ARDS肺复张的实施.ppt
http://www.100md.com
参见附件(3893KB)。
ARDS肺复张的实施
邱海波
东南大学附属中大医院ICU
东南大学急诊与危重病医学研究所
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
Low tidal volume:more alv collapse
小Vt不能复张塌陷肺泡，加重低氧血症
实施肺保护性通气策略
至少15~25%患者需提高FiO2
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
Surfactant move away
? When lung regions collapse at end -expiration, surfactant molecules move away from the alv surface toward terminal bronchioles
?and
? cannot be reused during next inflation
D. 预防Biotrauma和MODS
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
俯卧位通气的病理生理特征
? 改善通气过程
- ? 胸膜腔压力梯度
- ? 顺应性胸壁
- 促进分泌物的清除
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
Amato:CT + PV Curve
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- High PEEP
- RM
Recruitment is Time-Dependent
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- High PEEP
- RM
Recruitment mannuvers
? Basic Principles
? Methods for Recruitment
? Experimental Studies and Clinical Trials
- Efficacy
- Hazards
? CPAP模式:
PS 0, PEEP 30-40 cmH2O, 20-50s
2. BIPAP:
Ph /PL 30-40cmH2O, 20-50s
3. Insp Hold:
将吸气保持键按住，持续20- 40s
Multiple Maneuvers May Be Needed For Optimum RM Effect
Post-RM PEEP Determines PaO2
肺开放后的PEEP选择----PaO2/FiO2
BASELINE VENTILATION
Tidal volume=6ml/kg
PEEP=5cmH2O
Implications
? RM 的有效性
- ALI的病因 (direct vs in direct)
- Post RM PEEP
- Method in certain settings
? RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury
? PCV may be better tolerated than SI
Recommendations
? Use PCV in preference to SI
- Safer, "multiple", effective, maintains ventilation, simple
? Monitor hemodynamics during recruiting interval.
? 以下情况需重复作RM: 体位改变, 管路断开, 呼吸力学特征或PaO2明显恶化
? 对于顽固性难治性ARDS患者, 可考虑反复RM和更高的压力
? Employ Prone Position and/or PEEP to consolidate RM benefit.
ARDS肺复张的实施
邱海波
东南大学附属中大医院ICU
东南大学急诊与危重病医学研究所
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
Low tidal volume:more alv collapse
小Vt不能复张塌陷肺泡，加重低氧血症
实施肺保护性通气策略
至少15~25%患者需提高FiO2
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
Surfactant move away
? When lung regions collapse at end -expiration, surfactant molecules move away from the alv surface toward terminal bronchioles
?and
? cannot be reused during next inflation
D. 预防Biotrauma和MODS
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
俯卧位通气的病理生理特征
? 改善通气过程
- ? 胸膜腔压力梯度
- ? 顺应性胸壁
- 促进分泌物的清除
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- RM
Amato:CT + PV Curve
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- High PEEP
- RM
Recruitment is Time-Dependent
内容提要
? 肺保护性通气策略不能解决解决的问题
? 肺泡塌陷的病理生理后果
? 肺复张的临床实施
- Prone position
- Spontaneous breathing
- High VT and sigh
- High PEEP
- RM
Recruitment mannuvers
? Basic Principles
? Methods for Recruitment
? Experimental Studies and Clinical Trials
- Efficacy
- Hazards
? CPAP模式:
PS 0, PEEP 30-40 cmH2O, 20-50s
2. BIPAP:
Ph /PL 30-40cmH2O, 20-50s
3. Insp Hold:
将吸气保持键按住，持续20- 40s
Multiple Maneuvers May Be Needed For Optimum RM Effect
Post-RM PEEP Determines PaO2
肺开放后的PEEP选择----PaO2/FiO2
BASELINE VENTILATION
Tidal volume=6ml/kg
PEEP=5cmH2O
Implications
? RM 的有效性
- ALI的病因 (direct vs in direct)
- Post RM PEEP
- Method in certain settings
? RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury
? PCV may be better tolerated than SI
Recommendations
? Use PCV in preference to SI
- Safer, "multiple", effective, maintains ventilation, simple
? Monitor hemodynamics during recruiting interval.
? 以下情况需重复作RM: 体位改变, 管路断开, 呼吸力学特征或PaO2明显恶化
? 对于顽固性难治性ARDS患者, 可考虑反复RM和更高的压力
? Employ Prone Position and/or PEEP to consolidate RM benefit.
附件资料：