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1、急性呼吸窘迫综合征肺复张的测定与应用,内容提要,ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,Lung volume decreased markedly(TLC,VC,TV,FRC)-alveolar edema-pulmonary surfactant-Interstitial pumonary edema depress brochiole and induce spasmCompliance reduc
2、ed significantlyVentilation/perfusion mismatch-intrapulmonary shunt and dead space like effects,ARDS病理生理特点,ARDS病理生理,CT scan70-80%的肺野呈现高密度区分布：下垂部位(dependent field)提示：参与通气肺泡明显减少(20-30%)肺损伤具有不均一性,肺容积减少Small lung Baby Lung,ARDS病理生理,A and C finding in the acute or exudative phase,B and DFinding in the fi
3、brosing-alveolitis phase,ARDS病理生理,肺容积/顺应性明显降低,ARDS病理生理,Reduced range of volume excursion:Low complianceFlattening at low and high volumes:Lower and upper inflection pointsBigatello:Br J Anaest 1996,Volume,Pressure,NORMAL,ARDS,顺应性曲线明显右下移位,肺顺应性明显降低,ARDS病理生理,Upper and Lower Inflection Points,Lower呼气末肺泡
4、塌陷吸气早期肺泡再开放Upper吸气末肺泡顺应性明显降低，肺泡过度膨胀,ARDS病理生理,Volume,Pressure,Lower Inflection Point,Upper Inflection Point,通气/血流失调,肺泡塌陷：ARDS重力依赖区，炎症或不张区生理性低氧缩血管反应：障碍,ARDS病理生理,Imagine the Hardness to Blow up a Ballon.,easy,hard,spatial&elastic limitations,Laplacian Law,It needs higher initial pressures to overcome t
5、he surface tension to open up a bubble to wider diameters!,ARDS病理生理,Sustain inflation Sigh小潮气量通气PHC,避免肺泡过度膨胀最佳PEEP避免剪切力(Shear force)性损害,Volume,Pressure,肺开放与保护性通气策略的基本内容,ARDS病理生理,Lung volume decreased markedly,Atelectrauma,Keep the lung open,Open the lung,Prevent volutrauma,SI and Sigh,PEEP,ARDS病理生理,
6、内容提要,ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,PV曲线法,Step 1:测量PEEP所致的FRC(吸气末撤掉PEEP并延长呼气时间)FRCVE(ZEEP)VE(PEEP),肺复张容积测定,PV曲线法,Step 2:分别描计ZEEP和PEEP的PV曲线 Step 3:肺复张容积：RV=V20(PEEP)+FRC V20(ZEEP),肺复张容积测定,等压法,呼吸模式：BIPAP条件：Ph 20 cmH2O
7、，PEEP分别为0、5、10、15 cmH2O，Ti 6S测定：延长呼气时间，测定ZEEP呼出气量。在不同PEEP时吸气末撤掉PEEP，延长呼气时间，测定呼气量,肺复张容积测定,等压法,肺复张容积测定,P-V曲线法与等压法的比较,肺复张容积测定,肺复张容积测定P-V曲线法,等压法虽然简单，但准确性较差 不能代替P-V曲线法目前肺复张容积的测定仍宜采用 P-V曲线法,肺复张容积测定,CT method,膈顶上1cm CT层面PEEP与ZEEP比较Gattinoni L.Am J Respir CCM,1995,151:1807全肺扫描区别过度膨胀，膨胀，部分复张和塌陷区 Luiz M,Rouby
8、 JJ.Am J Respir CCM,2001,163:1444,肺复张容积测定,CT法-Gattinoni,肺复张容积测定,原理CT空气=0Hu，CT水=1000 HuCT值=500Hu，肺组织50%空气+50%水ARDS塌陷肺CT值100Hu100Hu，塌陷肺泡复张 后，100Hu+100Hu内肺组织减少方法ZEEP和PEEP通气呼气末CT扫描膈肌顶上1cm计算CT值在100 Hu 100 Hu范围内体素结果之差,Gattinoni L.Am J Respir CCM,1995,151:1807,原理 充气不良区(100Hu500Hu)、正常充气区(500Hu 900Hu)、无充气区(1
9、00Hu+100Hu)和过度充气区(900Hu1000Hu)。肺泡复张，充气不良和正常充气肺区体积增加 方法 ZEEP和PEEP呼气末螺旋CT，根据层面厚度计算不同CT值肺体积，肺复张后充气不良与正常充气肺组织体积增加值,肺复张容积测定,CT法-Rouby,Luiz M,Rouby JJ.Am J Respir CCM,2001,163:1444,Gattinonis vs Roubys CT法比较,肺复张容积测定,CT methods:Rouby vs Gattinoni,Luiz M,Rouby JJ.Am J Respir CCM,2001,163:1444,肺复张容积测定,内容提要,A
10、RDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,ARDS肺不张的影响因素-附加静水压,Hydrostatic pressure=(1 CT/-1000)Height Maximum sternovertebral dimention of human thorax:20cmH2OPEEP 20cmH2O不能使ARDS患者肺泡完全复张动物ARDS,Mean Airway pressure 25 cm H2O,ARDS
11、肺复张应用,ARDS下肺气体含量明显降低,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺复张应用,CT section lcated 5 cm below the carina No differences were observed in the percentage of lower lobes located beneath the heart in two groups,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺不张的影响因素-heart lung interdepend
12、ence,ARDS肺复张应用,Cardiac mass and volume in ARDS,Cardiac mass was increased by 27%vs NS Mechanism of cardiac mass:Edema of cardiac wallRV dilation secondary to pul hypertensionHyperkinetic state related to SIRS,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺复张应用,心脏下肺叶气体量明显降低ARDS 73%vs NS 21%,Close
13、d bar:Fraction of gas in lower lobes located beneath the heartOpen bar:lower lobes located outside the heart,CT scan ARDS study group.AJRCCM,2000,161:2005,ARDS肺复张应用,塌陷肺泡的分布,Local:Loss of aeration predominating in lower lobesDiffuse:Equal loss of aeration to the upper and lower lobes,ARDS肺复张应用,Lung m
14、orphology pattern,Local DiffuseLIPNoYesNormally aerated 5512%24 12%Poorly aerated 23 8%40 12%Distribution modal BimodalUnimodalPeak of CT distr-727Hu/27Hu7HuCompltot57 546 11,Vieira SRR.AJRCCM,1999,159:1612,ARDS肺复张应用,Diffuse distribution,ARDS肺复张应用,ARDS肺复张应用,local distribution,内容提要,ARDS病理生理ARDS肺复张容积测
15、定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价VT和SI or Sigh对肺复张的影响 评价PEEP维持肺复张的作用指导PEEP选择,SI前后绵羊复张容积的变化,*,*,与SI前相比，*P 0.05,ARDS肺复张应用,SI有效组绵羊肺气体交换变化,*,*,与SI前相比，*P 0.05,ARDS肺复张应用,潮气量对肺复张的影响,A:PEEP=0,B:PEEP=Pflex,C:at the end of inspiration,D:PEEP=Pflex as in C during expiration,Pelosi P,Go
16、ldner M,Mckibben A,et al.Am J Respir Crit Care Med,2001,164,131-140,ARDS肺复张应用,小潮气量通气的局限性,Cretti S,Mascheroni D,Caironi P,et al.Am J Respir Crit Care Med,2001,164,131-140,ARDS肺复张应用,Mean Airway pressure 5 cm H2O,CT Scan:ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,Mean Airway pressure
17、 25 cm H2O,CT Scan:ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,Mean Airway Pressure 40 cm H2O,CT Scan:ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,不同VT的肺复张容积,*,*#,与6ml/kg组相比，*P 0.05;与10 ml/kg相比，#P 0.05,ARDS肺复张应用,内容提要,ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs Ro
18、ubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,PEEP效应的影响因素-附加静水压与心脏的影响,ARDS肺复张应用,Rothen H.et al.Br J Anaesth 1993:71:788-795,Re-expansion of atelectasis during general anaethesia,A:CT scan at level of right disphragm B:CT scan 5cm above right diaphragm,ARDS肺复张应用,PEEP诱导recruitmen
19、t的分布,Puybasset L.ICM,2000,26:1215c,In lower lobes:Alv recruitment(ml)=0.16 X End-expir lung volume(ml)24ml,ARDS肺复张应用,PEEP导致overdistention的分布,Volume of overdistension(ml)=0.42Parenchyma-900;-800(ml)18ml,Puybasset L.ICM,2000,26:1215c,ARDS肺复张应用,PEEP效应的影响因素-塌陷肺泡的分布范围,塌陷肺泡的范围Efficiency of PEEP-induced al
20、v recruitment highly correlated with the proportion of poorly and nonaerated lung parenchyma in ZEEP,Puybasset L.ICM,2000,26:1215,ARDS肺复张应用,Diffuse:Equal loss of aeration to the upper and lower lobes,Vieira SRR.AJRCCM,1999,159:1612,ARDS肺复张应用,Local:Loss of aeration predominating in lower lobes,Vieira
21、 SRR.AJRCCM,1999,159:1612,ARDS肺复张应用,Effect of PEEP on recruitment and overdistention,Puybasset L.ICM,2000,26:1215,ARDS肺复张应用,PEEP效应的影响因素-LIP的影响,ARDS肺复张应用,绵羊有无LIP组PEEP复张容积,ARDS肺复张应用,有无LIP患者的复张容积,*,*#,*,*#,与PEEP5 cmH2O相比，*P 0.05与PEEP 10 cmH2O相比，#P 0.05与LIP组比较，P 0.05,ARDS肺复张应用,Effect of PEEP on recruitm
22、ent and overdistention,In LIP/+:PEEP1=LIP+2,PEEP2=LIP+7.In LIP/-:PEEP1=10,PEEP2=15,Vieira SRR.AJRCCM,1999,159:1612,ARDS肺复张应用,PEEP-induced alv recruitment,16pat with ARDSLIS 3Csts 39(ZEEP)CT scan Over-1000-900 Normal-900-500 Low-500-100 Ate 100+100 PEEP 0 vs 15,Luiz M,Rouby JJ.Am J Respir CCM,2001,16
23、3:1444,ARDS肺复张应用,对象：17例稳定ARDS患者VT=6ml/kg,PEEP=10cm/H2O肺复张方法：ZEEP,SI(40cmH2O,40s)，VT=6ml/kg,PEEP=Pflex+2cmH2O,PCV，PIP=15+PEEP，调整PEEP为25、30、35、40、45cmH2O，CT比较非通气区变化结果：PaO2从ZEEP的92.3mmHg上升至394mmHg，非通气区从ZEEP的63.7%降至28.6%,VT-induced alv recruitment,ARDS肺复张应用,VT-induced alv recruitment,ARDS肺复张应用,内容提要,ARDS
24、病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择,PEEP的选择,氧分压导向性PEEP选择 PaO2 method DO2导向性PEEP选择肺复张容积导向性PEEP选择Recruitment volume method,ARDS肺复张应用,open,closed,closed?,open,open up!,find closed!,re-open!,keep open!,airway pressure,time,氧分压导向
25、性PEEP选择,ARDS肺复张应用,Vazquez de Anda et al.Acta Anesth Scand 1998:42:63-66,PEEP,PIP,ARDS肺复张应用,对象：17例ARDS患者，VT=6ml/kg,PEEP=10cm/H2OPEEP选择方法：PCV，PIP=15+PEEP，每2min调PEEP 25、30、35、40、45cmH2O，至FiO2为100%PaO2+PaCO2400mmHg，每15-20min降低PEEP，至PaO2较前一次降低5%,PEEP水平为前一次PEEP结果：PaO2+PaCO2从178.476.5mmHg升至487.8 139.1mmHg，
26、维持肺复张PEEP水平为224cmH2O,V.N.Okamoto et al.Unpublished data,2003,ARDS肺复张应用,氧分压导向性PEEP选择,V.N.Okamoto et al.Unpublished data,2003,ARDS肺复张应用,氧分压导向性PEEP选择,对象：47例早期ARDS患者，VCV，VT=8ml/kg，PEEP=10cm/H2O，RR20次/分，I：E=1：1分组与方法：ARM+PEEP组：ARM实施方法为逐步增加PEEP至15、20、25、30cm/H2O(extended sigh)，结束后PEEP设为15cm/H2O ARM组：ARM后PE
27、EP仍为10cm/H2O PEEP组：基础通气模式,Lim CM,Jung H,Koh Y,et al.Crit Care Med,2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,Lim CM,Jung H,Koh Y,et al.Crit Care Med,2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,Lim CM,Jung H,Koh Y,et al.Crit Care Med,2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,Lim CM,Jung H,Koh Y,et al.Crit Care M
28、ed,2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,DO2导向性PEEP选择,ARDS传统的通气策略-经验性PEEP缺点：缺乏科学依据ARDS肺保护性通气策略-最佳PEEP优点：获得最大的DO2，同时考虑PEEP 对循环和呼吸的影响，LIP+2cmH2O 为最佳PEEP,ARDS肺复张应用,邱海波,郭凤梅,周韶霞等.中华内科杂志,2001,9,PEEP不足大量肺泡难以复张,LIP：塌陷肺泡开始复张压力，不是全部塌陷肺泡复张压力,ARDS肺复张应用,LIPStart of recruitment,Recruitment occurs along the entir
29、e PV curve,even beyond UIP,Gattinoni L.AJRCCM,2001,164:131,ARDS肺复张应用,PEEP and Survoval,A post hoc analysis,53 patients,Barbas CSV,Medeiros DM,Magaldi RB,et al.Am J Respir Crit Care Med,2002,165:A218,ARDS肺复张应用,PEEP肺复张与低氧血症改善,Gattinoni L,Caironi P,Pelosi P,et al.Am J Respir Crit Care Med,2001,164:1701
30、-1711,ARDS肺复张应用,ARDS绵羊不同PEEP复张容积,ARDS肺复张应用,ARDS患者不同PEEP复张容积,*,*#,与PEEP5cmH2O相比较，*P 0.05;与PEEP5cmH2O相比较，#P 0.05;,ARDS肺复张应用,ARDS早期PEEP的调整 肺复张容积与DO2的结合,ARDS肺复张应用,不同通气模式对肺NF-B的影响,1、2、3、4、5和6分别为正常、ARDS、HVZP、LVBP、LVHP、NVBP组,1 2 3 4 5 6,基础研究,不同通气模式对肺TNF-mRNA表达的影响,1 2 3 4 5 6,1、2、3、4、5和6分别为正常、ARDS、LVBP、LVHP
31、、NVBP和HVZP组,基础研究,不同通气模式对肺组织TNF的影响,基础研究,不同通气模式对肺组织MPO的影响,与对照组比较，*P0.05；与ARDS组比较，P0.05，与LVBP组比较，P 0.05；与HVZP组比较，P0.05,基础研究,不同通气模式对肺组织MDA的影响,与对照组比较，*P0.05；与ARDS组比较，P0.05，与LVBP组比较，P 0.05；比较，P0.05,基础研究,Bedside assessment of lung morphology(PEEP=5cmH2O),Diffuse,Chest X-rayDiffuse Predominating/CT scan/White lungs in lower lobesSlope of PV 50ml/cmH2OLIP530cmH2OPEEP trial10-15-20-255-8-10-12,Local,总 结,ARDS肺复张应用,The Right PEEP level does not allow to reduce FiO2 bellow 0.6,Prone position trial.If failureiNO trial(5-10ppm).If failureIf failureECOM,ARDS肺复张应用,Thanks for your attention,
