肺复张在ARDS中的应用烟台讲课.ppt

肺复张术的临床应用 第一天（10-21） PEEP由5 cmH2O逐渐增加至20 cmH2O，吸：呼=1：1，FiO2 100% 第五天（10-25）FiO2 50% SpO2 100% PaO2 104mmHg 呼吸频率 18-22 次/分 HR 105 bpm 病例二 男性，38岁 直肠癌术后复发 07-1-30行开腹探查+全盆腔脏器切除术 术后第二天出现发热，并出现渐进性呼吸困难，ARDS，07-2-4行气管插管，机械通气 10AM肺复张： CPAP 30cmH2O，30秒，二次 CPAP 60cmH2O，30秒，二次 PEEP上调至17cmH2O （11AM） PaO2 63.1mmHg，PaCO2 53.7mmHg （9PM） PaO2 113.7mmHg，PaCO2 36.9mmHg ARDS肺泡不张的临床意义 肺容积减少 功能残气量降低，通气血流比例失调 肺脏顺应性降低 加重肺脏损伤 增加VILI机会 呼吸机相关性肺损伤 Barotrauma- high airway pressures Volutrauma -excessive distending alveolar volumes 保护性肺通气策略 改善ARDS预后 小潮气量使肺泡不张增加 高PEEP并不能完全打开不张的肺泡 Why Sould We Open the Lung Gattinoni: 早期ARDS患者存在多区域的不张 最常见于下垂部位的肺区 充气的肺脏容量减少 小潮气量(5–7 mL/kg for body weight) 也可在非开放的肺脏产生气压伤和生物伤 早期肺复张及稳定肺泡: 可改善机械通气生理学的各个方面 对所有进行机械通气的患者进行“开放肺”治疗 肺复张是使肺开放，并处于压力容积曲线的呼气相 RM对SpO2的影响 肺复张手法和肺开放策略对肺内型ARDS机械通气患者氧合的影响（X±SD） 如何进行RM A sustained high-pressure inflation：应用压力35-50 cmH2O，持续20-120 s 压力需要个体化 常常采用CPAP模式，压力设定于想要达到的水平 可以使用短效的镇静剂，无需麻醉肌松 Methods of Alveolar Recruitment 1 High CPAP Levels Grasso CPAP 40 cm H2O for 40 secs. After 2 mins： 20±3% increase in PaO2/FIO2 in the nonresponder 175± 23% increase in the responder The responder group had been ventilated for a shorter period of time with less hemodynamic impairment than the nonresponder group. Methods of Alveolar Recruitment 2 Intermittent Sighs Pelosi three consecutive sighs per minute at 45 cm H2O plateau pressure an increase of PaO2/FIO2 and of EELV a decrease in venous admixture and PaCO2 during ventilation with sighs. returned to baseline within 30 mins of sigh interruption Methods of Alveolar Recruitment 3 PCV Barbas Group A: three cycles of pressure controlled ventilation (PCV) of 40 cmH2O for 6 secs every 3 hrs, Group B: three cycles of PCV of 40, 50, and 60 cmH2O for 6 secs every 3 hrs. The latter group had a further increment of the PaO2/FIO2 ratio after 1 hr and 6 hrs without hemodynamic impairment Methods of Alveolar Recruitment 4 High PEEP with BIPAP 1 sigh/min with a high PEEP level (38±3.2 cm