1、ARDS患者的肺復張北京協和醫院杜斌.內容小潮氣量通氣的問題肺復張的實際與實際肺復張與PEEP肺復張后的PEEP不同復張方法的差別肺復張的臨床順應癥肺復張的副作用肺復張存在的問題.內容小潮氣量通氣的問題肺復張的實際與實際肺復張與PEEP肺復張后的PEEP不同復張方法的差別肺復張的臨床順應癥肺復張的副作用肺復張存在的問題.ARDS的肺維護性通氣戰略患者數潮氣量病死率作者小潮氣量對照小潮氣量對照小潮氣量對照P值Amato29246.1 0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.2

2、47380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041.ARDS的肺維護性通氣戰略小潮氣量(6 ml/kg IBW)防止過度膨脹呵斥的容積傷(volutrauma)足夠的PEEP防止肺泡復張呵斥的剪切力損傷(atelectrauma).肺泡塌陷與復張呵斥的剪切力F = PL x (V0/V)2/3F:剪切力PL:跨肺壓V0:最初容積V:復張后容積假設:PL = 30 cmH2O, V0/V = 1/10那么:F = 140 c

3、mH2OMead J, Takishima T, Leith D. Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol 1970; 28(5): 596-608.小潮氣量通氣的問題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

4、 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.小潮氣量通氣的問題LVt(n = 15)CVt(n = 15)P valuePaO2, mmHg136 80156 82n.s.PaO2/FiO2, mmHg165 84183

5、 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, mmHg60 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 a

6、nd a Recruitment Maneuver. Am J Respir Crit Care Med 2001; 163: 1609-1613.小潮氣量通氣的問題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: 1609-161

7、3.受損的肺組織如何復張俯臥位足夠的PEEP足夠的潮氣量和(或)嘆氣?肺復張手法減少水腫(?)最低可接受的FiO2 (?)自主呼吸(?).內容小潮氣量通氣的問題肺復張的實際與實際肺復張與PEEP肺復張后的PEEP不同復張方法的差別肺復張的臨床順應癥肺復張的副作用肺復張存在的問題.肺泡的開放壓與閉合壓.PEEP不能使肺復張.LIP: 僅僅是肺復張的開場Hickling KG. The pressure-volume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir C

8、rit Care Med 1998: 158: 194-202.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低位轉機點之上仍有肺組織復張.肺泡的開放壓與閉合壓.肺泡開放壓與閉合壓0102

9、030405005101520253035404550Opening 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 pressure.ARDS的肺開放Edi

10、torialOpen up the lung and keep the lung openB. LachmannDept. of Anesthesiology, Erasmus University Rotterdam, The Netherlands(1992) 18:319-321.RM可以使肺開放RM: 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 Press

11、ure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003; 167: 1620-1626.肺復張可以改善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 respi

12、ratory failure. Intensive Care Med 1999, 25: 1297-1301.肺復張的各種方法CPAP (SI)incremental PEEPPCVSigh (modified)HFOV俯臥位.SI改善氧合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 dist

13、ress syndrome: Focusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744Sustained Inflation:45 cmH2O x 30 s.SI改善氧合Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lun

14、g endothelial injury. Crit Care Med 2005; 33: 181-188Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval.嘆氣的設置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

15、distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260充氣階段, 每30秒PEEP添加5 cmH2OVt減少2 ml/kg前2次呼吸除外直至Vt 2 ml/kg, PEEP 25 cmH2O暫停階段CPAP 30 cmH2Ofor 30 s放氣階段.嘆氣改善氧合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

16、a recruitment maneuver in patients with acute respiratory distress syndrome: A preliminary study. Crit Care Med 2001; 29: 1255-1260.嘆氣對氧合及呼吸力學的影響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 Ca

17、re Med 1999; 159: 872-880Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O.嘆氣的設置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. Ane

18、sthesiology 2002; 96: 788-94Baseline:PSVSigh:BIPAPPEEPhigh =1.2 x PIPpsv or35 cmH2OTi,s = 3 5 sf = 1 bpm.嘆氣改善呼吸力學及氧合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 Underg

19、oing Pressure Support Ventilation. Anesthesiology 2002; 96: 788-94.ARDS對RM的反響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; 1

20、65: 165-170.肺復張 CT的提示Henzler D, Mahnken AH, Wildberger JE, Rossaint 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: 1-9.肺復張 CT的提示Henzler D, Mahnken AH, Wildberger JE, Rossaint R, Gnther

21、 RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006; 16: 1-9.內容小潮氣量通氣的問題肺復張的實際與實際肺復張與PEEP肺復張后的PEEP不同復張方法的差別肺復張的臨床順應癥肺復張的副作用肺復張存在的問題.RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim

22、DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80.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-l

23、avaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003; 99: 71-80.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 200

24、3; 99: 71-80.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.RM vs. PEEPLim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD,

25、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.內容小潮氣量通氣的問題肺復張的實際與實際肺復張與PEEP肺復張后的PEEP不同復張方法的差別肺復張的臨床順應癥肺復張的副作用肺復張存在的問題.為什么肺復張作用不能耐久?baseline3 min post-RM30 min post-RMPaO2/FiO2 (m

26、mHg)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-expiratory Pressu

27、re Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5.為什么肺復張作用不能耐久?肺復張的方法?SI: 50 cmH2O x 30 s作者以為Oczenski W, Hrmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive End-expiratory Pressu

28、re Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004; 101: 620-5.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 respiratory distress syndrome

29、 according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418.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 a

30、cute 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.RM后的PEEP.RM后的PEEP可以穩定肺泡Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Niema

31、n 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.RM后的PEEP可以穩定肺泡RM: PIP 45 cmH2O, PEEP 35 cmH2O x 1 minPEEP 5 cmH2OPEEP 10 cmH2OHalter JM, Steinberg JM, Schiller HJ, DaSilv

32、a 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.肺泡穩定可以改善PaO2McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic ulmona

33、ry vasoconstriction. Crit Care med 2002; 30: 1315-1321.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 Med 2004; 32: 2371-2377.RM + PEEP vs. PEEP onlyLim CM, Adams

34、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.PEEP的設置RM之后通常將PEEP設置在可以維持PaO2 (防止塌陷)的程度最初將PEEP設置為20 cmH2O然后將FiO2減小到最低程度維持SpO2 90 95%每20 30分鐘降低PE

35、EP 2 cmH2O直至患者SpO2下降.PEEP的設置氧合下降前的PEEP程度防止大部分肺泡塌陷的PEEP一旦確認, 那么需反復肺復張操作, 然后把PEEP和FiO2重新設置在上述程度對于多數ARDS患者, PEEP介于15 20 cmH2O之間某些患者 20 cmH2O.PEEP的設置假設將PEEP設置于20 cmH2O后, 仍發現PaO2/FiO2顯著下降按照最初的PEEP設置25 cmH2O反復肺復張然后按照上述方法調理FiO2和PEEP.PEEP的設置將PEEP從不用要的高程度逐漸降低不要將PEEP由低程度添加到高程度好像P-V曲線所示, 根據設置方法不同, 同樣程度的PEEP所維持

36、的肺容積不同假設在肺泡塌陷后設置PEEP (添加PEEP), 那么所設置的PEEP程度可以使肺容積減少, PaO2降低.PEEP/FiO2的調整引薦意見降低PEEP之前該當首先降低FiO2, 以防止肺泡塌陷普通情況下FiO2該當減低到 5 min)時假設沒有察看到氧合下降, 那么需求每日進展一次或兩次肺復張未知.總結肺復張是肺維護性通氣戰略的重要組成開放肺并維持肺開放是其實際根底運用氣道高壓使塌陷肺泡開放運用足夠的PEEP維持肺泡開放肺復張對循環的影響肺復張尚未處理的問題壓力時間頻率順應癥.PEEP能否使肺復張?PEEP可以防止肺泡塌陷(derecruitment)低程度的PEEP只能使很少的肺復張對于ARDS, 將壓力繼續維持在常用的