao2/Fio2 (p =.001) decreased. Wet/dry lun

10、g weights (p .0001) and dry lung/body weights (p 0.050.050.050.050.051對(duì)照組（對(duì)照組（NPM)： 應(yīng)用人工呼吸機(jī)限壓定時(shí)持續(xù)氣流型，通氣模式為應(yīng)用人工呼吸機(jī)限壓定時(shí)持續(xù)氣流型，通氣模式為IMV，持續(xù)脈搏血氧飽和度監(jiān)測(cè)使其，持續(xù)脈搏血氧飽和度監(jiān)測(cè)使其維持在維持在8595%，每，每8h監(jiān)測(cè)動(dòng)脈血?dú)庖淮?，要求血?dú)饩S持在正常范圍內(nèi)，監(jiān)測(cè)動(dòng)脈血?dú)庖淮?，要求血?dú)饩S持在正常范圍內(nèi)，PaO2 40-70mmHg, PaCO2 35-45mmHg1觀察組（觀察組（PM組）組）： 1、肺力學(xué)監(jiān)測(cè)儀、肺力學(xué)監(jiān)測(cè)儀(Bicore CP100)每每8

11、12h 監(jiān)測(cè)一次機(jī)械通氣時(shí)肺力學(xué)參數(shù)監(jiān)測(cè)一次機(jī)械通氣時(shí)肺力學(xué)參數(shù) 2、監(jiān)測(cè)時(shí)要求患兒與呼吸機(jī)完全同步或無自主呼吸狀態(tài)（必要時(shí)通過藥物抑制呼吸）、監(jiān)測(cè)時(shí)要求患兒與呼吸機(jī)完全同步或無自主呼吸狀態(tài)（必要時(shí)通過藥物抑制呼吸） 3、肺力學(xué)監(jiān)測(cè)儀的傳感器置于近端接口、肺力學(xué)監(jiān)測(cè)儀的傳感器置于近端接口 4、氣管插管氣漏率小于、氣管插管氣漏率小于20% 5、每監(jiān)測(cè)一次持續(xù)、每監(jiān)測(cè)一次持續(xù)0.51h至數(shù)據(jù)穩(wěn)定后記錄監(jiān)測(cè)的數(shù)據(jù)至數(shù)據(jù)穩(wěn)定后記錄監(jiān)測(cè)的數(shù)據(jù)1NPM 組和組和PM組的評(píng)估指標(biāo)組的評(píng)估指標(biāo) 1. 疾病極期，即生后疾病極期，即生后2448h時(shí)呼吸機(jī)要求最高值，包括時(shí)呼吸機(jī)要求最高值，包括FiO2、 PIP、

12、PEEP、Ti、MAP、VR 2. VE、C20/C、TC（限于（限于PM組），組）， 3. 記錄血記錄血pH、PaO2、PaCO2、氧合指數(shù)（、氧合指數(shù)（OI ）（OI=FiO2MAP/PaO2）和心率、血壓和心率、血壓 4. 呼吸機(jī)應(yīng)用時(shí)間，用氧時(shí)間，住院天數(shù)，病死率，呼吸機(jī)應(yīng)用時(shí)間，用氧時(shí)間，住院天數(shù)，病死率，PDA，IVH和呼吸機(jī)相關(guān)性肺損傷的和呼吸機(jī)相關(guān)性肺損傷的發(fā)生率。發(fā)生率。1兩組呼吸機(jī)參數(shù)比較兩組呼吸機(jī)參數(shù)比較 FiO2（%） PIP（cmH2O) P E E P（cmH2O)MAP（cmH2O) Ti (sec) VR（次（次/分）分）NPM601930.53.45.60.8

13、14.93.40.750.1399PM621826.71.75.40.611.92.00.450.14210t0.1847.5271.3395.81818.101.81p0.050.050.0010.051PIP30.526.705101520253035NPMPMPIPMAP14.911.90246810121416NPMPMMAPMAP14.911.90246810121416NPMPMMAPPEEP5.65.40123456NPMPMPEEP1兩組血?dú)獗O(jiān)測(cè)結(jié)果比較兩組血?dú)獗O(jiān)測(cè)結(jié)果比較 PHPaO2(mmHg)PaCO2 (mmHg)HR(次次/分）分）BP(mmHg)OINPM7.310

14、.1571740101448404.61913PM7.30.045916486.31456393.6147.7t0.2890.5164.6630.7980.9422.011p0.050.050.050.050.051pH7.317.377.17.27.37.47.5NPMPMpHPaO25759010203040506070NPMPMPaO2PaCO240480102030405060NPMPMPaCO2PaCO240480102030405060NPMPMPaCO21兩組呼吸機(jī)相關(guān)性肺損傷、兩組呼吸機(jī)相關(guān)性肺損傷、PDA、IVH、呼吸機(jī)應(yīng)用時(shí)間、用氧時(shí)間、住院天數(shù)、病死率比較呼吸機(jī)應(yīng)用時(shí)間、

15、用氧時(shí)間、住院天數(shù)、病死率比較 VALI%PDA%IVH%IMV(d)用氧時(shí)用氧時(shí)間間(d)住院天住院天數(shù)數(shù)(d)病死率病死率%NPM3236423.91.8117191414PM13.333.3404.21.713722118.3t 0.8671.4741.22 5.570.090.05 0.9p0.050.050.050.050.050.051肺力學(xué)監(jiān)測(cè)能指導(dǎo)正確應(yīng)用呼吸機(jī)，降低呼吸機(jī)相關(guān)性肺損傷肺力學(xué)監(jiān)測(cè)能指導(dǎo)正確應(yīng)用呼吸機(jī)，降低呼吸機(jī)相關(guān)性肺損傷 從本研究結(jié)果推薦從本研究結(jié)果推薦RDS呼吸機(jī)應(yīng)用的參數(shù)為：呼吸機(jī)應(yīng)用的參數(shù)為：PIP 25cmH2O左右，短左右，短Ti 0.30.5秒，應(yīng)

16、秒，應(yīng)用適當(dāng)?shù)挠眠m當(dāng)?shù)腜EEP 5-7cmH2O治療治療RDS，不影響氧合。，不影響氧合。 PaCO2的輕度增高（的輕度增高（PaCO2 45-60），），IVH的發(fā)生未見增加。的發(fā)生未見增加。 1允許性高碳酸血癥允許性高碳酸血癥Permissive hypercapnia1Permissive hypercapnia-role in protective lung ventilatory strategies First, we consider the evidence that protective lung ventilatory strategies improve survival

17、 and we explore current paradigms regarding the mechanisms underlying these effects Second, we examine whether hypercapnic acidosis may have effects that are additive to the effects of protective ventilation Third, we consider whether direct elevation of CO2, in the absence of protective ventilation

18、, is beneficial or deleteriousFourth, we address the current evidence regarding the buffering of hypercapnic acidosis1 Lung-protective ventilation in acute respiratory distress syndrome: protection by reduced lung stress or by therapeutic hypercapnia? hypercapnic acidosis lung-protective ventilation

19、 respiratory acidosis protected the lung The protective effect of respiratory acidosis inhibition of xanthine oxidase prevented by buffering the acidosis . the protection resulted from the acidosis rather than hypercapnia Am J Respir Crit Care Med. 2000 Dec;162(6):2021-2. 1Permissive hypercapnia in

20、ARDS and its effect on tissue oxygenationThe right-shift of the haemoglobin-oxygen dissociation curvereduce intrapulmonary shunt (Qs/Qt) by potentiating hypoxic pulmonary vasoconstrictionaffect the distribution of systemic blood flow both within organs and between organs Acta Anaesthesiol Scand Supp

21、l. 1995;107:201-81 Hypercapnic acidosis attenuates endotoxin induced acute lung injuryattenuated the decrement in oxygenation improved lung compliancereduced alveolar neutrophil infiltration and histologic indices of lung injury Am J Respir Crit Care Med. 2004 Jan 1;169(1):46-561Hypercapnic acidosis

22、 is protective in an in vivo model of ventilator-induced lung injury12 rabbits ventilator-induced lung injury (VILI)PaCO2 40 mm Hg n = 6 PaCO2 80-100 mm Hg n = 6respiratory mechanics (plateau pressures) 27.0 2.5 20.9 3.0 p = 0.016gas exchange (PaO2 ) 165.2 19.4 77.3 87.9 p = 0.02wet:dry weight 9.7 2

23、.3 6.6 1.8 p = 0.04bronchoalveolar lavage fluid protein concentration 1350 228 656 511 p = 0.03 cell count 6.86 x 105 2.84 x 105 p = 0.021 injury score 7.0 3.3 0.7 0.9 p 0.0001 Am J Respir Crit Care Med. 2002 Aug 1;166(3):403-8 1Effects of high PCO2 on ventilated preterm lamb lungsPreterm surfactant

24、-treated lambs with a high tidal volume (Vt) 30 min acute lung injury. Vt 6-9 mL/kg 5.5 h PCO2 40-50 mm Hg add to the ventilator circuit PCO2 95 5 mm Hgheart rates blood pressures plasma cortisol values oxygenation no different white blood cells hydrogen peroxide production IL-1beta, IL-8 cytokine m

25、RNA expression in cells from the alveolar washHistopathology less lung injury Pediatr Res. 2003 Mar;53(3):468-72.1Permissive hypercapnia for the prevention of morbidity and mortality in mechanically ventilated newborn infantsTwo trials involving 269 newborn infants no evidence the incidence of death

26、 or CLD at 36 weeks (RR 0.94, 95% CI 0.78, 1.15) no evidence IVH 3 or 4 (RR 0.84, 95% CI 0.54, 1.31) no evidence PVL (RR 1.02, 95% CI 0.49, 2.12).no evidence Long term neurodevelopmental outcomes One trial reported that permissive hypercapnia reduced the incidence of CLD in the 501 to 750 gram subgr

27、oup Cochrane Database Syst Rev. 2001;(2):CD0020611Permissive hypercapnia in neonates: the case of the good, the bad, and the ugly PaCO2 levels of 45-55 mmHg in high-risk neonates are safe and well tolerated Pediatr Pulmonol. 2002 Jan;33(1):56-641高頻震蕩通氣高頻震蕩通氣High-frequency oscillatory ventilation1 Hi

28、gh-frequency oscillatory ventilation for acuterespiratory distress syndrome in adult patients148 randomized, controlled trial ARDS HFOV PCVPaO2/FiO2 72h noThirty-day mortality 37% or 52% (p=0.102)barotrauma, hemodynamic instability, or mucus plugging no differentclinical use in adults FiO260% and MA

29、P 20 cm H2O or PEEP15 cm H2O Crit Care Med. 2003 Apr;31(4 Suppl):S317-231Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants updated in May 2003 3275 Randomized controlled trials comparing HFOV and CV in preterm or low bi

30、rth weight infants with pulmonary dysfunctionno evidence of effect on CLD and mortality at 28-30 days Pre-specified subgroup analyses Short term neurological morbidity Grade 3 or 4 IVH and PVL (no using high volume strategy) Cochrane Database Syst Rev. 2003(4):CD0001041Open lung ventilation improves

31、 gas exchange and attenuates secondary lung injury in a piglet model of meconium aspirationProspective, randomized animal study36 newborn piglets (6 saline controls) PPV(OLC), HFOV(OLC), PPV(CON) ventilated for 5 hrsbronchoalveolar lavage fluid myeloperoxidase activity lung injury score Alveolar pro

32、tein influx no differentsuperior oxygenation and less ventilator-induced lung injury Crit Care Med. 2004 Feb;32(2):443-91Changes in mean airway pressure during HFOV influences cardiac output in neonates and infants14 patients 1 year weight 10 kg HFOVstudy group (n = 9) MAP +5 and -3 cmH2Ocontrol group (n = 5) Cardiac output echocardiography Doppler techniqueCardiac output the study group (P = 0.02)the greatest change at the highest Paw at -11% (range: -19 to -9) compared with baseline. Acta Anaesthesiol Scand. 2004 Feb;48(2):218-231Randomized