ARDS肺复张的测定

1、.,1,急性呼吸窘迫综合征肺复张的测定与应用,邱海波 东南大学附属中大医院 东南大学急诊与危重病研究所,.,2,.,3,.,4,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,.,5,Lung volume decreased markedly (TLC, VC, TV, FRC) -alveolar edema -pulmonary surfactant -Interstitial p

2、umonary edema depress brochiole and induce spasm Compliance reduced significantly Ventilation/perfusion mismatch -intrapulmonary shunt and dead space like effects,ARDS病理生理特点,ARDS病理生理,.,6,CT scan 70-80% 的肺野呈现高密度区 分布：下垂部位(dependent field) 提示： 参与通气肺泡明显减少(20-30%) 肺损伤具有不均一性,肺容积减少Small lung Baby Lung,ARDS

3、病理生理,.,7,A and C finding in the acute or exudative phase,B and D Finding in the fibrosing-alveolitis phase,ARDS病理生理,.,8,肺容积/顺应性明显降低,ARDS病理生理,.,9,Reduced range of volume excursion: Low compliance Flattening at low and high volumes: Lower and upper inflection points Bigatello: Br J Anaest 1996,Volume,

4、Pressure,NORMAL,ARDS,顺应性曲线明显右下移位,肺顺应性明显降低,ARDS病理生理,.,10,Upper and Lower Inflection Points,Lower 呼气末肺泡塌陷 吸气早期肺泡再开放 Upper 吸气末肺泡顺应性明显 降低，肺泡过度膨胀,ARDS病理生理,Volume,Pressure,Lower Inflection Point,Upper Inflection Point,.,11,通气/血流失调,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,ARDS病理生理,.,12,Imagine the Hardness to B

5、low up a Ballon .,easy,hard,spatial 与10 ml/kg相比， #P 0.05,ARDS肺复张应用,.,46,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,.,47,PEEP效应的影响因素-附加静水压与心脏的影响,ARDS肺复张应用,.,48,Rothen H. et al. Br J Anaesth 1993:71:788-795,Re-expans

6、ion of atelectasis during general anaethesia,A: CT scan at level of right disphragm B: CT scan 5cm above right diaphragm,ARDS肺复张应用,.,49,PEEP诱导recruitment的分布,Puybasset L. ICM, 2000, 26:1215c,In lower lobes: Alv recruitment (ml) = 0.16 X End-expir lung volume(ml) 24ml,ARDS肺复张应用,.,50,PEEP导致overdistenti

7、on的分布,Volume of overdistension(ml)=0.42Parenchyma-900;-800(ml)18ml,Puybasset L. ICM, 2000, 26:1215c,ARDS肺复张应用,.,51,PEEP效应的影响因素-塌陷肺泡的分布范围,塌陷肺泡的范围 Efficiency of PEEP-induced alv recruitment highly correlated with the proportion of poorly and nonaerated lung parenchyma in ZEEP,Puybasset L. ICM, 2000,26

8、:1215,ARDS肺复张应用,.,52,Diffuse: Equal loss of aeration to the upper and lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,.,53,Local: Loss of aeration predominating in lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,.,54,Effect of PEEP on recruitment and overdistention,Puybasset L. I

9、CM, 2000, 26:1215,ARDS肺复张应用,.,55,PEEP效应的影响因素-LIP的影响,ARDS肺复张应用,.,56,绵羊有无LIP组PEEP复张容积,ARDS肺复张应用,.,57,有无LIP患者的复张容积,*,*#,*,*#,与PEEP5 cmH2O相比，*P 0.05 与PEEP 10 cmH2O相比，#P 0.05 与LIP组比较，P 0.05,ARDS肺复张应用,.,58,Effect of PEEP on recruitment and overdistention,In LIP/+: PEEP1=LIP+2, PEEP2=LIP+7. In LIP/-: PEEP1

10、=10, PEEP2=15,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,.,59,PEEP-induced alv recruitment,16pat with ARDS LIS 3 Csts 39(ZEEP) CT scan Over -1000-900 Normal -900-500 Low -500-100 Ate 100+100 PEEP 0 vs 15,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,ARDS肺复张应用,.,60,对象：17例稳定ARDS患者VT=6ml/kg,PEEP=

11、10cm/H2O 肺复张方法：ZEEP, SI(40cmH2O,40s)，VT=6ml/kg, PEEP=Pflex+2cmH2O, PCV，PIP=15+PEEP，调整PEEP为25、30、35、40、45cmH2O，CT比较非通气区变化 结果：PaO2从ZEEP的92.3mmHg上升至394mmHg，非通气区从ZEEP的63.7%降至28.6%,VT-induced alv recruitment,ARDS肺复张应用,.,61,VT-induced alv recruitment,ARDS肺复张应用,.,62,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法

12、：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,.,63,PEEP的选择,氧分压导向性PEEP选择 PaO2 method DO2导向性PEEP选择 肺复张容积导向性PEEP选择Recruitment volume method,ARDS肺复张应用,.,64,open,closed,closed?,open,open up!,find closed!,re-open!,keep open!,airway pressure,time,氧分压导向性PEEP选择,ARDS

13、肺复张应用,.,65,Vazquez de Anda et al. Acta Anesth Scand 1998: 42:63-66,PEEP,PIP,ARDS肺复张应用,.,66,对象：17例ARDS患者，VT=6ml/kg, PEEP=10cm/H2O PEEP选择方法：PCV，PIP=15+PEEP，每2min调PEEP 25、30、35、40、45cmH2O，至FiO2为100% PaO2+PaCO2400mmHg，每15-20min降低PEEP，至PaO2较前一次降低5%, PEEP水平为前一次PEEP 结果：PaO2+PaCO2从178.476.5mmHg升至487.8 139.1

14、mmHg，维持肺复张PEEP水平为224cmH2O,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺复张应用,氧分压导向性PEEP选择,.,67,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺复张应用,氧分压导向性PEEP选择,.,68,对象：47例早期ARDS患者，VCV，VT=8ml/kg， PEEP=10cm/H2O，RR20次/分，I：E=1：1 分组与方法： ARM+PEEP组：ARM实施方法为逐步增加PEEP至15、 20、25、30cm/H2O(extended sigh)， 结束后PE

15、EP设为15cm/H2O ARM组：ARM后PEEP仍为10cm/H2O PEEP组：基础通气模式,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,.,69,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,.,70,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧

16、分压导向性PEEP选择,.,71,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,.,72,DO2导向性PEEP选择,ARDS传统的通气策略-经验性PEEP 缺点：缺乏科学依据 ARDS肺保护性通气策略-最佳PEEP 优点：获得最大的DO2，同时考虑PEEP 对循环和呼吸的影响，LIP+2cmH2O 为最佳PEEP,ARDS肺复张应用,邱海波, 郭凤梅, 周韶霞等. 中华内科杂志, 2001, 9,.,73,PEEP不足大量肺泡难以复张,LIP：塌陷肺泡开始复张压力，不是全部

17、塌陷肺泡复张压力,ARDS肺复张应用,.,74,LIPStart of recruitment,Recruitment occurs along the entire PV curve, even beyond UIP,Gattinoni L. AJRCCM, 2001, 164: 131,ARDS肺复张应用,.,75,PEEP and Survoval,A post hoc analysis, 53 patients,Barbas CSV, Medeiros DM, Magaldi RB, et al. Am J Respir Crit Care Med, 2002, 165: A218,A

18、RDS肺复张应用,.,76,PEEP肺复张与低氧血症改善,Gattinoni L, Caironi P, Pelosi P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711,ARDS肺复张应用,.,77,ARDS绵羊不同PEEP复张容积,ARDS肺复张应用,.,78,ARDS患者不同PEEP复张容积,*,*#,与PEEP5cmH2O相比较，*P 0.05; 与PEEP5cmH2O相比较，#P 0.05;,ARDS肺复张应用,.,79,ARDS早期PEEP的调整 肺复张容积与DO2的结合,ARDS肺复张应用,.,80,不同通气模式对肺NF-B的影响,1、2、3、4、5和6分别为正常、ARDS、HVZP、LVBP、LVHP、NVBP组,1 2 3 4 5 6,基础研究,.,81,不同通气模式对肺 TNF-mRNA表达的影响,1 2 3 4 5 6,1、2、3、4、5和6分别为正常、ARDS、LVBP、LVHP、NVBP和HVZP组,基