心臟病患者的正壓通氣─心肺相互作用

1、北京協(xié)和醫(yī)院北京協(xié)和醫(yī)院杜斌杜斌心臟病患者的正壓通氣:心肺相互作用利益沖突無(wú)機(jī)械通氣是心臟病患者常用的治療手段美國(guó)6個(gè)州共6,469,674名住院患者180,326 (2.8%)接受機(jī)械通氣AMI1.7%心臟功能不全18.4%全球20個(gè)國(guó)家361個(gè)ICU中15,757名患者5,183 (33%)接受機(jī)械通氣急性呼衰68.8%原因術(shù)后20.8%肺炎13.9%充血性心衰10.4%全身性感染8.8%創(chuàng)傷7.9%Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation in the U

2、nited States. Crit Care Med 2010; 38: 1947-1953Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-day international study. JAMA 2002; 287: 345-355自主呼吸及機(jī)械通氣對(duì)心血管的影響Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ven

3、tilation. Arch Dis Child 1999; 80: 475-480正壓通氣胸腔內(nèi)壓肺容積前負(fù)荷后負(fù)荷心率心肌收縮力正壓通氣對(duì)心血管的影響Scharf SM, Caldini P, Ingram RH. Cardiovascular effects of increasing airway pressure in the dog. Am J Physiol 1977; 232: H35-H43胸腔內(nèi)壓改變的血流動(dòng)力學(xué)影響Thorax自主呼吸對(duì)LV充盈的影響Lemaire, et al. Anesthesiol 1988; 69: 171-179胸腔內(nèi)負(fù)壓的劇烈波動(dòng)可導(dǎo)致肺水腫哮

4、喘持續(xù)狀態(tài)上氣道梗阻肺水腫Stalcup and Mellins. N Engl J Med 1977; 297: 592-596 Kanter and Watchko. Am J Dis Chil 1984; 138: 356-358Luke et al. Pediatrics 1966; 37: 762-768Oswalt et al. JAMA 1977; 238: 1833-1835Miro et al. Chest 1989; 96: 1430-1431NPPE的發(fā)病機(jī)制Upper Airway ObstructionMuller ManeuverITP more negativeP

5、ulm. blood volumePulm. arterial pressureTransudationPulmonary EdemaCapillary permeabilityPulm. capillary damagePulm. arterial constrictionSystemic vasoconstrictionCNSHypoxiaLV afterloadPulm. venous pressurePericapillary hydrostatic pressureCOITP升高能夠降低LV后負(fù)荷，增加心輸出量-受體阻滯劑誘導(dǎo)的急性心功能衰竭（犬模型）Pinsky et al. J

6、Appl Physiol 1983; 54: 950-955Pinsky et al. J Appl Physiol 1985; 58: 1189-1198合并CHF的心肌病患者Pinsky & Summer. Chest 1983; 84: 370-375急性心功能衰竭犬模型心動(dòng)周期特異性ITP增加Pinsky et al. J Appl Physiol 1986; 60: 604-612預(yù)防低血容量下CO下降Matuschak et al. J Appl Physiol 1986; 61: 44-53急性二尖瓣返流的犬模型Stein et al. J Appl Physiol 19

7、90; 69: 2120-2125ITP改變對(duì)LV射血的影響ITP下降能夠增加LV射血壓，增加LV后負(fù)荷ITP升高能夠降低LV射血壓，降低LV后負(fù)荷Buda, Pinsky, et al. N Engl J Med 1979; 301: 453-459Pinsky, et al. J Appl Physiol 1983; 54: 950-955呼吸周期對(duì)左室每搏輸出量的影響Jallon JF, Abdulhay E, Calabrese P, et al. A model of mechanical interactions between heart and lungs. Phil Tran

8、s R Soc A 2009; 367: 4741-4757LV PV曲線，MVO2和心臟做功的關(guān)系StrokeWorkElastance-DefinedPotentialWorkThe hidden mechanical work of the LVSuga H, Hayashi T, Shirahata M. Ventricular systolic pressure-volume area as predictor of cardiac oxygen consumption. Am J Physiol 1981; 240: H39-H44LV壓力容積面積(PVA)Vendelin M,

9、Bovendeerd PHM, Engelbrecht J, et al. Optimizing ventricular fibers: uniform strain or stress, but not ATP consumption, leads to high efficiency. Am J Physiol 2002; 283: H1072-H1081StrokeWorkPEPVALV PV曲線，MVO2和心臟做功的關(guān)系LV VolumeLV PressureABLV VolumeLV PressureABMVO2A MVO2B兩個(gè)P/V環(huán)：每搏功相同PVA及MVO2不同正壓通氣對(duì)LV

10、前負(fù)荷和后負(fù)荷的影響Denault AY, Gorcsan J, Pinsky MR. Dynamic effects of positive-pressure ventilation on canine left ventricular pressure-volume relations. J Appl Physiol 2001; 91: 298-308正壓通氣對(duì)LV前負(fù)荷和后負(fù)荷的影響Denault AY, Gorcsan J, Pinsky MR. Dynamic effects of positive-pressure ventilation on canine left ventri

11、cular pressure-volume relations. J Appl Physiol 2001; 91: 298-308正壓通氣對(duì)LV前負(fù)荷和后負(fù)荷的影響Dhainaut JF, Devaux JY, Monsallier JF, etal. Mechanisms of decreased left ventricular preload during continuous positive pressure ventilation in ARDS. Chest 1986; 90:74-80LV收縮力正常時(shí)ITPITPIncreased LV Ejection PressureInc

12、reased LV PreloadDecreased LV Ejection PressureDecreased LV PreloadESPVRPinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-503LV收縮力降低時(shí)ITPITPIncreased LV Ejection PressureIncreased LV PreloadDecreased LV Ejection PressureDecreased LV

13、 PreloadESPVRPinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-503無(wú)創(chuàng)CPAP和BiPAP能夠減輕心臟應(yīng)激CPAP能夠減輕急性心源性肺水腫(ACPE)患者的心臟缺血Rasanen et al. Am J Cardiol 55:296-300, 1985如果CPAP能夠消除ACPE患者的胸腔內(nèi)負(fù)壓，才能發(fā)揮有益作用Rasanen et al. Chest 87:158-62, 1985面罩CPA

14、P可避免ACPE患者氣管插管Bersten et al. N Engl J Med 325:1825-30, 1991面罩BiPAP以及PSV可改善ACPE患者氧合，避免氣管插管Massip et al. Lancet 356:2126-32, 2000Giacomini et al. Chest 123:2057-61, 2003Nava et al. Am J Respir Crit Care Med 168:1432-7, 2003Ferrer et al. Am J Respir Crit Care Med 168:1438-44, 2003CPAP和BiPAP對(duì)ACPE具有相似的有益

15、作用Park et al. Crit Care Med 32:2407-15, 2005面罩BiPAP能夠改善OSA患者的左心室功能Kaneko et al. N Engl J Med 348:1233-41, 2003急性心梗時(shí)的CPAPRasanen et al. Chest 1985； 87: 158-162CPAP對(duì)CHF患者ITP的影響Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular tran

16、smural pressures in patients with congestive heart failure. Circ 1995; 91: 1725-1731CPAP對(duì)CHF患者ITP的影響Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Circ 1995; 91:

17、 1725-1731CPAP改善CHF患者的LV功能24名合并CHF的OSA患者夜間CPAP x 1 mth vs. 對(duì)照組夜間CPAP組病情改善OSA發(fā)作減少收縮壓降低 (126 to 116 mmHg)心率減慢 (68 to 63 bpm)LV射血分?jǐn)?shù)改善 (25 to 34%)LV收縮末內(nèi)徑減小 (55 to 53 mm)Kaneko et al. N Engl J Med 2003; 348: 1233-1241CPAP改善CHF患者的LV功能Kaneko et al. N Engl J Med 2003; 348: 1233-1241ACPE時(shí)的面罩CPAP39名ACPE患者隨機(jī)分為

18、面罩CPAP組或氧療組(FiO2 0.4)研究持續(xù)24 h30分鐘后呼吸頻率及PaCO2下降24 h時(shí)兩組患者生理指標(biāo)相似氣管插管比例CPAP組0/20對(duì)照組7/19Bersten et al. N Engl J Med 1991; 325: 1825-1830ACPE時(shí)的面罩CPAPBersten et al. N Engl J Med 1991; 325: 1825-1830CPAPO2ACPE的無(wú)創(chuàng)通氣Masip, et al. Lancet 2000; 356: 2126-2132Control(n = 18)NIPSV(n = 19)ACPE的無(wú)創(chuàng)通氣Masip, et al. Lancet 2000; 356: 2126-2132ACPE的無(wú)創(chuàng)機(jī)械通氣Ferrer M,Esquinas A, Leon M et al. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168: 1438-1444ACPE的無(wú)創(chuàng)機(jī)械通氣Ferrer M,Esquinas A