ARDS患者的肺復(fù)張-北協(xié)和杜斌教授.ppt

1、ARDS患者的肺復(fù)張,北京協(xié)和醫(yī)院 杜斌,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,ARDS的肺保護(hù)性通氣策略,ARDS的肺保護(hù)性通氣策略,小潮氣量(6 ml/kg IBW) 避免過(guò)度膨脹造成的容積傷(volutrauma) 足夠的PEEP 防止肺泡復(fù)張?jiān)斐傻募羟辛p傷(atelectrauma),肺泡塌陷與復(fù)張?jiān)斐傻募羟辛?/p>

2、,F = PL x (V0/V)2/3 F:剪切力 PL:跨肺壓 V0:最初容積 V:復(fù)張后容積 如果:PL = 30 cmH2O, V0/V = 1/10 則: F = 140 cmH2O,Mead J, Takishima T, Leith D. Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 1970; 28(5): 596-608,小潮氣量通氣的問(wèn)題,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard

3、 L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613,小潮氣量通氣的問(wèn)題,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role

4、of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613,小潮氣量通氣的問(wèn)題,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163

5、: 1609-1613,受損的肺組織如何復(fù)張,俯臥位 足夠的PEEP 足夠的潮氣量和(或)嘆氣? 肺復(fù)張手法 減少水腫(?) 最低可接受的FiO2 (?) 自主呼吸(?),內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,肺泡的開放壓與閉合壓,PEEP不能使肺復(fù)張,LIP: 僅僅是肺復(fù)張的開始,Hickling KG. The pressure-volume curve is greatly modified by recruitment. A mathematical model of

6、 ARDS lungs. Am J Respir Crit Care Med 1998: 158: 194-202.,Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. PressureVolume Curves and Compliance in Acute Lung Injury: Evidence of Recruitment Above the Lower Inflection Point. Am J Respir Crit Care Med 1999; 159: 1172-1178,低位轉(zhuǎn)折點(diǎn)之上仍有肺組

7、織復(fù)張,肺泡的開放壓與閉合壓,肺泡開放壓與閉合壓,Paw (cmH2O),Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino M, Marini JJ, Gattinoni L. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.,ARDS的肺開放,Editorial Open up the lung and keep

8、 the lung open B. Lachmann Dept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands (1992) 18:319-321,RM能夠使肺開放,RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 min,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Ma

9、neuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,肺復(fù)張能夠改善ARDS氧合,Lapinsky SE, Aubin M, Mehta S, Boiteau P, Slutsky AS: Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure. Intensive

10、 Care Med 1999, 25: 1297-1301.,肺復(fù)張的各種方法,CPAP (SI) incremental PEEP PCV Sigh (modified) HFOV 俯臥位 ,SI改善氧合,Tugrul S, Akinci O, Ozcan PE, Ince, S, Esen F, Telci L, Akpir K, Cakar N. Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome: F

11、ocusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744,Sustained Inflation: 45 cmH2O x 30 s,SI改善氧合,Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial

12、 injury. Crit Care Med 2005; 33: 181-188,Sustained Inflation: 30 cmH2O x 30 s Twice with 1 min interval,嘆氣的設(shè)置,Lim CM, Koh Y, Park W, Chin JY, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD: Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress

13、syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260,充氣階段, 每30秒 PEEP增加5 cmH2O Vt減少2 ml/kg 前2次呼吸除外 直至Vt 2 ml/kg, PEEP 25 cmH2O 暫停階段 CPAP 30 cmH2O for 30 s 放氣階段,嘆氣改善氧合,Lim CM, Koh Y, Park W, Chin JY, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD: Mechanistic scheme and effect of extended sigh as

14、 a recruitment maneuver in patients with acute respiratory distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260,嘆氣對(duì)氧合及呼吸力學(xué)的影響,Pelosi P, Cadringher P, Bottino N, Panigada M, Carrieri F, Riva E, Lissoni A, Gattinoni L. Sigh in acute respiratory distress syndrome. Am J Respir Crit

15、Care Med 1999; 159: 872-880,Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O,嘆氣的設(shè)置,Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.

16、 Anesthesiology 2002; 96: 788-94,Baseline: PSV Sigh: BIPAP PEEPhigh = 1.2 x PIPpsv or 35 cmH2O Ti,s = 3 5 s f = 1 bpm,嘆氣改善呼吸力學(xué)及氧合,Patroniti N, Foti G, Cortinovis B, Maggioni E, Bigatello LM, Cereda M, Pesenti A. Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress S

17、yndrome Undergoing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-94,ARDS對(duì)RM的反應(yīng),Villagra A, Ochagavia A, Vatus S, Murias G, Fernandez MF, Aguilar JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit C

18、are Med 2002; 165: 165-170,肺復(fù)張 CT的提示,Henzler D, Mahnken AH, Wildberger JE, Rossaint R, Gnther RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006; 16: 1351-1359,肺復(fù)張 CT的提示,Henzler D, Mahnken AH, Wildberger

19、 JE, Rossaint R, Gnther RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006; 16: 1351-1359,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,RM vs. PEEP,Lim CM, Lee SS, Lee JS

20、, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects

21、of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed

22、Tomographic Analysis. Anesthesiology 2003; 99: 71-80,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,RM vs. PEEP,Lim CM

23、, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,為什么肺復(fù)張作用不能

24、持久?,Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5,為什么肺復(fù)張作用不能持久?,肺復(fù)張的方法? SI: 50 cmH2O x 30

25、 s 作者認(rèn)為,Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5,RM + PEEP vs. RM vs. PEEP,Lim CM, J

26、ung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418,

27、RM + PEEP vs. RM vs. PEEP,Lim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patien

28、t. Crit Care Med 2003; 31: 411-418,RM + PEEP,RM only,RM后的PEEP,RM后的PEEP能夠穩(wěn)定肺泡,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit C

29、are Med 2003; 167: 1620-1626,RM后的PEEP能夠穩(wěn)定肺泡,RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 min,PEEP 5 cmH2O,PEEP 10 cmH2O,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment

30、/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,肺泡穩(wěn)定能夠改善PaO2,McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic ulmonary vasoconstriction. Crit Care med 2002; 30: 1315-1321,RM后的PEEP,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. I

31、ntercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,RM + PEEP vs. PEEP only,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lun

32、g injury. Crit Care Med 2004; 32: 2371-2377,RM + PEEP,PEEP only,PEEP的設(shè)置,RM之后通常將PEEP設(shè)置在能夠維持PaO2 (防止塌陷)的水平 最初將PEEP設(shè)置為20 cmH2O 然后將FiO2減小到最低水平 維持SpO2 90 95% 每20 30分鐘降低PEEP 2 cmH2O 直至患者SpO2下降,PEEP的設(shè)置,氧合下降前的PEEP水平 防止大部分肺泡塌陷的PEEP 一旦確認(rèn), 則需重復(fù)肺復(fù)張操作, 然后把PEEP和FiO2重新設(shè)置在上述水平 對(duì)于多數(shù)ARDS患者, PEEP介于15 20 cmH2O之間 某些患者 2

33、0 cmH2O,PEEP的設(shè)置,如果將PEEP設(shè)置于20 cmH2O后, 仍發(fā)現(xiàn)PaO2/FiO2顯著下降 按照最初的PEEP設(shè)置25 cmH2O重復(fù)肺復(fù)張 然后按照上述方法調(diào)節(jié)FiO2和PEEP,PEEP的設(shè)置,將PEEP從不必要的高水平逐漸降低 不要將PEEP由低水平增加到高水平 如同P-V曲線所示, 根據(jù)設(shè)置方法不同, 同樣水平的PEEP所維持的肺容積不同 如果在肺泡塌陷后設(shè)置PEEP (增加PEEP), 則所設(shè)置的PEEP水平可以使肺容積減少, PaO2降低,PEEP/FiO2的調(diào)整,推薦意見 降低PEEP之前應(yīng)當(dāng)首先降低FiO2, 以避免肺泡塌陷 一般情況下 FiO2應(yīng)當(dāng)減低到 0.

34、45 如果降低PEEP導(dǎo)致氧合下降 應(yīng)當(dāng)重新設(shè)定PEEP 肺泡塌陷時(shí)不應(yīng)增加FiO2,肺復(fù)張后氧合穩(wěn)定所需時(shí)間,Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, T Akpir. Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 2

35、005; 33: 995-1000,= LIP + 2,肺復(fù)張后氧合穩(wěn)定所需時(shí)間,Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, T Akpir. Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 2005; 33: 995-10

36、00,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,不同RM方法的比較,基礎(chǔ)通氣方式 VCV: Vt 10 ml/kg, f 20 bpm, I:E 1:2, FiO2 0.5 肺復(fù)張:,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes n

37、egative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,不同RM方法的比較,Odenstedt H, Lindgren S, Olegard C, et al. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung

38、 mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,不同RM方法的比較,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negat

39、ive circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,不同RM方法的比較,對(duì)于灌洗造成的急性肺損傷模型 緩慢低壓復(fù)張操作可以 促進(jìn)肺泡復(fù)張 減少對(duì)循環(huán)系統(tǒng)的抑制 避免對(duì)呼吸力學(xué)的不良影響,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, S

40、tenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714,不同RM方法的比較,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard

41、 AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,Sustained inflation 45 for 40 s,Incremental PEEP PIP 35, PEEP 8 - 35,PCV PIP 45, PEEP 16 I:E 1:2, 2 min,對(duì)于VILI模型PCV是最佳的RM方法 其他模型結(jié)果相似,PEEP 8,PEEP 12,P

42、EEP 16,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,RM保護(hù)肺內(nèi)皮而非肺泡上皮,

43、試驗(yàn)動(dòng)物: 大鼠 模型制備: 酸(pH 1.5)吸入 機(jī)械通氣: Vt6 ml/kg PEEP5 cmH2O FiO21.0 F60 70 bpm 復(fù)張操作: 30 cmH2O x 30 s x 2 間隔1分鐘,Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Car

44、e Med 2005; 33: 181-188,RM保護(hù)肺內(nèi)皮而非肺泡上皮,Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Care Med 2005; 33: 181-188,RM: ARDS早期 vs. 晚期,Villagra A, Ochagavia A, V

45、atus S, Murias G, Fernandez MF, Aguilar JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2002; 165: 165-170,原發(fā)性ARDS對(duì)RM反應(yīng)不佳,Saline lavage,Oleic acid injury,Pneumonia,Van der Kloot TE, Blanch L, Youngb

46、lood AM, Weinert C, Adams AB, Marini JJ, Shapiro RS, Nahum A. Recruitment Maneuvers in Three Experimental: Models of Acute Lung Injury Effect on Lung Volume and Gas Exchange. Am J Respir Crit Care Med 2000; 161: 1485-1494,Sustained inflation CPAP 40/30 CPAP 60/30 CPAP 60/30,油酸損傷模型RM作用短暫,Lim CM, Adam

47、s AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,PEEP 8,PEEP 12,PEEP 16,不同病因?qū)M的反應(yīng),Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ.

48、 Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,RM + PEEP,PEEP only,RM: ARDSp與ARDSexp,Lim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory d

49、istress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418,SI改善氧合,Tugrul S, Akinci O, Ozcan PE, Ince, S, Esen F, Telci L, Akpir K, Cakar N. Effects of sustained inflation and postinflation p

50、ositive endexpiratory pressure in acute respiratory distress syndrome: Focusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744,Sustained Inflation: 45 cmH2O x 30 s,嘆氣: ARDSp與ARDSexp,Pelosi P, Cadringher P, Bottino N, Panigada M, Carrieri F, Riva E, Lissoni A, Gattinoni L. Sig

51、h in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159: 872-880,Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,RM不增加肺泡過(guò)度膨脹,Bugedo G, Bruhn A, Hernandez G, et al. Lung computed tomography during a l

52、ung recruitment maneuver in patients with acute lung injury. Intensive Care Med 2003; 29: 218-225,肺復(fù)張對(duì)內(nèi)臟血流的影響,Nunes S, Rothen HU, Brander L, Takala J, Jakob SM. Changes in Splanchnic Circulation During an Alveolar Recruitment Maneuver in Healthy Porcine Lungs. Anesth Analg 2004; 98: 1432-8,肺復(fù)張對(duì)胃腸道血流

53、的影響,Claesson J, Lehtipalo S, Winso D. Do lung recruitment maneuvers decrease gastric mucosal perfusion? Intensive Care Med 2003: 29: 1314-1321,肺復(fù)張對(duì)腦氧代謝的影響,Bein T, Kuhr LP, Bele S, Ploner F, Keyl C, Taeger K. Lung recruitment maneuver in patients with cerebral injury: effects on intracranial pressure

54、 and cerebral metabolism. Intensive Care Med 2002; 28: 554-558,內(nèi)容,小潮氣量通氣的問(wèn)題 肺復(fù)張的理論與實(shí)踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問(wèn)題,肺泡開放壓與閉合壓,Paw (cmH2O),Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino M, Marini JJ, Gattinoni L. Recruitment and derecruitment during acute re

55、spiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.,即使使用足夠的PEEP也不能使所有肺單位開放,RM對(duì)哪些患者療效好?,尚不清楚肺復(fù)張對(duì)哪類患者療效更好 肺復(fù)張對(duì)早期ARDS/ALI患者的效果更顯著 隨著ARDS的進(jìn)展, 肺進(jìn)入纖維增殖期 肺復(fù)張就無(wú)法有效改善氧合 氣壓傷的危險(xiǎn)反而增加,RM對(duì)哪些患者療效好?,ARDS的病因 繼發(fā)性ARDS (全身性感染, 創(chuàng)傷等)比原發(fā)性ARDS (肺炎)更容易復(fù)張 目前的推薦意見 在ARDS/ALI病程早期進(jìn)行肺復(fù)張 無(wú)論ARDS的病因如何,

56、肺復(fù)張操作的頻率,尚不清楚對(duì)某一患者進(jìn)行肺復(fù)張操作的適宜頻率 以下情況應(yīng)進(jìn)行肺復(fù)張操作 病程早期 當(dāng)肺泡塌陷時(shí) 例如呼吸機(jī)脫開,肺復(fù)張操作的頻率,對(duì)于ARDS患者 脫離呼吸機(jī)能夠?qū)е路闻菅杆偎? 從而發(fā)生嚴(yán)重的低氧血癥 為避免呼吸機(jī)脫開, 建議采用 密閉吸痰裝置 特殊霧化裝置,肺復(fù)張操作的頻率,肺復(fù)張操作 當(dāng)觀察到SpO2持續(xù)降低( 5 min)時(shí) 如果沒(méi)有觀察到氧合下降, 則需要每日進(jìn)行一次或兩次肺復(fù)張 未知,總結(jié),肺復(fù)張是肺保護(hù)性通氣策略的重要組成 開放肺并維持肺開放是其理論基礎(chǔ) 應(yīng)用氣道高壓使塌陷肺泡開放 應(yīng)用足夠的PEEP維持肺泡開放 肺復(fù)張對(duì)循環(huán)的影響 肺復(fù)張尚未解決的問(wèn)題 壓力

57、時(shí)間 頻率 適應(yīng)癥,PEEP能否使肺復(fù)張?,PEEP能夠防止肺泡塌陷(derecruitment) 低水平的PEEP只能使很少的肺復(fù)張 對(duì)于ARDS, 將壓力持續(xù)維持在常用的PEEP水平( 20 cmH2O)只能使小部分肺組織復(fù)張,PEEP能否使肺復(fù)張?,ARDS患者的肺復(fù)張貫穿于整個(gè)吸氣過(guò)程 by Hickling AJRCCM 1998 Tidal recruitment occurs below optimal PEEP, PEEP at the optimal level generally results in a decreased quasi-static compliance

58、when measured on the ventilator by Jonson et al AJRCCM 1999,肺復(fù)張所需的壓力,正常潮氣量通氣也能使肺組織復(fù)張 但是, 大部分肺組織可能仍未充分復(fù)張 在有限的吸氣時(shí)間內(nèi) 在目標(biāo)氣道峰壓水平 由于 塌陷肺泡表面液體的粘滯性 這些肺單位較高的表面張力 間質(zhì)組織的限制 塌陷的肺組織需要較高的氣道壓力和較長(zhǎng)的時(shí)間才能復(fù)張,How high a pressure?How long a time? - healthy lung,transpulmonary pressure of 30 cmH2O to recruit atelectatic he

59、althy lungs Greaves et al JAP 1990 peak alveolar pressures of 40 cmH2O for 7 to 15 seconds to recruit lungs of previously healthy normal patients following 20 minutes of general anesthesia by Rothen et al Br J Anaesth 1993, 1998 resolution of atelectasis during a 40 cmH2O RM has a time constant of 2.6 sec Rothen et al Br J Anaesth 1999,How high a pressure?How long a time? - healthy lung,As a result in previously healthy individuals the vast majority of atelectasis would be recruited within about 7-8 sec,How high a pressure?How long a time? - animal,peak airway pressures of 55 cmH2O