ards患者的肺复张-北京协和医院

时间：2023-08-07

　　ARDS患者的肺复张北京协和医院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患者数潮气量病死率作者小潮气量对照小潮气量对照小潮气量对照P值Amato29246.1?0.2?11.9?0.5?3871<0.001Stewart60607.2?0.8?10.6?0.2?50470.72Brochard58587.2?0.2§10.4?0.2§47380.38Brower26267.3?0.1?10.2?0.1?50460.60ARDSnet4324296.3?0.1?11.7?0.1?31400.007Villar50457.3?0.9?10.2?1.2?34550.041ARDS的肺保护性通气策略小潮气量(6ml/kgIBW)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=PLx(V0/V)2/3F: 剪切力PL: 跨肺压V0: 最初容积V: 复张后容积如果: PL=30cmH2O,V0/V=1/10则:F=140cmH2OMeadJ,TakishimaT,LeithD.Stressdistributioninlungs:amodelofpulmonaryelasticity.JApplPhysiol1970;28(5):596-608小潮气量通气的问题LVt(n=15)CVt(n=15)PvalueVt,ml411?55664?84<0.01Vt,ml/kg6?110?1<0.01setPEEP,cmH2O10?410?4n.s.PEEPtot,cmH2O11?411?4n.s.Pplat,cmH2O23?830?10<0.01RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613小潮气量通气的问题LVt(n=15)CVt(n=15)PvaluePaO2,mmHg136?80156?82n.s.PaO2/FiO2,mmHg165?84183?83n.s.SaO2,%94.8?5.097.6?2.1<0.05PaCO2,mmHg60?3538?21<0.001pH7.21?0.17.36?0.1<0.001SBP,mmHg125?25121?20n.s.DBP,mmHg60?960?10n.s.HR,bpm101?1593?15n.s.RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613小潮气量通气的问题RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;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HicklingKG.Thepressure-volumecurveisgreatlymodifiedbyrecruitment.AmathematicalmodelofARDSlungs.AmJRespirCritCareMed1998:158:194-202.JonsonB,RichardJC,StrausC,ManceboJ,LemaireF,BrochardL.Pressure–VolumeCurvesandComplianceinAcuteLungInjury:EvidenceofRecruitmentAbovetheLowerInflectionPoint.AmJRespirCritCareMed1999;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0102030405005101520253035404550OpeningpressurePaw(cmH2O)CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed2001:164:131-140.ClosingpressureARDS的肺开放EditorialOpenupthelungandkeepthelungopenB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands (1992)18:319-321 RM能够使肺开放RM:PIP45cmH2O,PEEP35cmH2Ox1minHalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626肺复张能够改善ARDS氧合LapinskySE,AubinM,MehtaS,BoiteauP,SlutskyAS:Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure.IntensiveCareMed1999,25:1297-1301.肺复张的各种方法CPAP(SI)incrementalPEEPPCVSigh(modified)HFOV俯卧位…SI改善氧合TugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed2003;31:738-744SustainedInflation:45cmH2Ox30sSI改善氧合FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed2005;33:181-188SustainedInflation:30cmH2Ox30sTwicewith1mininterval叹气的设置LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260充气阶段,每30秒PEEP增加5cmH2OVt减少2ml/kg前2次呼吸除外直至Vt2ml/kg,PEEP25cmH2O暂停阶段CPAP30cmH2Ofor30s放气阶段叹气改善氧合LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260叹气对氧合及呼吸力学的影响PelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880Sigh:3consecutivesighs/minatPplat45cmH2O叹气的设置PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh= 1.2xPIPpsvor 35cmH2OTi,s=3–5sf=1bpm叹气改善呼吸

　　力学及氧合PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94ARDS对RM的反应VillagraA,OchagaviaA,VatusS,MuriasG,FernandezMF,AguilarJL,FernandezR,BlanchL.RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome.AmJRespirCritCareMed2002;165:165-170肺复张–CT的提示HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GüntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359肺复张–CT的提示HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GüntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;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RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80RMvs.PEEPLimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;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?baseline3minpost-RM30minpost-RMPaO2/FiO2(mmHg)139?46246?111138?39PaCO2(mmHg)48.6?12.147.6?1346.4?12SvO2(%)70.4?6.172.4?5.670?6.2Qs/Qt(%)30.8?5.821.5?9.729.2?7.4Crs(ml/cmH2O)34.1?12.636.9?15.135.7?13.5OczenskiW,H?rmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology2004;101:620-5为什么肺复张作用不能持久?肺复张的方法?SI:50cmH2Ox30s作者认为OczenskiW,H?rmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology2004;101:620-5RM+PEEPvs.RMvs.PEEPLimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418RM+PEEPvs.RMvs.PEEPLimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418RM+PEEPRMonlyRM后的PEEPRM后的PEEP能够稳定肺泡HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626RM后的PEEP能够稳定肺泡RM:PIP45cmH2O,PEEP35cmH2Ox1minPEEP5cmH2OPEEP10cmH2OHalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626肺泡稳定能够改善PaO2McCannUG,SchillerHJ,GattoLA,etal.Alveolarmechanicsalterhypoxiculmonaryvasoconstriction.CritCaremed2002;30:1315-1321RM后的PEEPLimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377RM+PEEPvs.PEEPonlyLimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377RM+PEEPPEEPonlyPEEP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20cmH2O然后将FiO2减小到最低水平维持SpO290–95%每20–30分钟降低PEEP2cmH2O直至患者SpO2下降PEEP的设置氧合下降前的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15–20cmH2O之间某些患者<15cmH2O其他患者>20cmH2OPEEP的设置如果将PEEP设置于20cmH2O后,仍发现PaO2/FiO2显著下降按照最初的PEEP设置25cmH2O重复肺复张然后按照上述方法调节FiO2和PEEPPEEP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TugrulS,CakarN,AkinciO,OzcanPE,DisciR,EsenF,TelciL,TAkpir.Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend-expiratorypressureinacuterespiratorydistresssyndrome.CritCareMed2005;33:995-1000=LIP+2肺复张后氧合

　　稳定所需时间TugrulS,CakarN,AkinciO,OzcanPE,DisciR,EsenF,TelciL,TAkpir.Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend-expiratorypressureinacuterespiratorydistresssyndrome.CritCareMed2005;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:Vt10ml/kg,f20bpm,I:E1:2,FiO20.5肺复张:OdenstedtH,LindgrenS,OlegardC,ErlandssonK,LethvallS,AnemanA,StenqvistO,LundinS.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed2005;31:1706-1714ModefVt/PCPEEPI:ETimeRptViCMCPAP4030”3PCRMPCV2020201:130”3SLRMVCV2010151:215’每分钟2次将吸气末暂停延长至7s不同RM方法的比较OdenstedtH,LindgrenS,OlegardC,etal.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed2005;31:1706-1714SLRMPCRMViCM不同RM方法的比较OdenstedtH,LindgrenS,OlegardC,ErlandssonK,LethvallS,AnemanA,StenqvistO,LundinS.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed2005;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OdenstedtH,LindgrenS,OlegardC,ErlandssonK,LethvallS,AnemanA,StenqvistO,LundinS.Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects:evaluationofrecruitmentmaneuversusingelectricimpedancetomography.IntensiveCareMed2005;31:1706-1714不同RM方法的比较LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377Sustainedinflation45for40sIncrementalPEEPPIP35,PEEP8-35PCVPIP45,PEEP16I:E1:2,2min对于VILI模型PCV是最佳的RM方法其他模型结果相似PEEP8PEEP12PEEP16LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;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(pH1.5)吸入机械通气:Vt 6ml/kgPEEP 5cmH2OFiO2 1.0F 60–70bpm复张操作:30cmH2Ox30sx2间隔1分钟FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed2005;33:181-188RM保护肺内皮而非肺泡上皮FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed2005;33:181-188RM:ARDS早期vs.晚期VillagraA,OchagaviaA,VatusS,MuriasG,FernandezMF,AguilarJL,FernandezR,BlanchL.RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome.AmJRespirCritCareMed2002;165:165-170原发性ARDS对RM反应不佳SalinelavageOleicacidinjuryPneumoniaVanderKlootTE,BlanchL,YoungbloodAM,WeinertC,AdamsAB,MariniJJ,ShapiroRS,NahumA.RecruitmentManeuversinThreeExperimental:ModelsofAcuteLungInjuryEffectonLungVolumeandGasExchange.AmJRespirCritCareMed2000;161:1485-1494SustainedinflationCPAP40/30CPAP60/30CPAP60/30油酸损伤模型RM作用短暂LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377PEEP8PEEP12PEEP16不同病因对RM的反应LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377RM+PEEPPEEPonlyRM:ARDSp与ARDSexpLimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418SI改善氧合TugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed2003;31:738-744SustainedInflation:45cmH2Ox30s叹气:ARDSp与ARDSexpPelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880Sigh:3consecutivesighs/minatPplat45cmH2O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不增加肺泡过度膨胀BugedoG,BruhnA,HernandezG,etal.Lungcomputedtomographyduringalungrecruitmentmaneuverinpatientswithacutelunginjury.IntensiveCareMed2003;29:218-225肺复张对内脏血流的影响NunesS,RothenHU,BranderL,TakalaJ,JakobSM.ChangesinSplanchnicCirculationDuringanAlveolarRecruitmentManeuverinHealthyPorcineLungs.AnesthAnalg2004;98:1432-8肺复张对胃肠道血流的影响ClaessonJ,LehtipaloS,WinsoD.Dolungrecruitmentmaneuversdecreasegastricmucosalperfusion?IntensiveCareMed2003:29:1314-1321肺复张对脑氧代谢的影响BeinT,KuhrLP,BeleS,PlonerF,KeylC,TaegerK.Lungrecruitmentmaneuverinpatientswithcerebralinjury:effectsonintracranialpressureandcerebralmetabolism.IntensiveCareMed2002;28:554-558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开放压与闭合压0102030405005101520253035404550OpeningpressurePaw(cmH2O)CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed2001:164:131-140.Closingpressure即使使用足够的PEEP也不能使所有肺单位开放RM对哪些患者疗效好?尚不清楚肺复张对哪类患者疗效更好肺复张对早期ARDS/ALI患者的效果更显著随着ARDS的进展,肺进入纤维增殖期肺复张就无法有效改善氧合气压伤的危险反而增加RM对哪些患者疗效好?ARDS的病因继发性ARDS(全身性感染,创伤等)比原发性ARDS(肺炎)更容易复张目前的推荐意见在ARDS/ALI病程早期进行肺复张无论ARDS的病因如何肺复张操作的频率尚不清楚对某一患者进行肺复张操作的适宜频率以下情况应进行肺复张操作病程早期当肺泡塌陷时例如呼吸机脱开肺复张操作的频率对于ARDS患者脱离呼吸机能够导致肺泡迅速塌陷,从而发生严重的低氧血症为避免呼吸机脱开,建议采用密闭吸痰装置特殊雾化装置肺复张操作的频率肺复张操作当观察到SpO2持续降低(>5min)时如果没有观察到氧合下降,则需要每日进行一次或两次肺复张未知总结肺复张是肺保护性通气策略的重要组成开放肺并维持肺开放是其理论基础应用气道高压使塌陷肺泡开放应用足够的PEEP维持肺泡开放肺复张对循环的影响肺复张尚未解决的问题压力时间频率适应症PEEP能否使肺复张?PEEP能够防止肺泡塌陷(derecruitment)低水平的PEEP只能使很少的肺复张对于ARDS,将压力持续维持在常用的PEEP水平(<20cmH2O)只能使小部分肺组织复张PEEP能否使肺复张?ARDS患者的肺复张贯穿于整个吸气过程byHicklingAJRCCM1998TidalrecruitmentoccursbelowoptimalPEEP,PEEPattheoptimallevelgenerallyresultsinadecreasedquasi-staticcompliancewhenmeasuredontheventilatorbyJonsonetalAJRCCM1999肺复张所需的压力正常潮气量通气也能使肺组织复张但是,大部分肺组织可能仍未充分复张在有限的吸气时间内在目标气道峰压水平由于塌陷肺泡表面液体的粘滞性这些肺单位较高的表面张力间质组织的限制塌陷的肺组织需要较高的气道压力和较长的时间才能复张Howhighapressure?

　　Howlongatime?-healthylungtranspulmonarypressureof30cmH2OtorecruitatelectatichealthylungsGreavesetalJAP1990peakalveolarpressuresof40cmH2Ofor7to15secondstorecruitlungsofpreviouslyhealthynormalpatientsfollowing20minutesofgeneralanesthesiabyRothenetalBrJAnaesth1993,1998resolutionofatelectasisduringa40cmH2ORMhasatimeconstantof2.6secRothenetalBrJAnaesth1999Howhighapressure?

　　Howlongatime?-healthylungAsaresultinpreviouslyhealthyindividualsthevastmajorityofatelectasiswouldberecruitedwithinabout7-8secHowhighapressure?

　　Howlongatime?-animalpeakairwaypressuresof55cmH2Ofor5–10mintoopencollapsedlunginaporcinemodelofARDSSjosrandetalICM1995tomaximallyrecruitlunginasheepsalinelavagelunginjuredmodel40cmH2OPEEP,20cmH2OPC,Ppeak60cmH2O,I:Eof1:1,andarateof10bpmfor2minutesFujinoetalAJRCCM1999Howhighapressure?

　　Howlongatime?-animalanimalsrecruitedwith40cmH2OCPAPfor60secnotmaximallyrecruitedtofullyrecruitthelungmultiple(2-3)RMsrequiredevenatpeakpressuresof60cmH2OHowhighapressure?

　　Howlongatime?-patientpeakairwaypressureof46cmH2OtorecruitcollapsedlunginARDSpatientsGattinonietalAJRCCM198635–40cmH2OCPAPfor30–40secpriortoestablishingalungprotectiveventilatorystrategywhenevermechanicalventilationwasdisruptedAmatoetalNEJM1998Howhighapressure?

　　Howlongatime?-patientInapatientwithsepticARDSinitialrecruitmentmaneuverswith40cmH2OCPAPfor40secfailedPEEP40cmH2OPEEPandPCV20cmH2OatanI:Eratioof1:1witharateof10bpmfor2minutestofullyrecruitthelungMedoffetalCCM2000Howhighapressure?

　　Howlongatime?-patientThesuccessofPCvsCPAPintheexamplesemphasizetherelationshipbetweenpressureandtimeFujinoetalAJRCCM1999MedoffetalCCM2000TheoptimalrelationshipbetweenthesetwovariablestomaximizeefficacyandmaintainsafetyremainsunclearMechanismoflungrecruitmentFirst,theairwaysmustbeopenedinordertorecruitcollapsedlungAirwayopeningoccursbyeithermovingthemeniscusformedbyfluidliningtheairwaytowardtheperipheryorovercomingtheparenchymatetheringpresentinactualcollapsedairwayMechanismoflungrecruitmentSecond,thecollapsedalveolimustbeopenedcollapsedinjuredlungunitswithincreasedsurfacetensionrequireveryhighpressurestoestablishsufficientlateralstresstoopenthelungMeadetalJAP1970WhatisclearisthattheoptimalmethodoflungrecruitmentinsuringmaximalefficacyandsafetyhasnotbeendeterminedSideEffectsofRMshemodynamiccompromisedelayeduntilpatientshemodynamicallystabledevelopmentofbarotraumathebenefitsandpotentialrisksmustbecarefullyweighedinpatientswithpreexistingpulmonarycysticorbullouslungdiseasepreexistingairleaksMonitoringofPatientsarterialpressurepulserateandrhythmSpO2ifcompromisedevelopstherecruitmentmaneuverabortedPerformanceofaRMFIO2increasedto1.0for5-10minutesbeforeRMsedationgenerallyrequiredtoinsurepassiveinflationduringtherecruitmentperiod30cmH2OCPAPfor30-40secduringthefirstRMfollowedbycarefulassessmentoftheresultsPerformanceofaRMIftheresponseisinadequatebutpatienttoleranceisgoodRMshouldberepeatedin15-20minutesatahigherCPAPlevel(35-40cmH2O)IftheresponsetothesecondRMisinadequateathirdRMat40cmH2OCPAPshouldbeperformedPerformanceofaRMCPAP40/60PCV(2min)PC 20PEEP 40F 10I/E 1:1PCV(30min)PC 15PEEP 20F 20I/E 1:1FujinoY,GoddonS,DolhnikoffM,HessD,AmatoMBP;KacmarekRM.Repetitivehigh-pressurerecruitmentmaneuversrequiredtomaximallyrecruitlunginasheepmodelofacuterespiratorydistresssyndrome.CritCareMed2001;29:1579-1586PerformanceofaRMwhethertousepressuresbeyond40cmH2Ostillunclearanimaldataimplythatpressuresupto60cmH2OaresafethoughthesepressuresmuststillbeconsideredexperimentalandappliedverycautiouslyunderwellmonitoredconditionsFujinoetalAJRCCM1999PerformanceofaRMIfaCPAPof40cmH2Ofor30-40secinsufficienttorecruitthelungPCV20cmH2OwithPEEP30cmH2O,I:E1:1;rate10/minfor2minIfthisisineffectivePCV20cmH2OwithPEEP40cmH2O,I:E1:1,rate10/minfor2minasmalldropinCOandanincreaseinPAPinsomeanimals,withacompletereturntopreRMhomodynamicstatuswithin10mininallanimalsstudiedFujinoetalAJRCCM1999WhatisSuccessfulRecruitment?PaO2/FIO2ratio>300mmHgTheP-VCurveOntheinflationlimbofthecurvelowerinflectionpoint(Pflex)aregionofchangingslopeinearlyinflationwherelungrecruitmentbeginstheminimalPEEPnecessarytopreventpartialderecruitmentofthelungduringexhalationTheP-VCurveOntheexpiratorylimbthepointofmaximumcurvature(PMCEX)theareawherethemaximumvolumechange/unitpressureoccursduringexhalationthemaximumPEEPrequiredtopreventderecruitmentTheP-VCurvethesetwo“points”identifytherangeofPEEPneededinARDSPflex =theminimumPMCEX =themaximumIdeally,acompleteP-VshouldbepreformedonallpatientsidentifyingthesepointstoallowaccuratesettingofPEEPRM后的PEEP影响PaO2LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitme