ARDS患者的肺复张 内容 小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题 内容 小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题 ARDS的肺保护性通气策略 ARDS的肺保护性通气策略 小潮气量 6ml kgIBW 避免过度膨胀造成的容积伤 volutrauma 足够的PEEP防止肺泡复张造成的剪切力损伤 atelectrauma 肺泡塌陷与复张造成的剪切力 F PLx V0 V 2 3F 剪切力PL 跨肺压V0 最初容积V 复张后容积如果 PL 30cmH2O V0 V 1 10则 F 140cmH2O MeadJ TakishimaT LeithD Stressdistributioninlungs amodelofpulmonaryelasticity JApplPhysiol1970 28 5 596 608 小潮气量通气的问题 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 小潮气量通气的问题 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 小潮气量通气的问题 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 受损的肺组织如何复张 俯卧位足够的PEEP足够的潮气量 和 或 叹气 肺复张手法减少水肿 最低可接受的FiO2 自主呼吸 内容 小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题 肺泡的开放压与闭合压 PEEP不能使肺复张 LIP 仅仅是肺复张的开始 HicklingKG Thepressure volumecurveisgreatlymodifiedbyrecruitment AmathematicalmodelofARDSlungs AmJRespirCritCareMed1998 158 194 202 JonsonB RichardJC StrausC ManceboJ LemaireF BrochardL Pressure VolumeCurvesandComplianceinAcuteLungInjury EvidenceofRecruitmentAbovetheLowerInflectionPoint AmJRespirCritCareMed1999 159 1172 1178 低位转折点之上仍有肺组织复张 肺泡的开放压与闭合压 肺泡开放压与闭合压 Paw cmH2O CrottiS MascheroniD CaironiP PelosiP RonzoniG MondinoM MariniJJ GattinoniL Recruitmentandderecruitmentduringacuterespiratoryfailure aclinicalstudy AmJRespirCritCareMed2001 164 131 140 ARDS的肺开放 EditorialOpenupthelungandkeepthelungopenB LachmannDept ofAnesthesiology ErasmusUniversityRotterdam TheNetherlands 1992 18 319 321 RM能够使肺开放 RM PIP45cmH2O PEEP35cmH2Ox1min HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 肺复张能够改善ARDS氧合 LapinskySE AubinM MehtaS BoiteauP SlutskyAS Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure IntensiveCareMed1999 25 1297 1301 肺复张的各种方法 CPAP SI incrementalPEEPPCVSigh modified HFOV俯卧位 SI改善氧合 TugrulS AkinciO OzcanPE Ince S EsenF TelciL AkpirK CakarN Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome Focusingonpulmonaryandextrapulmonaryforms CritCareMed2003 31 738 744 SustainedInflation 45cmH2Ox30s SI改善氧合 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 SustainedInflation 30cmH2Ox30sTwicewith1mininterval 叹气的设置 LimCM KohY ParkW ChinJY ShimTS LeeSD KimWS KimDS KimWD Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome Apreliminarystudy CritCareMed2001 29 1255 1260 充气阶段 每30秒PEEP增加5cmH2OVt减少2ml kg前2次呼吸除外直至Vt2ml kg PEEP25cmH2O暂停阶段CPAP30cmH2Ofor30s放气阶段 叹气改善氧合 LimCM KohY ParkW ChinJY ShimTS LeeSD KimWS KimDS KimWD Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome Apreliminarystudy CritCareMed2001 29 1255 1260 叹气对氧合及呼吸力学的影响 PelosiP CadringherP BottinoN PanigadaM CarrieriF RivaE LissoniA GattinoniL Sighinacuterespiratorydistresssyndrome AmJRespirCritCareMed1999 159 872 880 Sigh 3consecutivesighs minatPplat45cmH2O 叹气的设置 PatronitiN FotiG CortinovisB MaggioniE BigatelloLM CeredaM PesentiA SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation Anesthesiology2002 96 788 94 Baseline PSVSigh BIPAPPEEPhigh 1 2xPIPpsvor35cmH2OTi s 3 5sf 1bpm 叹气改善呼吸力学及氧合 PatronitiN FotiG CortinovisB MaggioniE BigatelloLM CeredaM PesentiA SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation Anesthesiology2002 96 788 94 ARDS对RM的反应 VillagraA OchagaviaA VatusS MuriasG FernandezMF AguilarJL FernandezR BlanchL RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome AmJRespirCritCareMed2002 165 165 170 肺复张 CT的提示 HenzlerD MahnkenAH WildbergerJE RossaintR G ntherRW KuhlenR Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury EurRadiol2006 16 1351 1359 肺复张 CT的提示 HenzlerD MahnkenAH WildbergerJE RossaintR G ntherRW KuhlenR Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury EurRadiol2006 16 1351 1359 内容 小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnaly