ARDS肺可復張性評估.ppt

1、a,1,ARDS肺可復張性評估,山東大學齊魯醫(yī)院 重癥醫(yī)學科 張帆,a,2,ARDS的病理生理,病理學特點：肺組織損傷的不均一性,N Engl J Med, 2006,354:1775-1786,a,3,HEART,SP,ARDS肺保護性通氣,1.小潮氣量/PHC 2. RM +最佳PEEP,a,4,肺可復張性,Lung tissue in which aeretion can be restored N Engl J Med, 2006, 354:1775-1786 在壓力的作用下，不通氣的肺泡恢復通氣的能力 Crit Care Med, 2011, 39: 1839-1840,a,5,肺復

2、張的生理作用,促進塌陷肺泡復張，增加肺容積 提升肺順應性 降低肺內(nèi)分流 減輕肺內(nèi)、肺外器官的炎癥反應,中國危重病急救醫(yī)學，2004,16:603-607,a,6,肺復張手法,a,7,肺可復張性初步評估,N Engl J Med, 2006 :1775-1786,a,8,肺可復張性的評估辦法,a,9,CT評價肺通氣的金標準,“diffuse” ARDS,“l(fā)obar” ARDS,Crit Care Med 2003;31Suppl.:S285S295,a,10,CT定量分析定量評價肺水腫和通氣,張帆，吳大瑋， BioMedical Engineering OnLine2014,13:30,a,1

3、1,肺可復張性的評價Gattinoni method,The percentage of potentially recruitable lung9% 為高可復張性,The percentage of potentially recruitable lung：氣道壓力由5cmH2O升至45cmH2O時，不通氣區(qū)的減少占全肺重量的百分比,N Engl J Med 2006;354:1775-86,a,12,PEEP-induced alveolar recruitment (RECALV) was expressed as percentage of variation of the weigh

4、t of the nonaerated lung parenchyma: RECALV (%)=(WZEEP-WPEEP)/WZEEP,N Engl J Med 2006;354:1775-86,肺可復張性的評價Gattinoni method,The decrease in the percentage of nonaerated lung tissue as PEEP was raised from 5cmH2O to 15cmH2O was highly correlated with the percentage of potentially recruitable lung (r2

5、= 0.72, P0.001),a,13,肺可復張性的評價The CT Scan ARDS Study Group method,“diffuse” ARDS,“l(fā)obar” ARDS,Am J Respir Crit Care Med 2001:14441450,PEEP-induced alveolar recruitment was computed as the increase in gas volume within the poorly and nonaerated lung regions following PEEP divided by the FRC measured i

6、n ZEEP conditions RECALV (%) = (VGas PEEP VGas ZEEP)/FRCZEEP,a,14,P-V曲線評估肺可復張性,Critical Care 2008, 12:R7,EELVZEEP：ZEEP時的呼氣末肺容積 ILV-10、ELV-10：氣道壓力10cmH2O，吸氣/呼氣支對應的肺容積 TLC：氣道壓力40cmH2O時肺總量 MH： maximal volume hysteresis，最大閉陷容積,a,15,MH/TLC與肺力學及血氣分析的相關(guān)性,MH/TLC與EELV、Crs、PaCO2的變化明顯相關(guān)（R2分別為0.55，0.57 and 0.36

7、，P 0.05) MH/TLC 與PaO2的變化之間未見明顯的相關(guān)性 (R2 = 0.05，P 0.26),Critical Care 2008, 12:R7,a,16,MH/TLC評價肺可復張性的敏感性和特異性,MH/TLC 預測肺復張后EELV改善的敏感度達 1.0，特異度0.85 預測Crs改善的敏感度和特異度0.88 、1.0 PaCO2 的改善為0.78 、0.60 PaO2 的改善為1.0 、0.69,Critical Care 2008, 12:R7,a,17,P-V曲線評估肺可復張性與CT對比,Crit Care, 2006, 10:R95,a,18,Crit Care, 20

8、06, 10:R95,P-V曲線評估肺可復張性與CT對比,P-V曲線計算FRC與CT計算的肺泡閉陷容積呈明顯的相關(guān)性和良好的一致性,a,19,呼氣末肺容積（EELV）,a,20,P-V曲線與EELV的一致性良好,a,21,EIT可以顯示肺復張后各區(qū)域呼氣末肺容積的變化,a,22,EELV評估肺可復張性,Journal of Critical Care,2013,28: 534.e1534.e5,肺復張EELV的增加與氧合指數(shù)的改善明顯相關(guān),a,23,EELV評估肺可復張性,The optimal cutoff value of the EELV to predict a 15% change

9、in the P/F ratio was 9.25% (sensitivity, 86.7%; specificity, 84.4%),Journal of Critical Care,2013,28: 534.e1534.e5,a,24,肺牽張指數(shù)（Stress Index）,Y=atb +c,a,25,容量控制通氣吸氣支形狀與肺牽張指數(shù)的關(guān)系,a,26,肺牽張指數(shù)評估肺可復張性,J Surg Res2013 Nov;185(1):347-52.,a,27,Electrical Impedance Tomography (EIT),肺組織的電學特征受氣體含量的影響，肺內(nèi)氣體含量的改變導致電阻

10、抗的變化,基本信息 - 通氣分布情況 - 局部位置的呼氣末肺容量的變化(EELV),a,28,EIT可以顯示肺復張后各區(qū)域呼氣末肺容積的變化,a,29,EIT可以顯示肺復張后通氣分布的變化,a,30,經(jīng)PEEP遞增法行肺復張后，全肺的阻抗變化明顯增加，反應全肺的通氣量增加。,經(jīng)肺復張后，肺通氣明顯改善，尤其是重力依賴區(qū)通氣明顯增加，PEEP降低時，重力依賴區(qū)通氣首先出現(xiàn)下降，與CT變化基本一致。,a,31,Crit Care Med 2012;40:903911,EIT可以評價肺的可復張性，隨著PEEP的升高，全肺通氣得到改善，重力依賴區(qū)通氣明顯增加，與CT的變化基本一致。,a,32,EIT使

11、局部肺通氣的床旁評估成為現(xiàn)實： 區(qū)域1代表非重力依賴區(qū)，通氣量始終較重力依賴區(qū)占有優(yōu)勢，當PEEP由30cmH2O開始下降時出現(xiàn)通氣量的一過性增高，說明存在局部肺泡的過度通氣； 區(qū)域4代表重力依賴區(qū)，在PEEP升高至20cmH2O時出現(xiàn)通氣量的突然增加，給予表面活性物質(zhì)治療后，肺泡開放的閾值降低至10cmH2O。,a,33,ARDS肺部超聲,J Am Soc Echocardiogr 2006;19:356-363,a,34,ARDS肺部超聲,normal lung,interstitial syndrome,a,35,嚴重肺水腫的超聲表現(xiàn),組織樣征,碎片征,a,36,ARDS肺部超聲的演變,

12、Cardiovascular Ultrasound2011,9:6,a,37,肺復張前后的肺部超聲,Respir Care, 2012 ,57(5):773-81,a,38,超聲評價肺的可復張性,Four ultrasound aeration patterns were defined: (1) normal aeration(N): presence of lung sliding with A lines or fewer than two isolated B lines (2) moderate loss of lung aeration: multiple well-defined

13、 B lines(B1 lines) (3) severe loss of lung aeration: multiple coalescent B lines (B2 lines) (4) lung consolidation (C): the presence of a tissue pattern characterized by dynamic air bronchograms,Am J Respir Crit Care Med, 2011,183:341-347,a,39,Ultrasound Reaeration Score,Am J Respir Crit Care Med, 2

14、011,183:341-347,a,40,PEEP誘導肺復張的超聲表現(xiàn),Am J Respir Crit Care Med, 2011,183:341-347,a,41,肺部超聲法與其他評估方法的比較,Am J Respir Crit Care Med, 2011,183:341-347,a,42,肺部超聲評價肺可復張性,優(yōu)點 即時操作，無鎮(zhèn)靜肌松要求 可用于重力依賴區(qū)或非重力依賴區(qū)肺復張效果的評估,缺點 肺非靜態(tài)，可能低估肺復張狀況 患者因素影響準確性（胸壁皮下脂肪厚度、胸壁皮下氣腫等） 受操作者熟練程度限制 不能區(qū)分正常通氣或過度通氣，不能作為肺復張評價的唯一指標,Am J Respir Crit Care Med, 2011,183:341-347,a,43,病例摘要,患者女，20歲，因促排卵藥物治療后“卵巢過度刺激綜合征”，并出現(xiàn)高熱，血小板減少至0109/L，由120送我院急診。 查體：貧血貌，全身紫癜，腹膨隆，壓痛伴反跳痛，腹水征陽性。,a,44,急癥超聲,左卵巢72mm56mm，內(nèi)見62mm52mm低回聲團塊， 盆腹腔積液，內(nèi)見細點狀回聲，深60mm 考慮左卵巢黃體或囊腫破裂并腹腔內(nèi)出血,a,45