1、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,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 Prone position Spontaneous breathing High VT and sigh RM,ARDSnet: 小潮气量通气,ARDS Net. N Engl J Med. 2000 May 4;342(18):1301-8.,Low tidal volume: more alv collapse,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1525%患者需提高F
2、iO2,邱海波, 刘大为, 陈德昌等. 中华麻醉学杂志, 1998, 18: 202-205,LIP：塌陷肺泡开始复张的压力 不是全部塌陷肺泡复张的压力,PEEP not enough: more alv keep collapse,30 kg Pig Post Lavage PCV Paw 13 cmH2O PEEP 5 cmH2O,Experimental study-Pig with ARDS,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，20
3、04, 16: 399.,Clinical Trial11 ARDS pats,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 Prone position Spontaneous breathing High VT and sigh RM,A. Hypoxamia B. Shear forces C. Surfactants inactivate D. Biotrauma and MODS,Pathophysiology Consolidation and alv collapse,A .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
4、血管反应：障碍,How Does Excessive Mechanical Stress Inflame the Lung?,“Shear”,Verbrugge et al. Crit Care Med 1999;27：779,Ventilator-associated lung injury,Purine: a marker of ATP breakdown and VILI 42 SD rats PCV 6min PCV Pre/PEEP BALF purine and protein,Lachmann. ICM, 1994; 20:6-11,Intra-alveolar proteins
5、 inactivate alv surfactant in a dose-dependent way1mg surfactant = inhibitory effect of 1mg plasma protein,C. Surfactant 灭活,Surfactant move away,When lung regions collapse at end expiration, surfactant molecules move away from the alv surface toward terminal bronchiolesand cannot be reused during ne
6、xt inflation,Rouby JJ. Am J Respir Crit Care Med, 2001, 165: 1182,D. 预防Biotrauma和MODS,Marini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two Crit Care Med. 2004 Jan;32(1):250-5.,“Stretch”,“Shear”,Airway Trauma,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
7、临床实施 Prone position Spontaneous breathing High VT and sigh RM,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,Closing pressure,Closing pressure,Time course of Prone on PaO2/FiO2 between ARDSp vs ARDSexp,Time response of Prone position on PaO2/FiO2 between ARDSp vs ARDSexp,黄英姿, 邱海波. 肺内外源性ARDS实施俯卧位通气时间的选择.
8、 中华内科杂志2004, 43(12):883-887,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 Prone position Spontaneous breathing High VT and sigh RM,保留自主呼吸的优点,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 Prone position Spontaneous breathing High VT and sigh RM,Paw cmH2O,%,Opening and Closing Pressures,0,5,10,15,20,25,30
9、,35,40,45,50,0,10,20,30,40,50,5 patients, ALI / ARDS,From Crotti et al AJRCCM 2001.,Some units cant be kept open by any reasonable PEEP!,Amato: CT + PV Curve,Heart,Sp,P,V,LIP,UIP,Insp recruit,Larger Vt/Sigh: Pressure must be high enough Even up to UIP,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 Pron
10、e position Spontaneous breathing High VT and sigh High PEEP RM,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.,Clinical Trial11 ARDS pats,Recruitment is Time-Dependent, 40 SECONDS,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 Prone positio
11、n Spontaneous breathing High VT and sigh High PEEP RM,Recruitment mannuvers,Basic Principles Methods for Recruitment Experimental Studies and Clinical Trials Efficacy Hazards,1. 控制性肺膨胀(SI)法2. PEEP递增法3. 压力控制(PCV)法,Methods for Recruitment,CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cm
12、H2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续20- 40s,控制性肺膨胀(SI)法,Multiple Maneuvers May Be Needed For Optimum RM Effect,Fujino et al, Crit Care Med 2001; 29(8):1579-1586,Post-RM PEEP Determines PaO2,Post-RM-PEEP 肺开放效应持续时间的决定因素,CCM, 2004, 32: 2371-2377,28 mixed-breed pigs Models of ARDS: OA VILI Pneumonia(PN
13、M) RM SI Increased PEEP PCV,肺开放后的PEEP选择-PaO2/FiO2,1. RM后 PEEP: 20cmH2O2. PEEP递减: 2cmH2O/5min3. PEEP阈值: PaO2/FiO25%4. PEEP: PEEP阈值 +2cmH2O,BASELINE VENTILATION Tidal volume=6ml/kg PEEP=5cmH2O,Modify PEEP to get a 1.10.9,recruiting maneuver,Measure,1.10.9 Leave PEEP unchanged,stress index 0.9,1.1 Decr
14、ease PEEP until 1.1stress index 0.9,Crit Care Med, 2004, 32: 1018-1027,肺开放后的PEEP选择- Stress index,Implications,RM 的有效性 ALI的病因 (direct vs in direct) Post RM PEEP Method in certain settings RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury PCV may be better tolerated than SI,Recommendations,Use PCV in preference to SI Safer, “multiple”, effective, maintains ventilation, simple Monitor hemodynamics during recruiting interval. 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 Employ Prone Position and/or PEEP to consolidate RM benefit.,
