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1、ARDS肺可复张性评估,山东大学齐鲁医院 重症医学科张帆,1,ARDS的病理生理,病理学特点：肺组织损伤的不均一性,N Engl J Med,2006,354:1775-1786,2,HEART,SP,ARDS肺保护性通气,1.小潮气量/PHC2.RM+最佳PEEP,3,肺可复张性,Lung tissue in which aeretion can be restoredN Engl J Med,2006,354:1775-1786在压力的作用下，不通气的肺泡恢复通气的能力Crit Care Med,2011,39:1839-1840,4,肺复张的生理作用,促进塌陷肺泡复张，增加肺容积提升肺顺
2、应性降低肺内分流减轻肺内、肺外器官的炎症反应,中国危重病急救医学，2004,16:603-607,5,肺复张手法,6,肺可复张性初步评估,N Engl J Med,2006:1775-1786,7,肺可复张性的评估办法,8,CT评价肺通气的金标准,“diffuse”ARDS,“lobar”ARDS,Crit Care Med 2003;31Suppl.:S285S295,9,CT定量分析定量评价肺水肿和通气,张帆，吴大玮，BioMedical Engineering OnLine2014,13:30,10,肺可复张性的评价Gattinoni method,The percentage of p
3、otentially recruitable lung9%为高可复张性,The percentage of potentially recruitable lung：气道压力由5cmH2O升至45cmH2O时，不通气区的减少占全肺重量的百分比,N Engl J Med 2006;354:1775-86,11,PEEP-induced alveolar recruitment(RECALV)was expressed as percentage of variation of the weight of the nonaerated lung parenchyma:RECALV(%)=(WZEE
4、P-WPEEP)/WZEEP,N Engl J Med 2006;354:1775-86,肺可复张性的评价Gattinoni method,The decrease in the percentage of nonaerated lung tissue as PEEP was raised from 5cmH2O to 15cmH2O was highly correlated with the percentage of potentially recruitable lung(r2=0.72,P0.001),12,肺可复张性的评价The CT Scan ARDS Study Group m
5、ethod,“diffuse”ARDS,“lobar”ARDS,Am J Respir Crit Care Med 2001:14441450,PEEP-induced alveolar recruitment was computed as the increase in gas volume within the poorly and nonaerated lung regions following PEEP divided by the FRC measured in ZEEP conditionsRECALV(%)=(VGas PEEP VGas ZEEP)/FRCZEEP,13,P
6、-V曲线评估肺可复张性,Critical Care 2008,12:R7,EELVZEEP：ZEEP时的呼气末肺容积ILV-10、ELV-10：气道压力10cmH2O，吸气/呼气支对应的肺容积TLC：气道压力40cmH2O时肺总量MH：maximal volume hysteresis，最大闭陷容积,14,MH/TLC与肺力学及血气分析的相关性,MH/TLC与EELV、Crs、PaCO2的变化明显相关（R2分别为0.55，0.57 and 0.36，P 0.05)MH/TLC 与PaO2的变化之间未见明显的相关性(R2=0.05，P 0.26),Critical Care 2008,12:R7
7、,15,MH/TLC评价肺可复张性的敏感性和特异性,MH/TLC 预测肺复张后EELV改善的敏感度达 1.0，特异度0.85预测Crs改善的敏感度和特异度0.88、1.0PaCO2 的改善为0.78、0.60PaO2 的改善为1.0、0.69,Critical Care 2008,12:R7,16,P-V曲线评估肺可复张性与CT对比,Crit Care,2006,10:R95,17,Crit Care,2006,10:R95,P-V曲线评估肺可复张性与CT对比,P-V曲线计算FRC与CT计算的肺泡闭陷容积呈明显的相关性和良好的一致性,18,呼气末肺容积（EELV）,19,P-V曲线与EELV的
8、一致性良好,20,EIT可以显示肺复张后各区域呼气末肺容积的变化,21,EELV评估肺可复张性,Journal of Critical Care,2013,28:534.e1534.e5,肺复张EELV的增加与氧合指数的改善明显相关,22,EELV评估肺可复张性,The optimal cutoff value of the EELV to predict a 15%change in the P/F ratio was 9.25%(sensitivity,86.7%;specificity,84.4%),Journal of Critical Care,2013,28:534.e1534.e
9、5,23,肺牵张指数（Stress Index）,Y=atb+c,24,容量控制通气吸气支形状与肺牵张指数的关系,25,肺牵张指数评估肺可复张性,J Surg Res2013 Nov;185(1):347-52.,26,Electrical Impedance Tomography(EIT),肺组织的电学特征受气体含量的影响，肺内气体含量的改变导致电阻抗的变化,基本信息-通气分布情况-局部位置的呼气末肺容量的变化(EELV),27,EIT可以显示肺复张后各区域呼气末肺容积的变化,28,EIT可以显示肺复张后通气分布的变化,29,经PEEP递增法行肺复张后，全肺的阻抗变化明显增加，反应全肺的通气
10、量增加。,经肺复张后，肺通气明显改善，尤其是重力依赖区通气明显增加，PEEP降低时，重力依赖区通气首先出现下降，与CT变化基本一致。,30,Crit Care Med 2012;40:903911,EIT可以评价肺的可复张性，随着PEEP的升高，全肺通气得到改善，重力依赖区通气明显增加，与CT的变化基本一致。,31,EIT使局部肺通气的床旁评估成为现实：区域1代表非重力依赖区，通气量始终较重力依赖区占有优势，当PEEP由30cmH2O开始下降时出现通气量的一过性增高，说明存在局部肺泡的过度通气；区域4代表重力依赖区，在PEEP升高至20cmH2O时出现通气量的突然增加，给予表面活性物质治疗后，
11、肺泡开放的阈值降低至10cmH2O。,32,ARDS肺部超声,J Am Soc Echocardiogr 2006;19:356-363,33,ARDS肺部超声,normal lung,interstitial syndrome,34,严重肺水肿的超声表现,组织样征,碎片征,35,ARDS肺部超声的演变,Cardiovascular Ultrasound2011,9:6,36,肺复张前后的肺部超声,Respir Care,2012,57(5):773-81,37,超声评价肺的可复张性,Four ultrasound aeration patterns were defined:(1)norma
12、l aeration(N):presence of lung sliding with A lines or fewer than two isolated B lines(2)moderate loss of lung aeration:multiple well-defined B lines(B1 lines)(3)severe loss of lung aeration:multiple coalescent B lines(B2 lines)(4)lung consolidation(C):the presence of a tissue pattern characterized
13、by dynamic air bronchograms,Am J Respir Crit Care Med,2011,183:341-347,38,Ultrasound Reaeration Score,Am J Respir Crit Care Med,2011,183:341-347,39,PEEP诱导肺复张的超声表现,Am J Respir Crit Care Med,2011,183:341-347,40,肺部超声法与其他评估方法的比较,Am J Respir Crit Care Med,2011,183:341-347,41,肺部超声评价肺可复张性,优点即时操作，无镇静肌松要求可用于
14、重力依赖区或非重力依赖区肺复张效果的评估,缺点肺非静态，可能低估肺复张状况患者因素影响准确性（胸壁皮下脂肪厚度、胸壁皮下气肿等）受操作者熟练程度限制不能区分正常通气或过度通气，不能作为肺复张评价的唯一指标,Am J Respir Crit Care Med,2011,183:341-347,42,病例摘要,患者女，20岁，因促排卵药物治疗后“卵巢过度刺激综合征”，并出现高热，血小板减少至0109/L，由120送我院急诊。查体：贫血貌，全身紫癜，腹膨隆，压痛伴反跳痛，腹水征阳性。,43,急症超声,左卵巢72mm56mm，内见62mm52mm低回声团块，盆腹腔积液，内见细点状回声，深60mm考虑左卵巢黄体或囊肿破裂并腹腔内出血,44,因“ARDS、DIC、血小板减少、盆腔出血、卵巢过度刺激综合征”转入ICU。,45,EIT检测下肺复张PEEP递增法,46,EIT检测下肺复张PEEP递增法,肺复张后呼气末肺容积明显增加，增加的EELV主要分布在ROI2和3,47,PEEP的滴定最低Global Inhomogeneity index法,12,15,18,21,25,21,18,15,12,48,病情变化,49,60小时 CT检查,72小时后病人脱离呼吸机并拔除气管插管,50,
