肺保护机械通气2009seminar-课件

1、Lung Protective Mechanical Ventilation肺保护性机械通气Adoption & discussion张翔宇急救重症科上海同济大学上海市第十人民医院Lung protective strategy Ventilator Induced Lung Injury, VILILung protective strategy PEEP VT Recruitment Maneuver, RM PIP=? Pplateau=? Mode ?Ventilator Induced Lung InjuryVILI Overdistention Barotrauma Volutra

2、uma Recruitment/Derecruitment Injury Translocation of Cells BiotraumaVILI： Recruitment/Derecruitment Injury PIP=14, PEEP=0PIP= 45, PEEP=10PIP= 45, PEEP = 0Webb&Tierney ARRD 1974;110;556Ventilation Strategies & BAL CytokinesTremblay, Valenza, Ribeiro, Li, Slutsky J Clinical Investigation 99:944-52, 1

3、99773MVHP1510HVZPCcontrol40identical dV/dtVT(cc/kg)PEEP cm H2O15MVZP1002001,2001,400*CMVHPMVZPHVZPTNF-a, pg/ml50倍！Serum Cytokines in Acid Aspiration ModelChiumello, Pristine, Slutsky AJRCCM 1999;160:109-16Vt, ml/kgPEEP, cmH2OHVZPHVPLVZPLVP16165555Cytokines in HumansStuber et al Int Care Med 2002;28:

4、834-841JAMA 289:2104-2112,2003Systemic Effects of VILIImai et al JAMA 289:2104-2112,2003BiophysicalInjury shear overdistention cyclic stretch D intrathoracicpressure alveolar-capillarypermeability cardiac output organ perfusionBiochemical Injury (Biotrauma)mfcytokines, complement,PGs, LTs, ROS,prote

5、asesbacteriaEpithelium/interstitiumneutrophilsDistal Organ DysfunctionMechanical VentilationSlutsky, Tremblay Am J Resp Crit Care Med. 1998;157:1721-5DEATHProtect the lungs? PEEP=? VT=? PIP=? Pplateau=? RM ?PEEP=? PEEP/FiO2 combination? X! ARDSnet, 2000, NEJM, 2000; 18: 1301中华医学会重症医学分会急性肺损伤/急性呼吸窘迫综合

6、征诊断与治疗指南2006推荐意见7：对ARDS患者实施机械通气时应采用肺保护性通气策略，气道平台压不应超过30-35cmH2O推荐级别：B级推荐意见8：可采用肺复张手法促进ARDS患者塌陷肺泡复张，改善氧合推荐级别：E级ALI/ARDS指南： 中华内科杂志,2007, 46(5):430-435推荐意见9：应使用能防止肺泡塌陷的最低PEEP，有条件情况下，应根据静态P-V曲线低位转折点压力+2cmH2O来确定PEEP推荐级别：C级推荐意见10：ARDS患者机械通气时应尽量保存自主呼吸推荐级别：C级推荐意见11：假设无禁忌证，机械通气的ARDS患者应采用30-45度半卧位推荐级别：B级推荐意见1

7、2：常规机械通气治疗无效的重度ARDS患者，假设无禁忌证，可考虑采用俯卧位通气推荐级别：DSSC 2021Crit Care Med 2021 Vol. 36, No. 1SSC 2021推荐对ALI/ARDS病人应用6ml/kg预测体重的目标潮气量。1B推荐对ALI/ARDS病人进行平台压监测，对于被动通气的病人初始平台压目标设定在30cmH2O;检测平台压时应当考虑到胸廓的顺应性。1C推荐对ALI/ARDS病人在必要降低平台压或减少潮气量时施行允许性高碳酸血症PaCO2水平高于病前。1CSSC 20214. 推荐设定PEEP以阻止张开的肺在呼气末塌陷。1C5. 建议在有经验的单位，对于需要

8、可能有害的FiO2和平台压的ALI/ARDS病人在没有不良后果高风险的条件下应用俯卧位通气。2C6a. 除非有禁忌，推荐机械通气的病人床头抬高减少误吸风险，防止呼吸机相关性肺炎 。1B6b. 建议床头抬高3045.2C7. 建议无创通气NIV只能在少数轻中度低氧的、血流动力学稳定的、易于唤醒的、能够自我呼吸道保护的、能自主咳痰的、能很快恢复的ALI/ARDS病人考虑应用。SSC 20218. 推荐制定一套适当的脱机方案，当患者还须满足以下条件时常规对机械通气患者施行自主呼吸试验以评估脱离机械通气的能力，：可唤醒，血流动力学稳定不用升压药，没有新的潜在严重疾患，只需低通气量和低PEEP，面罩或鼻

9、导管给氧可满足吸氧浓度要求。应选择低水平压力支持、持续气道正压CPAP，5cmH2O或T管进行自主呼吸试验1A。9. 不推荐对ALI/ARDS患者常规应用肺动脉导管1A。10. 对已有ALI且无组织低灌注证据的患者，推荐保守补液策略，以减少机械通气和住ICU天数1C。潮气量 VT 6 ml/kg Pplateau Puip Pplateau 30cmH2O肺复张术Lung recruitment maneuver, RM SI PC Stepwise RMRecruitment ManeuverMassachusetts General HospitalPerformance of RM MG

10、H30 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 35 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 secAllow 15 to 20 minutes between RMPerformance of RM MGHSet FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple RMsM

11、onitoring during RM (MGH)The RM should be aborted if:MAP 20 mmHgSpO2 130 or 400 mmHgAmatoARDS protocolRecruitFIO2 = 1Titrate PEEPTitrate PdrivingWAIT( 15 )FIO2 30%( High PEEP + PSV )WAITFIO2 30%( High PEEP + PSV )Decrease PS down to 8Decrease PEEP down to 12NIMV(CPAP = 12, PS = 8)PEEP / FIO2 target

12、( 814 cmH2O)PEEP at PFLEX ( 1418 cmH2O)PEEP enough to fully avoid airway collapse ( 1626 cmH2O)Amato: 2004 China张翔宇的 方 法 所有患者均行有创动脉压持续监测 SpO2持续监测 CVP持续监测 清醒患者适当镇静 复张术RM前排除气压伤 排除肺气肿患者 Protocol Mode: PEEP+PCV or PEEP+PSV PEEP: increment 2 cmH2O Interval: 2 min PEEP target: 16/1st RM, 20/2nd RM, 2630/3

13、rd RM PIPmax: 45 cmH2O Abort if ABP or SpO2 start fall Rest interval: 1530 min May repeat twice a day结 果心脏外科术后低氧患者 有效：100% PaO2/FiO2 improve：110%36% 无并发症多发伤并发ALI/ARDS患者有效：92% PaO2/FiO2 improve：86%32%无并发症 军团菌病1例，无效，出现气压伤 RM一次，PEEPmax: 22, PIPmax: 32纵隔气肿临床观察252例次RM有93次血压短暂降低37%出现血压下降的PEEP水平为623cmH2O,平

14、均13.9cmH2OPEEP降低之后动脉恢复到原来水平所有病人有创持续血压监测1例经心超证实卵圆孔未闭，在PEEP=6时发生右向左分流，同时SpO2下降张翔宇，等，中国危重病急救医学，2007，199Crit Care Med 2007 Vol. 35, No. 1Fernando Suarez-Sipmann, et al Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental studyEight healthy pigsLung lavage

15、sCT slices were obtained 2 cm cranial of the right diaphragmatic domeProtocolResultSuarez-Sipmanns clusiondynamic compliance identified the beginning of lung collapse in a pig model.the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying the level

16、of PEEP that prevents end-expiratory lung collapse？Bobs new protocol 2007Performance of RMSet FIO2 at 1.0Allow time for stabilizationInsure appropriate sedationInsure hemodynamic stabilityBobs new protocolPerformance of RM - PCVPressure control ventilation:PEEP 20-30 cmH2OPeak Inspir Press 40-50 cmH

17、2OInspir Time: 1 to 3 secRate: 8 to 20/ minTime 1 to 3 minSet PEEP at 20, ventilate VC, VT 4 to 6 ml/kg PBW, increase rate, avoid auto-PEEPMeasure dynamic complianceDecrease PEEP 2 cm H2OBobs new protocolPerformance of RM - PCVMeasure dynamic complianceRepeat until max compliance determinedOptimal P

18、EEP max comp PEEP+2 to 3 cm H2ORepeat recruitment maneuver and set PEEP at the identified settings, adjust ventilationAfter PEEP and ventilation set and stabilized, decrease FIO2 until PO2 in target rangeIf response is poor, repeat RM, PEEP 25, Peak Pressure 45If response is poor, repeat RM, PEEP 30

19、, Peak Pressure 50Bobs new protocol 2007Lung RecruitmentPerform early in ARDSIdeal approach to RM most likely PC, limited patient data available using PC!Works better in extra pulmonary than primary ARDS?More difficult to recruit the lung the stiffer the chest wall!Start with low pressure, increase

20、as tolerated and needed!If benefit lost after RM, PEEP inadequate!Bobs new protocolA comparison of methods to identify open-lung PEEP.Caramez MP, Kacmarek RM, et al In this animal model of ARDS, dynamic tidal respiratory compliance, maximum PaO2, maximum PaO2 + PaCO2, minimum shunt, inflation lower

21、Pflex and Pmci,i yield similar values for PEEP following a recruitment maneuver.Intensive Care Med. 2009 Apr;35(4):740-7. Patients ( n=549 ) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 12.9 4 8.4 4 RR (b/min) 30 TV ( ml /Kg ) 6 The NIH randomized multicenter study assessing the effect on mortality of l

22、ow vs high PEEP in ARDS New Engl J Med 2004; 351: 327-336NIHPEEP selected according to a Table to achieve minimal physiological oxygenation (88-95%) Patients ( n=983) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 16.3 3 RR (b/min) 30 TV ( ml /Kg ) 6 9.1 4The LOVS: Lung Open Ventilation Canadian Study Can

23、adianTrial Oxygenation was better in High PEEP Compliance was better in High PEEP Less rescue therapies in High PEEP0,40,50,60,70,80,910102030405060Days after randomizationProbability of survivalLow PEEPHigh PEEPPEEP selected according to a table to achieve minimal physiological oxygenation + RMStew

24、art T et al JAMA. 2021;299(6):637-645 Patients ( n=752 ) ARDS/ ALI P plat (cmH2O) 30 PEEP (cmH2O) 14.9 4 RR (b/min) 30 TV ( ml /Kg ) 6 7.4 4French Trial“ExpressPEEP selected to avoid overdistension or to achieve maximal recruitmentPEEP set for PEEP tot 5-9 cmH2O PEEP set for Plat 28-30 cmH2O Oxygena

25、tion was better in Max distension Higher ventilation free days in Max distension Higher organ failure free days in Max distensionMercat A et al JAMA. 2021;299(6):646-655The Express Study: randomized multicenter study assessing the effect on mortality of low vs high PEEP in ARDS Critical Care 2021, 1

26、3:R22 Younsuck Koh, et alEfficacy of positive end-expiratory pressure titration after thealveolar recruitment manoeuvre in patients with acute respiratorydistress syndromeCritical Care 2021, 13:R22 Younsuck Koh, et alEfficacy of positive end-expiratory pressure titration after thealveolar recruitmen

27、t manoeuvre in patients with acute respiratorydistress syndrome. Younsuck Koh, et alCritical Care 2009, 13:R22MARCELO AMATO, M.D.,et al. (N Engl J Med 1998;338:347-54.)EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROMEMechanical Ventilation Guided by Esophageal Pressure in Acute Lung InjuryN Engl J Med 2008;359:2095-104.N Engl J Med 2021;359:2095-104N Engl J Med 2021;359:2095-104N Engl J Med 360;8 February 19, 2021N Engl J Med 359;20, november 13, 2021Effect of the chest wall on pressurevolume curve analysis