ARDS肺可复张性评估.ppt

ARDS肺可复张性评估 山东大学齐鲁医院 重症医学科 张帆 ARDS的病理生理 肺顺应性下降 通气血流比例失调 肺血管通透性升高，血管外肺水增加 病理学特点：肺组织损伤的不均一性 N Engl J Med, 2006,354:1775-1786 HEART SP ARDS肺保护性通气 1.小潮气量/PHC 2. RM +最佳PEEP 肺可复张性 Lung tissue in which aeretion can be restored N Engl J Med, 2006, 354:1775-1786 在压力的作用下，不通气的肺泡恢复通气的能力 Crit Care Med, 2011, 39: 1839-1840 肺复张的生理作用 促进塌陷肺泡复张，增加肺容积 提升肺顺应性 降低肺内分流 减轻肺内、肺外器官的炎症反应 中国危重病急救医学，2004,16:603-607 肺复张手法 控制性肺膨胀 PEEP递增法 压力控制法 肺可复张性初步评估 N Engl J Med, 2006 :1775-1786 肺可复张性的评估办法 肺可复张性评估 影像学评估 胸部CT 电阻抗断层成像 肺部超声 功能性评估 P-V曲线 呼气末肺容积 肺牵张指数 CT——评价肺通气的金标准 “diffuse” ARDS “lobar” ARDS Crit Care Med 2003;31[Suppl.]:S285–S295 CT定量分析——定量评价肺水肿和通气 张帆，吴大玮， BioMedical Engineering OnLine 2014, 13:30 肺可复张性的评价——Gattinoni method The percentage of potentially recruitable lung≥9% 为高可复张性 The percentage of potentially recruitable lung：气道压力由5cmH2O升至45cmH2O时，不通气区的减少占全肺重量的百分比 N Engl J Med 2006;354:1775-86 PEEP-induced alveolar recruitment (RECALV) was expressed as percentage of variation of the weight of the nonaerated lung parenchyma: RECALV (%)=(WZEEP-WPEEP)/WZEEP N Engl J Med 2006;354:1775-86 肺可复张性的评价——Gattinoni method The decrease in the percentage of nonaerated lung tissue as PEEP was raised from 5cmH2O to 15cmH2O was highly correlated with the percentage of potentially recruitable lung (r2 = 0.72, P0.001) 肺可复张性的评价——The CT Scan ARDS Study Group method “diffuse” ARDS “lobar” ARDS Am J Respir Crit Care Med 2001:1444–1450 PEEP-induced alveolar recruitment was computed as the increase in gas volume within the poorly and nonaerated lung regions following PEEP divided by the FRC measured in ZEEP conditions RECALV (%) = (VGas PEEP – VGas ZEEP)/FRCZEEP P-V曲线评估肺可复张性 Critical Care 2008, 12:R7 EELVZEEP：ZEEP时的呼气末肺容积 ILV-10、ELV-10：气道压力10cmH2O，吸气/呼气支对应的肺容积 TLC：气道压力40cmH2O时肺总量 MH： maximal volume hysteresis，最大闭陷容积 MH/TLC与肺力学及血气分析的相关性 MH/TLC与EELV、Crs、PaCO2的变化明显相关（R2分别为0.55，0.57 and 0.36，P 0.05) MH/TLC 与PaO2的变化之间未见明显的相关性 (R2 = 0.05，P 0.26) Critical Care 2008, 12:R7 MH/TLC