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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,Biotruama?,Magaret Parker,MD,FCCM.(SCCM Chair 2004),ARDS,Beijing 2005,Ventilation Strat
3、egies&BAL CytokinesTremblay,Valenza,Ribeiro,Li,Slutsky J Clinical Investigation 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 Cytokine
4、s in Acid Aspiration ModelChiumello,Pristine,Slutsky AJRCCM 1999;160:109-16,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,
5、Hudson et al,Chest 116:74S-2S,ARDS Mortality Decreased Abruptly,Shanghai 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?,P
6、EEP=?VT=?PIP=?Pplateau=?RM?Mode?,Protect the lungs?How?,PEEP too low:Recruitment/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 DISTR
7、ESS SYNDROME,METHODSStudy Population,Marcelo BP Amato,MD,PV curve(static),P-V curve Methodology,The supersyringe technique,Recruitment Maneuver and PV curve hysteresis,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 boost
8、ed on the deflation limb,Post-Operative Atelectasis Healthy Lung,40 cmH2O peak alveolar pressure held for 7-15 sec needed to reopen lungRothen Br J Anaesth 1993;71:788Rothen Br J Anaesth 1998;81:681Rothen Br J Anaesth 1999;82:551,Recruitment Maneuver,Massachusetts General Hospital,Performance of RM
9、MGH,30 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 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
10、 RMs,Monitoring during RM(MGH),The RM should be aborted if:MAP 20 mmHgSpO2 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 m
11、mHg,Amato,ARDS protocol,Recruit,FIO2=1,Titrate PEEP,Titrate Pdriving,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
12、 lung maneuver 450 mmHg on pure oxygen.When a lung is“open”,Hickling K.AJRCCM 2001;163:69-78.,Stepwise 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 P
13、ROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME,Lim CCM 2001;29:1255,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 protoc
14、ol with HFOV and RM25 patients with early ARDSInclusion:Age18,P/F75,Significant heart disease,Details of protocol,RM:mPaw 40 cmH2O 40 sec 3Repeated RM:twice daily at leastHFOV:P=60 cmH2O,F=5Hz,Results,P/F increase:200117 vs 9236 mmHgFiO2 reduce:0.50.2 vs 0.90.1RM:411(median:7)/patientRM aborted:8/24
15、4(3.3%)in 6 patientsRM abolition reason:Hypotension,but recovered quickly.4/6 intolerant patients:tolerated later.,Stepwise 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 ass
16、ure homogenous ventilation in ARDS.,Curr Opin Crit Care.2005 Feb;11(1):18-28,Stepwise PEEP RM practice,26 pts5 cmH2O steps Pinsp 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
17、 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/FiO2:49/85%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 Inte
18、rval: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 min 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,Subc
19、utaneous emphysema,结 果,心脏外科术后低氧患者 所有患者在第一次RM出现血压迅速下降 血压下降同时伴随SpO2下降 第一次RM在PEEP1216出现血压下降 在以后的RM中，耐受性增强多发伤并发ALI/ARDS患者 12/18（66.6%）在第一次RM出现血压迅速下降血压下降同时伴随SpO2下降在以后的RM中，耐受性增强,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PEEP=6时发生右向左分流，同时SpO2下降,
20、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 recruitment.These findings wer
21、e 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,Result,Clinical Observ
22、ation,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 cmH2OInspir Time:1 to 3 secRa
23、te: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 comp PEEP+2 to 3 cm H2OR
24、epeat 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 50,Bobs new protocol,Lun
25、g 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 needed!If benefit lost afte
26、r 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 consensus of two.CONCLUSIONS
27、: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-executed clinical trials.A
28、t 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,(PV curve)Super-syringe L
29、ow-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,Pflex,“maximum differenc
30、e 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.Schnitzer,M.D.,Robert M.
31、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 practical?Not yet.SpO2 i
32、s 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 to achieve minimal phy
33、siological 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 High PEEP,PEEP selected ac
34、cording 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 recruitmentPEEP set for
35、 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 assessing the effect on mo
36、rtality 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 contraindication:Untreated p
37、neumothoraxTension pneomothoraxMechanical VentilationSusan P.PilbeamMosby Year Book,1992,St.Luis,Amato(1998):METHODSStudy Population,Details of results,Hemodynamics(same trail)Am J Respir Crit Care Med.1997 Nov;156(5):1458-66.,immediate increase in heart rate(p=0.0002),cardiac output(p=0.0002),oxyge
38、n delivery(DO2l,p=0.0003),mixed venous PO2(p=0.0006),maintained systemic oxygen consumption(p=0.52)mean pulmonary arterial pressure markedly increased(mean increment 8.8 mm Hg;p 0.0001)pulmonary vascular resistance did not change(p=0.32),Hemodynamics(same trail)Am J Respir Crit Care Med.1997 Nov;156
39、(5):1458-66,Cardiac filling pressures increased(p 0.001)systemic vascular resistance fell(p=0.003)these alterations were progressively attenuated in the course of the first 36 hPlasma lactate suffered a progressive decrement along the early period in lung protective approach(LPA)but not in control p
40、atients(p 0.0001).No hemodynamic consequences of LPA were noticed in the late period and renal function was preserved.In contrast,high plateau pressures were associated with cardiovascular depression,Odenstedt H,Lindgren S,Olegard C,Erlandsson K,et alIntensive Care Med.2005 Dec;31(12):1706-14,Slow m
41、oderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effectsvital capacity maneuver to an inspiratory pressure of 40 cmH2O-ViCM pressure-controlled recruitment maneuver with peak pressure 40 and PEEP 20 cmH2O-PCRMslow recruitment with PEEP elevation to 15 cmH2O
42、 with end inspiratory pauses for 7 s twice per minute over 15 min-SLRM,Intensive Care Med.2005 Dec;31(12):1706-14,Cardiac output decreased by 634%during ViCM,442%during PCRM,213%during SLRM.,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,
