ARDS急性呼吸窘迫綜合征肺復(fù)張的測定

1、急性呼吸窘迫綜合征肺復(fù)張的測定與應(yīng)用,內(nèi)容提要,ARDS病理生理 ARDS肺復(fù)張容積測定 P-V曲線法 等壓法 CT法：Gattinonis vs Roubys ARDS肺復(fù)張測定應(yīng)用 明確肺不張的分布與特點(diǎn) 評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用 指導(dǎo)PEEP選擇,Lung volume decreased markedly (TLC, VC, TV, FRC) -alveolar edema -pulmonary surfactant -Interstitial pumonary edema depress brochiole and induce spasm

2、Compliance reduced significantly Ventilation/perfusion mismatch -intrapulmonary shunt and dead space like effects,ARDS病理生理特點(diǎn),ARDS病理生理,CT scan 70-80% 的肺野呈現(xiàn)高密度區(qū) 分布：下垂部位(dependent field) 提示： 參與通氣肺泡明顯減少(20-30%) 肺損傷具有不均一性,肺容積減少Small lung Baby Lung,ARDS病理生理,A and C finding in the acute or exudative phase,

3、B and D Finding in the fibrosing-alveolitis phase,ARDS病理生理,肺容積/順應(yīng)性明顯降低,ARDS病理生理,Reduced range of volume excursion: Low compliance Flattening at low and high volumes: Lower and upper inflection points Bigatello: Br J Anaest 1996,Volume,Pressure,NORMAL,ARDS,順應(yīng)性曲線明顯右下移位,肺順應(yīng)性明顯降低,ARDS病理生理,Upper and Lowe

4、r Inflection Points,Lower 呼氣末肺泡塌陷 吸氣早期肺泡再開放 Upper 吸氣末肺泡順應(yīng)性明顯 降低，肺泡過度膨脹,ARDS病理生理,Volume,Pressure,Lower Inflection Point,Upper Inflection Point,通氣/血流失調(diào),肺泡塌陷：ARDS重力依賴區(qū)，炎癥或不張區(qū) 生理性低氧縮血管反應(yīng)：障礙,ARDS病理生理,Imagine the Hardness to Blow up a Ballon .,easy,hard,spatial 與10 ml/kg相比， #P 0.05,ARDS肺復(fù)張應(yīng)用,內(nèi)容提要,ARDS病理生理

5、 ARDS肺復(fù)張容積測定 P-V曲線法 等壓法 CT法：Gattinonis vs Roubys ARDS肺復(fù)張測定應(yīng)用 明確肺不張的分布與特點(diǎn) 評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用 指導(dǎo)PEEP選擇,PEEP效應(yīng)的影響因素-附加靜水壓與心臟的影響,ARDS肺復(fù)張應(yīng)用,Rothen H. et al. Br J Anaesth 1993:71:788-795,Re-expansion of atelectasis during general anaethesia,A: CT scan at level of right disphragm B: CT scan

6、5cm above right diaphragm,ARDS肺復(fù)張應(yīng)用,PEEP誘導(dǎo)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肺復(fù)張應(yīng)用,PEEP導(dǎo)致overdistention的分布,Volume of overdistension(ml)=0.42Parenchyma-900;-800(ml)18ml,Puybasset L. ICM, 2000, 26:1215c,ARDS肺

7、復(fù)張應(yīng)用,PEEP效應(yīng)的影響因素-塌陷肺泡的分布范圍,塌陷肺泡的范圍 Efficiency of PEEP-induced alv recruitment highly correlated with the proportion of poorly and nonaerated lung parenchyma in ZEEP,Puybasset L. ICM, 2000,26:1215,ARDS肺復(fù)張應(yīng)用,Diffuse: Equal loss of aeration to the upper and lower lobes,Vieira SRR. AJRCCM, 1999, 159: 16

8、12,ARDS肺復(fù)張應(yīng)用,Local: Loss of aeration predominating in lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺復(fù)張應(yīng)用,Effect of PEEP on recruitment and overdistention,Puybasset L. ICM, 2000, 26:1215,ARDS肺復(fù)張應(yīng)用,PEEP效應(yīng)的影響因素-LIP的影響,ARDS肺復(fù)張應(yīng)用,綿羊有無LIP組PEEP復(fù)張容積,ARDS肺復(fù)張應(yīng)用,有無LIP患者的復(fù)張容積,*,*#,*,*#,與PEEP5 cmH2O相比，*P

9、0.05 與PEEP 10 cmH2O相比，#P 0.05 與LIP組比較，P 0.05,ARDS肺復(fù)張應(yīng)用,Effect of PEEP on recruitment and overdistention,In LIP/+: PEEP1=LIP+2, PEEP2=LIP+7. In LIP/-: PEEP1=10, PEEP2=15,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺復(fù)張應(yīng)用,PEEP-induced alv recruitment,16pat with ARDS LIS 3 Csts 39(ZEEP) CT scan Over -1000-9

10、00 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肺復(fù)張應(yīng)用,對象：17例穩(wěn)定ARDS患者VT=6ml/kg,PEEP=10cm/H2O 肺復(fù)張方法：ZEEP, SI(40cmH2O,40s)，VT=6ml/kg, PEEP=Pflex+2cmH2O, PCV，PIP=15+PEEP，調(diào)整PEEP為25、30、35、40、45cmH2O，CT比較非通氣區(qū)變化 結(jié)果：PaO2從ZEEP的92.3mmHg上升至394mmHg，非通

11、氣區(qū)從ZEEP的63.7%降至28.6%,VT-induced alv recruitment,ARDS肺復(fù)張應(yīng)用,VT-induced alv recruitment,ARDS肺復(fù)張應(yīng)用,內(nèi)容提要,ARDS病理生理 ARDS肺復(fù)張容積測定 P-V曲線法 等壓法 CT法：Gattinonis vs Roubys ARDS肺復(fù)張測定應(yīng)用 明確肺不張的分布與特點(diǎn) 評價SI or Sigh的肺復(fù)張作用 評價PEEP維持肺復(fù)張的作用 指導(dǎo)PEEP選擇,PEEP的選擇,氧分壓導(dǎo)向性PEEP選擇 PaO2 method DO2導(dǎo)向性PEEP選擇 肺復(fù)張容積導(dǎo)向性PEEP選擇Recruitment volu

12、me method,ARDS肺復(fù)張應(yīng)用,open,closed,closed?,open,open up!,find closed!,re-open!,keep open!,airway pressure,time,氧分壓導(dǎo)向性PEEP選擇,ARDS肺復(fù)張應(yīng)用,Vazquez de Anda et al. Acta Anesth Scand 1998: 42:63-66,PEEP,PIP,ARDS肺復(fù)張應(yīng)用,對象：17例ARDS患者，VT=6ml/kg, PEEP=10cm/H2O PEEP選擇方法：PCV，PIP=15+PEEP，每2min調(diào)PEEP 25、30、35、40、45cmH2O，

13、至FiO2為100% PaO2+PaCO2400mmHg，每15-20min降低PEEP，至PaO2較前一次降低5%, PEEP水平為前一次PEEP 結(jié)果：PaO2+PaCO2從178.476.5mmHg升至487.8 139.1mmHg，維持肺復(fù)張PEEP水平為224cmH2O,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,對象：47例早期ARDS患者，VCV，VT=8ml/kg，

14、 PEEP=10cm/H2O，RR20次/分，I：E=1：1 分組與方法： ARM+PEEP組：ARM實(shí)施方法為逐步增加PEEP至15、 20、25、30cm/H2O(extended sigh)， 結(jié)束后PEEP設(shè)為15cm/H2O ARM組：ARM后PEEP仍為10cm/H2O PEEP組：基礎(chǔ)通氣模式,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,

15、ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,DO2導(dǎo)向性PEEP選擇,ARDS傳統(tǒng)的通氣策略-經(jīng)驗(yàn)性PEEP 缺點(diǎn)：缺乏科學(xué)依據(jù) ARDS肺保護(hù)性通氣策略-最佳PEEP 優(yōu)點(diǎn)：獲得最大的DO2，同時考慮PEEP 對循環(huán)和呼吸的影響，LIP+2cmH2O 為最佳P

16、EEP,ARDS肺復(fù)張應(yīng)用,邱海波, 郭鳳梅, 周韶霞等. 中華內(nèi)科雜志, 2001, 9,PEEP不足大量肺泡難以復(fù)張,LIP：塌陷肺泡開始復(fù)張壓力，不是全部塌陷肺泡復(fù)張壓力,ARDS肺復(fù)張應(yīng)用,LIPStart of recruitment,Recruitment occurs along the entire PV curve, even beyond UIP,Gattinoni L. AJRCCM, 2001, 164: 131,ARDS肺復(fù)張應(yīng)用,PEEP and Survoval,A post hoc analysis, 53 patients,Barbas CSV, Medeir

17、os DM, Magaldi RB, et al. Am J Respir Crit Care Med, 2002, 165: A218,ARDS肺復(fù)張應(yīng)用,PEEP肺復(fù)張與低氧血癥改善,Gattinoni L, Caironi P, Pelosi P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711,ARDS肺復(fù)張應(yīng)用,ARDS綿羊不同PEEP復(fù)張容積,ARDS肺復(fù)張應(yīng)用,ARDS患者不同PEEP復(fù)張容積,*,*#,與PEEP5cmH2O相比較，*P 0.05; 與PEEP5cmH2O相比較，#P 0.05;,ARDS肺復(fù)張應(yīng)用,A

18、RDS早期PEEP的調(diào)整 肺復(fù)張容積與DO2的結(jié)合,ARDS肺復(fù)張應(yīng)用,不同通氣模式對肺NF-B的影響,1、2、3、4、5和6分別為正常、ARDS、HVZP、LVBP、LVHP、NVBP組,1 2 3 4 5 6,基礎(chǔ)研究,不同通氣模式對肺 TNF-mRNA表達(dá)的影響,1 2 3 4 5 6,1、2、3、4、5和6分別為正常、ARDS、LVBP、LVHP、NVBP和HVZP組,基礎(chǔ)研究,不同通氣模式對肺組織TNF的影響,基礎(chǔ)研究,不同通氣模式對肺組織MPO的影響,與對照組比較，* P0.05；與ARDS組比較， P0.05，與LVBP組比較，P 0.05；與HVZP組比較， P0.05,基礎(chǔ)研究,不同通氣模式對肺組織MDA的影響,與對照組比較，* P0.05；與ARDS組比較， P0.05，與LVBP組比較，P 0.05；比較， P0.05,基礎(chǔ)研究,Bedside assessment of lung morphology (PEEP=5cmH2O),Diffuse,Chest X-rayDiffuse Predominating /CT scan /