ARDS肺可复张性评估课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,ARDS,肺可复张性评估,山东大学齐鲁医院 重症医学科,张帆,1,ARDS,的病理生理,病理学特点：肺组织损伤的不均一性,N Engl J Med,2006,354:1775-1786,2,HEART,SP,ARDS,肺保护性通气,1.,小潮气量,/PHC,2.RM+,最佳,PEEP,3,肺可复张性,Lung tissue in which aeretion can be restored,N Engl J Med,2006,354:1775-1786,在压力的作用下，不通气的肺泡恢复通气的能力,Crit Care Med,2011,39:1839-1840,4,肺复张的生理作用,促进塌陷肺泡复张，增加肺容积,提升肺顺应性,降低肺内分流,减轻肺内、肺外器官的炎症反应,中国危重病急救医学，,2004,16:603-607,5,肺复张手法,6,肺可复张性初步评估,N Engl J Med,2006:1775-1786,7,肺可复张性的评估办法,8,CT,评价肺通气的金标准,“diffuse”ARDS,“lobar”ARDS,Crit Care Med 2003;31Suppl.:S285S295,9,CT,定量分析,定量评价肺水肿和通气,张帆，吴大玮，,BioMedical Engineering OnLine2014,13:30,10,肺可复张性的评价,Gattinoni method,The percentage of potentially recruitable lung,9%,为,高可复张性,The percentage of potentially recruitable lung,：气道压力由,5cmH,2,O,升至,45cmH,2,O,时，不通气区的减少占全肺重量的百分比,N Engl J Med 2006;354:1775-86,11,PEEP-induced alveolar recruitment(REC,ALV,)was expressed as percentage of variation of the weight of the nonaerated lung parenchyma:,REC,ALV,(%)=(W,ZEEP,-W,PEEP,)/W,ZEEP,N Engl J Med 2006;354:1775-86,肺可复张性的评价,Gattinoni method,The decrease in the percentage of nonaerated lung tissue as PEEP was raised from 5cmH,2,O to 15cmH,2,O was highly correlated with the percentage of potentially recruitable lung(r,2,=0.72,P0.001),12,肺可复张性的评价,The CT Scan ARDS Study Group method,“diffuse”ARDS,“lobar”ARDS,Am J Respir Crit Care Med,2001:14441450,PEEP-induced alveolar recruitment,was computed as the increase in gas volume within the poorly and nonaerated lung regions following PEEP divided by the FRC measured in ZEEP conditions,REC,ALV,(%)=(V,Gas PEEP,V,Gas ZEEP,)/FRC,ZEEP,13,P-V,曲线评估肺可复张性,Critical Care 2008,12:R7,EELV,ZEEP,：,ZEEP,时的呼气末肺容积,ILV-10,、,ELV-10,：气道压力,10cmH,2,O,，吸气,/,呼气支对应的肺容积,TLC,：气道压力,40cmH,2,O,时肺总量,MH,：,maximal volume hysteresis,，最大闭陷容积,14,MH/TLC,与肺力学及血气分析的相关性,MH/TLC,与,EELV,、,Crs,、,PaCO,2,的变化明显相关（,R,2,分别为,0.55,，,0.57 and 0.36,，,P 0.05),MH/TLC,与,PaO,2,的变化之间未见明显的相关性,(R,2,=0.05,，,P 0.26),Critical Care 2008,12:R7,15,MH/TLC,评价肺可复张性的敏感性和特异性,MH/TLC,预测肺复张后,EELV,改善的敏感度达,1.0,，特异度,0.85,预测,Crs,改善的敏感度和特异度,0.88,、,1.0,PaCO,2,的改善为,0.78,、,0.60,PaO,2,的改善为,1.0,、,0.69,Critical Care 2008,12:R7,16,P-V,曲线评估肺可复张性与,CT,对比,Crit Care,2006,10:R95,17,Crit Care,2006,10:R95,P-V,曲线评估肺可复张性与,CT,对比,P-V,曲线计算,FRC,与,CT,计算的肺泡闭陷容积呈明显的相关性和良好的一致性,18,呼气末肺容积（,EELV,）,19,P-V,曲线与,EELV,的一致性良好,20,EIT,可以显示肺复张后各区域呼气末肺容积的变化,21,EELV,评估肺可复张性,Journal of Critical Care,2013,28:534.e1534.e5,肺复张,EELV,的增加与氧合指数的改善明显相关,22,EELV,评估肺可复张性,The optimal cutoff value of the EELV to predict a 15%change in the P/F ratio was 9.25%(sensitivity,86.7%;,specificity,84.4%),Journal of Critical Care,2013,28:534.e1534.e5,23,肺牵张指数（,Stress Index,）,Y=at,b,+c,24,容量控制通气吸气支形状与肺牵张指数的关系,25,肺牵张指数评估肺可复张性,J Surg Res2013 Nov;185(1):347-52.,26,Electrical Impedance Tomography(EIT),肺组织的电学特征受气体含量的影响，肺内气体含量的改变导致电阻抗的变化,基本信息,-,通气分布情况,-,局部位置的呼气末肺容量的变化,(,EELV),27,EIT,可以显示肺复张后各区域呼气末肺容积的变化,28,EIT,可以显示肺复张后通气分布的变化,29,经,PEEP,递增法行肺复张后，全肺的阻抗变化明显增加，反应全肺的通气量增加。,经肺复张后，肺通气明显改善，尤其是重力依赖区通气明显增加，,PEEP,降低时，重力依赖区通气首先出现下降，与,CT,变化基本一致。,30,Crit Care Med 2012;40:903911,EIT,可以评价肺的可复张性，随着,PEEP,的升高，全肺通气得到改善，重力依赖区通气明显增加，与,CT,的变化基本一致。,31,EIT,使局部肺通气的床旁评估成为现实：,区域,1,代表非重力依赖区，通气量始终较重力依赖区占有优势，当,PEEP,由,30cmH,2,O,开始下降时出现通气量的一过性增高，说明存在局部肺泡的过度通气；,区域,4,代表重力依赖区，在,PEEP,升高至,20cmH,2,O,时出现通气量的突然增加，给予表面活性物质治疗后，肺泡开放的阈值降低至,10cmH,2,O,。,32,ARDS,肺部超声,J Am Soc,Echocardiogr 2006;19:356-363,33,ARDS,肺部超声,normal lung,interstitial syndrome,34,严重肺水肿的超声表现,组织样征,碎片征,35,ARDS,肺部超声的演变,Cardiovascular Ultrasound2011,9:6,36,肺复张前后的肺部超声,Respir Care,2012,57(5):773-81,37,超声评价肺的可复张性,Four ultrasound aeration patterns were defined:,(1)normal aeration(,N,):presence of lung sliding with A lines or fewer than two isolated B lines,(2)moderate loss of lung aeration:multiple well-defined B lines(,B1 lines,),(3)severe loss of lung aeration:multiple coalescent B lines(,B2 lines,),(4)lung consolidation(,C,):the presence of a tissue pattern characterized by dynamic air bronchograms,Am J Respir Crit Care Med,2011,183:341-347,38,Ultrasound Reaeration Score,Quantification of reaeration,1 point,3 points,5 points,B1,N,B2,N,C,N,B2,B1,C,B1,C,B2,Am J Respir Crit Care Med,2011,183:341-347,39,PEEP,诱导肺复张的超声表现,Am J Respir Crit Care Med,2011,183:341-347,40,肺部超声法与其他评估方法的比较,Am J Respir Crit Care Med,2011,183:341-347,41,肺部超声评价肺可复张性,优点,即时操作，无镇静肌松要求,可用于重力依赖区或非重力依赖区肺复张效果的评估,缺点,肺非静态，可能低估肺复张状况,患者因素影响准确性（胸壁皮下脂肪厚度、胸壁皮下气肿等）,受操作者熟练程度限制,不能区分正常通气或过度通气，不能作为肺复张评价的唯一指标,Am J Respir Crit Care Med,2011,183:341-347,42,病例摘要,患者女，,20,岁，,因促排卵药物治疗,后,“卵巢过度刺激综合,征,”，并出现高热，,血小板减少至,010,9,/L,，由,120,送,我院,急诊,。,查体：贫血貌，全身,紫癜,，腹膨隆，压痛伴反跳痛，,腹水征,阳性。,43,急症超声,左卵巢,72mm56mm,，内见,62mm52mm,低回声团块，,盆腹腔积液，内见细点状回声，深,60mm,考虑左卵巢黄体或囊肿破裂并腹腔内出血,44,因“,ARDS,、,DIC,、血小板减少、盆腔出血、卵巢过度刺激综合,征,”转入,ICU,。,PiCCO,结果：,CI,4.97,GEDI,637,ITBI,796,ELWI,21,PVPI,4.4,血气及呼吸机参数：,PO2,47,PCO2,45,FiO2,100%,PEEP,12,Phigh,35,VT,400,45,EIT,检测下肺复张,PEEP,递增法,46,EIT,检测下肺复张,PEEP,递增法,肺复张后呼气末肺容积明显增加，增加的,EELV,主要分布在,ROI2,和,3,47,PEEP,的滴定,最低,Global Inhomogeneity index,法,12,15,18,21,25,21,18,15,12,48,病情变化,49,60,小时,CT,检查,72,小时后病人,脱离呼吸机并拔除,气管,插管,50,