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1、Lung Protective Mechanical Ventilation肺保护性机械通气Adoption&discussion,张翔宇SICU上海同济大学上海市第十人民医院,Ventilator Induced Lung InjuryVILI,Overdistention Barotrauma Volutrauma Recruitment/Derecruitment Injury Translocation of Cells Biotrauma,Overdistention Barotrauma&Volutrauma,VILI：Recruitment/Derecruitment Injur
2、y,PIP=14,PEEP=0PIP=45,PEEP=10PIP=45,PEEP=0Webb556,Translocation of Cells,Bilek,A.M.D.P.Gaver III,J Appl Physiol 94:770783,2003,Translocation of Cells,disrupt the alveolar epithelium tears in capillary endothelium,Ventilation Strategies&BAL CytokinesTremblay,Valenza,Ribeiro,Li,Slutsky J Clinical Inve
3、stigation 99:944-52,1997,50倍！,Ventilatory Strategy and BAL Cytokines,Tremblay,Valenza,Ribeiro,Li,Slutsky J Clinical Investigation 99:944-52,1997,*p 0.05 vs.C,MVHP,MVZP,&p 0.05 vs.C,MVHP,#p 0.05 vs.C,Arthur S Slutsky,Serum Cytokines in Acid Aspiration ModelChiumello,Pristine,Slutsky AJRCCM 1999;160:1
4、09-16,Cytokines in HumansStuber et al Int Care Med 2002;28:834-841,JAMA 289:2104-2112,2003,Systemic Effects of VILIImai et al JAMA 289:2104-2112,2003,Mechanical Ventilation,Slutsky,Tremblay Am J Resp Crit Care Med.1998;157:1721-5,Hudson et al,Chest 116:74S-2S,ARDS Mortality Decreased Abruptly,Shangh
5、ai ARDS Study Group.,15 ICUs in 12 university hospitals in ShanghaiIn-hospital mortality of ARDS patients were 68.5%and 90-day mortality of ARDS patients were 70.4%,Intensive Care Med.2004 Dec;30(12):2197-203.,Protect the lungs?,PEEP=?VT=?PIP=?Pplateau=?RM?Mode?,Protect the lungs?How?,PEEP too low:R
6、ecruitment/Derecruitment InjuryPplateau too high:Overdistention Barotrauma Volutrauma,MARCELO AMATO,M.D.,et al.(N Engl J Med 1998;338:347-54.),EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME,METHODSStudy Population,Marcelo BP Amato,MD,PV curve(stat
7、ic),8,30,Prssure,Small tidal volume(5 ml/kg),Rimensberger PC Crit Care Med 1999;27:1946-52 27:1940-45,The ventilatory cycle can be boosted on the deflation limb,Recruitment Maneuver,Massachusetts General Hospital,Performance of RM MGH,30 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well
8、35 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 secAllow 15 to 20 minutes between RM,Performance of RM MGH,Set FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple RMs,Monitoring during RM(MGH),The RM should be aborted if:MAP 20 mmH
9、gSpO2 130 or 60/minuteNew arrhythmias,Amato NEJM 1998;338:347,35 40 cmH2O CPAP for 30 to 40 secAt enrollmentAfter ventilator disconnectNo severe hemodynamic compromiseNo barotrauma,Amato:2004 China,FULL RECRUITMENT:PaO2+PaCO2 400 mmHg,Amato,ARDS protocol,Recruit,FIO2=1,Titrate PEEP,Titrate Pdriving,
10、WAIT,(15),FIO2 30%,(High PEEP+PSV),WAIT,FIO2 30%,(High PEEP+PSV),Decrease PS down to 8,Decrease PEEP down to 12,NIMV(CPAP=12,PS=8),J.J.HAITSMA,B.LACHMANNMINERVA ANESTESIOL 2006;72:117-32,Lung protective ventilation in ARDS:the open lung maneuver 450 mmHg on pure oxygen.When a lung is“open”,Stepwise
11、Recruitment Strategy,Time,0,10,20,30,40,50,60,70,45,50,55,60,Baseline,25 cmH2O,Airway Pressures(cmH2O),40,CPAP,OLA,DP=15 cmH2O,MARCELO AMATO,M.D.,et al.(N Engl J Med 1998;338:347-54.),EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME,Lim CCM 2001;29:
12、1255,Foti ICM 1999;26:501,Treatment with Oscillation and an Open Lung strategy(TOOLS)Crit Care Med 2005;33(3):479,Multi-center:Toronto,Paris,Cardiff，BostonFerguson,Kacmarek,Slutsky,et al.New protocol with HFOV and RM25 patients with early ARDSInclusion:Age18,P/F75,Significant heart disease,Stepwise
13、PEEP recruitment maneuvers(Amatos team),Stepwise PEEP recruitment maneuvers can open collapsed ARDS lungs.Higher levels of PEEP are necessary to maintain the lungs open and assure homogenous ventilation in ARDS.,Curr Opin Crit Care.2005 Feb;11(1):18-28,Stepwise PEEP RM practice,26 pts5 cmH2O steps P
14、insp reached 60 cmH2O 2/26,PaO2+PaCO2 400 mmHg not reachedopen the lung and keep the lung open in 24/26Titrating PEEP by oxygenationNo barotrauma,Am J Respir Crit Care Med.2006 May 11,RM in our ICU,心脏外科术后低氧患者16例 男10例，女6例 年龄：5269 多发伤并发ALI/ARDS患者18例 男13例，女6例 年龄：1356 军团菌病1例，女、26岁，MSOF/ARDS，PaO2/FiO2:49
15、/85%所有病例均为机械通气疗效不佳的低氧血症 PaO2/FiO2:57.6166mmHg,方 法,所有患者均行有创动脉压持续监测 SpO2持续监测 CVP持续监测 清醒患者适当镇静 复张术（RM）前排除气压伤 排除肺气肿患者,Protocol,Mode:PEEP+PCV or PEEP+PSV PEEP:increment 2 cmH2O Interval:2 min PEEP target:16/1st RM,20/2nd RM,2630/3rd RM PIPmax:45 cmH2O Abort if ABP or SpO2 start fall Rest interval:1530 mi
16、n May repeat twice a day,结 果,心脏外科术后低氧患者 有效：100%PaO2/FiO2 improve：110%36%无并发症多发伤并发ALI/ARDS患者有效：92%PaO2/FiO2 improve：86%32%无并发症 军团菌病1例，无效，出现气压伤 RM一次，PEEPmax:22,PIPmax:32纵隔气肿,Subcutaneous emphysema,临床观察,252例次RM有93次血压短暂降低（37%）出现血压下降的PEEP水平为623cmH2O,平均13.9cmH2OPEEP降低之后动脉恢复到原来水平所有病人有创持续血压监测1例经心超证实卵圆孔未闭，在P
17、EEP=6时发生右向左分流，同时SpO2下降,张翔宇，等，中国危重病急救医学，2007，19（9）,Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study,Conclusions:In this experimental model,the continuous monitoring of dynamic compliance identified the beginning of collapse after lung recruit
18、ment.These findings were confirmed by oxygenation and computed tomography scans.This method might become a valuable bedside tool for identifying the level of PEEP that prevents end-expiratory collapse.,Fernando Suarez-Sipmann,MD;Stephan H.Bhm,MD;Gerardo Tusman,MD,et al.Crit Care Med 2007 Vol.35,No.1
19、,Result,Clinical Observation,Clinical Observation,Bobs new protocol,Performance of RM,Set FIO2 at 1.0Allow time for stabilizationInsure appropriate sedationInsure hemodynamic stability,Bobs new protocol,Performance of RM-PCV,Pressure control ventilation:PEEP 20-30 cmH2OPeak Inspir Press 40-50 cmH2OI
20、nspir Time:1 to 3 secRate:8 to 20/minTime 1 to 3 minSet PEEP at 20,ventilate VC,VT 4 to 6 ml/kg PBW,increase rate,avoid auto-PEEPMeasure dynamic complianceDecrease PEEP 2 cm H2O,Bobs new protocol,Performance of RM-PCV,Measure dynamic complianceRepeat until max compliance determinedOptimal PEEP max c
21、omp PEEP+2 to 3 cm H2ORepeat recruitment maneuver and set PEEP at the identified settings,adjust ventilationAfter PEEP and ventilation set and stabilized,decrease FIO2 until PO2 in target rangeIf response is poor,repeat RM,PEEP 25,Peak Pressure 45If response is poor,repeat RM,PEEP 30,Peak Pressure 5
22、0,Bobs new protocol,Lung Recruitment,Perform early in ARDSIdeal approach to RM most likely PC,limited patient data available using PC!Works better in extra pulmonary than primary ARDS?More difficult to recruit the lung the stiffer the chest wall!Start with low pressure,increase as tolerated and need
23、ed!If benefit lost after RM,PEEP inadequate!,Bobs new protocol,Current conclusion,PEEP=Pflex+2?PEEP=Pdeflex?Vt=6 ml/Kg Vt:Pplat 30 Vt:Pplat Puip,Guidelines?Not available yet,Marini JJ,Gattinoni L.Crit Care Med.2004 Jan;32(1):250-5.Ventilatory management of acute respiratory distress syndrome:a conse
24、nsus of two.CONCLUSIONS:Prevention of ventilator-induced lung injury while accomplishing the essential life-supporting roles of mechanical ventilation is a complex undertaking that requires application of principles founded on a broad experimental and clinical database and on the results of well-exe
25、cuted clinical trials.At the bedside,execution of an effective lung-protective ventilation strategy remains an empirical process best guided by integrated physiology and a readiness to revise the management approach depending on the individuals response.,Titrating PEEP fellowing RM,Pdeflex+2cmH2O,(P
26、V curve)Super-syringe Low-flow Multiple occlusion Linear ramping(Hamilton Galilio Gold)Oxygenation PaO2 drop 10%,PV curve for Pdeflex,Recognizable?And percentage of them?Is this Pdeflex constant over time?Or RM?Is Pdeflex after RM repeatable?Is PEEP on Pdeflex clinically practical?Not answered yet,P
27、flex,“maximum difference of 11 cm H2O for the same patient”AM J RESPIR CRIT CARE MED 2000;161:432439.R.SCOTT HARRIS,DEAN R.HESS,and JOS G.VENEGAS,Anesthesiology,V 99,No 5,Nov 2003Khaled A.Sedeek,M.D.,*Muneyuki Takeuchi,M.D.,*Klaudiusz Suchodolski,M.D.,*Sara O.Vargas,M.D.,Motomu Shimaoka,M.D.,Jay J.S
28、chnitzer,M.D.,Robert M.Kacmarek,R.R.T.,Ph.D.,The PEEP or PAW preceding that causing the PaO2 decrease was considered optimal.until the target PaO2 decreased by more than 10%from the above target level.,Titrating PEEP according to oxygenation,Is it practical for clinical?Possible.Is continuous PaO2 p
29、ractical?Not yet.SpO2 is probably a useful tool,Patients(n=549)ARDS/ALI P plat(cmH2O)30 PEEP(cmH2O)12.9 4 8.4 4 RR(b/min)30 TV(ml/Kg)6,The NIH randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDS,New Engl J Med 2004;351:327-336,PEEP selected according to a Table
30、 to achieve minimal physiological oxygenation(88-95%),Patients(n=983)ARDS/ALI P plat(cmH2O)30 PEEP(cmH2O)16.3 3 RR(b/min)30 TV(ml/Kg)6,9.1 4,The LOVS:Lung Open Ventilation Canadian Study,CanadianTrial,Oxygenation was better in High PEEP Compliance was better in High PEEP Less rescue therapies in Hig
31、h PEEP,PEEP selected according to a table to achieve minimal physiological oxygenation+RM,Stewart T et al JAMA.2008;299(6):637-645,Patients(n=752)ARDS/ALI P plat(cmH2O)30 PEEP(cmH2O)14.9 4 RR(b/min)30 TV(ml/Kg)6,7.4 4,French Trial“Express”,PEEP selected to avoid overdistension or to achieve maximal
32、recruitmentPEEP set for PEEP tot 5-9 cmH2O PEEP set for Plat 28-30 cmH2O,Oxygenation was better in Max distension Higher ventilation free days in Max distension Higher organ failure free days in Max distension,Mercat A et al JAMA.2008;299(6):646-655,The Express Study:randomized multicenter study ass
33、essing the effect on mortality of low vs high PEEP in ARDS,Mercat A et al JAMA.2008;299(6):646-655,肺复张术对血流动力学的影响RM on Hemodynamics,PEEP的禁忌症,未经有效治疗的气胸低容量（hypovolume）腔静脉-肺动脉分流术（Fontan,Glenn,et al）张翔宇，in 顾恺时胸心外科手术学2003,上海,Contraindication to PEEP/CPAP,Relative contraindication:HypovolemiaAbsolute contr
34、aindication:Untreated pneumothoraxTension pneomothoraxMechanical VentilationSusan P.PilbeamMosby Year Book,1992,St.Luis,CPB心脏手术后的低氧患者,19/20例改善氧合明显所有病例在RM中均有动脉压较快速下降1例不能耐受应该有持续动脉压监测,张翔宇，等，同济大学学报（医学版），2008；29（2）,结 论,心脏外科术后低氧患者、老年患者 心功能很差，循环很脆弱 PEEP升高很容易影响循环 PEEP上升要缓慢，ABP/SpO2变化应立即降低PEEP 2nd,3rd,4th,RM 病人耐受性明显提高 应该持续监测有创ABP、SpO2,ECMO,RM并非万能，对于严重的低氧血症，尤其是心脏功能很差的病人，ECMO可能是很有潜力的新疗法。,张翔宇，等。中国急救医学，2006；26（5）：398,
