ARDS患者的肺復(fù)張

ARDS患者肺復(fù)張北京協(xié)和醫(yī)院杜 斌ARDS患者的肺復(fù)張第1頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第2頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第3頁ARDS肺保護(hù)性通氣策略患者數(shù)潮氣量病死率作者小潮氣量對照小潮氣量對照小潮氣量對照P值A(chǔ)mato29246.10.2?11.90.5?3871<0.001Stewart60607.20.8?10.60.2?50470.72Brochard58587.20.2§10.40.2§47380.38Brower26267.30.1?10.20.1?50460.60ARDSnet4324296.30.1?11.70.1?31400.007Villar50457.30.9?10.21.2?34550.041ARDS患者的肺復(fù)張第4頁ARDS肺保護(hù)性通氣策略小潮氣量(6ml/kgIBW)防止過分膨脹造成容積傷(volutrauma)足夠PEEP預(yù)防肺泡復(fù)張?jiān)斐杉羟辛p傷(atelectrauma)ARDS患者的肺復(fù)張第5頁肺泡塌陷與復(fù)張?jiān)斐杉羟辛=PLx(V0/V)2/3F: 剪切力PL: 跨肺壓V0: 最初容積V: 復(fù)張后容積假如: PL=30cmH2O,V0/V=1/10則:F=140cmH2OMeadJ,TakishimaT,LeithD.Stressdistributioninlungs:amodelofpulmonaryelasticity.JApplPhysiol1970;28(5):596-608ARDS患者的肺復(fù)張第6頁小潮氣量通氣問題LVt(n=15)CVt(n=15)PvalueVt,ml4115566484<0.01Vt,ml/kg61101<0.01setPEEP,cmH2O104104n.s.PEEPtot,cmH2O114114n.s.Pplat,cmH2O2383010<0.01RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed;163:1609-1613ARDS患者的肺復(fù)張第7頁小潮氣量通氣問題LVt(n=15)CVt(n=15)PvaluePaO2,mmHg1368015682n.s.PaO2/FiO2,mmHg1658418383n.s.SaO2,%94.85.097.62.1<0.05PaCO2,mmHg60353821<0.001pH60.1<0.001SBP,mmHg1252512120n.s.DBP,mmHg6096010n.s.HR,bpm101159315n.s.RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed;163:1609-1613ARDS患者的肺復(fù)張第8頁小潮氣量通氣問題RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed;163:1609-1613ARDS患者的肺復(fù)張第9頁受損肺組織怎樣復(fù)張俯臥位足夠PEEP足夠潮氣量[和(或)’嘆氣’?]肺復(fù)張手法降低水腫(?)最低可接收FiO2(?)自主呼吸(?)ARDS患者的肺復(fù)張第10頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第11頁肺泡開放壓與閉合壓ARDS患者的肺復(fù)張第12頁P(yáng)EEP不能使肺復(fù)張ARDS患者的肺復(fù)張第13頁LIP:僅僅是肺復(fù)張開始HicklingKG.Thepressure-volumecurveisgreatlymodifiedbyrecruitment.AmathematicalmodelofARDSlungs.AmJRespirCritCareMed1998:158:194-202.ARDS患者的肺復(fù)張第14頁JonsonB,RichardJC,StrausC,ManceboJ,LemaireF,BrochardL.Pressure–VolumeCurvesandComplianceinAcuteLungInjury:EvidenceofRecruitmentAbovetheLowerInflectionPoint.AmJRespirCritCareMed1999;159:1172-1178低位轉(zhuǎn)折點(diǎn)之上仍有肺組織復(fù)張ARDS患者的肺復(fù)張第15頁肺泡開放壓與閉合壓ARDS患者的肺復(fù)張第16頁肺泡開放壓與閉合壓0102030405005101520253035404550OpeningpressurePaw(cmH2O)CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed:164:131-140.ClosingpressureARDS患者的肺復(fù)張第17頁ARDS肺開放EditorialOpenupthelungandkeepthelungopenB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands (1992)18:319-321 ARDS患者的肺復(fù)張第18頁RM能夠使肺開放RM:PIP45cmH2O,PEEP35cmH2Ox1minHalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed;167:1620-1626ARDS患者的肺復(fù)張第19頁肺復(fù)張能夠改進(jìn)ARDS氧合LapinskySE,AubinM,MehtaS,BoiteauP,SlutskyAS:Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure.IntensiveCareMed1999,25:1297-1301.ARDS患者的肺復(fù)張第20頁肺復(fù)張各種方法CPAP(SI)incrementalPEEPPCVSigh(modified)HFOV俯臥位…ARDS患者的肺復(fù)張第21頁SI改進(jìn)氧合TugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed;31:738-744SustainedInflation:45cmH2Ox30sARDS患者的肺復(fù)張第22頁SI改進(jìn)氧合FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed;33:181-188SustainedInflation:30cmH2Ox30sTwicewith1minintervalARDS患者的肺復(fù)張第23頁嘆氣設(shè)置LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed;29:1255-1260充氣階段,每30秒PEEP增加5cmH2OVt降低2ml/kg前2次呼吸除外直至Vt2ml/kg,PEEP25cmH2O暫停階段CPAP30cmH2Ofor30s放氣階段ARDS患者的肺復(fù)張第24頁嘆氣改進(jìn)氧合LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed;29:1255-1260ARDS患者的肺復(fù)張第25頁嘆氣對氧合及呼吸力學(xué)影響PelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880Sigh:3consecutivesighs/minatPplat45cmH2OARDS患者的肺復(fù)張第26頁嘆氣設(shè)置PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh= 1.2xPIPpsvor 35cmH2OTi,s=3–5sf=1bpmARDS患者的肺復(fù)張第27頁嘆氣改進(jìn)呼吸

力學(xué)及氧合PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology;96:788-94ARDS患者的肺復(fù)張第28頁ARDS對RM反應(yīng)VillagraA,OchagaviaA,VatusS,MuriasG,FernandezMF,AguilarJL,FernandezR,BlanchL.RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome.AmJRespirCritCareMed;165:165-170ARDS患者的肺復(fù)張第29頁肺復(fù)張–CT提醒HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GüntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol;16:1351-1359ARDS患者的肺復(fù)張第30頁肺復(fù)張–CT提醒HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GüntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol;16:1351-1359ARDS患者的肺復(fù)張第31頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第32頁RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology;99:71-80ARDS患者的肺復(fù)張第33頁RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology;99:71-80ARDS患者的肺復(fù)張第34頁RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology;99:71-80ARDS患者的肺復(fù)張第35頁RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology;99:71-80ARDS患者的肺復(fù)張第36頁RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology;99:71-80ARDS患者的肺復(fù)張第37頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第38頁為何肺復(fù)張作用不能持久?baseline3minpost-RM30minpost-RMPaO2/FiO2(mmHg)1394624611113839PaCO2(mmHg)48.612.147.61346.412SvO2(%)5.6706.2Qs/Qt(%)30.85.821.59.729.27.4Crs(ml/cmH2O)34.112.636.915.135.713.5OczenskiW,H?rmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology;101:620-5ARDS患者的肺復(fù)張第39頁為何肺復(fù)張作用不能持久?肺復(fù)張方法?SI:50cmH2Ox30s作者認(rèn)為OczenskiW,H?rmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology;101:620-5ARDS患者的肺復(fù)張第40頁RM+PEEPvs.RMvs.PEEPLimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed;31:411-418ARDS患者的肺復(fù)張第41頁RM+PEEPvs.RMvs.PEEPLimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed;31:411-418RM+PEEPRMonlyARDS患者的肺復(fù)張第42頁RM后PEEPARDS患者的肺復(fù)張第43頁RM后PEEP能夠穩(wěn)定肺泡HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed;167:1620-1626ARDS患者的肺復(fù)張第44頁RM后PEEP能夠穩(wěn)定肺泡RM:PIP45cmH2O,PEEP35cmH2Ox1minPEEP5cmH2OPEEP10cmH2OHalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed;167:1620-1626ARDS患者的肺復(fù)張第45頁肺泡穩(wěn)定能夠改進(jìn)PaO2McCannUG,SchillerHJ,GattoLA,etal.Alveolarmechanicsalterhypoxiculmonaryvasoconstriction.CritCaremed;30:1315-1321ARDS患者的肺復(fù)張第46頁RM后PEEPLimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed;32:2371-2377ARDS患者的肺復(fù)張第47頁RM+PEEPvs.PEEPonlyLimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed;32:2371-2377RM+PEEPPEEPonlyARDS患者的肺復(fù)張第48頁P(yáng)EEP設(shè)置RM之后通常將PEEP設(shè)置在能夠維持PaO2(預(yù)防塌陷)水平最初將PEEP設(shè)置為20cmH2O然后將FiO2減小到最低水平維持SpO290–95%每20–30分鐘降低PEEP2cmH2O直至患者SpO2下降A(chǔ)RDS患者的肺復(fù)張第49頁P(yáng)EEP設(shè)置氧合下降前PEEP水平預(yù)防大部分肺泡塌陷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)置在上述水平對于多數(shù)ARDS患者,PEEP介于15–20cmH2O之間一些患者<15cmH2O其它患者>20cmH2OARDS患者的肺復(fù)張第50頁P(yáng)EEP設(shè)置假如將PEEP設(shè)置于20cmH2O后,仍發(fā)覺PaO2/FiO2顯著下降按照最初PEEP設(shè)置25cmH2O重復(fù)肺復(fù)張然后按照上述方法調(diào)整FiO2和PEEPARDS患者的肺復(fù)張第51頁P(yáng)EEP設(shè)置將PEEP從無須要高水平逐步降低不要將PEEP由低水平增加到高水平如同P-V曲線所表示,依據(jù)設(shè)置方法不一樣,一樣水平PEEP所維持肺容積不一樣假如在肺泡塌陷后設(shè)置PEEP(增加PEEP),則所設(shè)置PEEP水平能夠使肺容積降低,PaO2降低ARDS患者的肺復(fù)張第52頁P(yáng)EEP/FiO2調(diào)整推薦意見降低PEEP之前應(yīng)該首先降低FiO2,以防止肺泡塌陷普通情況下FiO2應(yīng)該減低到<0.45假如降低PEEP造成氧合下降應(yīng)該重新設(shè)定PEEP肺泡塌陷時(shí)不應(yīng)增加FiO2ARDS患者的肺復(fù)張第53頁肺復(fù)張后氧合穩(wěn)定所需時(shí)間TugrulS,CakarN,AkinciO,OzcanPE,DisciR,EsenF,TelciL,TAkpir.Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend-expiratorypressureinacuterespiratorydistresssyndrome.CritCareMed;33:995-1000=LIP+2ARDS患者的肺復(fù)張第54頁肺復(fù)張后氧合

穩(wěn)定所需時(shí)間TugrulS,CakarN,AkinciO,OzcanPE,DisciR,EsenF,TelciL,TAkpir.Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend-expiratorypressureinacuterespiratorydistresssyndrome.CritCareMed;33:995-1000ARDS患者的肺復(fù)張第55頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第56頁不一樣RM方法比較基礎(chǔ)通氣方式VCV:Vt10ml/kg,f20bpm,I:E1:2,FiO20.5肺復(fù)張:OdenstedtH,LindgrenS,OlegardC,ErlandssonK,LethvallS,AnemanA,StenqvistO,LundinS.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed;31:1706-1714ModefVt/PCPEEPI:ETimeRptViCMCPAP4030”3PCRMPCV2020201:130”3SLRMVCV2010151:215’每分鐘2次將吸氣末暫停延長至7sARDS患者的肺復(fù)張第57頁不一樣RM方法比較OdenstedtH,LindgrenS,OlegardC,etal.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed;31:1706-1714SLRMPCRMViCMARDS患者的肺復(fù)張第58頁不一樣RM方法比較OdenstedtH,LindgrenS,OlegardC,ErlandssonK,LethvallS,AnemanA,StenqvistO,LundinS.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed;31:1706-1714ARDS患者的肺復(fù)張第59頁不一樣RM方法比較對于灌洗造成急性肺損傷模型遲緩低壓復(fù)張操作能夠促進(jìn)肺泡復(fù)張降低對循環(huán)系統(tǒng)抑制防止對呼吸力學(xué)不良影響OdenstedtH,LindgrenS,OlegardC,ErlandssonK,LethvallS,AnemanA,StenqvistO,LundinS.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed;31:1706-1714ARDS患者的肺復(fù)張第60頁不一樣RM方法比較LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed;32:2371-2377Sustainedinflation45for40sIncrementalPEEPPIP35,PEEP8-35PCVPIP45,PEEP16I:E1:2,2minARDS患者的肺復(fù)張第61頁對于VILI模型PCV是最正確RM方法其它模型結(jié)果相同PEEP8PEEP12PEEP16LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed;32:2371-2377ARDS患者的肺復(fù)張第62頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第63頁RM保護(hù)肺內(nèi)皮而非肺泡上皮試驗(yàn)動物:大鼠模型制備:酸(pH1.5)吸入機(jī)械通氣:Vt 6ml/kgPEEP 5cmH2OFiO2 1.0F 60–70bpm復(fù)張操作:30cmH2Ox30sx2間隔1分鐘FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed;33:181-188ARDS患者的肺復(fù)張第64頁RM保護(hù)肺內(nèi)皮而非肺泡上皮FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed;33:181-188ARDS患者的肺復(fù)張第65頁RM:ARDS早期vs.晚期VillagraA,OchagaviaA,VatusS,MuriasG,FernandezMF,AguilarJL,FernandezR,BlanchL.RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome.AmJRespirCritCareMed;165:165-170ARDS患者的肺復(fù)張第66頁原發(fā)性ARDS對RM反應(yīng)不佳SalinelavageOleicacidinjuryPneumoniaVanderKlootTE,BlanchL,YoungbloodAM,WeinertC,AdamsAB,MariniJJ,ShapiroRS,NahumA.RecruitmentManeuversinThreeExperimental:ModelsofAcuteLungInjuryEffectonLungVolumeandGasExchange.AmJRespirCritCareMed;161:1485-1494SustainedinflationCPAP40/30CPAP60/30CPAP60/30ARDS患者的肺復(fù)張第67頁油酸損傷模型RM作用短暫LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed;32:2371-2377PEEP8PEEP12PEEP16ARDS患者的肺復(fù)張第68頁不一樣病因?qū)M反應(yīng)LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed;32:2371-2377RM+PEEPPEEPonlyARDS患者的肺復(fù)張第69頁RM:ARDSp與ARDSexpLimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed;31:411-418ARDS患者的肺復(fù)張第70頁SI改進(jìn)氧合TugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed;31:738-744SustainedInflation:45cmH2Ox30sARDS患者的肺復(fù)張第71頁嘆氣:ARDSp與ARDSexpPelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880Sigh:3consecutivesighs/minatPplat45cmH2OARDS患者的肺復(fù)張第72頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第73頁RM不增加肺泡過分膨脹BugedoG,BruhnA,HernandezG,etal.Lungcomputedtomographyduringalungrecruitmentmaneuverinpatientswithacutelunginjury.IntensiveCareMed;29:218-225ARDS患者的肺復(fù)張第74頁ARDS患者的肺復(fù)張第75頁肺復(fù)張對內(nèi)臟血流影響NunesS,RothenHU,BranderL,TakalaJ,JakobSM.ChangesinSplanchnicCirculationDuringanAlveolarRecruitmentManeuverinHealthyPorcineLungs.AnesthAnalg;98:1432-8ARDS患者的肺復(fù)張第76頁肺復(fù)張對胃腸道血流影響ClaessonJ,LehtipaloS,WinsoD.Dolungrecruitmentmaneuversdecreasegastricmucosalperfusion?IntensiveCareMed:29:1314-1321ARDS患者的肺復(fù)張第77頁肺復(fù)張對腦氧代謝影響B(tài)einT,KuhrLP,BeleS,PlonerF,KeylC,TaegerK.Lungrecruitmentmaneuverinpatientswithcerebralinjury:effectsonintracranialpressureandcerebralmetabolism.IntensiveCareMed;28:554-558ARDS患者的肺復(fù)張第78頁內(nèi)容小潮氣量通氣問題肺復(fù)張理論與實(shí)踐肺復(fù)張與PEEP肺復(fù)張后PEEP不一樣復(fù)張方法差異肺復(fù)張臨床適應(yīng)癥肺復(fù)張副作用肺復(fù)張存在問題ARDS患者的肺復(fù)張第79頁肺泡開放壓與閉合壓0102030405005101520253035404550OpeningpressurePaw(cmH2O)CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed:164:131-140.Closingpressure即使使用足夠PEEP也不能使全部肺單位開放ARDS患者的肺復(fù)張第80頁RM對哪些患者療效好?尚不清楚肺復(fù)張對哪類患者療效更加好肺復(fù)張對早期ARDS/ALI患者效果更顯著伴隨ARDS進(jìn)展,肺進(jìn)入纖維增殖期肺復(fù)張就無法有效改進(jìn)氧合氣壓傷危險(xiǎn)反而增加ARDS患者的肺復(fù)張第81頁RM對哪些患者療效好?ARDS病因繼發(fā)性ARDS(全身性感染,創(chuàng)傷等)比原發(fā)性ARDS(肺炎)更輕易復(fù)張當(dāng)前推薦意見在ARDS/ALI病程早期進(jìn)行肺復(fù)張不論ARDS病因怎樣ARDS患者的肺復(fù)張第82頁肺復(fù)張操作頻率尚不清楚對某一患者進(jìn)行肺復(fù)張操作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)比如呼吸機(jī)脫開ARDS患者的肺復(fù)張第83頁肺復(fù)張操作頻率對于ARDS患者脫離呼吸機(jī)能夠造成肺泡快速塌陷,從而發(fā)生嚴(yán)重低氧血癥為防止呼吸機(jī)脫開,提議采取密閉吸痰裝置特殊霧化裝置ARDS患者的肺復(fù)張第84頁肺復(fù)張操作頻率肺復(fù)張操作當(dāng)觀察到SpO2連續(xù)降低(>5min)時(shí)假如沒有觀察到氧合下降,則需要每日進(jìn)行一次或兩次肺復(fù)張未知ARDS患者的肺復(fù)張第85頁總結(jié)肺復(fù)張是肺保護(hù)性通氣策略主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PEEP維持肺泡開放肺復(fù)張對循環(huán)影響肺復(fù)張還未處理問題壓力時(shí)間頻率適應(yīng)癥ARDS患者的肺復(fù)張第86頁ARDS患者的肺復(fù)張第87頁P(yáng)EEP能否使肺復(fù)張?PEEP能夠預(yù)防肺泡塌陷(derecruitment)低水平PEEP只能使極少肺復(fù)張對于ARDS,將壓力連續(xù)維持在慣用PEEP水平(<20cmH2O)只能使小部分肺組織復(fù)張ARDS患者的肺復(fù)張第88頁P(yáng)EEP能否使肺復(fù)張?ARDS患者肺復(fù)張貫通于整個(gè)吸氣過程byHicklingAJRCCM1998TidalrecruitmentoccursbelowoptimalPEEP,PEEPattheoptimallevelgenerallyresultsinadecreasedquasi-staticcompliancewhenmeasuredontheventilatorbyJonsonetalAJRCCM1999ARDS患者的肺復(fù)張第89頁肺復(fù)張所需壓力正常潮氣量通氣也能使肺組織復(fù)張不過,大部分肺組織可能仍未充分復(fù)張?jiān)谟邢尬鼩鈺r(shí)間內(nèi)在目標(biāo)氣道峰壓水平因?yàn)樗莘闻荼砻嬉后w粘滯性這些肺單位較高表面張力間質(zhì)組織限制塌陷肺組織需要較高氣道壓力和較長時(shí)間才能復(fù)張ARDS患者的肺復(fù)張第90頁Howhighapressure?

Howlongatime?-healthylungtranspulmonarypressureof30cmH2OtorecruitatelectatichealthylungsGreavesetalJAP1990peakalveolarpressuresof40cmH2Ofor7to15secondstorecruitlungsofpreviouslyhealthynormalpatientsfollowing20minutesofgeneralanesthesiabyRothenetalBrJAnaesth1993,1998resolutionofatelectasisduringa40cmH2ORMhasatimeconstantof2.6secRothenetalBrJAnaesth1999ARDS患者的肺復(fù)張第91頁Howhighapressure?

Howlongatime?-healthylungAsaresultinpreviouslyhealthyindividualsthevastmajorityofatelectasiswouldberecruitedwithinabout7-8secARDS患者的肺復(fù)張第92頁Howhighapressure?

Howlongatime?-animalpeakairwaypressuresof55cmH2Ofor5–10mintoopencollapsedlunginaporcinemodelofARDSSjosrandetalICM1995tomaximallyrecruitlunginasheepsalinelavagelunginjuredmodel40cmH2OPEEP,20cmH2OPC,Ppeak60cmH2O,I:Eof1:1,andarateof10bpmfor2minutesFujinoetalAJRCCM1999ARDS患者的肺復(fù)張第93頁Howhighapressure?

Howlongatime?-animalanimalsrecruitedwith40cmH2OCPAPfor60secnotmaximallyrecruitedtofullyrecruitthelungmultiple(2-3)RMsrequiredevenatpeakpressuresof60cmH2OARDS患者的肺復(fù)張第94頁Howhighapressure?

Howlongatime?-patientpeakairwaypressureof46cmH2OtorecruitcollapsedlunginARDSpatientsGattinonietalAJRCCM198635–40cmH2OCPAPfor30–40secpriortoestablishingalungprotectiveventilatorystrategywhenevermechanicalventilationwasdisruptedAmatoetalNEJM1998ARDS患者的肺復(fù)張第95頁Howhighapressure?

Howlongatime?-patientInapatientwithsepticARDSinitialrecruitmentmaneuverswith40cmH2OCPAPfor40secfailedPEEP40cmH2OPEEPandPCV20cmH2OatanI:Eratioof1:1witharateof10bpmfor2minutestofullyrecruitthelungMedoffetalCCMARDS患者的肺復(fù)張第96頁Howhighapressure?

Howlongatime?-patientThesuccessofPCvsCPAPintheexamplesemphasizetherelationshipbetweenpressureandtimeFujinoetalAJRCCM1999MedoffetalCCMTheoptimalrelationshipbetweenthesetwovariablestomaximizeefficacyandmaintainsafetyremainsunclearARDS患者的肺復(fù)張第97頁MechanismoflungrecruitmentFirst,theairwaysmustbeopenedinordertorecruitcollapsedlungAirwayopeningoccursbyeithermovingthemeniscusformedbyfluidliningtheairwaytowardtheperipheryorovercomingtheparenchymatetheringpresentinactualcollapsedairwayARDS患者的肺復(fù)張第98頁MechanismoflungrecruitmentSecond,thecollapsedalveolimustbeopenedcollapsedinjuredlungunitswithincreasedsurfacetensionrequireveryhighpressurestoestablishsufficientlateralstresstoopenthelungMeadetalJAP1970ARDS患者的肺復(fù)張第99頁WhatisclearisthattheoptimalmethodoflungrecruitmentinsuringmaximalefficacyandsafetyhasnotbeendeterminedARDS患者的肺復(fù)張第100頁SideEffectsofRMshemodynamiccompromisedelayeduntilpatientshemodynamicallystabledevelopmentofbarotraumathebenefitsandpotentialrisksmustbecarefullyweighedinpatientswithpreexistingpulmonarycysticorbullouslungdiseasepreexistingairleaksARDS患者的肺復(fù)張第101頁MonitoringofPatientsarterialpressurepulserateandrhythmSpO2ifcompromisedevelopstherecruitmentmaneuverabortedARDS患者的肺復(fù)張第102頁P(yáng)erformanceofaRMFIO2increasedto1.0for5-10minutesbeforeRMsedationgenerallyrequiredtoinsurepassiveinflationduringtherecruitmentperiod30cmH2OCPAPfor30-40secduringthefirstRMfollowedbycarefulassessmentoftheresultsARDS患者的肺復(fù)張第103頁P(yáng)erformanceofaRMIftheresponseisinadequatebutpatienttoleranceisgoodRMshouldberepeatedin15-20minutesatahigherCPAPlevel(35-40cmH2O)IftheresponsetothesecondRMis