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1、呼吸機(jī)治療的肺保護(hù)策略浙江大學(xué)醫(yī)學(xué)院附屬兒童醫(yī)院施麗萍1.呼吸機(jī)治療的肺保護(hù)策略浙江大學(xué)醫(yī)學(xué)院附屬兒童醫(yī)院1.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 mortality2.呼吸機(jī)相關(guān)性肺損傷2.呼吸機(jī)相關(guān)性肺損傷ventilator-induced lung injury容量性損傷 Volutrauma(large

2、gas volumes )壓力性損傷 Barotrauma(high airway pressure )不張性損傷 Atelectotrauma(alveolar collapse and re-expansion)生物性損傷 Biotrauma(increased inflammation )3.呼吸機(jī)相關(guān)性肺損傷ventilator-induced l肺 損 傷 病 理alveolar structural damagepulmonary edema、 inflammation、 fibrosis surfactant dysfunctionother organ dysfunctione

3、xacerbate the disturbance of lung development Semin Neonatol. 2002 Oct;7(5):353-60.4.肺 損 傷 病 理alveolar structural d Approaches in the management of acute respiratory failure in childrenprotective ventilatory and potential protectiveventilatory modes lower tidal volume and PEEP permissive hypercapnia

4、 high-frequency oscillatory ventilation airway pressure release ventilation partial liquid ventilationimprove oxygenation recruitment maneuvers prone positioning kinetic therapy reduce FiO2 and facilitate gas exchange inhaled nitric oxide and surfactant Curr Opin Pediatr. 2004 Jun;16(3):293-8.5. App

5、roaches in the managementCan mechanical ventilation strategies reduce chronic lung disease?continuous positive airway pressurepermissive hypercapnia patient-triggered ventilation volume-targeted ventilation proportional assist ventilation high-frequency ventilation Semin Neonatol. 2003 Dec;8(6):441-

6、86.Can mechanical ventilation str小潮氣量和呼氣末正壓 lower tidal volume and PEEP7.小潮氣量和呼氣末正壓7.Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS1202 patientslower tidal volume (7ml/kg) low plateau pressure 30 cm H2O versus tidal volume 10 to 15 ml/kgMortality at

7、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):CD0038448.Ventilation with lower tidal vHigher versus lower positive end-expiratory pressures in patients with the acute resp

8、iratory distress syndrome549 patients acute lung injury 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 13.8

9、10.6 days (p=0.5)clinical outcomes are similar whether lower or higher PEEP levels are used. N Engl J Med. 2004 Jul 22;351(4):327-36.9.Higher versus lower positive eIncreasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilationSprague-D

10、awley rats negative control group low pressures (PIP = 12 cm H2O), rate = 30, iT = 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

11、 ,static lung compliance (p =.0002) and Pao2/Fio2 (p =.001) decreased. Wet/dry lung weights (p .0001) and dry lung/body weights (p 0.050.050.050.050.0514.兩組胎齡、體重、病情嚴(yán)重程度比較胎齡(周)體重日齡AaDO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IMV,持續(xù)脈搏血氧飽和度監(jiān)測使其維持在8595%,每8h監(jiān)測動(dòng)脈血?dú)庖淮?,要求血?dú)饩S持在正常范圍內(nèi),PaO2 40-70mmHg, PaCO2 35-45mmHg15.

12、對(duì)照組(NPM):15.觀察組(PM組): 1、肺力學(xué)監(jiān)測儀(Bicore CP100)每812h 監(jiān)測一次機(jī)械通氣時(shí)肺力學(xué)參數(shù) 2、監(jiān)測時(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)測儀的傳感器置于近端接口 4、氣管插管氣漏率小于20% 5、每監(jiān)測一次持續(xù)0.51h至數(shù)據(jù)穩(wěn)定后記錄監(jiān)測的數(shù)據(jù)16.觀察組(PM組):16.NPM 組和PM組的評(píng)估指標(biāo) 1. 疾病極期,即生后2448h時(shí)呼吸機(jī)要求最高值,包括FiO2、 PIP、PEEP、Ti、MAP、VR 2. VE、C20/C、TC(限于PM組), 3. 記錄血pH、PaO2、PaCO2、氧合指數(shù)(OI )

13、(OI=FiO2MAP/PaO2)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,PDA,IVH和呼吸機(jī)相關(guān)性肺損傷的發(fā)生率。17.NPM 組和PM組的評(píng)估指標(biāo)17.兩組呼吸機(jī)參數(shù)比較FiO2(%) PIP(cmH2O) PEEP(cmH2O)MAP(cmH2O) Ti (sec) VR(次/分)NPM601930.53.45.60.814.93.40.750.1399PM621826.71.75.40.611.92.00.450.14210t0.1847.5271.3395.81818.101.81p0.050.050.0010.0518.兩組呼吸機(jī)參數(shù)比較FiO2 PIP(

14、cmH2O) PE19.19.兩組血?dú)獗O(jiān)測結(jié)果比較PHPaO2(mmHg)PaCO2 (mmHg)HR(次/分)BP(mmHg)OINPM7.310.1571740101448404.61913PM7.30.045916486.31456393.6147.7t0.2890.5164.6630.7980.9422.011p0.050.050.050.050.0520.兩組血?dú)獗O(jiān)測結(jié)果比較PHPaO2PaCO2 (mmHg)H21.21.兩組呼吸機(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VALI%PDA%IVH%IMV(d)用氧時(shí)間(d)住院天數(shù)(d)病死率%N

15、PM3236423.91.8117191414PM13.333.3404.21.713722118.3t0.8671.4741.225.570.090.050.9p0.050.050.050.050.050.0522.兩組呼吸機(jī)相關(guān)性肺損傷、PDA、IVH、呼吸機(jī)應(yīng)用時(shí)間、用結(jié)論肺力學(xué)監(jiān)測能指導(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RDS呼吸機(jī)應(yīng)用的參數(shù)為:PIP 25cmH2O左右,短Ti 0.30.5秒,應(yīng)用適當(dāng)?shù)腜EEP 5-7cmH2O治療RDS,不影響氧合。 PaCO2的輕度增高(PaCO2 45-60),IVH的發(fā)生未見增加。 23.結(jié)論肺力學(xué)監(jiān)測能指導(dǎo)正確應(yīng)用呼

16、吸機(jī),降低呼吸機(jī)相關(guān)性肺損傷2允許性高碳酸血癥Permissive hypercapnia24.允許性高碳酸血癥24.Permissive hypercapnia-role in protective lung ventilatory strategies First, we consider the evidence that protective lung ventilatory strategies improve survival and we explore current paradigms regarding the mechanisms underlying these eff

17、ects 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, is beneficial or deleteriousFourth, we address the current evidence regarding

18、 the buffering of hypercapnic acidosis25.Permissive hypercapnia-role i Lung-protective ventilation in acute respiratory distress syndrome: protection by reduced lung stress or by therapeutic hypercapnia? hypercapnic acidosis lung-protective ventilation respiratory acidosis protected the lung The pro

19、tective 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. 26. Lung-protective ventilationPermissive hypercapnia in ARDS and its effec

20、t 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 Suppl. 1995;107:201-82

21、7.Permissive hypercapnia in ARDS 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):46-5628. Hyp

22、ercapnic acidosis attenuHypercapnic acidosis 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

23、 19.4 77.3 87.9 p = 0.02wet:dry weight 9.7 2.3 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 29.Hypercapnic acidosis is p

24、rotecEffects of high PCO2 on ventilated preterm lamb lungsPreterm surfactant-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 differ

25、ent white blood cells hydrogen peroxide production IL-1beta, IL-8 cytokine mRNA expression in cells from the alveolar washHistopathology less lung injury Pediatr Res. 2003 Mar;53(3):468-72.30.Effects of high PCO2 on ventilPermissive hypercapnia for the prevention of morbidity and mortality in mechan

26、ically ventilated newborn infantsTwo trials involving 269 newborn infants no evidence the incidence of death 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 outco

27、mes One trial reported that permissive hypercapnia reduced the incidence of CLD in the 501 to 750 gram subgroup Cochrane Database Syst Rev. 2001;(2):CD00206131.Permissive hypercapnia for thePermissive hypercapnia in neonates: the case of the good, the bad, and the ugly PaCO2 levels of 45-55 mmHg in

28、high-risk neonates are safe and well tolerated Pediatr Pulmonol. 2002 Jan;33(1):56-6432.32.高頻震蕩通氣High-frequency oscillatory ventilation33.高頻震蕩通氣33. High-frequency oscillatory ventilation for acuterespiratory distress syndrome in adult patients148 randomized, controlled trial ARDS HFOV PCVPaO2/FiO2 7

29、2h noThirty-day mortality 37% or 52% (p=0.102)barotrauma, hemodynamic instability, or mucus plugging no differentclinical use in adults FiO260% and MAP20 cm H2O or PEEP15 cm H2O Crit Care Med. 2003 Apr;31(4 Suppl):S317-2334. High-frequency oscillatory veElective high frequency oscillatory ventilatio

30、n 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 birth weight infants with pulmonary dysfunctionno evidence of effect on CLD and mortality at 28-30 days Pre-specified sub

31、group analyses Short term neurological morbidity Grade 3 or 4 IVH and PVL (no using high volume strategy) Cochrane Database Syst Rev. 2003(4):CD00010435.Elective high frequency oscillOpen lung ventilation improves gas exchange and attenuates secondary lung injury in a piglet model of meconium aspira

32、tionProspective, 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 protein influx no differentsuperior oxygenation and less ventilator-induced lung injury Cr

33、it Care Med. 2004 Feb;32(2):443-936.Open lung ventilation improvesChanges 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):218-2337.Changes in mean airway pressurRandomized trial of high-frequency oscillatory ventilation versus conventio

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