肺保护机械通气seminarppt课件.ppt

临床观察 Prospective 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 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 我们的未来 未来还是有希望 ARDS协作组十分必要 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 Dreager’s new idea EIT in process of develop We hope it work before RM Information provided by EIT after RM Patient ventilated with same tidal volumes before and after RM (both images with same color scale) max. min. Reference webs: * * * * * * * PEEP / FIO2 target (≈ 8～14 cmH2O) PEEP at PFLEX (≈ 14～18 cmH2O) PEEP enough to fully avoid airway collapse (≈ 16～26 cmH2O) Amato: 2004 China 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 张翔宇，等，中国危重病急救医学，2007，19（9） Crit Care Med 2007 Vol. 35, No. 1Fernando Suarez-Sipmann, et al Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study Eight healthy pigs Lung lavages CT slices were obtained 2 cm cranial of the right diaphragmatic dome Protocol Result Suarez-Sipmann’s clusion dynamic compliance identified the beginning of lung collapse in a pig model. the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying the level of PEEP that prevents end-expiratory lung collapse ？？？ Bob’s new protocol 2007 Performance of RM Set FIO2 at 1.0 Allow time for stabilization Insure appropriate sedation Insure hemodynamic stability Bob’s new protocol Performance of RM - PCV Pressure control ventilation: