ARDS肺复张的测定-邱海波

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：Gattinoni’s

vs

Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SIorSigh的肺复张作用

评价PEEP维持肺复张的作用指导PEEP选择

Lungvolumedecreasedmarkedly(TLC,VC,TV,FRC)---alveolaredema---pulmonarysurfactant---InterstitialpumonaryedemadepressbrochioleandinducespasmCompliancereducedsignificantlyVentilation/perfusionmismatch---intrapulmonaryshuntanddeadspacelikeeffectsARDS病理生理特点ARDS病理生理CTscan70-80%的肺野呈现高密度区分布：下垂部位(dependentfield)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—SmalllungBabyLungARDS病理生理AandCfindingintheacuteorexudativephaseBandDFindinginthefibrosing-alveolitisphaseARDS病理生理肺容积/顺应性明显降低ARDS病理生理Reducedrangeofvolumeexcursion:LowcomplianceFlatteningatlowandhighvolumes:LowerandupperinflectionpointsBigatello:BrJAnaest1996VolumePressureNORMALARDS顺应性曲线明显右下移位肺顺应性明显降低ARDS病理生理UpperandLowerInflectionPointsLower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VolumePressureLowerInflectionPointUpperInflectionPoint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ImaginetheHardnesstoBlowupaBallon...easyhardspatial&elasticlimitationsLaplacianLawItneedshigherinitialpressurestoovercomethesurfacetensiontoopenupabubbletowiderdiameters!ARDS病理生理SustaininflationSigh小潮气量通气—PHC,避免肺泡过度膨胀最佳PEEP－避免剪切力(Shearforce)性损害VolumePressure肺开放与保护性通气策略的基本内容ARDS病理生理LungvolumedecreasedmarkedlyAtelectraumaKeepthelungopenOpenthelungPreventvolutraumaSIandSighPEEPARDS病理生理内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinoni’s

vs

Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SIorSigh的肺复张作用

评价PEEP维持肺复张的作用指导PEEP选择

P－V曲线法

Step1:

测量PEEP所致的FRC(吸气末撤掉PEEP并延长呼气时间)

FRC＝VE(ZEEP)－VE(PEEP)肺复张容积测定

P－V曲线法Step2:分别描计ZEEP和PEEP的P－V曲线

Step3:肺复张容积：RV=V20(PEEP)+FRCV20(ZEEP)肺复张容积测定等压法呼吸模式：BIPAP条件：Ph20cmH2O，PEEP分别为0、5、10、15cmH2O，Ti6S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，测定呼气量肺复张容积测定等压法肺复张容积测定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CTmethod膈顶上1cmCT层面PEEP与ZEEP比较

GattinoniL.AmJRespirCCM,1995,151:1807全肺扫描区别过度膨胀，膨胀，部分复张和塌陷区

LuizM,RoubyJJ.AmJRespirCCM,2001,163:1444肺复张容积测定CT法--Gattinoni

肺复张容积测定原理CT空气=0Hu，CT水=1000HuCT值=500Hu，肺组织50%空气+50%水ARDS塌陷肺CT值100Hu~100Hu，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100Hu~100Hu范围内体素结果之差

GattinoniL.AmJRespirCCM,1995,151:1807

原理充气不良区(100Hu~500Hu)、正常充气区(500Hu~900Hu)、无充气区(100Hu~+100Hu)和过度充气区(900Hu~1000Hu)。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

LuizM,RoubyJJ.AmJRespirCCM,2001,163:1444Gattinoni’svsRouby’sCT法比较肺复张容积测定优点缺点Gattinoni结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CTmethods:RoubyvsGattinoniLuizM,RoubyJJ.AmJRespirCCM,2001,163:1444肺复张容积测定内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinoni’s

vs

Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SIorSigh的肺复张作用

评价PEEP维持肺复张的作用指导PEEP选择

ARDS肺不张的影响因素---附加静水压Hydrostaticpressure=

(1–[CT/-1000])Height

Maximumsternovertebral

dimentionofhuman

thorax:

20cmH2OPEEP20cmH2O不能使ARDS患者肺泡完全复张动物ARDSMeanAirwaypressure25cmH2OARDS肺复张应用ARDS下肺气体含量明显降低CTscanARDSstudygroup.AJRCCM,2000,161:2005

ARDS肺复张应用CTsectionlcated5cmbelowthecarinaNodifferenceswereobservedinthepercentageoflowerlobeslocatedbeneaththeheartintwogroupsCTscanARDSstudygroup.AJRCCM,2000,161:2005

ARDS肺不张的影响因素

---heartlunginterdependenceARDS肺复张应用CardiacmassandvolumeinARDSCardiacmasswasincreasedby27%vsNSMechanismofcardiacmass:EdemaofcardiacwallRVdilationsecondarytopulhypertensionHyperkineticstaterelatedtoSIRSCTscanARDSstudygroup.AJRCCM,2000,161:2005

ARDS肺复张应用心脏下肺叶气体量明显降低

ARDS–73%vsNS–21%Closedbar:FractionofgasinlowerlobeslocatedbeneaththeheartOpenbar:lowerlobeslocatedoutsidetheheartCTscanARDSstudygroup.AJRCCM,2000,161:2005

ARDS肺复张应用塌陷肺泡的分布Local:LossofaerationpredominatinginlowerlobesDiffuse:EquallossofaerationtotheupperandlowerlobesARDS肺复张应用Lungmorphologypattern

Local DiffuseLIP No YesNormallyaerated 5512% 2412%Poorlyaerated 238% 4012%Distributionmodal Bimodal UnimodalPeakofCTdistr -727Hu/27Hu 7HuCompltot 575 4611 VieiraSRR.AJRCCM,1999,159:1612

ARDS肺复张应用DiffusedistributionARDS肺复张应用ARDS肺复张应用localdistribution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：Gattinoni’s

vs

Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价VT和SIorSigh对肺复张的影响

评价PEEP维持肺复张的作用指导PEEP选择

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肺复张应用潮气量对肺复张的影响A:PEEP=0,B:PEEP=Pflex,C:attheendofinspiration,D:PEEP=PflexasinCduringexpirationPelosiP,GoldnerM,MckibbenA,etal.AmJRespirCritCareMed,2001,164,131-140ARDS肺复张应用小潮气量通气的局限性CrettiS,MascheroniD,CaironiP,etal.AmJRespirCritCareMed,2001,164,131-140ARDS肺复张应用MeanAirwaypressure5cmH2O

CTScan:ARDSpigmodel30kgOptimizedLungVolumeStrategyARDS肺复张应用MeanAirwaypressure25cmH2O

CTScan:ARDSpigmodel30kgOptimizedLungVolumeStrategyARDS肺复张应用MeanAirwayPressure40cmH2OCTScan:ARDSpigmodel30kgOptimizedLungVolumeStrategyARDS肺复张应用不同VT的肺复张容积**#与6ml/kg组相比，*P<0.05;与10ml/kg相比，

#P<0.05ARDS肺复张应用内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinoni’s

vs

Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SIorSigh的肺复张作用

评价PEEP维持肺复张的作用指导PEEP选择

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RothenH.etal.BrJAnaesth1993:71:788-795Re-expansionofatelectasisduringgeneralanaethesiaA:CTscanatlevelofrightdisphragmB:CTscan5cmaboverightdiaphragmARDS肺复张应用PEEP诱导recruitment的分布PuybassetL.ICM,2000,26:1215c

Inlowerlobes:Alvrecruitment(ml)=0.16XEnd-expirlungvolume(ml)–24mlARDS肺复张应用PEEP导致overdistention的分布Volumeofoverdistension(ml)=0.42Parenchyma-900;-800(ml)–18mlPuybassetL.ICM,2000,26:1215cARDS肺复张应用PEEP效应的影响因素

---塌陷肺泡的分布范围塌陷肺泡的范围EfficiencyofPEEP-inducedalvrecruitmenthighlycorrelatedwiththeproportionofpoorlyandnonaeratedlungparenchymainZEEPPuybassetL.ICM,2000,26:1215

ARDS肺复张应用Diffuse:EquallossofaerationtotheupperandlowerlobesVieiraSRR.AJRCCM,1999,159:1612

ARDS肺复张应用Local:LossofaerationpredominatinginlowerlobesVieiraSRR.AJRCCM,1999,159:1612

ARDS肺复张应用EffectofPEEPonrecruitmentandoverdistentionPuybassetL.ICM,2000,26:1215ARDS肺复张应用PEEP效应的影响因素

---LIP的影响ARDS肺复张应用绵羊有无LIP组PEEP复张容积**#**#与5cmH2O相比，*P<0.05;与10cmH2O相比，#P<0.05ARDS肺复张应用有无LIP患者的复张容积

**#**#与PEEP5cmH2O相比，*P<0.05与PEEP10cmH2O相比，#P<0.05与LIP组比较，P<0.05ARDS肺复张应用EffectofPEEPonrecruitmentandoverdistention

InLIP/+:PEEP1=LIP+2,PEEP2=LIP+7.InLIP/-:PEEP1=10,PEEP2=15VieiraSRR.AJRCCM,1999,159:1612ARDS肺复张应用PEEP-inducedalvrecruitment16patwithARDSLIS3Csts39(ZEEP)CTscanOver-1000~-900Normal-900~-500Low-500~-100Ate–100~+100PEEP0vs15LuizM,RoubyJJ.AmJRespirCCM,2001,163:1444ARDS肺复张应用对象：17例稳定ARDS患者VT=6ml/kg,PEEP=10cm/H2O肺复张方法：ZEEP,SI(40cmH2O,40s)，VT=6ml/kg,PEEP=Pflex+2cmH2O,PCV，PIP=15+PEEP，调整PEEP为25、30、35、40、45cmH2O，CT比较非通气区变化结果：PaO2从ZEEP的92.3mmHg上升至394mmHg，非通气区从ZEEP的63.7%降至28.6%VT-inducedalvrecruitmentARDS肺复张应用VT-inducedalvrecruitmentARDS肺复张应用内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinoni’s

vs

Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SIorSigh的肺复张作用

评价PEEP维持肺复张的作用指导PEEP选择

PEEP的选择氧分压导向性PEEP选择PaO2methodDO2导向性PEEP选择肺复张容积导向性PEEP选择RecruitmentvolumemethodARDS肺复张应用openclosedclosed?openopenup!findclosed!re-open!keepopen!airwaypressuretime氧分压导向性PEEP选择ARDS肺复张应用VazquezdeAndaetal.ActaAnesthScand1998:42:63-66

PEEPPIPARDS肺复张应用对象：17例ARDS患者，VT=6ml/kg,PEEP=10cm/H2OPEEP选择方法：PCV，PIP=15+PEEP，每2min调PEEP25、30、35、40、45cmH2O，至FiO2为100%PaO2+PaCO2>400mmHg，每15-20min降低PEEP，至PaO2较前一次降低>5%,PEEP水平为前一次PEEP结果：PaO2+PaCO2从178.476.5mmHg升至487.8139.1mmHg，维持肺复张PEEP水平为224cmH2OV.N.Okamotoetal.Unpublisheddata,2003ARDS肺复张应用氧分压导向性PEEP选择V.N.Okamotoetal.Unpublisheddata,2003ARDS肺复张应用氧分压导向性PEEP选择对象：47例早期ARDS患者，VCV，VT=8ml/kg，PEEP=10cm/H2O，RR20次/分，I：E=1：1分组与方法：ARM+PEEP组：ARM实施方法为逐步增加PEEP至15、20、25、30cm/H2O(extendedsigh)，

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LimCM,JungH,KohY,etal.CritCareMed,2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择LimCM,JungH,KohY,etal.CritCareMed,2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择LimCM,JungH,KohY,etal.CritCareMed,2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择LimCM,JungH,KohY,etal.CritCareMed,2003,31:411-418ARDS肺复张应用氧分压导向性PEEP选择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PEEP

ARDS肺复张应用邱海波,郭凤梅,周韶霞等.中华内科杂志,2001,9PEEP不足大量肺泡难以复张CollapsedairwayPressureV1V2VolumeV1V1+V2OpeningpressureNormalARDSPEEPadjustmentLIP：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LIP—StartofrecruitmentRecruitmentoccursalongtheentirePVcurve,evenbeyondUIPGattinoniL.AJRCCM,2001,164:131ARDS肺复张应用PEEPandSurvovalAposthocanalysis,53patientsBarbasCSV,MedeirosDM,MagaldiRB,etal.AmJRespirCritCareMed,2002,165:A218ARDS肺复张应用PEEP—

肺复张与

低氧血症改善GattinoniL,CaironiP,PelosiP,etal.AmJRespirCritCareMed,2001,164:1701-1711

ARDS肺复张应