肺复张术与PEEP调定课件.ppt

Recruitment Maneuver & PEEP Titration 肺复张术与PEEP调定,Ventilator Induced Lung InjuryVILI,Overdistention Barotrauma Volutrauma Recruitment/Derecruitment Injury Translocation of Cells Biotrauma,Overdistention Barotrauma & Volutrauma,Vt too highPplateau too high,VILI： Recruitment/Derecruitment Injury,PIP=14, PEEP=0PIP= 45, PEEP=10PIP= 45, PEEP = 0Webb556,Biotruama?,Protect the lungs? How?,PEEP=? RM ? Pplateau=? VT=? PIP=? Mode ?,PV curve (static),P-V curve Methodology,The supersyringe technique,Recruitment Maneuver and PV curve hysteresis,Airway Pressure cmH2O,%,Opening and Closing Pressures,0,5,10,15,20,25,30,35,40,45,50,0,10,20,30,40,50,5 patients,ALI / ARDS,Am J Respir Crit Care Med Vol 164. pp 131140,2001,Marini & Gattinoni,Recruitment maneuver is needed,Methodology Sustained inflation Stepwise Recruitment Strategy Pressure control with prone position, with HFOV, et al Titrating PEEPdeflex after RM PV curve (looking for Pdeflex) Oxygenation (PaO2 drop 10%),Amato: 2004 China,FULL RECRUITMENT: PaO2 + PaCO2 400 mmHgFiO2=100%,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”,Titrating PEEP fellowing RM,Pdeflex + 2cmH2O, (PV 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,Pflex,“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,PEEP / FIO2 target ( 814 cmH2O)PEEP at PFLEX ( 1418 cmH2O)PEEP enough to fully avoid airway collapse ( 1626 cmH2O),Amato: 2004 China,ARDSnet,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,Lapinsky ICM 1999;25:1297,Titrating PEEP fellowing RMAccording to oxygenation,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. 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 is probably a useful tool,Hickling K. AJRCCM 2001;163:69-78.,Hickling K. AJRCCM 2001;163:69-78.,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 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,Crit Care Med 2007 Vol. 35, No. 1,Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental studyEight healthy pigsLung lavagesCT slices were obtained 2 cm cranial of the right diaphragmatic dome,Protocol,Result,CONCLUSIONS,dynamic compliance identified the beginning of lung collapse in a pig model.the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying the level of PEEP that prevents end-expiratory lung collapse？,Clinical Observation,Clinical Observation,急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南（2006）中华医学会重症医学分会,推荐意见8：可采用肺复张手法促进ARDS患者塌陷肺泡复张，改善氧合。（E级） 中国危重病急救医学，2006；18（12）：706,Recruitment Maneuver,Massachusetts General Hospital,Performance of RM MGH,Set FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple RMs,Performance of RM 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,Monitoring during RM (MGH),The RM should be aborted if:MAP 20 mmHgSpO2 130 or 60/ minuteNew arrhythmias,RM in our ICU,Hypoxia after CPB & open heart surgery 17 pts Male 11，female 6 Age：4669 Trauma or sepsis ARDS 22 pts (early ARDS) Male 15，female 7 Age：1359 Legionnaires Disease 1 pt, female, 26 y o MSOF/ARDS， PaO2/FiO2 = 49/0.85 All pts were refractory hypoxia with conventional mechanical ventilation PaO2/FiO2: 57.6166mmHg,Method,Invasive artery pressure applied continuously to all cases Continuous SpO2 Continuous CVP Sedation applied to Ramsay 34 Pre-existed barotrauma excluded Emphysema excluded,Protocol,Mode: PEEP+PCV or PEEP+PSV PEEP: increment 23 cmH2O Interval: 12 min PEEP target: 16/1st RM, 20/2nd RM, 2630/3rd RM PIPmax: 40 cmH2O Abort if ABP or SpO2 start fall Rest interval: 1530 min May repeat twice a day Titrating PEEP by oxygenation after RM,Result,Hypoxia after CPB & open heart surgery Responsive: (16/17) 94.1% (PaO2/FiO2 improve20%) PaO2/FiO2 improve：92%27% No barotraumaTrauma or sepsis ARDS (early ARDS) Responsive: (18/22) 81.8% PaO2/FiO2 improve: 71%26% No barotrauma Legionnaires Disease 1 pt, nonresponsive, RM only one time Severe subcutaneous emphysema,Subcutaneous emphysema,ECMO on ARDS,APRV,Result,Hypoxia after CPB & open heart surgery All pts appeared obvious ABP drop in 1st RM SpO2 drop together with ABP drop ABP drop occurred at PEEP1216 at 1st RM Pts tolerance improved in later RMsTrauma or sepsis ARDS 12/22（54.5%）appeared ABP drop at 1st RM SpO2drop with ABP drop Pts tolerance improved in later RMs,