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1、ARDS患者(hunzh)(hunzh)的肺复张北京协和医院杜斌第一页，共一百二十页。内容(nirng)w小潮气量通气的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异(chy)w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题第二页，共一百二十页。内容(nirng)w小潮气量通气的问题(wnt)w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题第三页，共一百二十页。ARDS的肺保护性通气(tng q)策略患者数患者数潮气量潮气量病死率病死率作者作者小潮气量小潮气量对照对照小
2、潮气量小潮气量对照对照小潮气量小潮气量对照对照P值值Amato29246.1 0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041第四页，共一百二十页。ARDS的肺保护性通气(tng q)策略w小潮气量(6 ml/kg IBW)w防止过度膨胀造成(zo chn)的
3、容积伤(volutrauma)w足够的PEEPw防止肺泡复张造成的剪切力损伤(atelectrauma)第五页，共一百二十页。肺泡(fipo)塌陷与复张造成的剪切力F=PL x(V0/V)2/3F:剪切力剪切力PL:跨肺压跨肺压V0:最初容积最初容积(rngj)V:复张后容积复张后容积如果如果:PL=30 cmH2O,V0/V=1/10那么那么:F=140 cmH2OMead J,Takishima T,Leith D.Stress distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):5
4、96-608第六页，共一百二十页。小潮气量通气(tng q)的问题LVt(n=15)CVt(n=15)P valueVt,ml411 55664 84 0.01Vt,ml/kg6 110 1 0.01setPEEP,cmH2O10 410 4n.s.PEEPtot,cmH2O11 411 4n.s.Pplat,cmH2O23 830 10 0.01Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective R
5、ole of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613第七页，共一百二十页。小潮气量通气(tng q)的问题LVt(n=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,mmHg165 84183 83n.s.SaO2,%94.8 5.097.6 2.1 0.05PaCO2,mmHg60 3538 21 0.001pH7.21 0.17.36 0.1 0.001SBP,mmHg125 25121 20n.s.DBP,mmHg6
6、0 960 10n.s.HR,bpm101 1593 15n.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第八页，共一百二十页。小潮气量通气(tng q)的问题Richard JC,Maggiore SM,Jonson B,
7、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第九页，共一百二十页。受损的肺组织(zzh)如何复张w俯卧位w足够的PEEPw足够的潮气量和(或)叹气(tn q)?w肺复张手法肺复张手法w减少水肿(?)w最低可接受的FiO2(?)w自主呼吸(?)第十页，共一百二十页。内容(nirng)w小潮气量
8、通气的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同(b tn)复张方法的差异w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题第十一页，共一百二十页。肺泡(fipo)的开放压与闭合压第十二页，共一百二十页。PEEP不能使肺复张第十三页，共一百二十页。LIP:仅仅(jnjn)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
9、:194-202.第十四页，共一百二十页。Jonson B,Richard JC,Straus C,Mancebo J,Lemaire F,Brochard L.PressureVolume 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低位转折点低位转折点之上仍有肺之上仍有肺组织组织(zzh)复张复张第十五页，共一百二十页。肺泡的开放(kifng)压与闭
10、合压第十六页，共一百二十页。肺泡开放(kifng)压与闭合压0102030405005101520253035404550Opening pressurePaw(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.Closing
11、 pressure第十七页，共一百二十页。ARDS的肺开放(kifng)EditorialOpen up the lung and keep the lung openB.LachmannB.LachmannDept.of Anesthesiology,Erasmus University Rotterdam,The NetherlandsDept.of Anesthesiology,Erasmus University Rotterdam,The Netherlands(1992)18:319-321(1992)18:319-321第十八页，共一百二十页。RM能够(nnggu)使肺开放RM:
12、PIP 45 cmH2O,PEEP 35 cmH2O x 1 minHalter 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第十九页，共一百二十页。肺复张能够(nnggu)改
13、善ARDS氧合Lapinsky SE,Aubin M,Mehta S,Boiteau P,Slutsky AS:Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.第二十页，共一百二十页。肺复张的各种(zhn)方法wCPAP(SI)wincremental PEEPwPCVwSigh(modified)wHFOVw俯卧(f w)位w第二十一页，共一百二十页。SI改善
14、(gishn)氧合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;31:738-744Sustained Inflation:45 cmH2O x
15、 30 s第二十二页，共一百二十页。SI改善(gishn)氧合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;33:181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval第
16、二十三页，共一百二十页。叹气(tn q)的设置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充气阶段,每30秒PEEP增加(zngji)5 cmH2OVt减少2 m
17、l/kg前2次呼吸除外直至Vt 2 ml/kg,PEEP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段第二十四页，共一百二十页。叹气(tn q)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
18、.Crit Care Med 2001;29:1255-1260第二十五页，共一百二十页。叹气(tn q)对氧合及呼吸力学的影响Pelosi P,Cadringher P,Bottino N,Panigada M,Carrieri F,Riva E,Lissoni A,Gattinoni L.Sigh in acute respiratory distress syndrome.Am J Respir Crit Care Med 1999;159:872-880Sigh:3 consecutive sighs/min at Pplat 45 cmH2O第二十六页，共一百二十页。叹气(tn q)
19、的设置Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,
20、s=3 5 sf=1 bpm第二十七页，共一百二十页。叹气改善呼吸(hx)力学及氧合Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94第二十八页，共一百二十页。ARDS对
21、RM的反响(fnyng)Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar JL,Fernandez R,Blanch L.Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome.Am J Respir Crit Care Med 2002;165:165-170第二十九页，共一百二十页。肺复张 CT的提示(tsh)Henzler D,Mahnken AH,Wildberger JE,Ros
22、saint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359第三十页，共一百二十页。肺复张 CT的提示(tsh)Henzler D,Mahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography
23、 to determine the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359第三十一页，共一百二十页。内容(nirng)w小潮气量通气的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异w肺复张的临床(ln chun)适应症w肺复张的副作用w肺复张存在的问题第三十二页，共一百二十页。RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD
24、.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第三十三页，共一百二十页。RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine
25、 Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第三十四页，共一百二十页。RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第三十五页，共
26、一百二十页。RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第三十六页，共一百二十页。RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Ki
27、m WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80第三十七页，共一百二十页。内容(nirng)w小潮气量通气(tng q)的问题w肺复张的理论与实践w肺复张与PEEPw肺复张后的PEEPw不同复张方法的差异w肺复张的临床适应症w肺复张的副作用w肺复张存在的问题第三十八页，共一百二十页。为什么肺复张作用(zuyng)不能持久?baseline3 min pos
28、t-RM30 min post-RMPaO2/FiO2(mmHg)139 46246 111138 39PaCO2(mmHg)48.6 12.147.6 1346.4 12SvO2(%)70.4 6.172.4 5.670 6.2Qs/Qt(%)30.8 5.821.5 9.729.2 7.4Crs(ml/cmH2O)34.1 12.636.9 15.135.7 13.5Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End
29、-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5第三十九页，共一百二十页。为什么肺复张作用(zuyng)不能持久?w肺复张的方法(fngf)?SI:50 cmH2O x 30 sw作者认为Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers afte
30、r a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5第四十页，共一百二十页。RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in early acute
31、respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418第四十一页，共一百二十页。RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitm
32、ent maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM only第四十二页，共一百二十页。RM后的PEEP第四十三页，共一百二十页。RM后的PEEP能够稳定(wndng)肺泡Halter JM,Steinberg JM,Schi
33、ller 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第四十四页，共一百二十页。RM后的PEEP能够(nnggu)稳定肺泡RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEE
34、P 10 cmH2OHalter 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第四十五页，共一百二十页。肺泡(fipo)稳定能够改善PaO2McCann UG,Schiller
35、 HJ,Gatto LA,et al.Alveolar mechanics alter hypoxic ulmonary vasoconstriction.Crit Care med 2002;30:1315-1321第四十六页，共一百二十页。RM后的PEEPLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Me
36、d 2004;32:2371-2377第四十七页，共一百二十页。RM+PEEP vs.PEEP onlyLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377RM+PEEPPEEP only第四十八页，共一百二十页。PEEP的设置(shzh)wRM之后通常将PEEP设置在能够
37、维持PaO2(防止塌陷)的水平w最初(zuch)将PEEP设置为20 cmH2Ow然后将FiO2减小到最低水平维持SpO2 90 95%w每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降第四十九页，共一百二十页。PEEP的设置(shzh)w氧合下降前的PEEP水平w防止大局部肺泡塌陷的PEEPw一旦确认,那么需重复肺复张操作,然后把PEEP和FiO2重新设置在上述水平w对于多数ARDS患者(hunzh),PEEP介于15 20 cmH2O之间w某些患者 20 cmH2O第五十页，共一百二十页。PEEP的设置(shzh)w如果将PEEP设置于20 cmH2O后,仍发现PaO2/F
38、iO2显著下降按照(nzho)最初的PEEP设置25 cmH2O重复肺复张然后按照上述方法调节FiO2和PEEP第五十一页，共一百二十页。PEEP的设置(shzh)w将PEEP从不必要的高水平逐渐(zhjin)降低w不要将PEEP由低水平增加到高水平w如同P-V曲线所示,根据设置方法不同,同样水平的PEEP所维持的肺容积不同w如果在肺泡塌陷后设置PEEP(增加PEEP),那么所设置的PEEP水平可以使肺容积减少,PaO2降低第五十二页，共一百二十页。PEEP/FiO2的调整(tiozhng)推荐意见降低PEEP之前应当首先降低FiO2,以防止肺泡塌陷一般情况(qngkung)下FiO2应当减低
39、到 5 min)时w如果没有观察到氧合下降,那么需要每日进行一次或两次肺复张w未知第八十五页，共一百二十页。总结(zngji)w肺复张是肺保护性通气策略的重要组成w开放肺并维持肺开放是其理论根底(jch)w应用气道高压使塌陷肺泡开放w应用足够的PEEP维持肺泡开放w肺复张对循环的影响w肺复张尚未解决的问题w压力w时间w频率w适应症第八十六页，共一百二十页。第八十七页，共一百二十页。PEEP能否(nn fu)使肺复张?wPEEP能够防止肺泡塌陷(derecruitment)w低水平的PEEP只能使很少的肺复张w对于ARDS,将压力持续(chx)维持在常用的PEEP水平(300 mmHg第一百零八
40、页，共一百二十页。第一百零九页，共一百二十页。The P-V CurvewOn the inflation limb of the curvewlower inflection point(Pflex)a region of changing slope in early inflation where lung recruitment beginsthe minimal PEEP necessaryto prevent partial derecruitment of the lung during exhalation第一百一十页，共一百二十页。The P-V CurvewOn the e
41、xpiratory limbwthe point of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during exhalationthe maximum PEEP requiredto prevent derecruitment第一百一十一页，共一百二十页。The P-V Curvewthese two“points identify the range of PEEP needed in ARDSwPflex=the minimumwPMCEX=the maxi
42、mumwIdeally,a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEP第一百一十二页，共一百二十页。第一百一十三页，共一百二十页。第一百一十四页，共一百二十页。第一百一十五页，共一百二十页。第一百一十六页，共一百二十页。RM后的PEEP影响(yngxing)PaO2Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomp
43、arison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377第一百一十七页，共一百二十页。第一百一十八页，共一百二十页。肺泡(fipo)开放压与闭合压0102030405005101520253035404550Opening pressureClosing pressurePaw(cmH2O)Crotti S,Mascheroni D,Caironi P,Pelosi P,Ronzoni G,Mondino M,Marini JJ,Gat
44、tinoni L.Recruitment and derecruitment during acute respiratory failure:a clinical study.Am J Respir Crit Care Med 2001:164:131-140.第一百一十九页，共一百二十页。内容(nirng)总结ARDS患者(hunzh)的肺复张。Open up the lung and keep the lung open。RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 min。VCV:Vt 10 ml/kg,f 20 bpm,I:E 1:2,FiO2 0.5。30 cmH2O x 30 s x 2第一百二十页，共一百二十页。