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邱海波东南大学附属中大医院ICU东南大学急诊与危重病医学研究所ARDS肺复张的实施科学与艺术的困惑
1内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM
2ARDSnet:小潮气量通气LowTidalVolumesTraditionalTidalVolumesP-valueDeathbeforedischargehomeandbreathingwithoutassistant(%)31.039.80.007Breathingwithoutassistancebydays(%)65.755.0<0.001NOofventilatorfreedaysDay1-2812±1110±110.007Boratrauma,Day1-28(%)10110.43NOofdayswithoutfailureofnonpulmonaryorgansorsystemsDay1-2815±1112±110.006ARDSNet.NEnglJMed.2000May4;342(18):1301-8.
3Lowtidalvolume:morealvcollapse小Vt不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略至少15~25%患者需提高FiO2邱海波,刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205
4CollapsedairwayV1V2PressureVolumeV1V1+V2OpeningpressureNormalARDSPEEPadjustmentLIP：塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力PEEPnotenough:morealvkeepcollapse
530kgPigPostLavagePCVPaw13cmH2OPEEP5cmH2OExperimentalstudy-PigwithARDS
6许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.ClinicalTrial－11ARDSpats
7内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM
8A.HypoxamiaB.ShearforcesC.SurfactantsinactivateD.BiotraumaandMODSPathophysiologyConsolidationandalvcollapse
9A.低氧血症肺泡塌陷：ARDS重力依赖区炎症或不张区生理性低氧缩血管反应：障碍
10HowDoesExcessiveMechanicalStressInflametheLung?“Shear”
11Verbruggeetal.CritCareMed1999;27：779Ventilator-associatedlunginjuryPurine:amarkerofATPbreakdownandVILI42SDratsPCV6minPCVPre/PEEPBALFpurineandprotein
12Lachmann.ICM,1994;20:6-11Intra-alveolarproteinsinactivatealvsurfactantinadose-dependentway1mgsurfactant=inhibitoryeffectof1mgplasmaproteinC.Surfactant灭活
13SurfactantmoveawayWhenlungregionscollapseatend–expiration,surfactantmoleculesmoveawayfromthealvsurfacetowardterminalbronchiolesandcannotbereusedduringnextinflationRoubyJJ.AmJRespirCritCareMed,2001,165:1182
14D.预防Biotrauma和MODSMariniJJ,GattinoniL.Ventilatorymanagementofacuterespiratorydistresssyndrome:aconsensusoftwoCritCareMed.2004Jan;32(1):250-5.“Stretch”“Shear”AirwayTrauma
15内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM
16俯卧位通气的病理生理特征改善通气过程胸膜腔压力梯度顺应性胸壁促进分泌物的清除ClosingpressureClosingpressure
17TimecourseofProneonPaO2/FiO2betweenARDSpvsARDSexpTimeresponseofPronepositiononPaO2/FiO2betweenARDSpvsARDSexp黄英姿,邱海波.肺内外源性ARDS实施俯卧位通气时间的选择.中华内科杂志2004,43(12):883-887
18内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM
19保留自主呼吸的优点
20内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighRM
21Paw[cmH2O]%OpeningandClosingPressures0510152025303540455001020304050OpeningpressureClosingpressure5patients,ALI/ARDSFromCrottietalAJRCCM2001.Someunitscan’tbekeptopenbyanyreasonablePEEP!
22Amato:CT+PVCurveHeartSpPVLIPUIPInsprecruitLargerVt/Sigh:PressuremustbehighenoughEvenuptoUIP
23内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighHighPEEPRM
24许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.ClinicalTrial－11ARDSpats
25RecruitmentisTime-Dependent~40SECONDS
26内容提要肺保护性通气策略不能解决解决的问题肺泡塌陷的病理生理后果肺复张的临床实施PronepositionSpontaneousbreathingHighVTandsighHighPEEPRM
27RecruitmentmannuversBasicPrinciplesMethodsforRecruitmentExperimentalStudiesandClinicalTrialsEfficacyHazards
281.控制性肺膨胀(SI)法2.PEEP递增法3.压力控制(PCV)法MethodsforRecruitment
29CPAP模式: PS0,PEEP30-40cmH2O,20-50s 2.BIPAP: Ph/PL30-40cmH2O,20-50s 3.InspHold:将吸气保持键按住，持续20-40s控制性肺膨胀(SI)法
30MultipleManeuversMayBeNeededForOptimumRMEffectFujinoetal,CritCareMed2001;29(8):1579-1586
31Post-RMPEEPDeterminesPaO2AverageddatafromthreemodelsRMS-CLim,CCM2004TransientBenefitPost-RM-PEEP－ 肺开放效应持续时间的决定因素CCM,2004,32:2371-237728mixed-breedpigsModelsofARDS:OAVILIPneumonia(PNM)RMSIIncreasedPEEPPCV
32肺开放后的PEEP选择----PaO2/FiO21.RM后PEEP:20cmH2O2.PEEP递减:2cmH2O/5min3.PEEP阈值:PaO2/FiO2<400的PEEP或PaO2/FiO2降低>5%4.PEEP:PEEP阈值+2cmH2O
33BASELINEVENTILATIONTidalvolume=6ml/kgPEEP=5cmH2OModifyPEEPtogeta1.1>ｂ>0.9recruitingmaneuverMeasureｂ1.1>ｂ>0.9LeavePEEPunchangedｂ<0.9IncreasePEEPuntil1.1>stressindex>0.9ｂ>1.1DecreasePEEPuntil1.1>stressindex>0.9CritCareMed,2004,32:1018-1027肺开放后的PEEP选择----Stressindex
34ImplicationsRM的有效性ALI的病因(directvsindirect)PostRMPEEPMethodincertainsettingsRMhazardsaregreatestandeffectivenessleastinpneumonia-causedacutelunginjuryPCVmaybebettertoleratedthanSI
35RecommendationsUsePCVinpreferencetoSISafer,“multiple”,effective,maintainsventilation,simpleMonitorhemodynamicsduringrecruitinginterval.以下情况需重复作RM:体位改变,管路断开,呼吸力学特征或PaO2明显恶化对于顽固性难治性ARDS患者,可考虑反复RM和更高的压力EmployPronePositionand/orPEEPtoconsolidateRMbenefit.
