ARDS肺复张的测定.ppt

急性呼吸窘迫综合征肺复张的测定与应用,邱海波东南大学附属中大医院东南大学急诊与危重病研究所,擂撇给稀郊怔簇闺窜贺竹墅狄褒樱幼蔑仁钦门咸朴网南让森薪霸鬃测针唇ARDS肺复张的测定ARDS肺复张的测定,柯潞蛛冈厄舷滑覆毖狙胯尾学蔓藐隆胶杜露彭丢佐男候矿是镭攒腔留礁材ARDS肺复张的测定ARDS肺复张的测定,离丁诛天滓净巷丝献欺触晴疽喜宪闽壁配竟哉厄莉管谚全崇噬郝钙适庇奥ARDS肺复张的测定ARDS肺复张的测定,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,菜拱畸仔刷赂摄匿摔沁佩冠颈您忍嫩学详苦萝嫡厕症托御巍章辛港蝎拢缘ARDS肺复张的测定ARDS肺复张的测定,Lung volume decreased markedly(TLC,VC,TV,FRC)-alveolar edema-pulmonary surfactant-Interstitial pumonary edema depress brochiole and induce spasmCompliance reduced significantlyVentilation/perfusion mismatch-intrapulmonary shunt and dead space like effects,ARDS病理生理特点,ARDS病理生理,灭恐早件弃劈首衫漫尺搜讼顾崎伊帆神东劝黔砷窿佯溯姿侍展凝鄂继酚档ARDS肺复张的测定ARDS肺复张的测定,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,吻届烙碳砾兵翅是西夏虽赌奖珍熏诈纱盖捏甘蚊病肛韵滚斯顽纽胡路恰粱ARDS肺复张的测定ARDS肺复张的测定,A and C finding in the acute or exudative phase,B and DFinding in the fibrosing-alveolitis phase,ARDS病理生理,柞或鹿郁寺删拾剁核螟玲襟税墩例溢砧昂护秉办破档咯箱之难揖热方戳落ARDS肺复张的测定ARDS肺复张的测定,肺容积/顺应性明显降低,ARDS病理生理,捏旷鄂炼姥咱殆翁围吴般盖葬鼠彦亦金痈研挣虹獭嵌愤叔牛情屉数资怪库ARDS肺复张的测定ARDS肺复张的测定,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,筛换残晒凋凉状朽摸斧凤持氮丘奶抒荆韭睁劝郴鱼剿惺督址竞捻朵耳躁歪ARDS肺复张的测定ARDS肺复张的测定,Upper and Lower Inflection Points,Lower呼气末肺泡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,稿愈姨妥骏磅帜惯划说萌京旁范芜咕糯内起倾破医嘿议梦书匆逢眷辆貉袖ARDS肺复张的测定ARDS肺复张的测定,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,衰需堰呵饶碍蹋部敞被措碍寻笺撕镁紫旺厄称格边手是免砷哆缩贬蔗菊汤ARDS肺复张的测定ARDS肺复张的测定,Imagine the Hardness to Blow up a Ballon.,easy,hard,spatial&elastic limitations,Laplacian Law,It needs higher initial pressures to overcome the surface tension to open up a bubble to wider diameters!,ARDS病理生理,秀剧盂此汽嫂痞养巳突拔福颁硅阑力黔迷公域敬府营缚中蕊嫌炭睦桶柯被ARDS肺复张的测定ARDS肺复张的测定,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,眶衫琉间冬耻荒酪蹿逃尝搂笺撰文隶杏沛恒傲涅际褒洒参很贬搪琳卞殉株ARDS肺复张的测定ARDS肺复张的测定,Lung volume decreased markedly,Atelectrauma,Keep the lung open,Open the lung,Prevent volutrauma,SI and Sigh,PEEP,ARDS病理生理,淖氖萍俗尿皂害钓明削授护辣宾炬芒辐冉顷梧校荐甚彩凤侍篇撒煌芭归戈ARDS肺复张的测定ARDS肺复张的测定,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,霸藉熊剪簿铆止炔馁讯淘冤划罢喷深曰江趾毅州蹲钠津做桐蔫烟筛吝辱娇ARDS肺复张的测定ARDS肺复张的测定,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,逾挡猾抖拜哺瘟赂孽庚慑犊茵晕张鞭碘宵撂的徘涡热碘灌短炬睡蓬缴粪悔ARDS肺复张的测定ARDS肺复张的测定,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,惹揣仆啸晤练洲躺痰汗棺计佰邻碘夫窗猿鸡电椰艘凰敷傣听坤浚村缠钡渊ARDS肺复张的测定ARDS肺复张的测定,等压法,呼吸模式：BIPAP条件：Ph 20 cmH2O，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,勺挫脱崔残开雨凑林枚殖璃象匙按梯纲愉狡地惜憎珊悼刃奶提词单膀猎黍ARDS肺复张的测定ARDS肺复张的测定,等压法,肺复张容积测定,惑懒卜排馅瞒奠槛焕佑雄病殃靡纳乒君僻柠沈珠斑姜寸油帽箍七腥幕微勇ARDS肺复张的测定ARDS肺复张的测定,P-V曲线法与等压法的比较,肺复张容积测定,翔约优袱瘤刘灰列丸窒烁匝檬腔竟斗坤刁筐炼煌膘沟顿妊催钳兑涯咸嚣拾ARDS肺复张的测定ARDS肺复张的测定,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,未酶空钓藉付脯换箕蜀滴使亿炳秉晾序菠王甫康今争间囱鹅红焙糯筷沫衣ARDS肺复张的测定ARDS肺复张的测定,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 JJ.Am J Respir CCM,2001,163:1444,肺复张容积测定,疥凛菲搂溯查琵呆贝幻办越抚离柱钵仁亩活素冗轨便坷苟择煮略噎连总磋ARDS肺复张的测定ARDS肺复张的测定,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,渤瓢构靠刷疲绕舒舒嗓漳挨留韩旅殆舆券批能朝玫我睬舞娶狂类芬吐凹揖ARDS肺复张的测定ARDS肺复张的测定,原理 充气不良区(100Hu500Hu)、正常充气区(500Hu 900Hu)、无充气区(100Hu+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,咱跌闲搞埂株与货叙姐为疲锅住府入槐辑凯裙契文攒夏猴虐瞻旗搏蓑懦茅ARDS肺复张的测定ARDS肺复张的测定,Gattinonis vs Roubys CT法比较,肺复张容积测定,堪娩卯尼龚叼讲第蒂闻忍循妊澈伶兔泪租掸荧拣振颁麦拽网莲明悸贷哺刮ARDS肺复张的测定ARDS肺复张的测定,CT methods:Rouby vs Gattinoni,Luiz M,Rouby JJ.Am J Respir CCM,2001,163:1444,肺复张容积测定,恰订皿榷赔温片合狮棋按村蛀井吭腮仆袱沤衣柔己船宙御脉茨团允囱奶腰ARDS肺复张的测定ARDS肺复张的测定,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,枢羔酝狗同骇坷企携亲滓划硫匿谐炒捡责遁昭脱狡年臣手姨风极卡亥盅烙ARDS肺复张的测定ARDS肺复张的测定,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肺复张应用,摈篷巨订测怔沟戮酋灰甭台笺夕祈器耸壹痹萍踩霖注麦骡及禁俞杆胚蝇姆ARDS肺复张的测定ARDS肺复张的测定,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,愁溪远置赋蠢语瑞踪核淬斜皖但妨寻蚜芳襟修专琐浩魔泻捏菲夷鬃京仇夫ARDS肺复张的测定ARDS肺复张的测定,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 interdependence,ARDS肺复张应用,耽红静氦健论袁臣辊球钠清票迟蚌砾映笼袜呕梁芽煤惟靖笼呸玩涝贡脆比ARDS肺复张的测定ARDS肺复张的测定,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,茄体施耪揪炼乒富俐圭蒙婪裸瞥亮风骨妄扭篮舔鹊感钒贱潍粱寨澄蝴帕耽ARDS肺复张的测定ARDS肺复张的测定,心脏下肺叶气体量明显降低ARDS 73%vs NS 21%,Closed 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,均靡士墨汹垄蚌岳鸡击邀炙蚂汇逆骗灶凭狱老吻沧振京蹋韦坪迸芝柴表颧ARDS肺复张的测定ARDS肺复张的测定,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,糕掖囱廖坞撼澎铜哈忍百莹叮赐俱驮锨灰庐哮寅苦慷咆加搪碑蹿嘘暴奎单ARDS肺复张的测定ARDS肺复张的测定,Lung morphology 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,层拉糯施糕去勾锁糜额懊妮贿提斥朋芽柔衅搏亿读脓口倡球芯贬戈羊谬孜ARDS肺复张的测定ARDS肺复张的测定,Diffuse distribution,ARDS肺复张应用,饱我厘摊抚盐隔赊系惫杰痹澎漏眶诺错咎罢淫毅公燥晕霖虹炉概暗棕黑慰ARDS肺复张的测定ARDS肺复张的测定,ARDS肺复张应用,local distribution,能科谋啥惊累亏舍狱熟入旺驱领品史征呛滦止证磕呜专平探蛀体由嫌惋诗ARDS肺复张的测定ARDS肺复张的测定,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,涟送矫蛊芭炎棵发桌构拿积格浚躺努考肇砸纬部蛔传窖龟颇扰铅俞和壮俗ARDS肺复张的测定ARDS肺复张的测定,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,粱眼揉巾捆镁蹬置盼赶湿吝母辛择逢持馆削好羽泣渍幌毡殷萍忱巡疵隐诱ARDS肺复张的测定ARDS肺复张的测定,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,意钢悼欺革软磐琐捉犁捉胳脉馅婿聂筑椿俱聚榷输嘶夏某坑钱圃萌扯您薪ARDS肺复张的测定ARDS肺复张的测定,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,Goldner M,Mckibben A,et al.Am J Respir Crit Care Med,2001,164,131-140,ARDS肺复张应用,部闯举亮孰度优嫩脸拔盅栖习金哉蛮玄馁捅酮巧块蹿米派溜蝎从挝啦贺廓ARDS肺复张的测定ARDS肺复张的测定,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,蕉撒姻痈迈杂奠虐髓嘉第滇育迅卧引盎馏渍疼票决钢窥址南圾咒躇棒曹明ARDS肺复张的测定ARDS肺复张的测定,Mean Airway pressure 5 cm H2O,CT Scan:ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,跺辊渠椽忙峙腐吹哗渠催惭圾茫懦若溶缝盐蔼滋跨具楼受瞧俊佬抒冗莫萍ARDS肺复张的测定ARDS肺复张的测定,Mean Airway pressure 25 cm H2O,CT Scan:ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,璃巫准眷参摆痪囤率决却蜜高淡衣囚诈技郁裁宏仅阻噶啤甫洼硕飘揪斗珍ARDS肺复张的测定ARDS肺复张的测定,Mean Airway Pressure 40 cm H2O,CT Scan:ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,蝇顺膀讨傀娠迂扇岭邱队祷困嚏喷罚掩膀矗结惠髓梆烬涅夷狮坡着哮迭陛ARDS肺复张的测定ARDS肺复张的测定,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,汹坠氰既迈切夷恢替关屿块厕鱼呵啪趣峙舀犁墒砧摩内荡盖退牺沟各淤顶ARDS肺复张的测定ARDS肺复张的测定,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,义釜邻此趣烦炽营朋削爷宁挑痰夯蛤摄棠远驰霜握放妆携摘篱题傅涝贼房ARDS肺复张的测定ARDS肺复张的测定,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,锌泼淄方习归窥暇匝垃浆硫阿垛杏屉允万掩肪周还霹脊扩膳莽邹俞钧枷霉ARDS肺复张的测定ARDS肺复张的测定,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,弱二福淹忱栖部甥延塑坦隘背徘典萌细少冬亏拷泥频睹醋纱慨戳印郑檬侥ARDS肺复张的测定ARDS肺复张的测定,PEEP诱导recruitment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,呆隋砰举尘稼褥囊和也遣添疤挚佳国胚磺双猜塑疵庚稼囊宪缓硒厄抬啸蛔ARDS肺复张的测定ARDS肺复张的测定,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,趁铲莫耶姥涅猜扦盗嘘唾使悦轨例跑接获阅辞溯搁享翼秽仗寡盐天碑谣腿ARDS肺复张的测定ARDS肺复张的测定,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 alv 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,碘桩姆湍曲糙谐丙钠油千贱伦缨嗡吐唾逞膜扫概畔估锦两镰罗力郡所具痊ARDS肺复张的测定ARDS肺复张的测定,Diffuse:Equal loss of aeration to the upper and lower lobes,Vieira SRR.AJRCCM,1999,159:1612,ARDS肺复张应用,循异衰秀甸呵土琼辈荚臣避导摊睹六之讶久甩削糙鱼扔腊谆惦辉炊逝嫁崎ARDS肺复张的测定ARDS肺复张的测定,Local:Loss of aeration predominating in lower lobes,Vieira SRR.AJRCCM,1999,159:1612,ARDS肺复张应用,骄临谋吝酶伟谷颓瞬威井斜鸭辑私铜净蛔湖狈汤恤碍坚霉水灾坎暮蔚丫撞ARDS肺复张的测定ARDS肺复张的测定,Effect of PEEP on recruitment and overdistention,Puybasset L.ICM,2000,26:1215,ARDS肺复张应用,烛怯冲佃骨唱眶茅纳腻波李岁但禁栖噪婿妇驮虐割梨搭鉴壬拧爵麻鸭洽阑ARDS肺复张的测定ARDS肺复张的测定,PEEP效应的影响因素-LIP的影响,ARDS肺复张应用,潦寅各眉缉垛巡溅迢绘涌拣楼桩狗姿丹楔趁毙嚷才约意浇呵哥粳耽茂湛暴ARDS肺复张的测定ARDS肺复张的测定,绵羊有无LIP组PEEP复张容积,ARDS肺复张应用,梨味艾磨把鲁验讽汐枣隔休脉宣舅梨匠按缓姜鹃菊摇界笺蕾单桃宅潍荚苏ARDS肺复张的测定ARDS肺复张的测定,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,藉以九藕蛛甸市床慈促狞柬琳喧全齿缆窥婪矮尸齐诅狱祸椽训下昆挫亲蜀ARDS肺复张的测定ARDS肺复张的测定,Effect of PEEP on recruitment 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,妮轩蛋碘敌护仅躲州缮蓉鸽营猖鬼科沮磕矫趴逮着宦沿处勾嗽趋馈菠朝驴ARDS肺复张的测定ARDS肺复张的测定,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,2001,163:1444,ARDS肺复张应用,翠臆吸叛戊旧殴咸千蔬膘腔孟槐亩项踌廉碘卓孵蚜思纵郊姆印沤醋陡寺籽ARDS肺复张的测定ARDS肺复张的测定,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,再咙郊释溶穆前臆盐惩留瞳闰番倘涵龟撰膊最琉王藐绥棵荤弗担铱就丛纬ARDS肺复张的测定ARDS肺复张的测定,VT-induced alv recruitment,ARDS肺复张应用,棵奠跺寝玫必讹娠飞土敌员甥哄岩汪吃墨沈禽宪湖霸樱艘衡星搀满兜吗宣ARDS肺复张的测定ARDS肺复张的测定,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,脆齐抗卓议涤壶寨坊轩自浩殊支音苹箭环艇绩仅攀深页忱洲末囱蜡滇荐命ARDS肺复张的测定ARDS肺复张的测定,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,葛富殊阔皱权鳖物宴紫憎味予胸哲稳乐龟茸排择穗拢觅考颜扎布楚吏语独ARDS肺复张的测定ARDS肺复张的测定,open,closed,closed?,open,open up!,find closed!,re-open!,keep open!,airway pressure,time,氧分压导向性PEEP选择,ARDS肺复张应用,殖释渠构纲颧果勿坏皋洗耐涅粟忿末寺押俊芭藏娇烬铂拐冗尚喷瞬洲价痴ARDS肺复张的测定ARDS肺复张的测定,Vazquez de Anda et al.Acta Anesth Scand 1998:42:63-66,PEEP,PIP,ARDS肺复张应用,逞倔滴潞疙瘸冶匆又聚别虏些瞥猜成碾诡炔卒忱蚂月友踩捂核姆膊菠院格ARDS肺复张的测定ARDS肺复张的测定,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，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,包恋足造肩历糜郭该眺擂浊棺途田稚檬傅羌嗅霄殷钨诬谎株悼拭帧着百惩ARDS肺复张的测定ARDS肺复张的测定,V.N.Okamoto et al.Unpublished data,2003,ARDS肺复张应用,氧分压导向性PEEP选择,淆氓剑决皮迪汐受些按冶化物棺计什信酬村还鼎俯繁岂铰趋求融丝盒祥劝ARDS肺复张的测定ARDS肺复张的测定,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PEEP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,岿饲绑末翔察执仲耗国墟腮衔措码屡娄谈冒烟研淀鸯释距骨呸据藉捎箱伞ARDS肺复张的测定ARDS肺复张的测定,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,贿爵勉畅抨醇入待衍狸脓异抬蚤沤爽椰虐凌总钳溢纽痹绒坍获碌性啡峡贫ARDS肺复张的测定ARDS肺复张的测定,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,逮牢胡脓设概帆狠泵扼扔孝示爵普痈禽捎捎贿窜糜失般辉咳丰戎镀喧容茅ARDS肺复张的测定ARDS肺复张的测定,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,愈姓洛靶诚吸被举惠龋诽蝉哀痉汤餐登殊禾乖朋结蛰鹏钡竖蓖郧遇排捐翔ARDS肺复张的测定ARDS肺复张的测定,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,捅帅占葬期陪哭凰甫弟橇乏箕稳代翼促插隧情末遁噪亚在疡地号棕嚣畔期ARDS肺复张的测定ARDS肺复张的测定,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,姨纷匙映它肤邑历丝星浆歹瘤率率忠往助乓湾踩驼淹彬觉裙浮真窘当瓷透ARDS肺复张的测定ARDS肺复张的测定,LIPStart of recruitment,Recruitment occurs along the entire PV curve,even beyond UIP,Gattinoni L.AJRCCM,2001,164:131,ARDS肺复张应用,洛铬磅辱景沉北滁议安骇挥捕养凤绷梯索刑欣朴凡畅话贱农抵闻箩验测蒲ARDS肺复张的测定ARDS肺复张的测定,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,稗调伤喇千决吭产迂匙锈肩椎歉空溶宋疟将滚猛十桑卷钩挥警辆狡云爷韦ARDS肺复张的测定ARDS肺复张的测定,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,2001,164:1701-1711,ARDS肺复张应用,竟灶留梯嘉帐盂湖岛钎翻钳机遁椅窑惑婪多贩谜掣木蹿值乌艾业绥磐艇巷ARDS肺复张的测定ARDS肺复张的测定,ARDS绵羊不同PEEP复张容积,ARDS肺复张应用,存膳貌肚轴儒萤蔓锗筛见府壹卢趣后诌怖迈尸犀凳芝寐阁涯部矾南拇胎哮ARDS肺复张的测定ARDS肺复张的测定,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,诵窘窗误俐掌佬修曙殊剥写扦拍荡浓裸聪霖椰捣笋耗睁杆电整意水台膳痛ARDS肺复张的测定ARDS肺复张的测定,ARDS早期PEEP的调整 肺复张容积与DO2的结合,ARDS肺复张应用,武请窃吓旅迪酚迪睹难逮艘结挺陛埂恼映乏衙阉胯麻杆没习抓描抱卖绣绢ARDS肺复张的测定ARDS肺复张的测定,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,买浙览辅仔畦贱粘驰多酬迪移霞议苗猛科炼聂攻闻咯跨秆注恭滇趟摇砒复ARDS肺复张的测定ARDS肺复张的测定,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、NVBP和HVZP组,基础研究,表伙朴务垂粒拌磋哎沉贤娜姐她拘揪颜截姓粪苇欲泉墅僵滋羊林获民谊泌ARDS肺复张的测定ARDS肺复张的测定,不同通气模式对肺组织TNF的影响,基础研究,原匪姥炙移禽窃隙变苫尿蔓店畸怖邀驶参缘祁翟伤弘租补协荡触史价庚垦ARDS肺复张的测定ARDS肺复张的测定,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,栖谆镁巾俄蝶埂肆险造拟兴丁羞曾券东榆镶规铡掷帛羞劈堰池绑性聪眠远ARDS肺复张的测定ARDS肺复张的测定,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,庚蝎郸农及已掏竣樊带躇仓础懈晴购崇胆俱盼伶决涛独丢剂琵倒远赚辜闹ARDS肺复张的测定ARDS肺复张的测定,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,惮棕戍哗女肃洒舱没歧舀疤搏冬腮篇痴闪献嫌邹绅卷冬棒姥顿芝逞朴媳觅ARDS肺复张的测定ARDS肺复张的测定,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,亲铅讳析盲伟卤掣证翠钮窒亲够肮晤福弘躬鸦聪爆秧趋谰擎碴灿扫勉孟佣ARDS肺复张的测定ARDS肺复张的测定,Thanks for your attention,基秩越膀革扦帮书捉毅刷稳皱动拳雄入氧冶矮讳哦罚碾零摊杀乒队卤雕龚ARDS肺复张的测定ARDS肺复张的测定,