ARDS及呼吸支持ppt课件.ppt

ARDS及其呼吸支持策略的浅见江苏省人民医院梅 勇内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题lALI/ARDS是在严重感染、休克、创伤及烧伤等非心源性疾病过程中，肺毛细血管内皮细胞和肺泡上皮细胞损伤造成弥漫性肺间质及肺泡水肿，导致的急性低氧性呼吸功能不全或衰竭。急性肺损伤急性肺损伤/急性呼吸窘迫综合征诊断治疗指南急性呼吸窘迫综合征诊断治疗指南(2006)中华医中华医学会重症医学分会学会重症医学分会l临床上表现为进行性低氧血症和呼吸窘迫，肺部影像学上表现为非均一性的渗出性病变。l2005年ALI/ARDS发病率分别在每年79/10万和59/10万。lKing County is the 12th most populous county in the United States.RubenfeldGD,CaldwellE,PeabodyE,etal.Incidenceandoutcomesofacutelunginjury.NEnglJMed,2005,353:1685-1693l严重感染ALI/ARDS患病率25%50%；l大量输血 40%；l多发性创伤11%25%；l严重误吸时，ARDS患病率也可达9%26%；l同时存在两个以上危险因素时，患病率进一步升高。l危险因素持续作用时间越长，ALI/ARDS的患病率越高，危险因素持续24、48及72h时，ARDS患病率分别为76%、85%和93%。IribarrenC,JacobsDR,SidneyS,etal.Cigarettesmoking,alcoholconsumption,andriskofARDS:a15-yearcohortstudyinamanagedcaresetting.Chest,2000,117:163-168.内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题lALI/ARDS的基本病理生理改变是肺泡上皮和肺毛细血管内皮通透性增加所致的非心源性肺水肿。急性肺损伤急性肺损伤/急性呼吸窘迫综合征诊断治疗指南急性呼吸窘迫综合征诊断治疗指南(2006)中华医中华医学会重症医学分会学会重症医学分会正常肺泡毛细血管结构l 肺泡毛细血管膜肺泡毛细血管膜间质部间质部毛细血管毛细血管肺泡肺泡ALI早期l肺泡毛细血管膜损伤、肺泡结构存在l间质轻度水肿影响气体交换肺泡毛细血管膜肺泡毛细血管膜间质部间质部ALI间质水肿期l肺泡毛细血管膜损伤l间质明显水肿，呼气期肺泡受压萎陷显著影响气体交换 肺泡毛细血管膜肺泡毛细血管膜间质部间质部ALI实变肺泡l肺泡毛细血管膜和表面活性物质损伤l间质、肺泡明显水肿、肺泡内无气体显著影响气体交换 肺泡毛细血管膜肺泡毛细血管膜间质部间质部肺水肿间质肺泡水肿期l肺泡毛细血管膜结构完整l肺泡进入液体，气水混合，明显影响气l体交换 肺泡毛细血管膜肺泡毛细血管膜间质部间质部l急性左心衰竭导致的高静水压性肺水肿lARDS的弥漫性肺泡损伤引起的是高通透性肺水肿，高蛋白性肺泡水肿l肺容积减少：ARDS 机械通气治 疗着眼点和难点。l肺顺应性降低；l通气/血流比例失调；急性肺损伤急性肺损伤/急性呼吸窘迫综合征诊断治疗指南急性呼吸窘迫综合征诊断治疗指南(2006)中华医中华医学会重症医学分会学会重症医学分会肺容积肺组织容积肺气体容积功能残气量功能残气量(FRC)的减少，的减少，参与气体交换的参与气体交换的肺泡减少肺泡减少l肺容积减少的原因和机制：l肺组织重量增加导致肺泡和终末气道塌陷；l肺泡水肿导致通气减少；l心脏和腹腔导致的压迫性肺不张；海绵模型(spongy model)学说GattinoniL,CaironiP,PelosiP,etal WhathascomputedtomographytaughtusabouttheacuterespiratorydistresssyndromeJ.AmJRespirCritCareMed,2001,164(9):17011711 内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题l目前ALI/ARDS诊断仍广泛沿用1994年欧美联席会议提出的诊断标准：急性起病；氧合指数200mmHg不管呼气末正压(PEEP)水平；正位X线胸片显示双肺均有斑片状阴影；肺动脉嵌顿压18mmHg，或无左心房压力增高的临床证据。如PaO2/FiO2300mmHg且满足上述其它标准，则诊断为ALI。l氧合指数200mmHg不管呼气末正压(PEEP)水平；l为什么不在乎“PEEP”的水平？l第4个诊断标准：PAWP18mmHgl难道ARDS的患者，就不能有左心衰竭或高容量状态，而有左心衰竭或高容量状态的患者，就不能患有ARDS？lPAWP18 mm Hg一定是急性左心衰竭所致？l液体复苏导致高容量状态、高PEEP或平台压，甚至测定方法不当。l有研究显示 PAWP18 mm Hg患者预后差。FergusonND，MeadeMO，HallettDC，eta1HighvaluesofthepulmonaryarterywedgepressureinpatientswithacutelunginjuryandacuterespiratorydistresssyndromeIntensiveCareMed，2002，28：1073-1077内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题lALI/ARDS患者氧疗的目的是改善低氧血症，使动脉血氧分压(PaO2)达到6080mmHg。lNIV在ARDS中的应用 却存在很多争议。l一项RCT研究显示，与标准氧疗比较，NIV虽然在应用第一小时明显改善ALI/ARDS患者的氧合，但不能降低气管插管率，也不改善患者预后。DelclauxC,LHerE,AlbertiC,etal.Treatmentofacutehypoxemicnonhypercapnicrespiratoryinsufficiencywithcontinuouspositiveairwaypressuredeliveredbyafacemask:Arandomizedcontrolledtrial.JAMA,2000,284:23522360.l指南推荐：ALI/ARDS患者慎用NIV。l哪些病人可以使用？lARDS患者神志清楚、血流动力学稳定，并能够得到严密监测和随时可行气管插管时，可以尝试NIV治疗。l如果预计患者的病情能够在4872h内缓解。l合并免疫抑制的ALI/ARDS患者。l实体器官移植 l血液系统肿瘤 l恶性肿瘤患者 l如NIV治疗12h后，低氧血症和全身情况得到改善，可继续应用NIV。若低氧血症不能改善或全身情况恶化，提示NIV治疗失败，应及时改为有创通气。l禁忌症与无创通气禁忌症一致。内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题l曲线为S 形状,可分为三个部分：l下端曲线平坦部分 l假使呼气末肺容量太低,是因呼气末小而远端肺泡将发生萎陷。在每一次吸气时必须使用额外的“打开肺泡的压力”，使这些萎陷的肺区能够开放。l曲线中间陡直（直线）部分：压力和容积的变化呈线性关系容积显著增大、压力轻度升高l人工气道机械通气气压伤发生的机会少对循环功能的抑制轻呼吸做功少l陡直段的容量是肺组织能耐受的潮气量 是自主呼吸和机械通气的适宜部位l上部曲线平坦部分：曲线的这一部分表示肺泡弹性最大。压力进一步增加不会引起较大容量的增加(UIP)，肺泡间隔过度牵张可导致弹性的丧失。有损害肺泡结构的危险,即肺泡气压/容积伤。Jonson B,Richard JC,Straus C,Mancebo J,Lemaire F,Brochard L.PressureVolume Curves and Compliance in Acute Lung Injury:Evidence of Recruitment Above the Lower Inflection Point.Am J Respir Crit Care Med 1999;159:1172-1178低位转折点低位转折点之上仍有肺之上仍有肺组织复张组织复张The P-V CurvelOn the expiratory limbl呼气支的最大曲率点压力lthe point of maximum curvature(PMCEX)the area where the maximum volume change/unit pressure occurs during exhalationthe maximum PEEP requiredlto prevent derecruitmentThe P-V Curvelthese two“points”identify the range of PEEP needed in ARDSPflex=the minimumPMCEX=the maximumlIdeally,a complete P-V should be preformed on all patients identifying these points to allow accurate setting of PEEP内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题l指南推荐：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3035cmH2O。ARDS的肺保护性通气策略l小潮气量(6 ml/kg IBW)避免过度膨胀造成的容积伤(volutrauma)l足够的PEEP防止肺泡复张造成的剪切力损伤(atelectrauma)l 允许性高碳酸血症（PHC）是采用小潮气量（46 mlkg），允许动脉血二氧化碳分压一定程度增高（4080 mmHg）。lPHC是肺保护性通气策略的结果，并非ARDS的治疗目标。l酸血症往往限制了允许性高碳酸血症的应用，目前尚无明确的二氧化碳分压上限值，一般主张保持pH值7.20，否则可考虑静脉输注碳酸氢钠。l颅内压增高是应用允许性高碳酸血症的禁忌证。Theacuterespiratorydistresssyndromenetwork:Ventilationwithlowertidalvolumesascomparedwithtraditionaltidalvolumesforacutelunginjuryandtheacuterespiratorydistresssyndrome.NEnglJMed,2000,342:1301-1308.l压力控制或压力支持通气 控制气道峰值压力，保证ARDS患者的气道压不会超过设定的吸气压力，避免高位转折点的出现。ARDS的肺保护性通气策略患者数患者数潮气量潮气量病死率病死率作者作者小潮气量小潮气量对照对照小潮气量小潮气量对照对照小潮气量小潮气量对照对照P值值Amato29246.1 0.211.9 0.53871 0.001Stewart60607.2 0.810.6 0.250470.72Brochard58587.2 0.210.4 0.247380.38Brower26267.3 0.110.2 0.150460.60ARDSnet4324296.3 0.111.7 0.131400.007Villar50457.3 0.910.2 1.234550.041小潮气量通气的问题LVt(n=15)CVt(n=15)P valueVt,ml411 55664 84 0.01Vt,ml/kg6 110 1 0.01setPEEP,cmH2O10 410 4n.s.PEEPtot,cmH2O11 411 4n.s.Pplat,cmH2O23 830 10 0.01Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613小潮气量通气的问题LVtn=15)CVt(n=15)P valuePaO2,mmHg136 80156 82n.s.PaO2/FiO2,mmHg165 84183 83n.s.SaO2,%94.8 5.097.6 2.1 0.05PaCO2,mmHg60 3538 21 0.001pH7.21 0.17.36 0.1 0.001SBP,mmHg125 25121 20n.s.DBP,mmHg60 960 10n.s.HR,bpm101 1593 15n.s.Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment Maneuver.Am J Respir Crit Care Med 2001;163:1609-1613小潮气量通气的问题Richard JC,Maggiore SM,Jonson B,Mancebo J,Lemaire F,Brochard L.Influence of Tidal Volume on Alveolar Recruitment:Respective Role of PEEP and a Recruitment ManeuverAm J Respir Crit Care Med 2001;163:1609-1613内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题ARDS的肺开放EditorialOpenupthelungandkeepthelungopenB.LachmannB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlandsDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands(1992)18:319-321(1992)18:319-321肺复张的各种方法lCPAP(SI)lincremental PEEPlPCV（High PEEP）lSigh(modified)lHFOVl俯卧位lRM能够使肺开放RM:PIP45cmH2O,PEEP35cmH2Ox1minHalter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment.Am J Respir Crit Care Med 2003;167:1620-1626肺复张能够改善ARDS氧合Lapinsky SE,Aubin M,Mehta S,Boiteau P,Slutsky AS:Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.Intensive Care Med 1999,25:1297-1301.Asustainedinflationusingapressureof30to45cmH2Owasappliedfor20s.SI改善氧合Tugrul S,Akinci O,Ozcan PE,Ince,S,Esen F,Telci L,Akpir K,Cakar N.Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome:Focusing on pulmonary and extrapulmonary forms.Crit Care Med 2003;31:738-744SustainedInflation:45cmH2Ox30sSI改善氧合Frank JA,McAuley DF,Gutierrez JA,Daniel BM,Dobbs L,Matthay MA.Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury.Crit Care Med 2005;33:181-188SustainedInflation:30cmH2Ox30sTwicewith1mininterval叹气的设置Lim CM,Koh Y,Park W,Chin JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260充气阶段充气阶段,每每30秒秒PEEP增加增加5cmH2OVt减少减少2ml/kg前前2次呼吸除外次呼吸除外直至直至Vt2ml/kg,PEEP25cmH2O暂停阶段暂停阶段CPAP30cmH2Ofor30s放气阶段放气阶段叹气改善氧合Lim CM,Koh Y,Park W,Chin JY,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD:Mechanistic scheme and effect of extended sigh as a recruitment maneuver in patients with acute respiratory distress syndrome:A preliminary study.Crit Care Med 2001;29:1255-1260叹气的设置Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94Baseline:PSVSigh:BIPAPPEEPhigh=1.2 x PIPpsv or35 cmH2OTi,s=3 5 sf=1 bpm叹气改善呼吸力学及氧合Patroniti N,Foti G,Cortinovis B,Maggioni E,Bigatello LM,Cereda M,Pesenti A.Sigh Improves Gas Exchange and Lung Volume in Patients with Acute Respiratory Distress Syndrome Undergoing Pressure Support Ventilation.Anesthesiology 2002;96:788-94内容lARDS的概念及流行病学lARDS的病理生理l指南中ARDS的诊断标准的思考lARDS与无创通气l压力容积环lARDS的肺保护性通气l肺复张的理论与实践l肺复张与PEEPl不同复张方法的差异l肺复张的副作用l肺复张存在的问题RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80RM vs.PEEPLim CM,Lee SS,Lee JS,Koh Y,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Morphometric Effects of the Recruitment Maneuver on Saline-lavaged Canine Lungs:A Computed Tomographic Analysis.Anesthesiology 2003;99:71-80为什么肺复张作用不能持久?baseline3 min post-RM30 min post-RMPaO2/FiO2(mmHg)139 46246 111138 39PaCO2(mmHg)48.6 12.147.6 1346.4 12SvO2(%)70.4 6.172.4 5.670 6.2Qs/Qt(%)30.8 5.821.5 9.729.2 7.4Crs(ml/cmH2O)34.1 12.636.9 15.135.7 13.5Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5为什么肺复张作用不能持久?l肺复张的方法?SI:50 cmH2O x 30 sl作者认为Oczenski W,Hrmann C,Keller C,Lorenzl N,Kepka A,Schwarz S,Fitzgerald RD.Recruitment Maneuvers after a Positive End-expiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome.Anesthesiology 2004;101:620-5RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEP vs.RM vs.PEEPLim CM,Jung H,Koh Y,Lee JS,Shim TS,Lee SD,Kim WS,Kim DS,Kim WD.Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy,etiological category of diffuse lung injury,and body position of the patient.Crit Care Med 2003;31:411-418RM+PEEPRM onlyRM后的PEEP能够稳定肺泡Halter JM,Steinberg JM,Schiller HJ,DaSilva M,Gatto LA,Landas S,Nieman GF.Positive End-Expiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/DerecruitmentAm J Respir Crit Care Med 2003;167:1620-1626RM后的PEEPLim CM,Adams AB,Simonson DA,Dries DJ,Broccard AF,Hotchkiss JR,Marini JJ.Intercomparison of recruitment maneuver efficacy in three models of acute lung injury.Crit Care Med 2004;32:2371-2377PEEP的设置lRM之后通常将PEEP设置在能够维持PaO2(防止塌陷)的水平l最初将PEEP设置为20 cmH2Ol然后将FiO2减小到最低水平维持SpO2 90 95%l每20 30分钟降低PEEP 2 cmH2O直至患者SpO2下降PEEP的设置l氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEPl一旦确认,则需重复肺复张操作,然后把PEEP和FiO2重新设置在上述水平l最佳氧合法最佳氧合法PEEP的设置l如果将PEEP设置于20 cmH2O后,仍发现PaO2/FiO2显著下降按照最初的PEEP设置25 cmH2O重复肺复张然后按照上述方法调节FiO2和PEEPPEEP的设置l将PEEP从不必要的高水平逐渐降低l不要将PEEP由低水平增加到高水平PEEP/FiO2的调整推荐意见l降低PEEP之前应当首先降低FiO2,以避免肺泡塌陷l一般情况下FiO2应当减低到 5 min)时l如果没有观察到氧合下降,则需要每日进行一次或两次肺复张未知How high a pressure?How long a time?lpeak airway pressure of 46 cmH2O to recruit collapsed lung in ARDS patientslGattinoni et al AJRCCM 1986l35 40 cmH2O CPAP for 30 40 secprior to establishing a lung protective ventilatory strategywhenever mechanical ventilation was disrupted lAmato et al NEJM 1998How high a pressure?How long a time?lIn a patient with septic ARDSinitial recruitment maneuvers with 40 cmH2O CPAP for 40 sec failedPEEP 40 cmH2O PEEP and PCV 20 cmH2O at an I:E ratio of 1:1 with a rate of 10 bpm for 2 minutes to fully recruit the lung What is clear is that the optimal method of lung recruitment insuring maximal efficacy and safety has not been determinedWhat is Successful Recruitment?lPaO2/FIO2 ratio 300 mmHgl美国的ARDS临床网，由美国国家心肺血液研究所（National Heart,Lung,and Blood Institute，NHLBI）和国家健康研究所（the National Heart,Lung,and Blood Institute，NIH），于1994年开始建立，其工作目标是对有望改善ARDS 病人状况的药品、器械、治疗方案和治疗策略，组织多中心的临床验证，提供规范地前瞻、随机、对照设计方案和统计总结发表研究结果。lhttp:/www.ardsnet.org/index.phpl谢谢大家！谢谢大家！l新春快乐！新春快乐！