ARDS肺復(fù)張的測定-邱海波

1、急性呼吸窘迫綜合征肺復(fù)張的測定與應(yīng)用邱海波東南大學(xué)附屬中大醫(yī)院東南大學(xué)急診與危重病研究所內(nèi)容提要ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinonis vs RoubysARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇 Lung volume decreased markedly (TLC, VC, TV, FRC) -alveolar edema -pulmonary surfactant -Interstitial pumonary edema depress brochiole a

2、nd induce spasmCompliance reduced significantlyVentilation/perfusion mismatch -intrapulmonary shunt and dead space like effectsARDS病理生理特點ARDS病理生理CT scan70-80% 的肺野呈現(xiàn)高密度區(qū)分布：下垂部位(dependent field)提示：參與通氣肺泡明顯減少(20-30%) 肺損傷具有不均一性肺容積減少Small lung Baby LungARDS病理生理A and C finding in the acute or exudative ph

3、aseB and DFinding in the fibrosing-alveolitis phaseARDS病理生理肺容積/順應(yīng)性明顯降低ARDS病理生理Reduced range of volume excursion: Low complianceFlattening at low and high volumes: Lower and upper inflection pointsBigatello: Br J Anaest 1996VolumePressureNORMALARDS順應(yīng)性曲線明顯右下移位肺順應(yīng)性明顯降低ARDS病理生理Upper and Lower Inflection

4、 PointsLower呼氣末肺泡塌陷吸氣早期肺泡再開放Upper吸氣末肺泡順應(yīng)性明顯降低，肺泡過度膨脹ARDS病理生理VolumePressureLower Inflection PointUpper Inflection Point通氣/血流失調(diào)肺泡塌陷：ARDS重力依賴區(qū)，炎癥或不張區(qū)生理性低氧縮血管反應(yīng)：障礙ARDS病理生理Imagine the Hardness to Blow up a Ballon .easyhardspatial & elastic limitationsLaplacian LawIt needs higher initial pressures to over

5、come the surface tension to open up a bubble to wider diameters!ARDS病理生理Sustain inflation Sigh小潮氣量通氣PHC, 避免肺泡過度膨脹最佳PEEP避免剪切力(Shear force)性損害VolumePressure肺開放與保護性通氣策略的基本內(nèi)容ARDS病理生理Lung volume decreased markedlyAtelectraumaKeep the lung openOpen the lungPrevent volutraumaSI and SighPEEPARDS病理生理內(nèi)容提要ARDS

6、病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinonis vs RoubysARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇 PV曲線法 Step 1: 測量PEEP所致的FRC(吸氣末撤掉PEEP并延長呼氣時間) FRCVE(ZEEP) VE(PEEP)肺復(fù)張容積測定 PV曲線法Step 2: 分別描計ZEEP和PEEP的PV曲線 Step 3: 肺復(fù)張容積：RV= V20(PEEP) + FRC V20(ZEEP)肺復(fù)張容積測定等壓法呼吸模式：BIPAP條件：Ph 20 cmH2O， PEEP

7、分別為0 、5 、 10、15 cmH2O，Ti 6S測定：延長呼氣時間，測定ZEEP呼出氣量。在不同PEEP時吸氣末撤掉PEEP，延長呼氣時間，測定呼氣量肺復(fù)張容積測定等壓法肺復(fù)張容積測定P-V曲線法與等壓法的比較*#與PEEP5cmH2O相比較，*P 0.05;與PEEP10cmH2O相比， P 0.05;與P-V曲線法相比， #P 0.05* #肺復(fù)張容積測定肺復(fù)張容積測定P-V曲線法等壓法雖然簡單，但準確性較差 不能代替P-V曲線法目前肺復(fù)張容積的測定仍宜采用 P-V曲線法肺復(fù)張容積測定CT method膈頂上1cm CT層面PEEP與ZEEP比較Gattinoni L. Am J R

8、espir CCM, 1995, 151: 1807全肺掃描區(qū)別過度膨脹，膨脹，部分復(fù)張和塌陷區(qū) Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444肺復(fù)張容積測定CT法-Gattinoni 肺復(fù)張容積測定原理CT空氣=0Hu，CT水=1000 HuCT值=500Hu，肺組織50%空氣+50%水ARDS塌陷肺CT值100Hu100Hu，塌陷肺泡復(fù)張 后，100Hu+100Hu內(nèi)肺組織減少方法ZEEP和PEEP通氣呼氣末CT掃描膈肌頂上1cm計算CT值在100 Hu 100 Hu范圍內(nèi)體素結(jié)果之差 Gattinoni L. Am J Respir CC

9、M, 1995, 151: 1807 原理 充氣不良區(qū)(100Hu500Hu)、正常充氣區(qū)(500Hu 900Hu)、無充氣區(qū)(100Hu+100Hu)和過度充氣區(qū)(900Hu1000Hu)。肺泡復(fù)張，充氣不良和正常充氣肺區(qū)體積增加 方法 ZEEP和PEEP呼氣末螺旋CT，根據(jù)層面厚度計算不同CT值肺體積，肺復(fù)張后充氣不良與正常充氣肺組織體積增加值肺復(fù)張容積測定CT法- Rouby Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444Gattinonis vs Roubys CT法比較肺復(fù)張容積測定優(yōu)點缺點Gattinoni結(jié)果直觀操作簡單設(shè)備要求低

10、單一層面不代表整體未計算充氣不良肺泡的復(fù)張掃描時間較長Rouby多層掃描，反映整肺情況計算充氣不良肺泡掃描時間縮短需特殊設(shè)備與軟件測定過程復(fù)雜CT methods: Rouby vs GattinoniLuiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444肺復(fù)張容積測定內(nèi)容提要ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinonis vs RoubysARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇 ARDS肺不張的影響因素-附加靜水壓Hydros

11、tatic pressure = (1 CT/-1000) Height Maximum sternovertebral dimention of human thorax: 20cmH2OPEEP 20cmH2O不能使ARDS患者肺泡完全復(fù)張動物ARDSMean Airway pressure 25 cm H2OARDS肺復(fù)張應(yīng)用ARDS下肺氣體含量明顯降低CT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺復(fù)張應(yīng)用CT section lcated 5 cm below the carina No differences were ob

12、served in the percentage of lower lobes located beneath the heart in two groupsCT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺不張的影響因素-heart lung interdependenceARDS肺復(fù)張應(yīng)用Cardiac mass and volume in ARDSCardiac mass was increased by 27% vs NS Mechanism of cardiac mass:Edema of cardiac wallRV dila

13、tion secondary to pul hypertensionHyperkinetic state related to SIRSCT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺復(fù)張應(yīng)用心臟下肺葉氣體量明顯降低ARDS 73% vs NS 21%Closed bar: Fraction of gas in lower lobes located beneath the heartOpen bar: lower lobes located outside the heartCT scan ARDS study group. AJRC

14、CM, 2000,161:2005 ARDS肺復(fù)張應(yīng)用塌陷肺泡的分布Local: Loss of aeration predominating in lower lobesDiffuse: Equal loss of aeration to the upper and lower lobesARDS肺復(fù)張應(yīng)用Lung morphology pattern Local DiffuseLIPNoYesNormally aerated 5512% 24 12%Poorly aerated 23 8% 40 12%Distribution modal BimodalUnimodalPeak of CT

15、 distr-727Hu/27Hu7HuCompltot57 546 11 Vieira SRR. AJRCCM, 1999, 159: 1612 ARDS肺復(fù)張應(yīng)用Diffuse distributionARDS肺復(fù)張應(yīng)用ARDS肺復(fù)張應(yīng)用local distribution內(nèi)容提要ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinonis vs RoubysARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點評價VT和SI or Sigh對肺復(fù)張的影響 評價PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇 SI前后綿羊復(fù)張容積的變化*與SI前相比，*P 0.05ARDS肺復(fù)張應(yīng)用

16、SI有效組綿羊肺氣體交換變化*與SI前相比，*P 0.05ARDS肺復(fù)張應(yīng)用潮氣量對肺復(fù)張的影響A:PEEP=0, B:PEEP=Pflex, C:at the end of inspiration,D:PEEP=Pflex as in C during expirationPelosi P, Goldner M, Mckibben A, et al. Am J Respir Crit Care Med, 2001, 164, 131-140ARDS肺復(fù)張應(yīng)用小潮氣量通氣的局限性Cretti S, Mascheroni D, Caironi P, et al. Am J Respir Crit

17、 Care Med, 2001, 164, 131-140ARDS肺復(fù)張應(yīng)用Mean Airway pressure 5 cm H2O CT Scan :ARDS pig model 30 kgOptimized Lung Volume StrategyARDS肺復(fù)張應(yīng)用Mean Airway pressure 25 cm H2O CT Scan :ARDS pig model 30 kgOptimized Lung Volume StrategyARDS肺復(fù)張應(yīng)用Mean Airway Pressure 40 cm H2OCT Scan :ARDS pig model 30 kgOptimi

18、zed Lung Volume StrategyARDS肺復(fù)張應(yīng)用不同VT的肺復(fù)張容積*#與6ml/kg組相比，*P 0.05;與10 ml/kg相比， #P 0.05ARDS肺復(fù)張應(yīng)用內(nèi)容提要ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinonis vs RoubysARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇 PEEP效應(yīng)的影響因素-附加靜水壓與心臟的影響ARDS肺復(fù)張應(yīng)用Rothen H. et al. Br J Anaesth 1993:71:788-795Re-expansi

19、on of atelectasis during general anaethesiaA: CT scan at level of right disphragm B: CT scan 5cm above right diaphragmARDS肺復(fù)張應(yīng)用PEEP誘導(dǎo)recruitment的分布Puybasset L. ICM, 2000, 26:1215c In lower lobes: Alv recruitment (ml) = 0.16 X End-expir lung volume(ml) 24mlARDS肺復(fù)張應(yīng)用PEEP導(dǎo)致overdistention的分布Volume of ov

20、erdistension(ml)=0.42Parenchyma-900;-800(ml)18mlPuybasset L. ICM, 2000, 26:1215cARDS肺復(fù)張應(yīng)用PEEP效應(yīng)的影響因素-塌陷肺泡的分布范圍塌陷肺泡的范圍Efficiency of PEEP-induced alv recruitment highly correlated with the proportion of poorly and nonaerated lung parenchyma in ZEEPPuybasset L. ICM, 2000,26:1215 ARDS肺復(fù)張應(yīng)用Diffuse: Equal

21、 loss of aeration to the upper and lower lobesVieira SRR. AJRCCM, 1999, 159: 1612 ARDS肺復(fù)張應(yīng)用Local: Loss of aeration predominating in lower lobesVieira SRR. AJRCCM, 1999, 159: 1612 ARDS肺復(fù)張應(yīng)用Effect of PEEP on recruitment and overdistentionPuybasset L. ICM, 2000, 26:1215ARDS肺復(fù)張應(yīng)用PEEP效應(yīng)的影響因素-LIP的影響ARDS肺復(fù)

22、張應(yīng)用綿羊有無LIP組PEEP復(fù)張容積*#*#與5cmH2O相比，* P 0.05;與10cmH2O相比，#P 0.05ARDS肺復(fù)張應(yīng)用有無LIP患者的復(fù)張容積 *#*#與PEEP5 cmH2O相比，*P 0.05與PEEP 10 cmH2O相比，#P 0.05與LIP組比較，P 400mmHg，每15-20min降低PEEP，至PaO2較前一次降低5%, PEEP水平為前一次PEEP結(jié)果：PaO2+PaCO2從178.476.5mmHg升至487.8 139.1mmHg，維持肺復(fù)張PEEP水平為224cmH2OV.N.Okamoto et al. Unpublished data, 200

23、3ARDS肺復(fù)張應(yīng)用氧分壓導(dǎo)向性PEEP選擇V.N.Okamoto et al. Unpublished data, 2003ARDS肺復(fù)張應(yīng)用氧分壓導(dǎo)向性PEEP選擇對象：47例早期ARDS患者，VCV，VT=8ml/kg， PEEP=10cm/H2O，RR20次/分，I：E=1：1分組與方法： ARM+PEEP組：ARM實施方法為逐步增加PEEP至15、 20、25、30cm/H2O(extended sigh)， 結(jié)束后PEEP設(shè)為15cm/H2O ARM組：ARM后PEEP仍為10cm/H2O PEEP組：基礎(chǔ)通氣模式Lim CM, Jung H, Koh Y, et al. Crit

24、 Care Med, 2003,31:411-418ARDS肺復(fù)張應(yīng)用氧分壓導(dǎo)向性PEEP選擇Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺復(fù)張應(yīng)用氧分壓導(dǎo)向性PEEP選擇Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺復(fù)張應(yīng)用氧分壓導(dǎo)向性PEEP選擇Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺復(fù)張應(yīng)用氧分壓導(dǎo)向性PEEP選擇DO2導(dǎo)向性PEEP

25、選擇ARDS傳統(tǒng)的通氣策略-經(jīng)驗性PEEP缺點：缺乏科學(xué)依據(jù)ARDS肺保護性通氣策略-最佳PEEP優(yōu)點：獲得最大的DO2，同時考慮PEEP 對循環(huán)和呼吸的影響，LIP+2cmH2O 為最佳PEEP ARDS肺復(fù)張應(yīng)用邱海波, 郭鳳梅, 周韶霞等. 中華內(nèi)科雜志, 2001, 9PEEP不足大量肺泡難以復(fù)張Collapsed airwayPressureV1V2VolumeV1V1 + V2Opening pressureNormalARDSPEEP adjustmentLIP：塌陷肺泡開始復(fù)張壓力，不是全部塌陷肺泡復(fù)張壓力ARDS肺復(fù)張應(yīng)用LIPStart of recruitmentRecr

26、uitment occurs along the entire PV curve, even beyond UIPGattinoni L. AJRCCM, 2001, 164: 131ARDS肺復(fù)張應(yīng)用PEEP and SurvovalA post hoc analysis, 53 patientsBarbas CSV, Medeiros DM, Magaldi RB, et al. Am J Respir Crit Care Med, 2002, 165: A218ARDS肺復(fù)張應(yīng)用PEEP肺復(fù)張與低氧血癥改善Gattinoni L, Caironi P, Pelosi P, et al.

27、Am J Respir Crit Care Med, 2001, 164:1701-1711 ARDS肺復(fù)張應(yīng)用ARDS綿羊不同PEEP復(fù)張容積*#與5cmH2O相比，* P 0.05;與10cmH2O相比，#P 0.05ARDS肺復(fù)張應(yīng)用ARDS患者不同PEEP復(fù)張容積*#與PEEP5cmH2O相比較，*P 0.05;與PEEP5cmH2O相比較，#P 0.05;ARDS肺復(fù)張應(yīng)用ARDS早期PEEP的調(diào)整 肺復(fù)張容積與DO2的結(jié)合ARDS肺復(fù)張應(yīng)用不同通氣模式對肺NF-B的影響1、2、3、4、5和6分別為正常、ARDS、HVZP、LVBP、LVHP、NVBP組 1 2 3 4 5 6基礎(chǔ)研

28、究不同通氣模式對肺TNF-mRNA表達的影響 1 2 3 4 5 61、2、3、4、5和6分別為正常、ARDS、LVBP、LVHP、NVBP和HVZP組 基礎(chǔ)研究不同通氣模式對肺組織TNF的影響基礎(chǔ)研究不同通氣模式對肺組織MPO的影響與對照組比較，* P0.05；與ARDS組比較， P0.05，與LVBP組比較，P 0.05；與HVZP組比較， P0.05基礎(chǔ)研究不同通氣模式對肺組織MDA的影響與對照組比較，* P0.05；與ARDS組比較， P0.05，與LVBP組比較，P 0.05；比較， P0.05基礎(chǔ)研究Bedside assessment of lung morphology (PE

29、EP=5cmH2O)DiffuseChest X-rayDiffuse Predominating/CT scan / White lungs in lower lobesSlope of PV 50ml/cmH2OLIP55cmH2OUIP30cmH2OPEEP trial10-15-20-255-8-10-12Local總 結(jié)ARDS肺復(fù)張應(yīng)用The Right PEEP level does not allow to reduce FiO2 bellow 0.6Prone position trial. If failureiNO trial (5-10ppm). If failureI

30、f failureECOMARDS肺復(fù)張應(yīng)用Thanks for your attention常用止血藥定義：凡能夠制止體內(nèi)外出血的藥物，稱為 止血藥。分類促凝血因子活性藥：是通過影響某些凝血因子，促進或恢復(fù)凝血過程而止血。代表藥物有血凝酶、去氨加壓素、維生素K1、維生素K3、維生素K4、醋甘氨酸乙二胺等分類降低毛細血管通透性藥：能增強毛細血管對損傷的抵抗力，降低毛細血管的通透性，促進受損毛血管端收縮而止血。代表藥物有卡巴克洛、卡絡(luò)磺鈉，維生素C等。分類抗纖維蛋白溶解藥：通過抑制纖維蛋白酶原的激活因子，使纖維蛋白溶酶原不能被激活，從而抑制纖維蛋白的溶解。代表藥物有氨基己酸、氨甲苯酸、氨甲環(huán)酸、

31、抑肽酶等。其中6-氨基己酸因作用強度弱、維持時間短、副作用較多，現(xiàn)已少用。分類其他外用止血藥：可吸收創(chuàng)面止血封固劑、明膠海綿、吸收性止血綾、小蘗胺、云南白藥、止血粉8號、止血消炎貼等。常用藥物劑量及用法血凝酶：靜脈注射、肌肉注射，也可局部使用。成人：每次1.02.0KU, 緊急情況下，立即靜脈注射1.0KU，同時肌肉注射1.0KU。各類外科手術(shù)：手術(shù)前1小時，肌肉注射1.0KU，或手術(shù)前15分鐘，靜脈注射1.0KU。手術(shù)后每日肌肉注射1.0KU，連用三天，或遵醫(yī)囑。在用藥期間，應(yīng)注意觀察病人的出、凝血時間。應(yīng)防止用藥過量，否則療效會下降。常用藥物劑量及用法去氨加壓素：控制大出血或侵入性手術(shù)前預(yù)防大出血：0.3ug/kg體重，皮下給藥或用生理鹽水稀釋至50-100ml，在15-30分鐘內(nèi)靜脈滴注。若療效呈陽性，可按起始劑量間隔6-12小時重復(fù)給藥1-2次，進一步重復(fù)給藥可能會使療效降低。血友病患者VIII：C的濃度達到預(yù)期值按與使用VIII因子濃縮物相同的原則進行估計，用藥期間應(yīng)定期對VIII：C的濃度進行跟蹤監(jiān)測，因為對某些閏例，重復(fù)給藥后療效反南昌降低。如果靜脈滴注本藥并沒有使血漿中VIII；C的濃度達到預(yù)期的增加，應(yīng)加用VIII因子濃縮物進行治療。對血友病患者的治療，應(yīng)