ARDS的肺保护性通气策略
患者数
潮气量
病死率
作者
小潮气量
对照
小潮气量
对照
小潮气量
对照
Amato
29
24
6.1 ± 0.2† 11.9 ± 0.5†
38
71
Stewart
60
60
7.2 ± 0.8‡ 10.6 ± 0.2‡
50
47
Brochard
58
58
7.2 ± 0.2§ 10.4 ± 0.2§
47
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
15 min
1 hr
4 hrs
ARDSp ARDSexp
6 hrs
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
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
PaO 2/FiO 2 PaO 2/FiO 2
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
150
100
50
0 baseline
Sustained Inflation: 45 cmH2O x 30 s
1
小潮气量通气的问题
Vt, ml
LVt (n = 15)
411 ± 55
CVt (n = 15)
664 ± 84
P value < 0.01
Vt, ml/kg
6±1
10 ± 1
< 0.01
setPEEP, cmH2O
10 ± 4
10 ± 4
n.s.
PEEPtot, cmH2O
11 ± 4
11 ± 4
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
受损的肺组织如何复张
俯卧位 足够的PEEP 足够的潮气量[和(或)’叹气’?] 肺复张手法 减少水肿(?) 最低可接受的FiO2 (?) 自主呼吸(?)
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
叹气的设置
充气阶段, 每30秒 PEEP增加5 cmH2O Vt减少2 ml/kg 前2次呼吸除外 直至Vt 2 ml/kg, PEEP 25 cmH2O
暂停阶段 CPAP 30 cmH2O for 30 s
放气阶段
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
n.s. n.s. < 0.05 < 0.001 < 0.001
SBP, mmHg
125 ± 25
121 ± 20
n.s.
DBP, mmHg
60 ± 9
60 ± 10
n.s.
HR, bpm
101 ± 15
93 ± 15
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
2
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.
38
Brower
26
26
7.3 ± 0.1¶ 10.2 ± 0.1¶
50
46
ARDSnet
432
429
6.3 ± 0.1¶ 11.7 ± 0.1¶
31
40
P值 < 0.001
0.72 0.38 0.60 0.007
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)
SI改善氧合
400
300
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
肺泡的开放压与闭合压
肺泡开放压与闭合压
50
Opening
pressure
40
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.
4
叹气改善氧合
叹气对氧合及呼吸力学的影响
Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O
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
3
RM能够使肺开放
RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 min
肺复张能够改善ARDS氧合
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
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