1、肺复张的临床实践,兰州军区乌鲁木齐总医院重症医学科 李新宇,新疆重症医学新技术新理论研讨班,临床面临的问题,ARDS死亡率居高不下总死亡率40-50%,？,萎陷的肺泡很难“保持开放”,需要较高的通气压力和吸入氧浓度,感染风险 明显增加,表面活性物 质功能丧失,容量伤导致VALI,JAMA 2002; 287: 345-55. Intensive Care Med 2004; 30: 51-61. Am J Respir Crit Care Med 2007; 176: 795-804.,3,ARDS AND RM,3,2,1,如何实施RM？,RM安全吗？,RM真的能使肺复张吗？,RM的理论基础
2、,对于ARDS的治疗，RM真的有用吗？,4,RM的理论基础肺泡的开放压,肺泡的不均一性,RM的理论基础肺泡的开放压与闭合压,肺泡开放压与闭合压,Crotti S etal. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.,肺泡开放压与闭合压,Crotti S etal. Recruitment and derecruitment during acute respiratory failu
3、re: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.,Paw (cmH2O),Crotti S etal. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131-140.,肺泡开放压与闭合压,PEEP不能使肺复张,RM理论基础,EditorialOpen up the lung and keep the lung open
4、B. Lachmann Dept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands(1992) 18:319-321,ARDS的肺开放,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
5、Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,RM真的能使肺开放吗？,至少可使患者暂时受益； 改善氧合：持续 or 暂时，与PEEP设置有关 有反应 or 无反应： 与多因素有关，如病因、病程、复张时间、压力、PEEP等试验设计缺陷可能导致结果误读 不对病程进行分层 不对PEEP进行个体化设置,Anesythesilogy 2002; 96: 795-802. Intensive Care Medicine 1999; 25: 1297-1
6、301. Am J Respir Crit Med 1999; 159: 872080. Crit Care Med 2003; 31: 738-44 Respiratory Care 2006; 51: 1132-9,已有的研究结果,我们的临床观察,复张前后PaO2/FiO2变化,早期正确的RM可使部分患者获益,ARDS肺的异质性,不同ARDS对肺复张的反应,ZEEP，PaO2= 153mmHg,ZEEP，PaO2= 89mmHg,PEEP=10，PaO2= 159mmHg,PEEP=12，PaO2= 128mmHg,RM，PaO2= 113mmHg,RM，PaO2= 313mmHg,PEE
7、P=10，PaO2= 189mmHg,PEEP=12，PaO2= 329mmHg,局灶型ARDS,弥漫型ARDS,不同程度ALI对肺复张的反应,安全性关注的问题血流动力学气压伤,RM对ARDS患者安全吗？,影响患者的预后,Response to RM = Balance,肺复张的利与弊,肺泡复张,肺泡过度充气,肺复张的利与弊,肺泡复张,肺泡过度充气,肺复张标准操作,应该如何做RM,FiO2维持1.0 判断肺开放标准(塌陷肺泡 400 PaO2/FiO2 300 PaO2 + PaCO2 400,RM基本思路,Airway Pr.,collapsed,Open,1. Recruitment,3.
8、 Re-recruitment,2. Find closing pr.,collapsed,4. Maintain recruitment,Open,接密闭式吸痰器，镇静、肌松,调整呼吸机模式PCV,调整参数： PC=15或20 cmH2O PEEP=30cmH2O I：E=1:1 FiO2=100%,实施复张，T=40-50s,调回呼吸机原参数,调最佳PEEP,肺复张的操作,应该如何做RM,应该如何做RM-持续气道正压法,以CPAP或BIPAP模式调节气道正压40cmH2O，维持40秒设置吸气压在40cmH2O，按住吸气保持40秒,应该如何做RMPEEP递增法,保持吸气压与PEEP差值不变，
9、每30秒递增PEEP5cm H2O，直到PEEP达35cm H2O，维持30秒，随后吸气压递增而PEEP每30秒递减5cm H2O,应该如何做RMPRM,应该如何做RMPRM,RM后的PEEP能够复张肺吗？,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/Derecr
10、uitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,RM后的PEEP能够稳定肺泡,RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 min,PEEP 5 cmH2O,PEEP 10 cmH2O,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveol
11、ar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626,RM后的PEEP能够稳定肺泡,McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic pulmonary vasoconstriction. Crit Care med 2002; 30: 1315-1321,肺泡稳定能够改善PaO2,Lim CM, Adams AB, Simonson DA, Dries DJ, Brocc
12、ard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377,RM后的PEEP,RM时间与肺开放,ARDS早期实施RM的确可以开放肺 正确的RM有助于改善氧合指数 RM后如果PEEP恰当则对患者有利 RM应在ARDS早期实施 平衡RM的利与弊 期待最佳RM能改善患者的预后,Take Home message,THANKS FOR YOUR ATTENTION！,
