通氣策略教授

?Aspirationof?AspirationofgastricNon---pulmonaryMajor*Notfullyexplainedbyeffusions,nodules,masses,orcollapse;usetrainingsetof*Notfullyexplainedbyeffusions,nodules,masses,orcollapse;usetrainingsetofCXRs;BodySurfaceArea)VECorr=xPaCO2/40(correctedAcuteonsetwithin1weekofaknownclinicalinsultornew/worseningrespiratorysymptomsPaO2/FiO201---withPEEP/CPAP≥withPEEP≥PaO2/FiO2≤100withPEEP≥OriginofRespiratoryfailureassociatedtoknownriskfactorsandnotfullyexplainedbycardiacfailureor?uidoverload.Needobjectiveassessmentofcardiacfailureor?uidoverloadifnoriskfactorarepresentBilateralBilateralleast3quadrants*VECorr>10CRS<4025--11---‐‐7--10--?60--40--15--25--11---‐‐7--10--?60--40--15--<7--M.Tobin,M.Tobin,NEJMnMildModerateSeverenMildModerateSevere...basedchest...basedchest---slopeofPVlowerin?ectionpointPEEPtriallimitedbyUIP---2結(jié)研究限制結(jié)研究限制仍需大規(guī)模中心研究低下低下低下低下低下低下低下低下低下低下低下正常低下4正常組低下組正常組低下組5PEEPLevel正常低下4正常組低下組正常組低下組5PEEPLevelPHC小VPHC小VT(6---8ml/Kg)不同模式、潮氣量對(duì)參數(shù)、血流動(dòng)力學(xué)的影響()不同模式、潮氣量對(duì)參數(shù)、血流動(dòng)力學(xué)的影響()不同模式、潮氣量水平對(duì)參數(shù)、血流動(dòng)力學(xué)的影響()不同模式、潮氣量水平對(duì)參數(shù)、血流動(dòng)力學(xué)的影響()不同模式、潮氣量水平對(duì)CI不同模式、潮氣量水平對(duì)CI不同模式、潮氣量水平對(duì)ITBVIMV對(duì)ITBI是有影響的,間接影響EVLWI的計(jì)算不同模式、潮氣量水平對(duì)ITBVIMV對(duì)ITBI是有影響的,間接影響EVLWI的計(jì)算不同模式、潮氣量水平對(duì)Pmean,PEEPi的影不同模式、潮氣量水平對(duì)Pmean,PEEPi的影小潮氣量策小潮氣量策沒(méi)有RCT研究明確的證PHV假設(shè)的益處直接與小VT、少采取PHC直接與小VT、少采取PHC策略同時(shí)應(yīng)采取措促進(jìn)CO2排出當(dāng)今應(yīng)該是：小VT+PHC+EECO2R的策略IncreasingIntensityofMildModerateSevereIncreasingIntensityofMildModerateSevereIncreasingSeverityofLungIncreasingIntensityofMildModerateIncreasingSeverityofLungIncreasingIntensityofMildModerateSeverebsolut！=應(yīng)性關(guān)=Pplat與右心功能Pplat與右心功能、ACP的發(fā)生相關(guān)AplateaupressureAplateaupressureabove26---28cmH2Oappearsmarkedlyharmful,particularlypatsexhibitingrightheartdysfunction;thus,dailybedsideConclusion:WehypothesizemonitoringofrightfunctionbyechocardiographyatbedsidemighthelptocontrolthesafetyofplateaupressureusedinARDS.平大約在6ml/kg左右學(xué)的干擾 H BJBBJHJHBHJHHHH H BJBBJHJHBHJHHHH HBHBHJBJJJJJJ HBHBHJBJJJJJJ HH HH JJJJBBHBBBBBH50 HH HH JJJJBBHBBBBBH50 HBHHBBJJBJBBJJJHHHH32.2basi HBHHBBJJBJBBJJJHHHH32.2basiB JJJBBBBHBBJJHHHJHHHHHbasiB JJJBBBBHBBJJHHHJHHHHHbasi如何如何行肺復(fù)張：涉及復(fù)張方法、VT、PEEP與Ptp設(shè)定設(shè)定PEEP水平與肺泡開(kāi)放數(shù)量相關(guān)理想理想的PEEP應(yīng)是相對(duì)最適的肺順應(yīng)性驅(qū)動(dòng)壓是設(shè)定最適PEEP驅(qū)動(dòng)壓是設(shè)定最適PEEP設(shè)定設(shè)定PEEP應(yīng)盡量使驅(qū)動(dòng)壓最低ARDS肺復(fù)張的研ARDS肺復(fù)張的研三種ALI豬模三種方三個(gè)復(fù)張后PEEP45for40復(fù)張三45for40復(fù)張三種方3545/16andfor120在模型復(fù)張?jiān)谀Ｐ蛷?fù)張后15分鐘容量S-CLim,S-CLim,PEEP 重癥肺炎一般不適宜進(jìn)行肺復(fù)張可加重PEEP PEEP不同損傷模型對(duì)CO不同損傷模型對(duì)CO的影響S-CLim, Averageddatafor3RM在肺炎模型RM在肺炎模型RM方法對(duì)心輸出量的S-CLim, ARDSARDS應(yīng)有參照指標(biāo)（如---V曲線及/或臨床判斷完整的開(kāi)放肺應(yīng)包括適當(dāng)?shù)拈_(kāi)放壓力與足夠的PEE有明顯的個(gè)體化傾向（包括復(fù)張壓力、次數(shù)、間隔時(shí)間）應(yīng)識(shí)別ARDS患者是否對(duì)開(kāi)放肺與PEEP設(shè)定有反應(yīng)IncreasingSeverityofLungIncreasingIntensityofMildModerateIncreasingSeverityofLungIncreasingIntensityofMildMod