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呼吸机治疗的肺保护策略.ppt
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    呼吸机治疗的肺保护策略

    浙江大学医学院附属儿童医院

    施丽萍

    呼吸机相关性肺损伤

    ? acute parenchymal lung injury and an acute inflammatory response in the lung.

    ? cytokines →alveoli and the systemic circulation →multiple organ dysfunction

    ? mortality↑

    呼吸机相关性肺损伤

    ventilator-induced lung injury

    ? 容量性损伤

    Volutrauma(large gas volumes )

    ? 压力性损伤

    Barotrauma(high airway pressure )

    ? 不张性损伤

    Atelectotrauma(alveolar collapse and re-expansion)

    ? 生物性损伤

    Biotrauma(increased inflammation )

    肺 损 伤 病 理

    ? alveolar structural damage

    ? pulmonary edema、 inflammation、 fibrosis

    ?surfactant dysfunction

    ? other organ dysfunction

    ? exacerbate the disturbance of lung development

    Semin Neonatol. 2002 Oct;7(5):353-60.

    Approaches in the management of acute respiratory failure in children

    protective ventilatory and potential protective

    ventilatory modes

    lower tidal volume and PEEP

    permissive hypercapnia

    high-frequency oscillatory ventilation

    airway pressure release ventilation

    partial liquid ventilation

    improve oxygenation

    recruitment maneuvers

    prone positioning

    kinetic therapy

    reduce FiO2 and facilitate gas exchange

    inhaled nitric oxide and surfactant

    Curr Opin Pediatr. 2004 Jun;16(3):293-8.

    Can mechanical ventilation strategies reduce chronic lung disease?

    ? continuous positive airway pressure

    ? permissive hypercapnia

    ?patient-triggered ventilation

    ?volume-targeted ventilation

    ?proportional assist ventilation

    ?high-frequency ventilation

    Semin Neonatol. 2003 Dec;8(6):441-8

    小潮气量和呼气末正压

    lower tidal volume and PEEP

    Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS

    ? 1202 patients

    ? lower tidal volume (≤7ml/kg)

    low plateau pressure ≤30 cm H2O versus

    ? tidal volume 10 to 15 ml/kg

    ? Mortality at day 28 ?

    ? long-term mortality was uncertain

    ? low and conventional tidal volume with plateau pressure≤31 cm H2O was not significantly different

    Cochrane Database Syst Rev. 2004;(2):CD003844

    Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome

    ? 549 patients acute lung injury and ARDS

    ? lower-PEEP group8.3±3.2cmH2O

    higher-PEEP group13.2±3.5cmH2O (P<0.001).

    ? tidal-volume6ml/kg

    end-inspiratory plateau-pressure≤30cmH2O

    ? The rates of death24.9 %27.5 %(p=0.48)

    From day 1 to day 28,breathing was unassisted

    14.5±10.4 days 13.8±10.6 days (p=0.5)

    ? clinical outcomes are similar whether lower or higher PEEP levels are used.

    N Engl J Med. 2004 Jul 22;351(4):327-36.

    Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilation

    ? Sprague-Dawley rats

    ?negative control group

    low pressures (PIP = 12 cm H2O), rate = 30, iT = 0.5,1.0, 1.5secs

    ?experimental groups

    high pressures (PIP = 45 cm H2O), rate = 10, iT = 0.5 , 1.0 , 1.5 secs

    ? lung compliance, PaO2 /FiO2 ratio, wet/dry lung weight, and dry lung/body weight

    ? as inspiratory time increased ,static lung compliance (p =.0002) and Pao2/Fio2 (p =.001) decreased. Wet/dry lung weights (p <.0001) and dry lung/body weights (p <.0001) increased

    ? Light microscopy revealed evidence of intra-alveolar edema and hemorrhage in the iT = 1.0 and iT = 1.5 animals but not the LoP and iT = 0.5 animals.

    Crit Care Med. 2002 Oct;30(10):2295-9.

    新生儿呼吸窘迫综合征

    呼吸机治疗的肺保护性策略研究

    施丽萍 孙眉月 杜立中

    中华儿科杂志2003

    本项目研究的目的

    ? 通过肺力学参数的监测(PM)指导呼吸机参数的调节来降低呼吸机相关性肺损伤的发生

    ? 探讨新生儿RDS最合适的呼吸机参数

    ? 允许性高碳酸血症对新生儿的影响

    ? 非肺力学监测组(NPM)：1994~1997年, RDS 50例，作为对照组

    ? 肺力学监测组(PM): 1998~2001年，RDS 60例，作为观察组

    ? 肺力学监测仪(BicoreCP100)

    两组胎龄、体重、病情严重程度比较

    对照组(NPM)：

    应用人工呼吸机限压定时持续气流型，通气模式为IMV，持续脉搏血氧饱和度监测使其维持在85~95%，每8h监测动脉血气一次，要求血气维持在正常范围内，PaO2 40-70mmHg, PaCO2 35-45mmHg

    观察组(PM组)：

    1、肺力学监测仪(BicoreCP100)每8~12h 监测一次机械通气时肺力学参数

    2、监测时要求患儿与呼吸机完全同步或无自主呼吸状态(必要时通过药物抑制呼吸)

    3、肺力学监测仪的传感器置于近端接口

    4、气管插管气漏率小于20%

    5、每监测一次持续0.5~1h至数据稳定后记录监测的数据

    NPM 组和PM组的评估指标

    1. 疾病极期，即生后24~48h时呼吸机要求最高值，包括FiO2、 PIP、PEEP、Ti、MAP、VR

    2. VE、C20/C、TC(限于PM组)，3. 记录血pH、PaO2、PaCO2、氧合指数(OI )(OI=FiO2×MAP/PaO2)和心率、血压

    4. 呼吸机应用时间，用氧时间，住院天数，病死率，PDA，IVH和呼吸机相关性肺损伤的发生率。

    两组呼吸机参数比较

    两组血气监测结果比较

    两组呼吸机相关性肺损伤、PDA、IVH、呼吸机应用时间、用氧时间、住院天数、病死率比较

    结论

    ? 肺力学监测能指导正确应用呼吸机，降低呼吸机相关性肺损伤

    ?从本研究结果推荐RDS呼吸机应用的参数为：PIP 25cmH2O左右，短Ti 0.3~0.5秒，应用适当的PEEP 5-7cmH2O治疗RDS，不影响氧合。

    ? PaCO2的轻度增高(PaCO2 45-60)，IVH的发生未见增加。

    允许性高碳酸血症

    Permissive hypercapnia

    Permissive hypercapnia--role in protective lung ventilatory strategies

    ?First, we consider the evidence that protective lung ventilatory strategies improve survival and we explore current paradigms regarding the mechanisms underlying these effects

    ?Second, we examine whether hypercapnic acidosis may have effects that are additive to the effects of protective ventilation

    ? Third, we consider whether direct elevation of CO2, in the absence of protective ventilation, is beneficial or deleterious

    ? Fourth, we address the current evidence regarding the buffering of hypercapnic acidosis

    Lung-protective ventilation in acute respiratory distress syndrome: protection by reduced lung stress or by therapeutic hypercapnia?

    hypercapnic acidosis

    lung-protective ventilation

    respiratory acidosis protected the lung

    The protective effect of respiratory acidosis

    inhibition of xanthine oxidase

    prevented by buffering the acidosis .

    the protection resulted from the acidosis rather

    than hypercapnia

    Am J Respir Crit Care Med. 2000 Dec;162(6):2021-2.

    Permissive hypercapnia in ARDS and its effect on tissue oxygenation

    ? The right-shift of the haemoglobin-oxygen dissociation curve......（后略) ......