肺复张与PEEP滴定

肺复张与PEEP滴定BetweenYesandNo,thefrontieristhin.GoodandEvilare

mixed.RoubyJJ.Yinand

YangAmJRespirCritCare

Med157.1721-1725

1998ARDSattributable

mortality

StapletonRDCHEST2005;

128:525–532肺损伤的机制Effectofmechanicalventilationoninflammatorymediatorsinpatientswithacuterespiratorydistresssyndrome:arandomizedcontrolled

trialRanieri

VM etalJAMA1999282:

54-61Shear

Force30cmH2OALVEOLARAIRWAY140cmH2OMeadJ.JApplPhysiol1970;

28:596–608.Higherorlower

PEEPNEnglJMed2004

351(4):327-36RecruitmentPressure(Pre)of

RMModePre(cmH2O)MedoffBD.

2000PCV+PEEP60BarbasCS.

2004CPAP40BrowerRG.

2004CPAP35-40GattinoniL.2006PCV+PEEP50How

Much

PEEP is

Enough?Open-Lung ApproachRM:a40-secondbreathholdat40cmH2Oairwaypressure,onanFIO2of

1.0.Plateauairwaypressuresnotexceeding40cm

H2ORecruitmentPressure(Pre)and

UIPPercent0%25%50%75%100%01020Paw（cmH2O)3040RECUITMENT

CURVEINSPIRATORY

CURVEUIP

22.9±5.0Pre

24.6±5.5P<0.05中华结核和呼吸杂志

2006;7:452-457滴定式肺复张AlbaicetaAmJRespirCritCareMed2004170：1066–1072开放肺泡的压力维持肺泡开放的通气范围Maximal alveolar

recruitmentBorgesJB.AmJRespirCritCareMed2006;174:

268–278PCV+PEEPPCV1515151515PEEP2025303540BILEVELPEEPhigh3540455055PEEPlow2025303540ModeofRMandtitrationRM

pressureGoal ofoxygenation parameterPaO2+PaCO2

≥400

mm HgthisformulamatchesaconvenientthresholdinquantitativeCTanalysis,indicatingthepresenceof5%collapsedlungmass,withgoodsensitivity/specificityIncrementsofPCO2inthealveolarspacedecreasethealveolarPO2inapproximatelya1:1ratio,especiallyunderlowshuntconditions

(＜10%)HICKLINGKG.AmJRespirCritCareMed.2001;163:

69–78AlveolarclosingandCmax(bde)ofexpiratorycurvePercent0%25%50%75%100%Paw(cmH2O)010203040bde

11.9±2.4LIP

6.5±1.6UIP

17.4±4.0Pcl

11.3±2.5中华结核和呼吸杂志

2006;7:452-457TidalHyperinflationduringlowtidalvolumeventilationinARDS□□□□30pts,lowtidal

volumeCTVTHGroupLess

protected: VTH≥40%Moreprotected:VTH

＜40%TerragniP.AmJRespirCritCareMed.

2007:175;160-166Theexperimentalventilationstrategywasbasedonapreviouslydefined“open-lungapproach”includingpressurecontrolmode;targettidalvolumeof6mL/kgofpredictedbodyweight,withallowancesfor4mL/kgto8mL/kg;andplateauairwaypressuresnotexceeding40cmH2O.Patientsstartedwitharecruitmentmaneuver,whichincludeda40-secondbreathholdat40cmH2Oairwaypressure,onanFIO2of1.0.however,plateauairwaypressuresrarelyexceeded35cmH2Owiththeexperimentalstrategy. FindingsinthisstudydidnotsuggestthattheinclusionofpatientswithacutelunginjurydilutedasurvivalbenefitthatisrestrictedtopatientswithARDS;wefailedtodetectaninteractionbetweenbaselineseverityoflunginjuryandtreatmenteffect.Nevertheless,asignificantproportionofpatientsreceivingtheexperimentalstrategymayhavefailedtoachieveanopenlungwiththeexperimentalstudy

protocol.Response

of

PEEP or

RMRecruitment/withoutoverdistensionNonrecruitment/ov-erdistensionPuybassetL.

200016/7155/71GrassoS.

20059/1910/19GattinoniL.

200634/6834/68TerragniP.

200720/3010/30102

105102105IL-6(pg/ml)IL-1

(pg/ml)IL-1ra(pg/ml)IL-8(pg/ml)TNF-

sR55(pg/ml)TNF-

sR55(pg/ml)moreprotectedlessprotectedP=

0.0001P=

0.0001P=

0.0833P=

0.0001P=

0.0001P=

0.0001moreprotectedlessprotectedmoreprotectedlessprotectedPulmonaryandextrapulmonary

ARDSGattinoniL.AmJRespirCritCareMed.1998;158:

3–11GrassoS.AmJRespirCritCareMed.

2005;171:1002–1008Lungrecruitmentinpatientswith

ARDS68ptsRMPCV45cmH2O,PEEP5cmH2O

for2minsCTend-inspirationof45cmH2Oend-expirationof5and

15cmH2OThepercentageofpotentiallyrecruitablelungwasdefinedastheproportionoflungtissueinwhichaerationisrestoredatairwaypressuresbetween5and45cm

H2O.GroupLowerpotential(percentage≤9%

N=34)higherpotential(percentage＞9%

N=34)GattinoniL.NEnglJMed

2006;354:1775-1786.Gattinoni L. suggestedPEEP

managementLowerpotential:

PEEP<10cmH2Ohigherpotential:

PEEP≥15cmH2OPEEP,recruitmentand

morphology□Consecutive

71ptsdiffuseCTattenuations(23%)PEEPinduceda

markedalveolarrecruitmentwithout

overdistensionlobar

or

patchy CTattenuations(77%)PEEPinducedamildalveolarrecruitmentassociatedwithoverdistensionofpreviouslyaeratedlung

areas.

PuybassetL.IntensiveCareMed.

2000;26:1215–1227.SelectingtheRightPEEPinPatientswith

ARDSRoubyJJ.AmJRespirCritCare

Med.2002;165:1182-1186Stress

IndexRanieriVM.Anesthesiology

2000;93:1320–1328.b=1,straight

curveb<1,progressiveincreaseincompliance;b>1,progressivedecreasein

compliancePaw=atimeb+

c□ CTimagesb<0.9:tidalrecruitment

(R=.917,p

<.0001)b>1.1:tidalhyperinflation(R=.911,p

<.0001)肺复张后

PEEP

setas 0.9<b<

1.1GrassoS.CritCareMed.

2004;32:1018-27□ CT imagesb<

0.9:

tidal recruitment

(R =.917,

p<.0001)b>

1.1:

tidal hyperinflation (R =.911,

p<.0001)PEEP setas 0.9< b < 1.1GrassoS.CritCareMed.

2004;32:1018-27PVcurveand

RMs中华结核和呼吸杂志

2003;

5:282-285SEEPPEEP³

IVrespondersnonresponders理想的肺复张最佳动脉氧合最小肺损伤滞后面积滞后率评估肺复张潜能---最大曲线顺应性差（△b

）2=10‹A.=)·31·)*1,

O04008001)001

000³04(1(645J*1,

Oh$

8

J

1

0

hrecruiternonrecruiter1=)‹A.=·20·’*0,

O04(1(

³05374J*0,

Oh

5

6

5

6

中华结核和呼吸杂志2006;

8:549-553 ∆b∆b肺复张潜能判定006798

cmH2O.ml25115

cmH2O.mlDemory.IntensiveCareMed

2008P-VV050010002000150001020P3040Vol曲线拟合0500100015002000010203040吸气相呼气相转折点位置02000010203040PUC:10.7+1.317*5.3=17.71500

○ ○UIP:22.7+1.317*6.6=31.31000吸气相呼气相500○LIP:22.7-1.317*6.6=14胸廓顺应性气道压是跨肺压的一个粗略估算值Talmor.CritCareMed

2006肺复张潜能---滞后面积0500200015001000010203040吸气相呼气相PulmonarySpiral(16–25mmHg)

:-DecreasedTLC,FRC,

RV.-Increas