Lung Protective Mechanical Ventilation 肺保护性机械通气 Adoption 110;556Ventilation Strategies 35(4):740-7.Patients Patients ( n=549 )( n=549 )ARDS/ ARDS/ALI ALIP plat P plat ( (cmHcmH2 2OO) ) 30 30PEEP PEEP ( (cmHcmH2 2OO) ) 12.9 4 12.9 4 8.4 8.4 44RR RR ( (b/minb/min) ) 30 30 TV TV ( ( ml /Kgml /Kg ) ) 6 6 The NIH randomized multicenter study assessing the The NIH randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDSeffect on mortality of low vs high PEEP in ARDS New Engl J Med 2004; 351: 327-336NIHPEEP selected according to a Table to achieve minimal physiological oxygenation (88-95%)Patients Patients ( ( n=983n=983) )ARDS/ ARDS/ALI ALIP plat P plat ( (cmHcmH2 2OO) ) 30 30PEEP PEEP ( (cmHcmH2 2OO) ) 16.3 316.3 3 RR RR ( (b/minb/min) ) 3030 TV TV ( ( ml /Kgml /Kg ) ) 6 9.1 4The LOVS: Lung Open Ventilation Canadian Study Canadian TrialOxygenation was better in High PEEP Compliance was better in High PEEPLess rescue therapies in High PEEP0,40,50,60,70,80,910102030405060Days after randomizationProbability of survivalLow PEEP High PEEPPEEP selected according to a table to achieve minimal physiological oxygenation + RMStewart T et al JAMA. 2008;299(6):637-645Patients Patients ( ( n=752n=752 ) )ARDS/ ARDS/ALI ALIP plat P plat ( (cmHcmH2 2OO) ) 30 30PEEP PEEP ( (cmHcmH2 2OO) ) 14.9 414.9 4 RR RR ( (b/minb/min) ) 3030 TV TV ( ( ml /Kgml /Kg ) ) 6 7.4 4French Trial “Express”PEEP selected to avoid overdistension or to achieve maximal recruitmentPEEP set for PEEP tot 5-9 cmH2O PEEP set for Plat 28-30 cmH2OOxygenation was better in Max distensionHigher ventilation free days in Max distensionHigher organ failure free days in Max distensionMercat A et al JAMA. 2008;299(6):646-655The Express Study: randomized multicenter study assessing The Express Study: randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDSthe effect on mortality of low vs high PEEP in ARDS Critical Care 2009, 13:R22Younsuck Koh, et alEfficacy of positive end-expiratory pressure titration after theEfficacy of positive end-expiratory pressure titration after the alveolar recruitment alveolar recruitment manoeuvremanoeuvre in patients with acute respiratory in patients with acute respiratory distress syndromedistress syndromeCritical Care 2009, 13:R22Younsuck Koh, et alEfficacy of positive end-expiratory pressure titration after the alveolar recruitment manoeuvre in patients with acute respiratory distress syndrome. Younsuck Koh, et alCritical Care 2009, 13:R22MARCELO AMATO, M.D.,et al.(N Engl J Med 1998;338:347-54.)EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROMETHE ACUTE RESPIRATORY DISTRESS SYNDROMEMechanical Ventilation Guided by Esophageal Pressure in Acute Lung InjuryN Engl J Med 2008;359:2095-104.N Engl J Med 2008;359:2095-104N Engl J Med 2008;359:2095-104N Engl J Med 360;8 February 19, 2009N Engl J Med 359;20, november 13, 2008Effect of the chest wall on pressure volume curve analysis of acute respiratory distress syndrome lungsConclusions: This method of “correcting” the total respiratory system P-V curve for the chest wall allows for calculation of an airway pressure that would place the lung at a desired volume on its P-V curve. For most patients, the chest wall had little influence on the total respiratory system P-V curve. However, there were patients in whom the chest wall did potentially have clinical significance.atory system P-V curve. Crit Care Med 2008; 36:2980 2985Crit Care Med 2008; 36:2980 2985 Dean Hess, et al.Animal Lab at JinShan 2009临床观察临床观察Prospective 胸廓顺应性、腹内压在不同的病人相差很大胸廓顺应性、腹内压在不同的病人相差很大 动物试验并不能代表临床动物试验并不能代表临床 氧合变化与肺塌陷存在时间延迟与不一致氧合变化与肺塌陷存在时间延迟与不一致 监测食管压、跨肺压难度较大监测食管压、跨肺压难度较大我们的未来我们的未来 未来还是有希望未来还是有希望 ARDSARDS协作组十分必要协作组十分必要 一致性的提高与临床数据收集十分重要一致性的提高与临床数据收集十分重要 提高本地救治水平，体现工作质量提高本地救治水平，体现工作质量Dreagers new ideaEIT in process o