ARDSnet
Villar
432
50
429
45
6.3 0.1¶
7.3 0.9¶
11.7 0.1¶
10.2 Leabharlann 1.2¶3134
40
55
0.007
0.041
ARDS的肺保护性通气策略
小潮气量(6 ml/kg IBW)
– 避免过度膨胀造成的容积伤(volutrauma)
足够的PEEP
肺复张的各种方法
CPAP (SI) incremental PEEP PCV Sigh (modified) HFOV 俯卧位 …
SI改善氧合
250 200
PaO 2/FiO 2
150
100
50
Sustained Inflation: 45 cmH2O x 30 s
baseline 15 min 1 hr 4 hrs
小潮气量通气的问题
LVt (n = 15) Vt, ml Vt, ml/kg 411 55 61 CVt (n = 15) 664 84 10 1 P value < 0.01 < 0.01
setPEEP, cmH2O
PEEPtot, cmH2O Pplat, cmH2O
10 4
叹气改善氧合
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 a recruitment maneuver in patients with acute respiratory distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260
ARDS的肺开放
Editorial
Open up the lung and keep the lung open
B. Lachmann
Dept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands
(1992) 18:319-321
低位转折点 之上仍有肺 组织复张
Jonson B, Richard JC, Straus C, Mancebo J, Lemaire F, Brochard L. Pressure–Volume 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
小潮气量通气的问题
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: 1609-1613
RM能够使肺开放
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 Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626
94.8 5.0
60 35 7.21 0.1 125 25 60 9 101 15
97.6 2.1
38 21 7.36 0.1 121 20 60 10 93 15
< 0.05
< 0.001 < 0.001 n.s. n.s. n.s.
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: 1609-1613
肺泡的开放压与闭合压
肺泡开放压与闭合压
50 40
Opening pressure Closing pressure
30
20 10 0 0 5 10 15 20 25 30 35 40 45 50
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.
SI改善氧合
400
300
PaO 2/FiO 2
200
100
0 baseline pre-RM
Sustained Inflation: 30 cmH2O x 30 s Twice with 1 min interval
2 min post-RM 20 min post-RM 40 min post-RM 60 min post-RM
– 防止肺泡复张造成的剪切力损伤 (atelectrauma)
肺泡塌陷与复张造成的剪切力
F = PL x (V0/V)2/3
F: PL: V0 : V: 如果: 则: 剪切力 跨肺压 最初容积 复张后容积 PL = 30 cmH2O, V0/V = 1/10
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
肺泡的开放压与闭合压
PEEP不能使肺复张
LIP: 仅仅是肺复张的开始
Hickling KG. The pressure-volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998: 158: 194-202.
11 4 23 8
10 4
11 4 30 10
n.s.
n.s. < 0.01
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: 1609-1613
ARDSp ARDSexp
6 hrs
0
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: Focusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744
ARDS患者的肺复张
北京协和医院 杜 斌
内容
小潮气量通气的问题 肺复张的理论与实践 肺复张与PEEP 肺复张后的PEEP 不同复张方法的差异 肺复张的临床适应症 肺复张的副作用 肺复张存在的问题
内容
小潮气量通气的问题 肺复张的理论与实践 肺复张与PEEP 肺复张后的PEEP 不同复张方法的差异 肺复张的临床适应症 肺复张的副作用 肺复张存在的问题
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
小潮气量通气的问题
LVt (n = 15) PaO2, mmHg PaO2/FiO2, mmHg 136 80 165 84 CVt (n = 15) 156 82 183 83 P value n.s. n.s.