肺保护机械通气seminar.ppt
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1、Lung Protective Mechanical Ventilation肺保护性机械通气Adoption&discussion,张翔宇SICU上海同济大学上海市第十人民医院,Ventilator Induced Lung InjuryVILI,Overdistention Barotrauma Volutrauma Recruitment/Derecruitment Injury Translocation of Cells Biotrauma,Overdistention Barotrauma&Volutrauma,VILI:Recruitment/Derecruitment Injur
2、y,PIP=14,PEEP=0PIP=45,PEEP=10PIP=45,PEEP=0Webb556,Translocation of Cells,Bilek,A.M.D.P.Gaver III,J Appl Physiol 94:770783,2003,Translocation of Cells,disrupt the alveolar epithelium tears in capillary endothelium,Biotruama?,Magaret Parker,MD,FCCM.(SCCM Chair 2004),ARDS,Beijing 2005,Ventilation Strat
3、egies&BAL CytokinesTremblay,Valenza,Ribeiro,Li,Slutsky J Clinical Investigation 99:944-52,1997,50倍!,Ventilatory Strategy and BAL Cytokines,Tremblay,Valenza,Ribeiro,Li,Slutsky J Clinical Investigation 99:944-52,1997,*p 0.05 vs.C,MVHP,MVZP,&p 0.05 vs.C,MVHP,#p 0.05 vs.C,Arthur S Slutsky,Serum Cytokine
4、s in Acid Aspiration ModelChiumello,Pristine,Slutsky AJRCCM 1999;160:109-16,Cytokines in HumansStuber et al Int Care Med 2002;28:834-841,JAMA 289:2104-2112,2003,Systemic Effects of VILIImai et al JAMA 289:2104-2112,2003,Mechanical Ventilation,Slutsky,Tremblay Am J Resp Crit Care Med.1998;157:1721-5,
5、Hudson et al,Chest 116:74S-2S,ARDS Mortality Decreased Abruptly,Shanghai ARDS Study Group.,15 ICUs in 12 university hospitals in ShanghaiIn-hospital mortality of ARDS patients were 68.5%and 90-day mortality of ARDS patients were 70.4%,Intensive Care Med.2004 Dec;30(12):2197-203.,Protect the lungs?,P
6、EEP=?VT=?PIP=?Pplateau=?RM?Mode?,Protect the lungs?How?,PEEP too low:Recruitment/Derecruitment InjuryPplateau too high:Overdistention Barotrauma Volutrauma,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 DISTR
7、ESS SYNDROME,METHODSStudy Population,Marcelo BP Amato,MD,PV curve(static),P-V curve Methodology,The supersyringe technique,Recruitment Maneuver and PV curve hysteresis,8,30,Prssure,Small tidal volume(5 ml/kg),Rimensberger PC Crit Care Med 1999;27:1946-52 27:1940-45,The ventilatory cycle can be boost
8、ed on the deflation limb,Post-Operative Atelectasis Healthy Lung,40 cmH2O peak alveolar pressure held for 7-15 sec needed to reopen lungRothen Br J Anaesth 1993;71:788Rothen Br J Anaesth 1998;81:681Rothen Br J Anaesth 1999;82:551,Recruitment Maneuver,Massachusetts General Hospital,Performance of RM
9、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,Performance of RM MGH,Set FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple
10、 RMs,Monitoring during RM(MGH),The RM should be aborted if:MAP 20 mmHgSpO2 130 or 60/minuteNew arrhythmias,Amato NEJM 1998;338:347,35 40 cmH2O CPAP for 30 to 40 secAt enrollmentAfter ventilator disconnectNo severe hemodynamic compromiseNo barotrauma,Amato:2004 China,FULL RECRUITMENT:PaO2+PaCO2 400 m
11、mHg,Amato,ARDS protocol,Recruit,FIO2=1,Titrate PEEP,Titrate Pdriving,WAIT,(15),FIO2 30%,(High PEEP+PSV),WAIT,FIO2 30%,(High PEEP+PSV),Decrease PS down to 8,Decrease PEEP down to 12,NIMV(CPAP=12,PS=8),J.J.HAITSMA,B.LACHMANNMINERVA ANESTESIOL 2006;72:117-32,Lung protective ventilation in ARDS:the open
12、 lung maneuver 450 mmHg on pure oxygen.When a lung is“open”,Hickling K.AJRCCM 2001;163:69-78.,Stepwise Recruitment Strategy,Time,0,10,20,30,40,50,60,70,45,50,55,60,Baseline,25 cmH2O,Airway Pressures(cmH2O),40,CPAP,OLA,DP=15 cmH2O,MARCELO AMATO,M.D.,et al.(N Engl J Med 1998;338:347-54.),EFFECT OF A P
13、ROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME,Lim CCM 2001;29:1255,Foti ICM 1999;26:501,Treatment with Oscillation and an Open Lung strategy(TOOLS)Crit Care Med 2005;33(3):479,Multi-center:Toronto,Paris,Cardiff,BostonFerguson,Kacmarek,Slutsky,et al.New protoc
14、ol with HFOV and RM25 patients with early ARDSInclusion:Age18,P/F75,Significant heart disease,Details of protocol,RM:mPaw 40 cmH2O 40 sec 3Repeated RM:twice daily at leastHFOV:P=60 cmH2O,F=5Hz,Results,P/F increase:200117 vs 9236 mmHgFiO2 reduce:0.50.2 vs 0.90.1RM:411(median:7)/patientRM aborted:8/24
15、4(3.3%)in 6 patientsRM abolition reason:Hypotension,but recovered quickly.4/6 intolerant patients:tolerated later.,Stepwise PEEP recruitment maneuvers(Amatos team),Stepwise PEEP recruitment maneuvers can open collapsed ARDS lungs.Higher levels of PEEP are necessary to maintain the lungs open and ass
16、ure homogenous ventilation in ARDS.,Curr Opin Crit Care.2005 Feb;11(1):18-28,Stepwise PEEP RM practice,26 pts5 cmH2O steps Pinsp reached 60 cmH2O 2/26,PaO2+PaCO2 400 mmHg not reachedopen the lung and keep the lung open in 24/26Titrating PEEP by oxygenationNo barotrauma,Am J Respir Crit Care Med.2006
17、 May 11,RM in our ICU,心脏外科术后低氧患者16例 男10例,女6例 年龄:5269 多发伤并发ALI/ARDS患者18例 男13例,女6例 年龄:1356 军团菌病1例,女、26岁,MSOF/ARDS,PaO2/FiO2:49/85%所有病例均为机械通气疗效不佳的低氧血症 PaO2/FiO2:57.6166mmHg,方 法,所有患者均行有创动脉压持续监测 SpO2持续监测 CVP持续监测 清醒患者适当镇静 复张术(RM)前排除气压伤 排除肺气肿患者,Protocol,Mode:PEEP+PCV or PEEP+PSV PEEP:increment 2 cmH2O Inte
18、rval:2 min PEEP target:16/1st RM,20/2nd RM,2630/3rd RM PIPmax:45 cmH2O Abort if ABP or SpO2 start fall Rest interval:1530 min May repeat twice a day,结 果,心脏外科术后低氧患者 有效:100%PaO2/FiO2 improve:110%36%无并发症多发伤并发ALI/ARDS患者有效:92%PaO2/FiO2 improve:86%32%无并发症 军团菌病1例,无效,出现气压伤 RM一次,PEEPmax:22,PIPmax:32纵隔气肿,Subc
19、utaneous emphysema,结 果,心脏外科术后低氧患者 所有患者在第一次RM出现血压迅速下降 血压下降同时伴随SpO2下降 第一次RM在PEEP1216出现血压下降 在以后的RM中,耐受性增强多发伤并发ALI/ARDS患者 12/18(66.6%)在第一次RM出现血压迅速下降血压下降同时伴随SpO2下降在以后的RM中,耐受性增强,临床观察,252例次RM有93次血压短暂降低(37%)出现血压下降的PEEP水平为623cmH2O,平均13.9cmH2OPEEP降低之后动脉恢复到原来水平所有病人有创持续血压监测1例经心超证实卵圆孔未闭,在PEEP=6时发生右向左分流,同时SpO2下降,
20、张翔宇,等,中国危重病急救医学,2007,19(9),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 wer
21、e 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,Result,Clinical Observ
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