肺保護(hù)機(jī)械通氣2009seminar

LungProtectiveMechanicalVentilation

肺保護(hù)性機(jī)械通氣

Adoption&discussion張翔宇急救重癥科上海同濟(jì)大學(xué)上海市第十人民醫(yī)院LungprotectivestrategyVentilatorInducedLungInjury,VILILungprotectivestrategyPEEPVTRecruitmentManeuver,RMPIP=?Pplateau=?Mode?VentilatorInducedLungInjury

VILIOverdistentionBarotraumaVolutraumaRecruitment/DerecruitmentInjuryTranslocationofCellsBiotraumaVILI：

Recruitment/DerecruitmentInjury

PIP=14,PEEP=0PIP=45,PEEP=10PIP=45,PEEP=0Webb&TierneyARRD1974;110;556VentilationStrategies&BALCytokinesTremblay,Valenza,Ribeiro,Li,SlutskyJClinicalInvestigation99:944-52,199773MVHP1510HVZPCcontrol40identicaldV/dtVT(cc/kg)PEEPcmH2O15MVZP1002001,2001,400*§§CMVHPMVZPHVZPTNF-a,pg/ml50倍！VentilatoryStrategyandBALCytokinesTremblay,Valenza,Ribeiro,Li,SlutskyJClinicalInvestigation99:944-52,1997*

p<0.05vs.C,MVHP,MVZP&p<0.05vs.C,MVHP#

p<0.05vs.CArthurSSlutskySerumCytokinesinAcidAspirationModel

Chiumello,Pristine,SlutskyAJRCCM1999;160:109-16Vt,ml/kgPEEP,cmH2OHVZPHVPLVZPLVP16165555CytokinesinHumans

StuberetalIntCareMed2002;28:834-841JAMA289:2104-2112,2003SystemicEffectsofVILI

ImaietalJAMA289:2104-2112,2003BiophysicalInjuryshear

overdistentioncyclicstretchDintrathoracicpressurealveolar-capillarypermeabilitycardiacoutputorganperfusionBiochemicalInjury(Biotrauma)mfcytokines,complement,PGs,LTs,ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistalOrganDysfunctionMechanicalVentilationSlutsky,TremblayAmJRespCritCareMed.1998;157:1721-5DEATHProtectthelungs?PEEP=?VT=?PIP=?Pplateau=?RM?PEEP=?PEEP/FiO2combination?X!ARDSnet,2000,NEJM,2000;18:1301中華醫(yī)學(xué)會重癥醫(yī)學(xué)分會急性肺損傷/急性呼吸窘迫綜合征診斷與治療指南（2006）推薦意見7：對ARDS患者實(shí)施機(jī)械通氣時應(yīng)采用肺保護(hù)性通氣策略，氣道平臺壓不應(yīng)超過30-35cmH2O（推薦級別：B級）推薦意見8：可采用肺復(fù)張手法促進(jìn)ARDS患者塌陷肺泡復(fù)張，改善氧合（推薦級別：E級）ALI/ARDS指南：

中華內(nèi)科雜志,2007,46(5):430-435推薦意見9：應(yīng)使用能防止肺泡塌陷的最低PEEP，有條件情況下，應(yīng)根據(jù)靜態(tài)P-V曲線低位轉(zhuǎn)折點(diǎn)壓力+2cmH2O來確定PEEP（推薦級別：C級）推薦意見10：ARDS患者機(jī)械通氣時應(yīng)盡量保留自主呼吸（推薦級別：C級）推薦意見11：若無禁忌證，機(jī)械通氣的ARDS患者應(yīng)采用30-45度半臥位（推薦級別：B級）推薦意見12：常規(guī)機(jī)械通氣治療無效的重度ARDS患者，若無禁忌證，可考慮采用俯臥位通氣（推薦級別：D

SSC2008CritCareMed2008Vol.36,No.1SSC2008推薦對ALI/ARDS病人應(yīng)用6ml/kg（預(yù)測體重）的目標(biāo)潮氣量。（1B）推薦對ALI/ARDS病人進(jìn)行平臺壓監(jiān)測，對于被動通氣的病人初始平臺壓目標(biāo)設(shè)定在≤30cmH2O;檢測平臺壓時應(yīng)當(dāng)考慮到胸廓的順應(yīng)性。（1C）推薦對ALI/ARDS病人在必要降低平臺壓或減少潮氣量時施行允許性高碳酸血癥（PaCO2水平高于病前）。（1C）SSC20084.推薦設(shè)定PEEP以阻止張開的肺在呼氣末塌陷。（1C）5.建議在有經(jīng)驗(yàn)的單位，對于需要可能有害的FiO2和平臺壓的ALI/ARDS病人在沒有不良后果高風(fēng)險的條件下應(yīng)用俯臥位通氣。（2C）6a.除非有禁忌，推薦機(jī)械通氣的病人床頭抬高減少誤吸風(fēng)險，防止呼吸機(jī)相關(guān)性肺炎

。（1B）6b.建議床頭抬高30～45o.（2C）7.建議無創(chuàng)通氣（NIV）只能在少數(shù)輕中度低氧的、血流動力學(xué)穩(wěn)定的、易于喚醒的、能夠自我呼吸道保護(hù)的、能自主咳痰的、能很快恢復(fù)的ALI/ARDS病人考慮應(yīng)用。SSC20088.推薦制定一套適當(dāng)?shù)拿摍C(jī)方案，當(dāng)患者還須滿足以下條件時常規(guī)對機(jī)械通氣患者施行自主呼吸試驗(yàn)以評估脫離機(jī)械通氣的能力，：①可喚醒，②血流動力學(xué)穩(wěn)定（不用升壓藥），③沒有新的潛在嚴(yán)重疾患，④只需低通氣量和低PEEP，⑤面罩或鼻導(dǎo)管給氧可滿足吸氧濃度要求。應(yīng)選擇低水平壓力支持、持續(xù)氣道正壓（CPAP，≈5cmH2O）或T管進(jìn)行自主呼吸試驗(yàn)（1A）。9.不推薦對ALI/ARDS患者常規(guī)應(yīng)用肺動脈導(dǎo)管（1A）。10.對已有ALI且無組織低灌注證據(jù)的患者，推薦保守補(bǔ)液策略，以減少機(jī)械通氣和住ICU天數(shù)（1C）。潮氣量

VT6ml/kgPplateau<PuipPplateau<30cmH2O肺復(fù)張術(shù)Lungrecruitmentmaneuver,RMSIPCStepwiseRMRecruitmentManeuverMassachusettsGeneralHospitalPerformanceofRM@MGH30cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell35cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell40cmH2OCPAPfor30to40secAllow15to20minutesbetweenRMPerformanceofRM@MGHSetFIO2at1.0Wait10minutesInsureappropriatesedationMayneedtodomultipleRMsMonitoringduringRM(MGH)TheRMshouldbeabortedif:MAP<60mmHgordecreasesby>20mmHgSpO2<88%Heartrate>130or<60/minuteNewarrhythmiasAmatoNEJM1998;338:34735–40cmH2OCPAPfor30to40secAtenrollmentAfterventilatordisconnectNoseverehemodynamiccompromiseNobarotraumaAmato:2004ChinaFULLRECRUITMENT: PaO2+PaCO2>400mmHgAmatoARDSprotocolRecruitFIO2=1TitratePEEPTitratePdrivingWAIT(<15)FIO2≤30%(HighPEEP+PSV)WAITFIO2≤30%(HighPEEP+PSV)DecreasePSdownto8DecreasePEEPdownto12NIMV(CPAP=12,PS=8)PEEP/FIO2target

(≈8～14cmH2O)PEEPatPFLEX

(≈14～18cmH2O)PEEPenoughtofullyavoid airwaycollapse

(≈16～26cmH2O)Amato:2004China張翔宇的方法

所有患者均行有創(chuàng)動脈壓持續(xù)監(jiān)測

SpO2持續(xù)監(jiān)測

CVP持續(xù)監(jiān)測清醒患者適當(dāng)鎮(zhèn)靜復(fù)張術(shù)（RM）前排除氣壓傷排除肺氣腫患者

Protocol

Mode:PEEP+PCVorPEEP+PSVPEEP:increment2cmH2OInterval:2minPEEPtarget:16/1stRM,20/2ndRM,26~30/3rdRMPIPmax:45cmH2OAbortifABPorSpO2startfallRestinterval:15～30minMayrepeattwiceaday結(jié)果心臟外科術(shù)后低氧患者有效：100%PaO2/FiO2improve：110%±36%

無并發(fā)癥多發(fā)傷并發(fā)ALI/ARDS患者有效：92%PaO2/FiO2improve：86%±32%無并發(fā)癥軍團(tuán)菌病1例，無效，出現(xiàn)氣壓傷

RM一次，PEEPmax:22,PIPmax:32縱隔氣腫臨床觀察252例次RM有93次血壓短暫降低（37%）出現(xiàn)血壓下降的PEEP水平為6～23cmH2O,平均13.9cmH2OPEEP降低之后動脈恢復(fù)到原來水平所有病人有創(chuàng)持續(xù)血壓監(jiān)測1例經(jīng)心超證實(shí)卵圓孔未閉，在PEEP=6時發(fā)生右向左分流，同時SpO2下降張翔宇，等，中國危重病急救醫(yī)學(xué)，2007，19（9）CritCareMed2007Vol.35,No.1

FernandoSuarez-Sipmann,etalUseofdynamiccomplianceforopenlungpositiveend-expiratorypressuretitrationinanexperimentalstudyEighthealthypigsLunglavagesCTsliceswereobtained2cmcranialoftherightdiaphragmaticdomeProtocolResultSuarez-Sipmann’sclusiondynamiccomplianceidentifiedthebeginningoflungcollapseinapigmodel.thecontinuousmonitoringofdynamiccompliancemightbecomeavaluablebedsidetoolforeasilyidentifyingthelevelofPEEPthatpreventsend-expiratorylungcollapse？？？Bob’snewprotocol2007PerformanceofRMSetFIO2at1.0AllowtimeforstabilizationInsureappropriatesedationInsurehemodynamicstabilityBob’snewprotocolPerformanceofRM-PCVPressurecontrolventilation:PEEP20-30cmH2OPeakInspirPress40-50cmH2OInspirTime:1to3secRate:8to20/minTime1to3minSetPEEPat20,ventilateVC,VT4to6ml/kgPBW,increaserate,avoidauto-PEEPMeasuredynamiccomplianceDecreasePEEP2cmH2OBob’snewprotocolPerformanceofRM-PCVMeasuredynamiccomplianceRepeatuntilmaxcompliancedeterminedOptimalPEEPmaxcompPEEP+2to3cmH2ORepeatrecruitmentmaneuverandsetPEEPattheidentifiedsettings,adjustventilationAfterPEEPandventilationsetandstabilized,decreaseFIO2untilPO2intargetrangeIfresponseispoor,repeatRM,PEEP25,PeakPressure45Ifresponseispoor,repeatRM,PEEP30,PeakPressure50Bob’snewprotocol2007LungRecruitmentPerformearlyinARDSIdealapproachtoRMmostlikelyPC,limitedpatientdataavailableusingPC!WorksbetterinextrapulmonarythanprimaryARDS?Moredifficulttorecruitthelungthestifferthechestwall!Startwithlowpressure,increaseastoleratedandneeded!IfbenefitlostafterRM,PEEPinadequate!Bob’snewprotocolAcomparisonofmethodstoidentifyopen-lungPEEP.

CaramezMP,KacmarekRM,etal

InthisanimalmodelofARDS,dynamictidalrespiratorycompliance,maximumPaO2,maximumPaO2+PaCO2,minimumshunt,inflationlowerPflexandPmci,iyieldsimilarvaluesforPEEPfollowingarecruitmentmaneuver.IntensiveCareMed.2009Apr;35(4):740-7.

Patients(n=549)

ARDS/ALI

Pplat(cmH2O)

<30

PEEP(cmH2O)

12.9±4

8.4±4

RR(b/min)30

TV

(ml/Kg) <6

TheNIHrandomizedmulticenterstudyassessingtheeffectonmortalityoflowvshighPEEPinARDS

NewEnglJMed2004;351:327-336NIHPEEPselectedaccordingtoaTabletoachieveminimalphysiologicaloxygenation(88-95%)

Patients(n=983)

ARDS/ALI

Pplat(cmH2O)

<30

PEEP(cmH2O)

16.3±3

RR(b/min)

30

TV

(ml/Kg)

<6

9.1±4TheLOVS:LungOpenVentilationCanadianStudy

CanadianTrial

OxygenationwasbetterinHighPEEPCompliancewasbetterinHighPEEPLessrescuetherapiesinHighPEEP0,40,50,60,70,80,910102030405060DaysafterrandomizationProbabilityofsurvivalLowPEEPHighPEEPPEEPselectedaccordingtoatabletoachieveminimalphysiologicaloxygenation+RMStewartTetalJAMA.2008;299(6):637-645

Patients(n=752)

ARDS/