心脏病患者的正压通气─心肺相互作用

1、北京协和医院北京协和医院杜斌杜斌心脏病患者的正压通气:心肺相互作用利益冲突无机械通气是心脏病患者常用的治疗手段美国6个州共6,469,674名住院患者180,326 (2.8%)接受机械通气AMI1.7%心脏功能不全18.4%全球20个国家361个ICU中15,757名患者5,183 (33%)接受机械通气急性呼衰68.8%原因术后20.8%肺炎13.9%充血性心衰10.4%全身性感染8.8%创伤7.9%Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation in the U

2、nited States. Crit Care Med 2010; 38: 1947-1953Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-day international study. JAMA 2002; 287: 345-355自主呼吸及机械通气对心血管的影响Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ven

3、tilation. Arch Dis Child 1999; 80: 475-480正压通气胸腔内压肺容积前负荷后负荷心率心肌收缩力正压通气对心血管的影响Scharf SM, Caldini P, Ingram RH. Cardiovascular effects of increasing airway pressure in the dog. Am J Physiol 1977; 232: H35-H43胸腔内压改变的血流动力学影响Thorax自主呼吸对LV充盈的影响Lemaire, et al. Anesthesiol 1988; 69: 171-179胸腔内负压的剧烈波动可导致肺水肿哮

4、喘持续状态上气道梗阻肺水肿Stalcup and Mellins. N Engl J Med 1977; 297: 592-596 Kanter and Watchko. Am J Dis Chil 1984; 138: 356-358Luke et al. Pediatrics 1966; 37: 762-768Oswalt et al. JAMA 1977; 238: 1833-1835Miro et al. Chest 1989; 96: 1430-1431NPPE的发病机制Upper Airway ObstructionMuller ManeuverITP more negativeP

5、ulm. blood volumePulm. arterial pressureTransudationPulmonary EdemaCapillary permeabilityPulm. capillary damagePulm. arterial constrictionSystemic vasoconstrictionCNSHypoxiaLV afterloadPulm. venous pressurePericapillary hydrostatic pressureCOITP升高能够降低LV后负荷，增加心输出量-受体阻滞剂诱导的急性心功能衰竭（犬模型）Pinsky et al. J

6、Appl Physiol 1983; 54: 950-955Pinsky et al. J Appl Physiol 1985; 58: 1189-1198合并CHF的心肌病患者Pinsky & Summer. Chest 1983; 84: 370-375急性心功能衰竭犬模型心动周期特异性ITP增加Pinsky et al. J Appl Physiol 1986; 60: 604-612预防低血容量下CO下降Matuschak et al. J Appl Physiol 1986; 61: 44-53急性二尖瓣返流的犬模型Stein et al. J Appl Physiol 19

7、90; 69: 2120-2125ITP改变对LV射血的影响ITP下降能够增加LV射血压，增加LV后负荷ITP升高能够降低LV射血压，降低LV后负荷Buda, Pinsky, et al. N Engl J Med 1979; 301: 453-459Pinsky, et al. J Appl Physiol 1983; 54: 950-955呼吸周期对左室每搏输出量的影响Jallon JF, Abdulhay E, Calabrese P, et al. A model of mechanical interactions between heart and lungs. Phil Tran

8、s R Soc A 2009; 367: 4741-4757LV PV曲线，MVO2和心脏做功的关系StrokeWorkElastance-DefinedPotentialWorkThe hidden mechanical work of the LVSuga H, Hayashi T, Shirahata M. Ventricular systolic pressure-volume area as predictor of cardiac oxygen consumption. Am J Physiol 1981; 240: H39-H44LV压力容积面积(PVA)Vendelin M,

9、Bovendeerd PHM, Engelbrecht J, et al. Optimizing ventricular fibers: uniform strain or stress, but not ATP consumption, leads to high efficiency. Am J Physiol 2002; 283: H1072-H1081StrokeWorkPEPVALV PV曲线，MVO2和心脏做功的关系LV VolumeLV PressureABLV VolumeLV PressureABMVO2A MVO2B两个P/V环：每搏功相同PVA及MVO2不同正压通气对LV

10、前负荷和后负荷的影响Denault AY, Gorcsan J, Pinsky MR. Dynamic effects of positive-pressure ventilation on canine left ventricular pressure-volume relations. J Appl Physiol 2001; 91: 298-308正压通气对LV前负荷和后负荷的影响Denault AY, Gorcsan J, Pinsky MR. Dynamic effects of positive-pressure ventilation on canine left ventri

11、cular pressure-volume relations. J Appl Physiol 2001; 91: 298-308正压通气对LV前负荷和后负荷的影响Dhainaut JF, Devaux JY, Monsallier JF, etal. Mechanisms of decreased left ventricular preload during continuous positive pressure ventilation in ARDS. Chest 1986; 90:74-80LV收缩力正常时ITPITPIncreased LV Ejection PressureInc

12、reased LV PreloadDecreased LV Ejection PressureDecreased LV PreloadESPVRPinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-503LV收缩力降低时ITPITPIncreased LV Ejection PressureIncreased LV PreloadDecreased LV Ejection PressureDecreased LV

13、 PreloadESPVRPinsky MR. The hemodynamic consequences of mechanical ventilation: an evolving story. Intensive Care Med 1997; 23: 493-503无创CPAP和BiPAP能够减轻心脏应激CPAP能够减轻急性心源性肺水肿(ACPE)患者的心脏缺血Rasanen et al. Am J Cardiol 55:296-300, 1985如果CPAP能够消除ACPE患者的胸腔内负压，才能发挥有益作用Rasanen et al. Chest 87:158-62, 1985面罩CPA

14、P可避免ACPE患者气管插管Bersten et al. N Engl J Med 325:1825-30, 1991面罩BiPAP以及PSV可改善ACPE患者氧合，避免气管插管Massip et al. Lancet 356:2126-32, 2000Giacomini et al. Chest 123:2057-61, 2003Nava et al. Am J Respir Crit Care Med 168:1432-7, 2003Ferrer et al. Am J Respir Crit Care Med 168:1438-44, 2003CPAP和BiPAP对ACPE具有相似的有益

15、作用Park et al. Crit Care Med 32:2407-15, 2005面罩BiPAP能够改善OSA患者的左心室功能Kaneko et al. N Engl J Med 348:1233-41, 2003急性心梗时的CPAPRasanen et al. Chest 1985； 87: 158-162CPAP对CHF患者ITP的影响Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular tran

16、smural pressures in patients with congestive heart failure. Circ 1995; 91: 1725-1731CPAP对CHF患者ITP的影响Naughton MT, Rahman A, Hara K, et al. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Circ 1995; 91:

17、 1725-1731CPAP改善CHF患者的LV功能24名合并CHF的OSA患者夜间CPAP x 1 mth vs. 对照组夜间CPAP组病情改善OSA发作减少收缩压降低 (126 to 116 mmHg)心率减慢 (68 to 63 bpm)LV射血分数改善 (25 to 34%)LV收缩末内径减小 (55 to 53 mm)Kaneko et al. N Engl J Med 2003; 348: 1233-1241CPAP改善CHF患者的LV功能Kaneko et al. N Engl J Med 2003; 348: 1233-1241ACPE时的面罩CPAP39名ACPE患者随机分为

18、面罩CPAP组或氧疗组(FiO2 0.4)研究持续24 h30分钟后呼吸频率及PaCO2下降24 h时两组患者生理指标相似气管插管比例CPAP组0/20对照组7/19Bersten et al. N Engl J Med 1991; 325: 1825-1830ACPE时的面罩CPAPBersten et al. N Engl J Med 1991; 325: 1825-1830CPAPO2ACPE的无创通气Masip, et al. Lancet 2000; 356: 2126-2132Control(n = 18)NIPSV(n = 19)ACPE的无创通气Masip, et al. Lancet 2000; 356: 2126-2132ACPE的无创机械通气Ferrer M,Esquinas A, Leon M et al. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168: 1438-1444ACPE的无创机械通气Ferrer M,Esquinas A