ARDS患者的肺复张-nursing.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,患者的肺复张,ALI/ARDS,的定义,ALI,急性起病,胸片对称的侵润影,PaO,2,/FiO,2,300 mmHg,PAWP,18 mmHg,或没有左心衰的证据,ARDS,急性起病,胸片对称的侵润影,PaO,2,/FiO,2,200 mmHg,PAWP,18 mmHg,或没有左心衰的证据,ARDS,肺部形态学的改变,Puybasset L,et al.Regional distribution of gas and tissue in acute respiratory distress syndrome.I.Consequences for lung morphology.Intensive Care Med 2000;26:857-69.,ARDS,肺部形态学的改变,ARDS,患者,健康对照,CT,平均密度,(HU),-256,21,-654,8,组织容积,(ml/m,2,BSA),31.6,1.7,16.7,0.8,气体容积,(ml/m,2,BSA),11.5,1.2,32.2,1.8,胸腔内总容积,(ml/m,2,BSA),43.0,2.3,49.0,2.5,Gattinoni L,et al.Relationships between lung computed tomographic density,gas exchange and PEEP in acute respiratory failure.Anesthesiology 1988;69:824-32.,ARDS,肺部形态学的改变,Patroniti N,Bellani G,Maggioni E,Manfio A,Marcora B,Pesenti A.Measurement of pulmonary edema in patients with acute respiratory distress syndrome.Crit Care Med 2005;33:2547-2554,ARDS,肺部形态学的改变,GATTINONI -3 ZONES,过度膨胀,“,干”,“,婴儿肺,湿,PEEP,可使其复张,塌陷或实变区域,Gattinoni L.J Thorac Imag 1986;1(3):25,ARDS,肺部形态学的改变,婴儿肺,(BABY LUNG),的概念,通气的肺仅相当于正常肺的,20 30%,ARDS,患者肺容积的减少并非意味胸腔内总容积的减少,仅仅是实变组织替代了气体,Gattinoni L,et al.Relationships between lung computed tomographic density,gas exchange and PEEP in acute respiratory failure.Anesthesiology 1988;69:824-32.,气压伤,(barotrauma),机械通气导致肺过度牵张所引起的肺损伤,容积伤,(volutrauma),Normal rat lungs,PIP 45,5 min,PIP 45,20 mins,剪切力损伤,(atelectrauma),指由于肺泡反复塌陷和复张所造成的损伤,肺泡塌陷时的剪切力损伤,驱动压力,30 cmH,2,O,时,通气肺泡与不通气肺泡交界处的剪切力可高达,140 cmH,2,O,(Mead 1970),F=P,L,x(V,0,/V),2/3,ARDS,保护性肺通气策略,机械通气时有两个肺损伤区域,肺容积过低可导致剪切力损伤,肺容积过高可导致肺泡过度牵张，引起容积伤,Froese AB,Crit Care Med 1997;25:906,肺开放与,ARDS,Editorial,Open up the lung and keep the lung open,B.Lachmann,Dept.of Anesthesiology,Erasmus University Rotterdam,The Netherlands,(1992)18:319-321,肺泡通气与吹气球,肺复张与,ARDS,ARDS,的肺复张,CPAP,CPAP30 45 cmH,2,O,PCV,PC15 cmH,2,O,PEEP30 45 cmH,2,O,叹气,(Sigh),肺复张操作,肺复张前,5 10,分钟将,FiO,2,提高到,1.0,通常需要镇静以保证肺复张过程中无自主呼吸,首先用,CPAP 30 cmH,2,O,共,30 40,秒,之后仔细评估效果,肺复张操作,如果效果不明显，但患者耐受较好,应在,15 20,分钟后用更高水平的,CPAP(35 40 cmH,2,O),进行肺复张,如果第二次肺复张操作效果也不佳,应当进行第三次肺复张操作,CPAP 40 cmH,2,O,肺复张操作,部分患者可能需要进行多次肺复张操作才能显示效果,Fujino et al,AJRCCM 1999,肺复张操作,尚不清楚是否需要使用,40 cmH,2,O,以上的压力,动物试验表明,高达,60 cmH,2,O,的压力是安全的,尽管这样高的压力仍处于试验阶段，且需要在密切监测的条件下谨慎实施,Fujino et al AJRCCM 1999,肺复张操作,如果,CPAP 40 cmH,2,O 30 40,秒不足以使肺复张,PCV 20 cmH,2,O,PEEP 30 cmH,2,O,I:E 1:1,f 10 bpm for 2 min,如果仍然无效,PCV 20 cmH,2,O,PEEP 40 cmH,2,O,I:E 1:1,f 10 bpm for 2 min,一些动物可能出现,CO,轻度下降，,PAP,升高,所有试验动物在,10,分钟内血流动力学均恢复到肺复张前的状态,Fujino et al AJRCCM 1999,如果判断肺复张成功,?,PaO,2,/FiO,2,300 mmHg,或,PaO,2,+PaCO,2,400 mmHg,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.,肺复张能够改善氧合,Schreiter D,Reske A,Stichert B,Seiwerts M,Bohm SH,Kloeppel R,Josten C.Alveolar recruitment in combination with sufficient positive endexpiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma.Crit Care Med 2004;32:968-975,肺复张能够维持肺泡稳定,Schreiter D,Reske A,Stichert B,Seiwerts M,Bohm SH,Kloeppel R,Josten C.Alveolar recruitment in combination with sufficient positive endexpiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma.Crit Care Med 2004;32:968-975,PEEP,能够有效维持氧合,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.,反复肺复张的作用,Fujino Y,Goddon S,Dolhnikoff M,Hess D,Amato MBP;Kacmarek RM.Repetitive high-pressure recruitment maneuvers required to maximally recruit lung in a sheep model of acute respiratory distress syndrome.Crit Care Med 2001;29:1579-1586,肺复张对脑氧代谢的影响,Bein T,Kuhr LP,Bele S,Ploner F,Keyl C,Taeger K.Lung recruitment maneuver in patients with cerebral injury:effects on intracranial pressure and cerebral metabolism.Intensive Care Med 2002;28:554-558,肺复张对内脏血流的影响,Nunes S,Rothen HU,Brander L,Takala J,Jakob SM.Changes in Splanchnic Circulation During an Alveolar Recruitment Maneuver in Healthy Porcine Lungs.Anesth Analg 2004;98:1432-8,肺复张的副作用,血流动力学紊乱,延迟到血流动力学稳定后再进行,发生气压伤,需对以下患者评估利弊,既往肺部囊性或大泡性疾病,既往肺部漏气,肺复张期间对患者的监测,动脉血压,脉搏和心律,SpO,2,如果出现并发症,立即终止肺复张操作,肺复张对护士的要求,了解肺复张的目的,密切监测生命体征的变化,肺复张后不要轻易脱开呼吸机,吸痰,吸痰对氧合及肺容积的影响,Dyhr T,Bonde J,Larsson A:Lung recruitment maneuvers are effective to regain lung volume and oxygenation after open endotracheal suctioning in acute respiratory distress syndrome.Crit Care 2003,7:55-62,吸痰管大小与压力改变,Morrow BM,Futter MJ,Argent AC.,Endotracheal suctioning:from principles to practice.,Intensive Care Med 2004;30:1167-1174,吸痰导致氧合下降,Lasocki S,Lu Q,Sartorius A,Fouillat D,Remerand F,Rouby J-J.Open and Closed-circuit Endotracheal Suctioning in Acute Lung Injury:Efficiency and Effects on Gas Exchange.Anesthesiology 2006;104:39-47,吸痰对氧合的影响,Lindgren S,Almgren B,Hgman M,Lethvall S,Houltz E,Lundin S,Stenqvist O.Effectiveness and side effects of closed and open suctioning:an experimental evaluation.Intensive Care Med 2004;30:1630-1637,肺复张防止吸痰导致的肺容积减少,SWIVELpsv,CLOSEDpsv,CLOSED,SWIVEL,DISCONNECTION,Prevention of Endotracheal Suctioning-induced Alveolar Derecruitment in Acute Lung Injury Maggiore SM,Lellouche F,Pigeot J,Taille S,Deye N,Durrmeyer X,Richard J-C,Mancebo J,Lemaire F,Brochard L.Am J Respir Crit Care Med 2003;167:1215-1224,肺复张能够防止吸痰导致的氧合下降,Lasocki S,Lu Q,Sartorius A,Fouillat D,Remerand F,Rouby J-J.Open and Closed-circuit Endotracheal Suctioning in Acute Lung Injury:Efficiency and Effects on Gas Exchange.Anesthesiology 2006;104:39-47,肺复张,:,总结,ARDS,患者有效肺容积缩小,肺泡反复塌陷与开放导致剪切力损伤,肺复张是保护性通气策略的重要组成,肺复张的成功取决于,足够的压力与时间,合适的,PEEP,医务人员的理解,