课件：肺保护性通气策略.ppt

1. 控制性肺膨胀(SI)法 2. PEEP递增法 3. 压力控制(PCV)法 肺开放的实施方法 Crit Care Med 2004; 32:2371–2377 RM－SI 控制性肺膨胀法(SI) PS/CPAP: 压力支持调至 0 cmH2O，PEEP 40 cmH2O，持续时间30 s BIPAP：高压与低压均为40 cmH2O，持续时间30 s PEEP递增法（IP） PC/BIPAP: 调节气道压上限为35 cmH2O，先保持压力差不变，低压每30 s递增5 cmH2O，高压随之上升5 cmH2O，直至PEEP为35 cmH2O，维持30 s。随后低压和高压每30 s递减5 cmH2O RM－IP 压力控制法(PCV) PC/BIPAP:高压 40 cmH2O，低压16-20 cmH2O，维持90 – 120 s，呼吸频率不变 RM －PCV Lower and higher Percentage of Potentially Recruitable Lung 低可复张性 高可复张性 肺复张后 氧合 血流动力学 呼吸力学 肺容积 肺内分流 影响肺复张效果的因素 肺复张手法的压力和时间 不同肺复张手法效应也不相同 不同病因ARDS：肺外源性的ARDS对肺复张手法的反应优于肺内源性的ARDS ARDS病程：早期ARDS肺复张效果好 可复张性 循环不稳定影响肺复张的实施 如何判断肺复张是否充分？ 最佳氧合 PaO2 + PaCO2 400(FiO2=1.0) PaO2/FiO2400mmHg 两次肺复张后PaO2/FiO2的变化5％ 测定肺复张容积 RM中止的临床指标 动脉收缩压降低到 90 mm Hg或下降30 mm Hg HR增加到140/min，或增加20/min SpO2降低到90%，或降低5%以上 发生心律失常 肺复张的并发症 循环干扰：低血压、低心输出量、低灌注 肺过度膨胀－气压伤 气胸(不常见) 患者不舒适、人机对抗 肺复张的注意事项 适当的镇静 循环不稳定者慎用 调整容量状态－－充足 根据患者情况选择合适的压力和时间 Thank you for your attention! Question? THANK YOU SUCCESS * * 可编辑 * In a low ARDS, the compliance curve shifts to the right. This results in either low volumes for any set pressure or higher pressure for any set volume. Why does V/Q matching matter? And….. Why does the supine position contribute to a V/Q mismatch for the ARDS patient? We have to have two things in order for diffusion to occur successfully. We have to have gas in the alveoli and we have to have adequate perfusion in the capillary. When the blood and gas match, diffusion is an efficient process for oxygen delivery. When all goes well, Oxygen will diffuse from the alveoli into the capillary and CO2 will diffuse from the capillary into the alveoli to be removed through exhalation based upon a simple pressure gradient. There are several factors that can hinder this process in an injured or diseased lung. If we have inadequate ventilation, inadequate perfusion or a diffusion defect, Oxygen delivery can be impaired. If we have a decreased (low) V/Q ratio, the result is typically some degree of pulmonary shunting