ARDS肺复张的临床实施

1、ARDS RMARDS RM的临床实施的临床实施邱海波邱海波东南大学附属中大医院东南大学附属中大医院东南大学急诊与危重病医学研究所东南大学急诊与危重病医学研究所BP 70/50，HR 170, cvp 8. NE 5 PHE 5 FiO2 70%, PEEP 12 Ph24 SaO2 90% ARDSARDS常见的临床综合征常见的临床综合征内容提要病理生理特点病理生理特点肺泡塌陷的危害肺泡塌陷的危害如何实施肺复张如何实施肺复张? ?肺复张疗效的判断肺复张疗效的判断影响肺复张实施的因素影响肺复张实施的因素30 kg 猪肺灌洗复制ARDS模型压力控制通气PCVPaw 13 cmH2O PEEP 5

2、 cmH2OARDS-肺泡塌陷广泛存在肺泡塌陷广泛存在肺容积明显降低肺容积明显降低(a)肺泡水肿肺泡水肿 (b)肺泡表面活性物质的消耗或不足肺泡表面活性物质的消耗或不足(c)肺间质水肿压迫远端细支气管肺间质水肿压迫远端细支气管肺顺应性明显降低肺顺应性明显降低通气通气/血流比例失调血流比例失调 肺内分流和死腔样通气肺内分流和死腔样通气CT scan 70-80% 的肺野呈现高密度区的肺野呈现高密度区 分布：下垂部位分布：下垂部位(dependent field)提示：提示：1. 参与通气的肺泡区域明显减少参与通气的肺泡区域明显减少(20-30%) 2. 肺损伤具有不均一性肺损伤具有不均一性肺容积

3、减少肺容积减少Small lung Baby Lung肺顺应性明显降低肺顺应性明显降低 Reduced range of volume excursion: Low compliance Flattening at low and high volumes: Lower and upper inflection pointsVolumePressureNORMALARDS顺应性曲线明显向右下移位顺应性曲线明显向右下移位肺内分流增加肺内分流增加肺泡塌陷：肺泡塌陷：ARDS重力依赖区重力依赖区 炎症或不张区炎症或不张区生理性低氧缩血管反应：障碍生理性低氧缩血管反应：障碍HEARTSPARDS-Ga

4、ttinoni分区分区1.1.过度通气区或过度通气区或“干区干区” “baby lungbaby lung2. 2. 可复张区或湿区可复张区或湿区3. 3. 实变实变区区内容提要病理生理特点病理生理特点肺泡塌陷的危害肺泡塌陷的危害如何实施肺复张如何实施肺复张? ?肺复张疗效的判断肺复张疗效的判断影响肺复张实施的因素影响肺复张实施的因素PEEP肺复张与肺复张与低氧血症改善低氧血症改善Gattinoni L, Caironi P, Pelosi P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711 A .低氧血症低氧血症PressureV

5、olumePressure wedgeShear forceB. 剪切力剪切力(Shear force) 盐水灌肺制造家兔盐水灌肺制造家兔ARDSARDS模型模型低流速法测定低流速法测定LIPLIP水平水平肺保护通气肺保护通气3 3h,Vt6ml/kg,PEEP=LIPh,Vt6ml/kg,PEEP=LIPDRDR后予后予SI SI的的RMRMDRDR后予后予PCVPCV的的RMRM每小时的每小时的0 0、1010、2020、3030、4040分钟分钟将呼吸机脱开将呼吸机脱开1 1分钟分钟制造肺泡的重复去复张制造肺泡的重复去复张( (DR)DR)动物处死，取肺病理检查、测湿动物处死，取肺病理检

6、查、测湿/ /干重比、测干重比、测TNF-mRNATNF-mRNA表达、表达、转录因子转录因子NF-BNF-B的活性的活性 、MPOMPO及及MDAMDA活性活性对照组对照组ARDSARDS组组LPLP组组DRDR组组PCVPCV组组SI SI组组动物准备动物准备1 2 3 456 1、2、3、4、5和和6泳道分别为正常、泳道分别为正常、ARDS、DR、LP、SI和和PCV组组肺复张手法对重复去复张肺复张手法对重复去复张ARDSARDS家兔家兔肺组织肺组织NF-NF- B B 活性的影响活性的影响 0200040006000800010000NormalARDSLPDRSIPCV肺组织NF-B

7、活性（积分光密度IOD）NormalARDSLPDRSIPCV肺复张手法对重复去复张肺复张手法对重复去复张ARDSARDS家兔家兔 肺组织肺组织TNFmRNA TNFmRNA 表达的影响表达的影响 04080120160200NormalARDSLPDRSIPCV肺组织TNFmRNA的表达（TNF/GAPDH）NormalARDSLPDRSIPCV01 23 45 6 1、2、3、4、5和和6泳道泳道分别为分别为Normal、ARDS、LP、DR、SI和和PCV组组0泳道为分子质量标准泳道为分子质量标准 RM改善重复去复张造成的氧合恶化0100200300400500600基础模型0小时1小时

8、2小时3小时Pao2（mmHg）3LP4DR5SI6PCV肺复张手法对重复去复张肺复张手法对重复去复张ARDS ARDS 家兔家兔PaO2 PaO2 的影响的影响C.C.感染与肺不张感染与肺不张 全麻-肺不张的发生率 90% 择期腹部手术：肺不张肺部感染9.6% 择期心脏手术：肺不张肺部感染5.7% 肥胖病人手术：25%-30%发生肺不张肺部感染 CHEST 1997; 111:564-71Qiu Haibo. Chin J Emerg Med, 2001, 10(5): 293-294 MODS/MOFD.气压伤、生物伤与气压伤、生物伤与MODSFrom SluskyARDSmotor of

9、 MODS邱海波邱海波. 中华急诊医学杂志中华急诊医学杂志, 2001, 10(5): 293-294 肺是炎症细胞激活和聚积的重要场所肺是炎症细胞激活和聚积的重要场所肺实质细胞可释放炎症介质肺实质细胞可释放炎症介质 MODS/MOF将大鼠常规镇静肌松将大鼠常规镇静肌松通气参数通气参数 : Vt 8 ml/kg; f 38 40 / min; PEEP 1 cm H2O; FiO2 0.21 剖腹术剖腹术(series1) 非剖腹术非剖腹术 (series2) 复张组复张组: 复张方法：复张方法： (PEEP 增增加到加到 8 cm H2O，10个呼吸周个呼吸周期期, 每每 30 分钟一次分钟

10、一次). PEEP 降至降至2 cm H2O 通气通气 无复张组无复张组 : 0 PEEP 不采取不采取任何肺复张手法任何肺复张手法Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.肺泡塌陷与复张对预后影响的实验研究肺泡塌陷与复张对预后影响的实验研究Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.持续肺泡塌陷持续肺泡塌陷-预后不良预后不良临床研究临

11、床研究: : 塌陷肺泡越多塌陷肺泡越多, , 病死率越高病死率越高N Engl J Med 2006;354:1775-86Villar and Amato trialVillar J. Crit Care Med 2006; 34:1311内容提要病理生理特点病理生理特点肺泡塌陷的危害肺泡塌陷的危害如何实施肺复张如何实施肺复张? ?肺复张疗效的判断肺复张疗效的判断影响肺复张实施的因素影响肺复张实施的因素20406080100Pressure cmH2O102030406050Total Lung Capacity %R = 22%R = 81%R = 100%R = 93%肺复张是压力依赖性

12、过程肺复张是压力依赖性过程00R = 0%R = 59%From Pelosi et alAJRCCM 20011/5 of “Recruitable” Units肺复张是肺复张是时间时间依赖性过程依赖性过程 40 SECONDS肺复张的常用方法肺复张的常用方法l控制性肺膨胀控制性肺膨胀(SI)lPEEP递增法递增法l压力控制法压力控制法(PCV)45 for 40 s 35 Peak45/16 and 1:2 for 120 sPCV Advantages-Same Recruiting Pressure-Repeated Maneuvers-Lower Mean Pressure-Pres

13、erved VentilationCPAP模式模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续将吸气保持键按住，持续20- 40s内容提要病理生理特点病理生理特点肺泡塌陷的危害肺泡塌陷的危害如何实施肺复张如何实施肺复张? ?肺复张疗效的判断肺复张疗效的判断影响肺复张实施的因素影响肺复张实施的因素肺泡完全复张的临床标准肺泡完全复张的临床标准 氧合标准 CT标准 EIT标准肺泡完全复张的临床标准肺泡完全复张的临床标准-PaO2/FiO2 PaO2/FiO2

14、400 PaO2 + PaCO2 400 2.PaO2/FiO2 降低降低5%lPaO2 + PaCO2 400 (at 100% oxygen): 维持肺开放的可靠指标维持肺开放的可靠指标l达到达到PaO2 + PaCO2 400时：时： CT显示只有显示只有5% 的肺泡塌陷的肺泡塌陷l PaO2 + PaCO2 400对塌陷肺泡的对塌陷肺泡的预测：预测： ROC曲线下面积曲线下面积 0.943Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006肺泡完全复张的临床标准肺泡完全复张的临床标准-CT肺泡完全复

15、张的临床标准肺泡完全复张的临床标准-CTBorges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006l动脉氧合与塌陷肺组织重量明显呈负相关动脉氧合与塌陷肺组织重量明显呈负相关 (R = 0.91)Lower vs higher Lower vs higher Percentage of Potentially Recruitable LungPercentage of Potentially Recruitable LungARDSARDS塌陷肺泡都能重新开放吗塌陷肺泡都能重新开放吗? ?N Engl J Med

16、2006;354:1775-86PEEP 5cmH2O Ppla 20cmH2OPEEP 17cmH2O Ppla 40cmH2OPEEP 25cmH2O Ppla 40cmH2OPEEP 25cmH2O Ppla 60cmH2OCorrespondence: Amato, N Engl J Med 2006, 355:319内容提要病理生理特点病理生理特点肺泡塌陷的危害肺泡塌陷的危害如何实施肺复张如何实施肺复张? ?肺复张疗效的判断肺复张疗效的判断影响肺复张实施的因素影响肺复张实施的因素Prespective, randomized study: Effect of RM on ARDS P

17、respective, randomized crossover study 34 ICU at 19 hosp RM: CPAP over 510 s to 35 cm H2O PEEP: FIO2/PEEPstep to maintain SpO2 8895%.CCM, 2003, 31(11): 2592-7肺泡复张的决定因素肺泡复张的决定因素(1): 肺内肺内 vs 肺外源性肺外源性ARDS ARDS Trial Network, Crit Care Med 2003; 31(11):2592-2597Starting Conditions For the ARDSnet Recrui

18、ting TrialPrimary为什么为什么RMRM改善氧合不明显？改善氧合不明显？病人的特点：病人的特点：l入组时入组时Ppla 26.4Ppla 26.4l肺内原因肺内原因ARDSARDS占占65% 65% Paw cmH2O %05 10 15 20 25 30 35 40 45 5001020304050Crotti et al. AJRCCM 2001.PPLATPRECRUITOpening Pressures: Primary ARDS RM能够实现能够实现ARDS肺完全开放肺完全开放实现实现 open the lung and keep the lung open in th

19、e 24/26 patsBorges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006麻醉导致的非炎症性肺泡塌陷麻醉导致的非炎症性肺泡塌陷肺泡复张的决定因素肺泡复张的决定因素(2): 病理特征病理特征Rothen HU. Dynamics of reexpansion of atelectasis during general anaesthesia. Br J Anaesth1999; 82: 5516Lim, et, al. Anesthesiology 2003; 99:71ARDS导致的炎症性肺泡塌陷导致的炎

20、症性肺泡塌陷SuperimposedPressureOpeningPressureInflated0Alveolar Collapse(Reabsorption)20-60 cmH2OSmall AirwayCollapse10-20 cmH2OConsolidation (modified from GattinoniRegional Spectrum of Opening Pressures肺泡复张的决定因素肺泡复张的决定因素(3): 压力与时间压力与时间 实现实现 open the lung and keep the lung open in the 24/26 patsBorges J

21、B, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006Multiple maneuvers- 获得理想的复张效应获得理想的复张效应Fujino et al, Crit Care Med 2001; 29(8):1579-1586肺泡复张的决定因素肺泡复张的决定因素(4):ARDS病程病程(早期早期vs 后期后期) N=17 ARDS with a lung protective vent Early ARDS (n=9) vs Late ARDS (n=8, 7d) RM: PCV 2min at PIP 50cmH2O/P

22、EEP PUIPAm J Respir Crit Care Med, 2002, 165:165170不同不同RM方法的肺复张效应不同方法的肺复张效应不同Volume increments at 15 min Post-RM in VILI ModelPaw cmH2O %Opening and Closing Pressures0510152025303540455001020304050 Opening pressureClosing pressure5 patients,ALI / ARDSFrom Crotti et alAJRCCM 2001.Some units cantbe ke

23、pt open by any reasonable PEEP!肺泡复张的决定因素肺泡复张的决定因素(5): 循环耐受情况循环耐受情况An RM Can Profoundly Depress COAveraged Data from 3 ModelsS-C Lim, et al 2004RM Effect on CO Varies Among Injury ModelsAveraged data for 3 RM MethodsS-C Lim, CCM 2004Effect of RM Method on CO in Pneumonia ModelS-C Lim, CCM 2004肺泡复张的决定

24、因素肺泡复张的决定因素(6):肺泡过度膨胀肺泡过度膨胀Clinical exp of Gattinonii l 低可复张的ARDS患者l Higher PEEP: little benefit and may actually be harmful. l 多数肺泡( 60 %)处于开放状态l 高PEEP和肺复张对开放的肺泡可能是有害的l 高可复张的ARDS患者l the use of higher PEEP levels seems appropriate l In our daily practicel PEEP 15 cmH2Ol PEEP 150 mllNonrecruiters: 15

25、0 ml影响ARDS肺复张效应的因素Am J Respir Crit Care Med Vol 171. pp 10021008, 2005l 影响复张响应的预测因素影响复张响应的预测因素 (原发病原发病No effect)l PEEP - PaO2/FiO2l PEPP - Compll PEEP - Stress index (b) 内容提要RMRM的病理生理基础与实施的病理生理基础与实施RMRM造成的循环问题造成的循环问题突破突破RMRM的循环限制的循环限制RM导致的血流动力学改变导致的血流动力学改变ARDS pats n=10 SI的实施：的实施：30cmH2O，20s SI时时vPA

26、P、CVP、PAWP、PVRI和和RVSWI均显著增加均显著增加(P 12%RM面临的循环困境面临的循环困境LMRs: 40 cmH2O for 10 s or 20 s lCO reduction 50%lLV end-diastolic area 45%lMean arterial pressure drop 20%Of course, hemodynamic status return stable within 3minIntensive Care Med (2005) 31:11891194An RM Can Profoundly Depress COAveraged Data fr

27、om 3 ModelsS-C Lim, et al 2004CO降低的原因降低的原因lContractilitylAfterloadlPreloadlProspective randomized cross-over studylPats with CABGlRM (40 cmH2O X 10 s/20sRM循环干扰的机制：循环干扰的机制： Effect of RM on LV preloadIntensive Care Med (2005) 31:11891194TEE: transgastric ED short axis view of the LVA before a 10s LRMB

28、 at the end of a 10-s LRMC before a 20s LRMD at the end of a 20-s LRMRM循环干扰的机制：循环干扰的机制：Effect of RM on RV afterloadIncrease in RV afterloadlAlveolar overdistention of aerated lung areaslHypoxic vasoconstriction in atelectatic lung areasAtelectasis causes vascular leak and lethal right ventricular fa

29、ilure in uninjured rat lungs. Am J Respir Crit Care Med 2003, 167:1633-1640.Ventilation above closing volume reduces pulmonary vascular resistance hysteresis. Am J Respir Crit Care Med 1998, 158:1114-1119.RM效应lRandomized, controlled, cross-over studylPig ARDS model by lung-lavagelRM: 12s-s X 40 cm H

30、2O OR 30-s X 40 cm H2ORM循环干扰的机制：循环干扰的机制：Effect of RM on Leftward septal shiftEchocardiogram: via the short axis end-diastolic view of the RV and LVBefore RM and at the end of a 30-s RMIntensive Care Med (2006) 32:585594Critical Care 2006, 10:R86Effect of RM on LVEffect of RMContractility and Afterlo

31、ad (SVR): NOTPreload: decreasePig with ARDS by repeated lung lavagelConventional MV (CMV): PEEP 5 cmH2O +Vt 810 ml/kg. No RMlOLC ventilation: RM for PaO2/FiO2 60 kPa. Vt 68 ml/kgRM Effect on CO Varies Among Injury ModelsAveraged data for 3 RM MethodsS-C Lim, CCM 2004突破循环限制血流动力学干扰 vs ARDS病因(a) Pigs w

32、ith BAL vs LPS-induced ALI RM for 1 min vital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2O PCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kgIntensive Care Med (2005) 31:112120Aortic blood flow (ABF)Mesenteric blood flow (QPV)BAL-ARDSLPS-ARDS突破循环限制血流动力学干扰 vs

33、ARDS病因(a)1.RM使三种使三种 ARDS模型模型 CI均明显下降均明显下降2.CI盐酸组降低盐酸组降低37% 油酸组油酸组 19% 生理盐水组生理盐水组 23%3盐酸组盐酸组5min后接近后接近 RM前水平前水平 不同病因的不同病因的ARDS vs RM对对CI的影响的影响Effect of RM Method on CO in Pneumonia ModelS-C Lim, CCM 2004突破循环限制血流动力学干扰 vs RM方法(b)*nHCI吸入复制模型吸入复制模型nCI降低程度不同降低程度不同pPCV: 降低降低25%pSI: 降低降低46%pIP: 降低降低39% RM方法

34、不同对方法不同对CI的影响的影响 Pigs with BAL vs LPS-induced ALI RM for 1 min vital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2O PCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kgIntensive Care Med (2005) 31:112120Aortic blood flow (ABF)Mesenteric blood flow (QPV)BAL-ARDSLP

35、S-ARDS突破循环限制血流动力学干扰 vs RM方法(b)突破循环限制血流动力学干扰 vs RM方法(b)Intensive Care Med (2006) 32:585594突破循环限制血流动力学干扰 vs Volume expansion(c) Volume status in pats with ARDS Intensive Care Med (2006) 32:585594 Pigs with ARDS, RM for 1 min vital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2O PCRM with peak airway

36、pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kgIntensive Care Med (2005) 31:112120Aortic blood flow (ABF)Mesenteric blood flow (QPV)BAL-ARDSLPS-ARDS突破循环限制血流动力学干扰 vs Volume expansion(c) lRandomized, controlled, cross-over studylPig ARDS model by lung-lavagelRM: 12s-s X 40 cm H2O OR

37、30-s X 40 cm H2OlVolume status: under hypovolemia, normovolemia and hypervolemiaEffect of volume status on Leftward septal shiftlEchocardiogram Screen: via the short axis end-diastolic view of the left and right ventricleslBefore RM and at the end of a 30-s RMIntensive Care Med (2006) 32:585594突破循环限

38、制血流动力学干扰 vs Volume/septal shift (d)hypovolemia, normovolemia and hypervolemia突破循环限制血流动力学干扰 vs Volume/septal shift (d) Anesthetized pigs A bronchial blocker was inserted in the right lower lobe, which was selectively lavaged to create a dense lobar collapse. Randomized into two groups Selective lung RM (using the inner lumen of the bronchial blocker) General lung RM RM 40cmH2O for 30 s突破循环限制血流动力学干扰 vs Selective RM (d)Before (A) and afte