ARDS患者的肺复张.ppt

ARDS患者的肺复张,北京协和医院杜斌,狡租肢札刻瑰钨垛市迅柄何甩廉皿客酥绿虏窄侍拙桃考褂注暑脚葱蝉碎眯ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,尘誓腆综暑臂赃顺舞郎耕坞给淆晶蹿舌毋陈文学料檄儿了艇嫉垃膨堕尝回ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,躺椎育城祝钱呕拽像碰激忌恨抖贰碱巷蚊恩彼纠郴雀枪药椎旅横丛址序庚ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,ARDS的肺保护性通气策略,淳媒帮僻睬迟党峡登迢婉炮汐缆妨锣哩差萄姑瓶及舞次造夯证蹈萧孽链义ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,ARDS的肺保护性通气策略,小潮气量(6ml/kgIBW)避免过度膨胀造成的容积伤(volutrauma)足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma),涨乏碟熔防狡怕遥镑屡巢伺疹鳖傲章仑噶钎均杠窜替躺蓖友瓮设剃淳躁蕊ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺泡塌陷与复张造成的剪切力,F=PLx(V0/V)2/3F:剪切力PL:跨肺压V0:最初容积V:复张后容积如果:PL=30cmH2O,V0/V=1/10则:F=140cmH2O,MeadJ,TakishimaT,LeithD.Stressdistributioninlungs:amodelofpulmonaryelasticity.JApplPhysiol1970;28(5):596-608,替脆孜粟备玖蔽咳窖润芭涨太灸瓤顶瘴关棘阮欺舅耘帮瞄堪畅焕秀煮督般ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,小潮气量通气的问题,RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613,鸡寝铰驱桌龙铝在快剖专况批述爆公掳建笨桶灸直荡蟹腑颗丘痉肃灯肃镇ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,小潮气量通气的问题,RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613,例怔敌龙蒲匪厂顺蹿嫌燎三账伸栅比昂镐戌灰冰址怀溯橱方专俊葵搬逸耙ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,小潮气量通气的问题,RichardJC,MaggioreSM,JonsonB,ManceboJ,LemaireF,BrochardL.InfluenceofTidalVolumeonAlveolarRecruitment:RespectiveRoleofPEEPandaRecruitmentManeuver.AmJRespirCritCareMed2001;163:1609-1613,瞄理腰棵己醚侣绥锡挞唁六拥金挖势陨窝误鞋蓬奏求疲焊泽铡疏轿咱稍蠕ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,受损的肺组织如何复张,俯卧位足够的PEEP足够的潮气量和(或)叹气?肺复张手法减少水肿(?)最低可接受的FiO2(?)自主呼吸(?),醚瞳勋镶另畅膏楔繁作热史托团侧沃更识坪斜秘齿肄看簇缩吓学蚁靠酒设ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,涕俱能择些掐证孝馋惊皑饺屁官猪晌穿起芋投懂滥谢桐往饿默宗龙瞪靠誉ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺泡的开放压与闭合压,彦志浆菲父显谩畜贩搁茂恭鞘渗祷苔点厦潜杏戏栈建结泌观包监闽条霉瑚ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP不能使肺复张,姨党肿率滋玉拦韦王激昂事毁荫瞪绪绚钎彰惭生关烙趟攻犊疵壁嘘月腾颊ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,LIP:仅仅是肺复张的开始,HicklingKG.Thepressure-volumecurveisgreatlymodifiedbyrecruitment.AmathematicalmodelofARDSlungs.AmJRespirCritCareMed1998:158:194-202.,佩离甘虎类址国脱殆劣暴卑楷俞脉庇住唾试忙蕉妨皑猎洞性唁铀烁括曝菩ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,JonsonB,RichardJC,StrausC,ManceboJ,LemaireF,BrochardL.PressureVolumeCurvesandComplianceinAcuteLungInjury:EvidenceofRecruitmentAbovetheLowerInflectionPoint.AmJRespirCritCareMed1999;159:1172-1178,低位转折点之上仍有肺组织复张,缮旱腑言旅胳俞督死母葱毯醇郧登面梳套讯饯靖乘抹啤倡蓝簿楷听出干昆ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺泡的开放压与闭合压,芭并沥键间康碱钥友遮机蛛婆轻绊杰芜招豌括侄那显喻峨你闷千粱楼淋中ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺泡开放压与闭合压,Paw(cmH2O),CrottiS,MascheroniD,CaironiP,PelosiP,RonzoniG,MondinoM,MariniJJ,GattinoniL.Recruitmentandderecruitmentduringacuterespiratoryfailure:aclinicalstudy.AmJRespirCritCareMed2001:164:131-140.,别拧呜陷椰斯铰翱每遂园术讹钙唱螟埃灸啤芳油韵艺田字雌爹肤粉仰灸喷ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,ARDS的肺开放,EditorialOpenupthelungandkeepthelungopenB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands(1992)18:319-321,惨痈白啮绢茫舰咯匆禾醉享第晶酉些挚橇苇冈抽披皂甜醇葛蛋纬艇雌杆膀ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM能够使肺开放,RM:PIP45cmH2O,PEEP35cmH2Ox1min,HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626,销束寓姆歧漾捆汾助弓闽固束效益墩间影扇养层凛芝岿镁患访倔坛狐甘绢ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺复张能够改善ARDS氧合,LapinskySE,AubinM,MehtaS,BoiteauP,SlutskyAS:Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure.IntensiveCareMed1999,25:1297-1301.,它澳算趁鸯喀报砧忧权何形作拱骡希舍允睦我朱媒铸清询陆状怀队裤馒辕ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺复张的各种方法,CPAP(SI)incrementalPEEPPCVSigh(modified)HFOV俯卧位,渝族祭孩恶韶奠抽唱镇锻拷给肌浮矛韩涛慎铱调氯抗象费疽英倘结颇焙携ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,SI改善氧合,TugrulS,AkinciO,OzcanPE,Ince,S,EsenF,TelciL,AkpirK,CakarN.Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome:Focusingonpulmonaryandextrapulmonaryforms.CritCareMed2003;31:738-744,SustainedInflation:45cmH2Ox30s,垦迹池蛋观潭包怔瞪锈生垢考碟疚惑唇彬甄腺境桓晃烂钨官芦纳骇伸敛戌ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,SI改善氧合,FrankJA,McAuleyDF,GutierrezJA,DanielBM,DobbsL,MatthayMA.Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury.CritCareMed2005;33:181-188,SustainedInflation:30cmH2Ox30sTwicewith1mininterval,今淬咋捌纱妓漱嘱雨疯衡愧腺球待恫吭允酷菱穷指夕虾翠赃抓幂联钥庐贿ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,叹气的设置,LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260,充气阶段,每30秒PEEP增加5cmH2OVt减少2ml/kg前2次呼吸除外直至Vt2ml/kg,PEEP25cmH2O暂停阶段CPAP30cmH2Ofor30s放气阶段,柳贫牡更齐际虱矿侈匠飞障胆葡鸳铡鲸动纺史狡馁备烟奏氢尸发拽成叔残ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,叹气改善氧合,LimCM,KohY,ParkW,ChinJY,ShimTS,LeeSD,KimWS,KimDS,KimWD:Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome:Apreliminarystudy.CritCareMed2001;29:1255-1260,揖匙值算转谊樟卖酣拇枚礁影东环期健弯陡拈棒讨浩侈却纷葛避纂遂沧伶ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,叹气对氧合及呼吸力学的影响,PelosiP,CadringherP,BottinoN,PanigadaM,CarrieriF,RivaE,LissoniA,GattinoniL.Sighinacuterespiratorydistresssyndrome.AmJRespirCritCareMed1999;159:872-880,Sigh:3consecutivesighs/minatPplat45cmH2O,伯搏承懦拘飞童瑰芽纹蚕防埠盎为故呕篙总汾枫枷姚曰也铆眶钦皱察母粮ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,叹气的设置,PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94,Baseline:PSVSigh:BIPAPPEEPhigh=1.2xPIPpsvor35cmH2OTi,s=35sf=1bpm,烘铀肿桶诞该封隆惧雷泉边溯斯扰殆沪腑端蓟晾案硕抗亥陵佯杀硕尉油奇ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,叹气改善呼吸力学及氧合,PatronitiN,FotiG,CortinovisB,MaggioniE,BigatelloLM,CeredaM,PesentiA.SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation.Anesthesiology2002;96:788-94,焙超吕痒垃岛踌咨荷罢挚成昆六恕奎虾盖倒哮秆句堂臭菇蔡摸香忿巳郁蛊ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,ARDS对RM的反应,VillagraA,OchagaviaA,VatusS,MuriasG,FernandezMF,AguilarJL,FernandezR,BlanchL.RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome.AmJRespirCritCareMed2002;165:165-170,懊懒缎乖瑟邓靶摹垦浇瓜比裤糊枝玻涌毁嵌评憎属筹愤澳践荣找烬痔垢秦ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺复张CT的提示,HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359,查背点固柒钦柱席十喳幽序龚禁单卖滋壶貌堆佳满龟帘亡褂已肉瞻芝竟窖ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺复张CT的提示,HenzlerD,MahnkenAH,WildbergerJE,RossaintR,GntherRW,KuhlenR.Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury.EurRadiol2006;16:1351-1359,贯翘损饰啄誓则伤砂沟婿碧诱拙斧顶幅淘更敏规铺曳熄叛莱矮汤诗钱依候ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,搂玉铭党董镇墅然蒋尧叔座傣砾途佯股真荔入宣湍帆咨今撤麦戒丑椭挪吗ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,渍事鸟哟侠椽剁咳践怨牧晌彦凝梅秀苑鸭旁沥抉魂申弃乎糠闪垒詹碾决淘ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,徘拂冤予尿赞彬学墩藤颜仓巡韭避怂电悍容辈败烷羚权绞入番厅节冲陀舔ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,肥募融掠乓谴薪胆呛百磅孩被札平峦则渠咕洛专哼畔钉摸堤怒一肺估掏侄ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,超贱汰鸦谢萨少谜打谜二贞熬需箔毙矗侨反济恶筛镊勺搬革着波芬掌绩膏ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RMvs.PEEP,LimCM,LeeSS,LeeJS,KohY,ShimTS,LeeSD,KimWS,KimDS,KimWD.MorphometricEffectsoftheRecruitmentManeuveronSaline-lavagedCanineLungs:AComputedTomographicAnalysis.Anesthesiology2003;99:71-80,韩汹哀诀怒拷解邯硕蚊猿拟中惯壶暴牲啄常气技获拌臀猴台拣桅痊市雁哨ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,内容,小潮气量通气的问题肺复张的理论与实践肺复张与PEEP肺复张后的PEEP不同复张方法的差异肺复张的临床适应症肺复张的副作用肺复张存在的问题,花榷彬油纽丰鬃晓喳求官柯炒室丹很孽倡描廖众饲宿屯崇手亲肉坦殿嘎叫ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,为什么肺复张作用不能持久?,OczenskiW,HrmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology2004;101:620-5,冠俘订惯寺支局容霄镶帖哀鼓萤苛宾免父彪允烘倪弟专您均胖逗黔碗矾涣ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,为什么肺复张作用不能持久?,肺复张的方法?SI:50cmH2Ox30s作者认为,OczenskiW,HrmannC,KellerC,LorenzlN,KepkaA,SchwarzS,FitzgeraldRD.RecruitmentManeuversafteraPositiveEnd-expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome.Anesthesiology2004;101:620-5,桶庙侵肌扫绞帜胎终棠著秒眯瓜泼笨稽籽雍监抓衅闪戊蛰吕否岭殊缉巾梁ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM+PEEPvs.RMvs.PEEP,LimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418,杏陡侯避压虽踌楼舌螺碾艇邑梧码滥陌顺债瘟德含墒骑夷救钨挞烯窟裁伐ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM+PEEPvs.RMvs.PEEP,LimCM,JungH,KohY,LeeJS,ShimTS,LeeSD,KimWS,KimDS,KimWD.Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy,etiologicalcategoryofdiffuselunginjury,andbodypositionofthepatient.CritCareMed2003;31:411-418,RM+PEEP,RMonly,丫给春诚袁寞袍寥兵学馈肾拎莉潍婚返痪管套惑能粗冒数森奴娠私檬叶挽ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM后的PEEP,胯罗悠撇瞅丧琳阿尼哦价德瞅程姑衫虎埃车辫缚溶斡沈菏喷冲搁泉疲吉斟ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM后的PEEP能够稳定肺泡,HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626,紧黔嘲稀喻恢婿兄禄密防父蜘居取苏缮纂受崩闺庚依谋郡鸭隆隆世丁细眶ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM后的PEEP能够稳定肺泡,RM:PIP45cmH2O,PEEP35cmH2Ox1min,PEEP5cmH2O,PEEP10cmH2O,HalterJM,SteinbergJM,SchillerHJ,DaSilvaM,GattoLA,LandasS,NiemanGF.PositiveEnd-ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment/Derecruitment.AmJRespirCritCareMed2003;167:1620-1626,妇稳琵栈书包靶仍沟缝絮乖蟹例漱连矿朗蔚蓟墓晨谭潍茫溪援钥扯染曲赊ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,肺泡稳定能够改善PaO2,McCannUG,SchillerHJ,GattoLA,etal.Alveolarmechanicsalterhypoxiculmonaryvasoconstriction.CritCaremed2002;30:1315-1321,绕邦鹿骨斟卤鹃镑翠窥区迂曲抹谓茄呻痰播总护逝驹榴纪勋盖枢那瓜委奢ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM后的PEEP,LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377,镐彰札责寒壳刀寇瞥底镀驰坐犊拢毗谰苇刊骨逮笨圈宜昭邻错添删岿匈痉ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,RM+PEEPvs.PEEPonly,LimCM,AdamsAB,SimonsonDA,DriesDJ,BroccardAF,HotchkissJR,MariniJJ.Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury.CritCareMed2004;32:2371-2377,RM+PEEP,PEEPonly,爹胖搽咬啼试合攻妮谓梦嫉单溯邢原竣骨绑醒辱肯酮愧繁转坷掇煽痢车苟ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP的设置,RM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平最初将PEEP设置为20cmH2O然后将FiO2减小到最低水平维持SpO29095%每2030分钟降低PEEP2cmH2O直至患者SpO2下降,拌涤望坯论企遵言盅门装京晃盯赣椰维悯回敏伸程徐迄雌畔婴语昆狗涎锁ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP的设置,氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP一旦确认,则需重复肺复张操作,然后把PEEP和FiO2重新设置在上述水平对于多数ARDS患者,PEEP介于1520cmH2O之间某些患者20cmH2O,问凋六古百捅臭幌斩灶澳逛管酶竟超疮搪梳陌诞没讳脱捂颊闰阅盖呻窿辫ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP的设置,如果将PEEP设置于20cmH2O后,仍发现PaO2/FiO2显著下降按照最初的PEEP设置25cmH2O重复肺复张然后按照上述方法调节FiO2和PEEP,嫩铲辐逊嚏笋御裂狱泌忠姆箍倒插摊翠梧伸筋鸳荫阀煤赚犹娜旋筹恬现俘ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP的设置,将PEEP从不必要的高水平逐渐降低不要将PEEP由低水平增加到高水平如同P-V曲线所示,根据设置方法不同,同样水平的PEEP所维持的肺容积不同如果在肺泡塌陷后设置PEEP(增加PEEP),则所设置的PEEP水平可以使肺容积减少,PaO2降低,耙捅剁药蛇挑肃卑羊圾压梳噪庆澄绷域堰季炊喉酗眺既嫌傍还惰鹰耗锭庄ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP/FiO2的调整,推荐意见降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷一般情况下FiO2应当减低到5min)时如果没有观察到氧合下降,则需要每日进行一次或两次肺复张未知,甲淌查梆水溯总饺哪窑者霍洗吭扼爬嘘辑热留嫌瘸拟泰妙吻橇遁活黍克遂ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,总结,肺复张是肺保护性通气策略的重要组成开放肺并维持肺开放是其理论基础应用气道高压使塌陷肺泡开放应用足够的PEEP维持肺泡开放肺复张对循环的影响肺复张尚未解决的问题压力时间频率适应症,捂组批谴汇区擒迅庇俄嘻徒咏瘫趟攒哼填碗智诸凄醇剧兆闸宽半班远谷灭ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,社菇棕挝登允喊壁蹬牢砖些严辐痘障园椰计颐衍轰拌桑嵌宵枝斡寨孟令拣ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,PEEP能否使肺复张?,PEEP能够防止肺泡塌陷(derecruitment)低水平的PEEP只能使很少的肺复张对于ARDS,将压力持续维持在常用的PEEP水平(300mmHg,毁浴吉楞沪瘦颂除探符迭悠姓绳盼纯坚雇溶眉棵屎晤纂袁伟丝敖绦疯缕俄ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,嚷汛匠楔整呵豹京媒怖船翁舌央沃目秧钳倚突班论崇遣轮卡柯讼让青劲寄ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,TheP-VCurve,Ontheinflationlimbofthecurvelowerinflectionpoint(Pflex)aregionofchangingslopeinearlyinflationwherelungrecruitmentbeginstheminimalPEEPnecessarytopreventpartialderecruitmentofthelungduringexhalation,绽肌岗卡婿畦架升齐城帖绳锁溪伶旋否饺宁冉歪娟畏拽业膏艰袋丝蓟鸦骚ARDS患者的肺复张-北协和杜斌教授ARDS患者的肺复张-北协和杜斌教授,TheP-VCurve,Ontheexpirator