病理生理基础课件

1、Stress index病理生理基础Stress index病理生理基础Ventilation in ALIBackgroundALI是ICU常见的危重病病理生理特点 肺容积明显降低 肺顺应性明显下降 通气/血流比例失调肺组织分布“不均一”Ventilation in ALIBackgroundALTIDAL recruitment end-expiration end-inspirationTIDAL recruitment end-expiraTIDAL hyperinflation end-expiration end-inspirationTIDAL hyperinflation en

2、d-expbackgroundIntensive Care Med,2005, 31:776784backgroundIntensive Care Med,2非重力依赖区过度膨胀重力依赖区潮汐性塌陷复张Best Practice & Research Clinical Anaesthesiology 2010;24:171-182.VILI立项依据非重力依赖区过度膨胀重力依赖区潮汐性塌陷复张Best PrAlways opening and closingVILITidal collapseVT0 10 20 30 400 10 20 30 40 50%Paw(cmH2O)Closing pr

3、essureOpening pressureCrotti,et al Am J Respir Crit Care Med 2001;164:131-140Always opening and closingVIHEARTSPPEEP-Keep the lung openLow VtRM Open lung BackgroundARDS病理生理变化肺保护性通气HEARTSPPEEP-Keep the lung ope机械通气患者病死率仍高达37%Intensive Care Med 2009;35:816825.13,322 pats admitted to 299 ICUs from 35 c

4、ountriesBackground机械通气患者病死率仍高达37%Intensive Care 6mlKg小潮气量非重力依赖区肺泡依然过度膨胀 Background中大医院重症医学科预试验6mlKg小潮气量非重力依赖区肺泡依然过度膨胀 Ba重力依赖区通气不良和塌陷肺泡明显增加 Background中大医院重症医学科预试验重力依赖区通气不良和塌陷肺泡明显增加 Background中HEARTSPAt present：Lung Protective Ventilation Strategies非重力依赖区肺泡过度膨胀 重力依赖区肺泡潮汐性塌陷复张 BackgroundVILI几乎无处不在潮气量和P

5、EEP的设定依然矛盾重重HEARTSPAt present：Lung Protect潮气量设置困难个体化难！重症ARDS大量肺泡塌陷即使“小”潮气量仍然导致VILI潮气量应更小VILI塌陷肺泡少“小”潮气量太小，肺泡通气无法保证，导致肺泡塌陷显然，6mlKg的“小”潮气量不适合所有ARDS潮气量设置困难个体化难！重症ARDS大量肺泡塌陷The most controversial issue in ALI/ARDS pts The most controversial issue i维持肺开放(Keep Lung Open) -最佳PEEPPEEP水平不足肺泡反复塌陷、复张，产生剪切力 VIL

6、IPEEP水平过高肺泡过度膨胀，导致气压伤 VILI立项依据维持肺开放(Keep Lung Open) Methods to titrate PEEP in ALI/ARDSBest PEEP(Suter, NEJM, 1975)Super PEEP(Kirby, Chest, 1975)Pflex(Amato, Am J Respir Crit Care Med, 1995)Oxygenation scale(ARDSnet, NEJM, 2000)Stress index(Ranieri, Anesthesiology, 2000)Pmc(Goddon, Anesthesiology, 2

7、001)FRC+Cst(Lambermont, Critical Care, 2008)Pes(Talmor, NEJM, 2008)Increased recruitment strategy(Mercat, JAMA, 2008)EIT(Meier, ICM, 2008)Which one is best?Methods to titrate PEEP in ALI滴定PEEP的最佳方法简便、床边快速安全可重复，为PEEP滴定提供可靠信息滴定PEEP的最佳方法简便、床边Stress index-肺牵张指数容量控制通气、恒定流速Stress index-肺牵张指数容量控制通气、恒定流Stre

8、ss index-肺牵张指数P-t曲线吸气支：曲线回归方程P=a * tb + c b 值：肺牵张指数描述曲线的形状，反映肺泡开放与塌陷程度的力学指标Slutsky AS, Aneathiology, 2000,93: 1320-8 Grasso S, Crit Care Med, 2004, 32: 101827Stress index-肺牵张指数Slutsky ASRanieri VM et al Anesthesiology 2000Stress index-肺牵张指数Ranieri VM et al Anesthesiolostress index= 1 before RMstress

9、 index = 1 after RM 0.6 stress index 0.8 0.8 stress index 11.1 stress index 1.31.3 stress index 1.5End InspirationEnd Expirationstress index= 1 before RMstresb值与塌陷和过度膨胀b值与塌陷和过度膨胀b值与塌陷和过度膨胀b值与塌陷和过度膨胀肺牵张指数指导ARDS患者PEEP的选择14例ARDS患者实施肺复张后容量控制通气用回归法求得方程: P=a*tb+c. b为肺牵张指数。复张后调整PEEP使b1(0.6b0.8)b=1(0.9b1(1.

10、1b1.3)与复张前比较，*P0.05; 与复张后b1比较，#P0.05; 与b=1比较，P0.05黄英姿，邱海波。中华医学杂志。2009,89:2739肺复张后b=1时，氧合、顺应性和肺复张容积明显改善肺牵张指数指导ARDS患者PEEP的选择14例ARDS患者实与基础状态比较*P0.05；与氧合法比较P0.05；与肺牵张指数法比较P0.05；与顺应性法比较P0.05 *不同方法选择最佳PEEP的比较 PEEP(cmH2O)与基础状态比较*P0.05；与氧合法比较P0.05；*PaO2/FiO2(mmHg)b值滴定PEEP对氧合的影响与基础状态比较，*P0.05*PaO2/FiO2(mmHg)

11、b值滴定PEEP对氧合的影响与*与基础状态比较，*P0.05复张容积(ml)Cst(ml/cmH2O )b值滴定PEEP对复张容积和Cst的影响*与基础状态比较，*P0.05复张容积(ml)Cst(mlTHE STRESS INDEX CONCEPT: experimental data0.0 0.5 1.0 1.5 2.0.Ranieri VM et al Anesthesiology 20000.0 0.5 1.0 1.5 2.0.THE STRESS INDEX CONCEPT: expTHE STRESS INDEX CONCEPT: experimental dataRanieri

12、VM, Slutsky AS Anesthesiology 2000THE STRESS INDEX CONCEPT: expBAL b=1 during SIventilationb=1 during SIventilationP 0.001b1 during NIHventilationb=1 during NIHventilationP 0.0541010IL-1 b=1，炎症反应降低BAL b=1 b=1 P 0.001b1 b=1 PB值滴定PEEPB值滴定PEEPB值反应肺顺应性的动态变化 btotal tot = 1.00 but the algorithm is still able to distinguish b1 = 0.91 b2 = 1.11KleisTEK - Advanced Electronic Systems, Bari - ItalyB值反应肺顺应性的动态变化 btotal tot = 1.First