肺复张术与PEEP调定课件.ppt
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1、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=1
2、4, 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,0,5,10,1
3、5,20,25,30,35,40,45,50,0,10,20,30,40,50,5 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
4、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”
5、,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? I
6、s 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
7、 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,Anesthesiolog
8、y, 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 tar
9、get 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
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