医学资料ARDS肺复张的测定-邱海波

1、急性呼吸窘迫综合征肺复张的测定与应用邱海波东南大学附属中大医院东南大学急诊与危重病研究所2021/7/19 星期一2021/7/19 星期一2021/7/19 星期一内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择 2021/7/19 星期一Lung volume decreased markedly (TLC, VC, TV, FRC) -alveolar edema -pulmonary surfact

2、ant -Interstitial pumonary edema depress brochiole and induce spasmCompliance reduced significantlyVentilation/perfusion mismatch -intrapulmonary shunt and dead space like effectsARDS病理生理特点ARDS病理生理2021/7/19 星期一CT scan70-80% 的肺野呈现高密度区分布：下垂部位(dependent field)提示：参与通气肺泡明显减少(20-30%) 肺损伤具有不均一性肺容积减少Small l

3、ung Baby LungARDS病理生理2021/7/19 星期一A and C finding in the acute or exudative phaseB and DFinding in the fibrosing-alveolitis phaseARDS病理生理2021/7/19 星期一肺容积/顺应性明显降低ARDS病理生理2021/7/19 星期一Reduced range of volume excursion: Low complianceFlattening at low and high volumes: Lower and upper inflection points

4、Bigatello: Br J Anaest 1996VolumePressureNORMALARDS顺应性曲线明显右下移位肺顺应性明显降低ARDS病理生理2021/7/19 星期一Upper and Lower Inflection PointsLower呼气末肺泡塌陷吸气早期肺泡再开放Upper吸气末肺泡顺应性明显降低，肺泡过度膨胀ARDS病理生理VolumePressureLower Inflection PointUpper Inflection Point2021/7/19 星期一通气/血流失调肺泡塌陷：ARDS重力依赖区，炎症或不张区生理性低氧缩血管反应：障碍ARDS病理生理202

5、1/7/19 星期一Imagine the Hardness to Blow up a Ballon .easyhardspatial & elastic limitationsLaplacian LawIt needs higher initial pressures to overcome the surface tension to open up a bubble to wider diameters!ARDS病理生理2021/7/19 星期一Sustain inflation Sigh小潮气量通气PHC, 避免肺泡过度膨胀最佳PEEP避免剪切力(Shear force)性损害Volu

6、mePressure肺开放与保护性通气策略的基本内容ARDS病理生理2021/7/19 星期一Lung volume decreased markedlyAtelectraumaKeep the lung openOpen the lungPrevent volutraumaSI and SighPEEPARDS病理生理2021/7/19 星期一内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择 2021/7

7、/19 星期一PV曲线法 Step 1: 测量PEEP所致的FRC(吸气末撤掉PEEP并延长呼气时间) FRCVE(ZEEP) VE(PEEP)肺复张容积测定2021/7/19 星期一 PV曲线法Step 2: 分别描计ZEEP和PEEP的PV曲线 Step 3: 肺复张容积：RV= V20(PEEP) + FRC V20(ZEEP)肺复张容积测定2021/7/19 星期一等压法呼吸模式：BIPAP条件：Ph 20 cmH2O， PEEP分别为0 、5 、 10、15 cmH2O，Ti 6S测定：延长呼气时间，测定ZEEP呼出气量。在不同PEEP时吸气末撤掉PEEP，延长呼气时间，测定呼气量肺

8、复张容积测定2021/7/19 星期一等压法肺复张容积测定2021/7/19 星期一P-V曲线法与等压法的比较*#与PEEP5cmH2O相比较，*P 0.05;与PEEP10cmH2O相比， P 0.05;与P-V曲线法相比， #P 0.05* #肺复张容积测定2021/7/19 星期一肺复张容积测定P-V曲线法等压法虽然简单，但准确性较差 不能代替P-V曲线法目前肺复张容积的测定仍宜采用 P-V曲线法肺复张容积测定2021/7/19 星期一CT method膈顶上1cm CT层面PEEP与ZEEP比较Gattinoni L. Am J Respir CCM, 1995, 151: 1807全

9、肺扫描区别过度膨胀，膨胀，部分复张和塌陷区 Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444肺复张容积测定2021/7/19 星期一CT法-Gattinoni 肺复张容积测定原理CT空气=0Hu，CT水=1000 HuCT值=500Hu，肺组织50%空气+50%水ARDS塌陷肺CT值100Hu100Hu，塌陷肺泡复张 后，100Hu+100Hu内肺组织减少方法ZEEP和PEEP通气呼气末CT扫描膈肌顶上1cm计算CT值在100 Hu 100 Hu范围内体素结果之差 Gattinoni L. Am J Respir CCM, 1995, 151:

10、18072021/7/19 星期一 原理 充气不良区(100Hu500Hu)、正常充气区(500Hu 900Hu)、无充气区(100Hu+100Hu)和过度充气区(900Hu1000Hu)。肺泡复张，充气不良和正常充气肺区体积增加 方法 ZEEP和PEEP呼气末螺旋CT，根据层面厚度计算不同CT值肺体积，肺复张后充气不良与正常充气肺组织体积增加值肺复张容积测定CT法- Rouby Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:14442021/7/19 星期一Gattinonis vs Roubys CT法比较肺复张容积测定优点缺点Gattinoni结

11、果直观操作简单设备要求低单一层面不代表整体未计算充气不良肺泡的复张扫描时间较长Rouby多层扫描，反映整肺情况计算充气不良肺泡扫描时间缩短需特殊设备与软件测定过程复杂2021/7/19 星期一CT methods: Rouby vs GattinoniLuiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444肺复张容积测定2021/7/19 星期一内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺

12、复张的作用指导PEEP选择 2021/7/19 星期一ARDS肺不张的影响因素-附加静水压Hydrostatic pressure = (1 CT/-1000) Height Maximum sternovertebral dimention of human thorax: 20cmH2OPEEP 20cmH2O不能使ARDS患者肺泡完全复张动物ARDSMean Airway pressure 25 cm H2OARDS肺复张应用2021/7/19 星期一ARDS下肺气体含量明显降低CT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺复张

13、应用2021/7/19 星期一CT section lcated 5 cm below the carina No differences were observed in the percentage of lower lobes located beneath the heart in two groupsCT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺不张的影响因素-heart lung interdependenceARDS肺复张应用2021/7/19 星期一Cardiac mass and volume in ARDSCard

14、iac mass was increased by 27% vs NS Mechanism of cardiac mass:Edema of cardiac wallRV dilation secondary to pul hypertensionHyperkinetic state related to SIRSCT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺复张应用2021/7/19 星期一心脏下肺叶气体量明显降低ARDS 73% vs NS 21%Closed bar: Fraction of gas in lower lobes

15、 located beneath the heartOpen bar: lower lobes located outside the heartCT scan ARDS study group. AJRCCM, 2000,161:2005 ARDS肺复张应用2021/7/19 星期一塌陷肺泡的分布Local: Loss of aeration predominating in lower lobesDiffuse: Equal loss of aeration to the upper and lower lobesARDS肺复张应用2021/7/19 星期一Lung morphology

16、pattern Local DiffuseLIPNoYesNormally aerated 5512% 24 12%Poorly aerated 23 8% 40 12%Distribution modal BimodalUnimodalPeak of CT distr-727Hu/27Hu7HuCompltot57 546 11 Vieira SRR. AJRCCM, 1999, 159: 1612 ARDS肺复张应用2021/7/19 星期一Diffuse distributionARDS肺复张应用2021/7/19 星期一ARDS肺复张应用local distribution2021/7

17、/19 星期一内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价VT和SI or Sigh对肺复张的影响 评价PEEP维持肺复张的作用指导PEEP选择 2021/7/19 星期一SI前后绵羊复张容积的变化*与SI前相比，*P 0.05ARDS肺复张应用2021/7/19 星期一SI有效组绵羊肺气体交换变化*与SI前相比，*P 0.05ARDS肺复张应用2021/7/19 星期一潮气量对肺复张的影响A:PEEP=0, B:PEEP=Pflex, C:at the end of inspi

18、ration,D:PEEP=Pflex as in C during expirationPelosi P, Goldner M, Mckibben A, et al. Am J Respir Crit Care Med, 2001, 164, 131-140ARDS肺复张应用2021/7/19 星期一小潮气量通气的局限性Cretti S, Mascheroni D, Caironi P, et al. Am J Respir Crit Care Med, 2001, 164, 131-140ARDS肺复张应用2021/7/19 星期一Mean Airway pressure 5 cm H2O

19、 CT Scan :ARDS pig model 30 kgOptimized Lung Volume StrategyARDS肺复张应用2021/7/19 星期一Mean Airway pressure 25 cm H2O CT Scan :ARDS pig model 30 kgOptimized Lung Volume StrategyARDS肺复张应用2021/7/19 星期一Mean Airway Pressure 40 cm H2OCT Scan :ARDS pig model 30 kgOptimized Lung Volume StrategyARDS肺复张应用2021/7/1

20、9 星期一不同VT的肺复张容积*#与6ml/kg组相比，*P 0.05;与10 ml/kg相比， #P 0.05ARDS肺复张应用2021/7/19 星期一内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinonis vs RoubysARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择 2021/7/19 星期一PEEP效应的影响因素-附加静水压与心脏的影响ARDS肺复张应用2021/7/19 星期一Rothen H. et al. Br J Anaesth 1993:71:788-79

21、5Re-expansion of atelectasis during general anaethesiaA: CT scan at level of right disphragm B: CT scan 5cm above right diaphragmARDS肺复张应用2021/7/19 星期一PEEP诱导recruitment的分布Puybasset L. ICM, 2000, 26:1215c In lower lobes: Alv recruitment (ml) = 0.16 X End-expir lung volume(ml) 24mlARDS肺复张应用2021/7/19 星

22、期一PEEP导致overdistention的分布Volume of overdistension(ml)=0.42Parenchyma-900;-800(ml)18mlPuybasset L. ICM, 2000, 26:1215cARDS肺复张应用2021/7/19 星期一PEEP效应的影响因素-塌陷肺泡的分布范围塌陷肺泡的范围Efficiency of PEEP-induced alv recruitment highly correlated with the proportion of poorly and nonaerated lung parenchyma in ZEEPPuyb

23、asset L. ICM, 2000,26:1215 ARDS肺复张应用2021/7/19 星期一Diffuse: Equal loss of aeration to the upper and lower lobesVieira SRR. AJRCCM, 1999, 159: 1612 ARDS肺复张应用2021/7/19 星期一Local: Loss of aeration predominating in lower lobesVieira SRR. AJRCCM, 1999, 159: 1612 ARDS肺复张应用2021/7/19 星期一Effect of PEEP on recru

24、itment and overdistentionPuybasset L. ICM, 2000, 26:1215ARDS肺复张应用2021/7/19 星期一PEEP效应的影响因素-LIP的影响ARDS肺复张应用2021/7/19 星期一绵羊有无LIP组PEEP复张容积*#*#与5cmH2O相比，* P 0.05;与10cmH2O相比，#P 0.05ARDS肺复张应用2021/7/19 星期一有无LIP患者的复张容积 *#*#与PEEP5 cmH2O相比，*P 0.05与PEEP 10 cmH2O相比，#P 0.05与LIP组比较，P 400mmHg，每15-20min降低PEEP，至PaO2较

25、前一次降低5%, PEEP水平为前一次PEEP结果：PaO2+PaCO2从178.476.5mmHg升至487.8 139.1mmHg，维持肺复张PEEP水平为224cmH2OV.N.Okamoto et al. Unpublished data, 2003ARDS肺复张应用氧分压导向性PEEP选择2021/7/19 星期一V.N.Okamoto et al. Unpublished data, 2003ARDS肺复张应用氧分压导向性PEEP选择2021/7/19 星期一对象：47例早期ARDS患者，VCV，VT=8ml/kg， PEEP=10cm/H2O，RR20次/分，I：E=1：1分组与

26、方法： ARM+PEEP组：ARM实施方法为逐步增加PEEP至15、 20、25、30cm/H2O(extended sigh)， 结束后PEEP设为15cm/H2O ARM组：ARM后PEEP仍为10cm/H2O PEEP组：基础通气模式Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择2021/7/19 星期一Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择2021/

27、7/19 星期一Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择2021/7/19 星期一Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择2021/7/19 星期一DO2导向性PEEP选择ARDS传统的通气策略-经验性PEEP缺点：缺乏科学依据ARDS肺保护性通气策略-最佳PEEP优点：获得最大的DO2，同时考虑PEEP 对循环和呼吸的影响，LIP+2cmH2O 为最佳

28、PEEP ARDS肺复张应用邱海波, 郭凤梅, 周韶霞等. 中华内科杂志, 2001, 92021/7/19 星期一PEEP不足大量肺泡难以复张Collapsed airwayPressureV1V2VolumeV1V1 + V2Opening pressureNormalARDSPEEP adjustmentLIP：塌陷肺泡开始复张压力，不是全部塌陷肺泡复张压力ARDS肺复张应用2021/7/19 星期一LIPStart of recruitmentRecruitment occurs along the entire PV curve, even beyond UIPGattinoni L

29、. AJRCCM, 2001, 164: 131ARDS肺复张应用2021/7/19 星期一PEEP and SurvovalA post hoc analysis, 53 patientsBarbas CSV, Medeiros DM, Magaldi RB, et al. Am J Respir Crit Care Med, 2002, 165: A218ARDS肺复张应用2021/7/19 星期一PEEP肺复张与低氧血症改善Gattinoni L, Caironi P, Pelosi P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711 ARDS肺复张应用2021/7/19 星期一ARDS绵羊不同PEEP复张容积*#与5cmH2O相比，* P 0.05;与10cmH2O相比，#P 0.05ARD