心臟病患者的正壓通氣─心肺相互作用

北京協(xié)和醫(yī)院杜斌心臟病患者的正壓通氣:

心肺相互作用利益沖突無機械通氣是心臟病患者常用的治療手段美國6個州共6,469,674名住院患者180,326(2.8%)接受機械通氣AMI 1.7%心臟功能不全 18.4%全球20個國家361個ICU中15,757名患者5,183(33%)接受機械通氣急性呼衰 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%WunschH,Linde-ZwirbleWT,AngusDC,etal.TheepidemiologyofmechanicalventilationintheUnitedStates.CritCareMed2010;38:1947-1953EstebanA,AnzuetoA,FrutosF,etal.Characteristicsandoutcomesinadultpatientsreceivingmechanicalventilation.A28-dayinternationalstudy.JAMA2002;287:345-355自主呼吸及機械通氣對心血管的影響ShekerdemianL,BohnD.Cardiovasculareffectsofmechanicalventilation.ArchDisChild1999;80:475-480正壓通氣胸腔內(nèi)壓肺容積前負荷后負荷心率心肌收縮力正壓通氣對心血管的影響ScharfSM,CaldiniP,IngramRH.Cardiovasculareffectsofincreasingairwaypressureinthedog.AmJPhysiol1977;232:H35-H43胸腔內(nèi)壓改變的血流動力學影響ThoraxVenousReturnLVEjection自主呼吸對LV充盈的影響Lemaire,etal.Anesthesiol1988;69:171-179胸腔內(nèi)負壓的劇烈波動可導致肺水腫哮喘持續(xù)狀態(tài)上氣道梗阻肺水腫StalcupandMellins.NEnglJMed1977;297:592-596KanterandWatchko.AmJDisChil1984;138:356-358Lukeetal.Pediatrics1966;37:762-768Oswaltetal.JAMA1977;238:1833-1835Miroetal.Chest1989;96:1430-1431NPPE的發(fā)病機制UpperAirwayObstructionMullerManeuverITPmorenegative

Pulm.bloodvolume

Pulm.arterialpressureTransudationPulmonaryEdema

CapillarypermeabilityPulm.capillarydamagePulm.arterialconstrictionSystemicvasoconstrictionCNSHypoxia

LVafterload

Pulm.venouspressure

Pericapillaryhydrostaticpressure

COITP升高能夠降低LV后負荷，增加心輸出量β-受體阻滯劑誘導的急性心功能衰竭（犬模型）Pinskyetal.JApplPhysiol1983;54:950-955Pinskyetal.JApplPhysiol1985;58:1189-1198合并CHF的心肌病患者Pinsky&Summer.Chest1983;84:370-375急性心功能衰竭犬模型心動周期特異性ITP增加Pinskyetal.JApplPhysiol1986;60:604-612預(yù)防低血容量下CO下降Matuschaketal.JApplPhysiol1986;61:44-53急性二尖瓣返流的犬模型Steinetal.JApplPhysiol1990;69:2120-2125ITP改變對LV射血的影響ITP下降能夠增加LV射血壓，增加LV后負荷ITP升高能夠降低LV射血壓，降低LV后負荷Buda,Pinsky,etal.NEnglJMed1979;301:453-459Pinsky,etal.JAppl

Physiol1983;54:950-955呼吸周期對左室每搏輸出量的影響JallonJF,AbdulhayE,CalabreseP,etal.Amodelofmechanicalinteractionsbetweenheartandlungs.PhilTransRSocA2009;367:4741-4757LVPV曲線，MVO2和心臟做功的關(guān)系StrokeWorkElastance-DefinedPotentialWorkThehiddenmechanicalworkoftheLVSugaH,HayashiT,ShirahataM.Ventricularsystolicpressure-volumeareaaspredictorofcardiacoxygenconsumption.AmJPhysiol1981;240:H39-H44LV壓力─容積面積(PVA)VendelinM,BovendeerdPHM,EngelbrechtJ,etal.Optimizingventricularfibers:uniformstrainorstress,butnotATPconsumption,leadstohighefficiency.AmJPhysiol2002;283:H1072-H1081LVVolumeStrokeWorkPELVVolumePVALVPressureATP/MVO2PVALVPV曲線，MVO2和心臟做功的關(guān)系LVVolumeLVPressureABLVVolumeLVPressureABMVO2A>>MVO2B兩個P/V環(huán)：每搏功相同PVA及MVO2不同正壓通氣對LV前負荷和后負荷的影響DenaultAY,GorcsanJ,PinskyMR.Dynamiceffectsofpositive-pressureventilationoncanineleftventricularpressure-volumerelations.JAppl

Physiol2001;91:298-308正壓通氣對LV前負荷和后負荷的影響DenaultAY,GorcsanJ,PinskyMR.Dynamiceffectsofpositive-pressureventilationoncanineleftventricularpressure-volumerelations.JAppl

Physiol2001;91:298-308正壓通氣對LV前負荷和后負荷的影響DhainautJF,DevauxJY,MonsallierJF,etal.MechanismsofdecreasedleftventricularpreloadduringcontinuouspositivepressureventilationinARDS.Chest1986;90:74-80LV收縮力正常時

ITP

ITPIncreasedLVEjectionPressureIncreasedLVPreloadDecreasedLVEjectionPressureDecreasedLVPreloadESPVRPinskyMR.Thehemodynamicconsequencesofmechanicalventilation:anevolvingstory.IntensiveCareMed1997;23:493-503LV收縮力降低時

ITP

ITPIncreasedLVEjectionPressureIncreasedLVPreloadDecreasedLVEjectionPressureDecreasedLVPreloadESPVRPinskyMR.Thehemodynamicconsequencesofmechanicalventilation:anevolvingstory.IntensiveCareMed1997;23:493-503無創(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Rasanenetal.AmJCardiol55:296-300,1985如果CPAP能夠消除ACPE患者的胸腔內(nèi)負壓，才能發(fā)揮有益作用Rasanenetal.Chest87:158-62,1985面罩CPAP可避免ACPE患者氣管插管Berstenetal.NEnglJMed325:1825-30,1991面罩BiPAP以及PSV可改善ACPE患者氧合，避免氣管插管Massipetal.Lancet356:2126-32,2000Giacominietal.Chest123:2057-61,2003Navaetal.AmJRespirCritCareMed168:1432-7,2003Ferreretal.AmJRespirCritCareMed168:1438-44,2003CPAP和BiPAP對ACPE具有相似的有益作用Parketal.CritCareMed32:2407-15,2005面罩BiPAP能夠改善OSA患者的左心室功能Kanekoetal.NEnglJMed348:1233-41,2003急性心梗時的CPAPRasanenetal.Chest1985；87:158-162CPAP對CHF患者ITP的影響NaughtonMT,RahmanA,HaraK,etal.Effectofcontinuouspositiveairwaypressureonintrathoracicandleftventriculartransmuralpressuresinpatientswithcongestiveheartfailure.Circ1995;91:1725-1731CPAP對CHF患者ITP的影響NaughtonMT,RahmanA,HaraK,etal.Effectofcontinuouspositiveairwaypressureonintrathoracicandleftventriculartransmuralpressuresinpatientswithcongestiveheartfailure.Circ1995;91:1725-1731CPAP改善CHF患者的LV功能24名合并CHF的OSA患者夜間CPAPx1mthvs.對照組夜間CPAP組病情改善OSA發(fā)作減少收縮壓降低(126to116mmHg)心率減慢(68to63bpm)LV射血分數(shù)改善(25to34%)LV收縮末內(nèi)徑減小(55to53mm)Kanekoetal.NEnglJMed2003;348:1233-1241CPAP改善CHF患者的LV功能Kanekoetal.NEnglJMed2003;348:1233-1241ACPE時的面罩CPAP39名ACPE患者隨機分為面罩CPAP組或氧療組(FiO20.4)研究持續(xù)24h30分鐘后呼吸頻率及PaCO2下降24h時兩組患者生理指標相似氣管插管比例CPAP組 0/20對照組 7/19Berstenetal.NEnglJMed1991;325:1825-1830ACPE時的面罩CPAPBerstenetal.NEnglJMed1991;325:1825-1830CPAPO2ACPE的無創(chuàng)通氣Masip,etal.Lancet2000;356