[医学]ARDS肺复张的实施邱海波.ppt

ARDS肺复张的实施 邱海波 东南大学附属中大医院ICU 东南大学急诊与危重病医学研究所 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh RM Low tidal volume: more alv collapse 小Vt不能复张塌陷肺泡，加重低氧血症 实施肺保护性通气策略 至少15~25%患者需提高FiO2 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh RM Surfactant move away When lung regions collapse at end –expiration, surfactant molecules move away from the alv surface toward terminal bronchioles and cannot be reused during next inflation D. 预防Biotrauma和MODS 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh RM 俯卧位通气的病理生理特征 改善通气过程 ? 胸膜腔压力梯度 ? 顺应性胸壁 促进分泌物的清除 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh RM 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh RM Amato: CT + PV Curve 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh High PEEP RM Recruitment is Time-Dependent 内容提要 肺保护性通气策略不能解决解决的问题 肺泡塌陷的病理生理后果 肺复张的临床实施 Prone position Spontaneous breathing High VT and sigh High PEEP RM Recruitment mannuvers Basic Principles Methods for Recruitment Experimental Studies and Clinical Trials Efficacy Hazards CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续20- 40s Multiple Maneuvers May Be Needed For Optimum RM Effect Post-RM PEEP Determines PaO2 肺开放后的PEEP选择----PaO2/FiO2 BASELINE VENTILATION Tidal volume=6ml/kg PEEP=5cmH2O Implications RM 的有效性 ALI的病因 (direct vs in direct) Post RM PEEP Method in certain settings RM hazards are greatest and effectiveness least in pneumonia-caused acute lung injury PCV may be better tolerated than SI Recommendations Use PCV in preference to SI Safer, “multiple”, effective, maintains ventilation, simple Monitor hemodynamics during recruiting interval. 以下情况需重复作RM: 体位改变, 管路断开, 呼吸力学特征或PaO2明显恶化 对