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1、ARDS患者的肺复张,北京协和医院杜斌,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,ARDS的肺保护性通气策略,ARDS的肺保护性通气策略,小潮气量(6 ml/kg IBW)避免过度膨胀造成的容积伤(volutrauma)足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma),肺泡塌陷与复张造成的剪切力,F=PL x(V0/V)2/3F:
2、剪切力PL:跨肺压V0:最初容积V:复张后容积如果:PL=30 cmH2O,V0/V=1/10则:F=140 cmH2O,Mead J,Takishima T,Leith D.Stress distribution in lungs:a model of pulmonary elasticity.J Appl Physiol 1970;28(5):596-608,小潮气量通气的问题,Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recrui
3、tment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613,小潮气量通气的问题,Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Me
4、d 2001;163:1609-1613,小潮气量通气的问题,Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613,受损的肺组织如何复张,俯卧位足够的PEEP足够的潮气量和(或)叹气?肺复张手法减少水肿(?)最低可接受的FiO2(?)自
5、主呼吸(?),内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,肺泡的开放压与闭合压,PEEP不能使肺复张,LIP:仅仅是肺复张的开始,Hickling KG.The pressure-volume curve is greatly modified by recruitment.A mathematical model of ARDS lungs.Am J Respir Crit Care Med 1998:158:194-202.,Jonson B,Richard JC,Straus C,Manc
6、ebo J,Lemaire F,Brochard L.PressureVolume Curves and Compliance in Acute Lung Injury:Evidence of Recruitment Above the Lower Inflection Point.Am J Respir Crit Care Med 1999;159:1172-1178,低位转折点之上仍有肺组织复张,肺泡的开放压与闭合压,肺泡开放压与闭合压,Paw(cmH2O),Crotti S,Mascheroni D,Caironi P,Pelosi P,Ronzoni G,Mondino M,Marin
7、i JJ,Gattinoni L.Recruitment and derecruitment during acute respiratory failure:a clinical study.Am J Respir Crit Care Med 2001:164:131-140.,ARDS的肺开放,EditorialOpen up the lung and keep the lung openB.LachmannDept.of Anesthesiology,Erasmus University Rotterdam,The Netherlands(1992)18:319-321,RM能够使肺开放
8、,RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 min,Halter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626,肺复张能够改善ARDS氧合,Lapin
9、sky SE,Aubin M,Mehta S,Boiteau P,Slutsky AS:Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.,肺复张的各种方法,CPAP(SI)incremental PEEPPCVSigh(modified)HFOV俯卧位,SI改善氧合,Tugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L
10、,Akpir K,Cakar N.Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome:Focusing on pulmonary and extrapulmonary forms.Crit Care Med 2003;31:738-744,Sustained Inflation:45 cmH2O x 30 s,SI改善氧合,Frank JA,McAuley DF,Gutierrez JA,Daniel BM,
11、Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury.Crit Care Med 2005;33:181-188,Sustained Inflation:30 cmH2O x 30 sTwice with 1 min interval,叹气的设置,Lim CM,Koh Y,Park W,Chin JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mec
12、hanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260,充气阶段,每30秒PEEP增加5 cmH2OVt减少2 ml/kg前2次呼吸除外直至Vt 2 ml/kg,PEEP 25 cmH2O暂停阶段CPAP 30 cmH2Ofor 30 s放气阶段,叹气改善氧合,Lim CM,Koh Y,Park W,Ch
13、in JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260,叹气对氧合及呼吸力学的影响,Pelosi P,Cadringher P,Bottino N,Panigada M,Carrieri F,Riva E,Lisso
14、ni A,Gattinoni L.Sigh in acute respiratory distress syndrome.Am J Respir Crit Care Med 1999;159:872-880,Sigh:3 consecutive sighs/min at Pplat 45 cmH2O,叹气的设置,Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Re
15、spiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94,Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,s=3 5 sf=1 bpm,叹气改善呼吸力学及氧合,Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume
16、in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94,ARDS对RM的反应,Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar JL,Fernandez R,Blanch L.Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Dis
17、tress Syndrome.Am J Respir Crit Care Med 2002;165:165-170,肺复张 CT的提示,Henzler D,Mahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359,肺复张 CT的提示,Henzler D,M
18、ahnken AH,Wildberger JE,Rossaint R,Gnther RW,Kuhlen R.Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury.Eur Radiol 2006;16:1351-1359,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,RM vs.PEEP,Lim CM,Lee SS,Lee
19、 JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80,RM vs.PEEP,Lim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment
20、 Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80,RM vs.PEEP,Lim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiolo
21、gy 2003;99:71-80,RM vs.PEEP,Lim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80,RM vs.PEEP,Lim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,K
22、im WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,为什么肺复张作用不能持久?,Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald
23、 RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5,为什么肺复张作用不能持久?,肺复张的方法?SI:50 cmH2O x 30 s作者认为,Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recru
24、itment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5,RM+PEEP vs.RM vs.PEEP,Lim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in e
25、arly acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418,RM+PEEP vs.RM vs.PEEP,Lim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitm
26、ent maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418,RM+PEEP,RM only,RM后的PEEP,RM后的PEEP能够稳定肺泡,Halter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto LA,L
27、andas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626,RM后的PEEP能够稳定肺泡,RM:PIP 45 cmH2O,PEEP 35 cmH2O x 1 min,PEEP 5 cmH2O,PEEP 10 cmH2O,Halter JM,Steinberg JM,Schiller H
28、J,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626,肺泡稳定能够改善PaO2,McCann UG,Schiller HJ,Gatto LA,et al.Alveolar mechanics alter hypoxic ulmonary
29、 vasoconstriction.Crit Care med 2002;30:1315-1321,RM后的PEEP,Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377,RM+PEEP vs.PEEP only,Lim CM,Adams AB,Simonson DA,Dr
30、ies DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377,RM+PEEP,PEEP only,PEEP的设置,RM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平最初将PEEP设置为20 cmH2O然后将FiO2减小到最低水平维持SpO2 90 95%每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降,PEEP的
31、设置,氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP一旦确认,则需重复肺复张操作,然后把PEEP和FiO2重新设置在上述水平对于多数ARDS患者,PEEP介于15 20 cmH2O之间某些患者 20 cmH2O,PEEP的设置,如果将PEEP设置于20 cmH2O后,仍发现PaO2/FiO2显著下降按照最初的PEEP设置25 cmH2O重复肺复张然后按照上述方法调节FiO2和PEEP,PEEP的设置,将PEEP从不必要的高水平逐渐降低不要将PEEP由低水平增加到高水平如同P-V曲线所示,根据设置方法不同,同样水平的PEEP所维持的肺容积不同如果在肺泡塌陷后设置PEEP(增加PEEP),则
32、所设置的PEEP水平可以使肺容积减少,PaO2降低,PEEP/FiO2的调整,推荐意见降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷一般情况下FiO2应当减低到 0.45如果降低PEEP导致氧合下降应当重新设定PEEP肺泡塌陷时不应增加FiO2,肺复张后氧合稳定所需时间,Tugrul S,Cakar N,Akinci O,Ozcan PE,Disci R,Esen F,Telci L,T Akpir.Time required for equilibration of arterial oxygen pressure after setting optimal positive end-
33、expiratory pressure in acute respiratory distress syndrome.Crit Care Med 2005;33:995-1000,=LIP+2,肺复张后氧合稳定所需时间,Tugrul S,Cakar N,Akinci O,Ozcan PE,Disci R,Esen F,Telci L,T Akpir.Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute
34、respiratory distress syndrome.Crit Care Med 2005;33:995-1000,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,不同RM方法的比较,基础通气方式VCV:Vt 10 ml/kg,f 20 bpm,I:E 1:2,FiO2 0.5肺复张:,Odenstedt H,Lindgren S,Olegard C,Erlandsson K,Lethvall S,Aneman A,Stenqvist O,Lundin S.Slow moderate pres
35、sure recruitment maneuver minimizes negative circulatory and lung mechanic side effects:evaluation of recruitment maneuvers using electric impedance tomography.Intensive Care Med 2005;31:1706-1714,不同RM方法的比较,Odenstedt H,Lindgren S,Olegard C,et al.Slow moderate pressure recruitment maneuver minimizes
36、negative circulatory and lung mechanic side effects:evaluation of recruitment maneuvers using electric impedance tomography.Intensive Care Med 2005;31:1706-1714,不同RM方法的比较,Odenstedt H,Lindgren S,Olegard C,Erlandsson K,Lethvall S,Aneman A,Stenqvist O,Lundin S.Slow moderate pressure recruitment maneuve
37、r minimizes negative circulatory and lung mechanic side effects:evaluation of recruitment maneuvers using electric impedance tomography.Intensive Care Med 2005;31:1706-1714,不同RM方法的比较,对于灌洗造成的急性肺损伤模型缓慢低压复张操作可以促进肺泡复张减少对循环系统的抑制避免对呼吸力学的不良影响,Odenstedt H,Lindgren S,Olegard C,Erlandsson K,Lethvall S,Aneman
38、A,Stenqvist O,Lundin S.Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects:evaluation of recruitment maneuvers using electric impedance tomography.Intensive Care Med 2005;31:1706-1714,不同RM方法的比较,Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hot
39、chkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377,Sustained inflation45 for 40 s,Incremental PEEPPIP 35,PEEP 8-35,PCVPIP 45,PEEP 16I:E 1:2,2 min,对于VILI模型PCV是最佳的RM方法其他模型结果相似,PEEP 8,PEEP 12,PEEP 16,Lim CM,Adams AB,
40、Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,RM保护肺内皮而非肺泡上皮,试验动物:大鼠模型制备:酸(pH 1.5)吸入机械通气:Vt6 ml/kgPEE
41、P5 cmH2OFiO21.0F60 70 bpm复张操作:30 cmH2O x 30 s x 2间隔1分钟,Frank JA,McAuley DF,Gutierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury.Crit Care Med 2005;33:181-188,RM保护肺内皮而非肺泡上皮,Frank JA,McAuley DF,Gu
42、tierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury.Crit Care Med 2005;33:181-188,RM:ARDS早期 vs.晚期,Villagra A,Ochagavia A,Vatus S,Murias G,Fernandez MF,Aguilar JL,Fernandez R,Blanch L.Recruitment
43、Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome.Am J Respir Crit Care Med 2002;165:165-170,原发性ARDS对RM反应不佳,Saline lavage,Oleic acid injury,Pneumonia,Van der Kloot TE,Blanch L,Youngblood AM,Weinert C,Adams AB,Marini JJ,Shapiro RS,Nahum A.Recruitment Maneuvers in Thr
44、ee Experimental:Models of Acute Lung Injury Effect on Lung Volume and Gas Exchange.Am J Respir Crit Care Med 2000;161:1485-1494,Sustained inflationCPAP 40/30CPAP 60/30CPAP 60/30,油酸损伤模型RM作用短暂,Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuv
45、er efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377,PEEP 8,PEEP 12,PEEP 16,不同病因对RM的反应,Lim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-
46、2377,RM+PEEP,PEEP only,RM:ARDSp与ARDSexp,Lim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the pat
47、ient.Crit Care Med 2003;31:411-418,SI改善氧合,Tugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L,Akpir K,Cakar N.Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome:Focusing on pulmonary and extrapulmonary forms.Crit Care Med 2003;31:738-
48、744,Sustained Inflation:45 cmH2O x 30 s,叹气:ARDSp与ARDSexp,Pelosi P,Cadringher P,Bottino N,Panigada M,Carrieri F,Riva E,Lissoni A,Gattinoni L.Sigh in acute respiratory distress syndrome.Am J Respir Crit Care Med 1999;159:872-880,Sigh:3 consecutive sighs/min at Pplat 45 cmH2O,内容,小潮气量通气的问题肺复张的理论与实践肺复张与P
49、EEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,RM不增加肺泡过度膨胀,Bugedo G,Bruhn A,Hernandez G,et al.Lung computed tomography during a lung recruitment maneuver in patients with acute lung injury.Intensive Care Med 2003;29:218-225,肺复张对内脏血流的影响,Nunes S,Rothen HU,Brander L,Takala J,Jakob SM.Changes in Splanchn
50、ic Circulation During an Alveolar Recruitment Maneuver in Healthy Porcine Lungs.Anesth Analg 2004;98:1432-8,肺复张对胃肠道血流的影响,Claesson J,Lehtipalo S,Winso D.Do lung recruitment maneuvers decrease gastric mucosal perfusion?Intensive Care Med 2003:29:1314-1321,肺复张对脑氧代谢的影响,Bein T,Kuhr LP,Bele S,Ploner F,Key
