肺保护机械通气2009seminar材料.ppt

Recruitment Maneuver Massachusetts General Hospital Performance of RM @ MGH 30 cmH2O CPAP for 30 to 40 sec If unresponsive but tolerated well 35 cmH2O CPAP for 30 to 40 sec If unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 sec Allow 15 to 20 minutes between RM Performance of RM @ MGH Set FIO2 at 1.0 Wait 10 minutes Insure appropriate sedation May need to do multiple RMs Monitoring during RM (MGH) The RM should be aborted if: MAP 60 mmHg or decreases by 20 mmHg SpO2 88% Heart rate 130 or 60/ minute New arrhythmias Amato NEJM 1998;338:347 35 – 40 cmH2O CPAP for 30 to 40 sec At enrollment After ventilator disconnect No severe hemodynamic compromise No barotrauma Amato: 2004 China FULL RECRUITMENT: PaO2 + PaCO2 400 mmHg Amato ARDS protocol 张翔宇的 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 Interval: 2 min PEEP target: 16/1st RM, 20/2nd RM, 26~30/3rd RM PIPmax: 45 cmH2O Abort if ABP or SpO2 start fall Rest interval: 15～30 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 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6～23cmH2O,平均13.9cmH2O PEEP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 Performance of RM Set FIO2 at 1.0 Allow time for stabilization Insure appropriate sedation Insure hemodynamic stability Performance of RM - PCV Pressure control ventilation: PEEP 20-30 cmH2O Peak Inspir Press 40-50 cmH2O Inspir Time: 1 to 3 sec Rate: 8 to 20/ min Time 1 to 3 min Set PEEP at 20, ventilate VC, VT 4 to 6 ml/kg PBW, increase rate, avoid auto-PEEP Measure dynamic compliance Decrease PEEP 2 cm H2O Performance of RM - PCV Measure dynamic compliance Repeat until max compliance determined Optimal PEEP max comp PEEP+2 to 3 cm H2O Repeat recruitment maneuver and set PEEP at the identified settings, adjust