撤机相关肺水肿.ppt

撤机相关肺水肿 2015.9.121机械通气撤机失败原发病原发病患者本身患者本身其他其他撤机相关肺水肿？2定义无明确定义文献报道：一般定义为自主呼吸试验（SBT）过程中出现不耐受撤机的临床表现，SBT结束时PAWP18mmHg发生率47.6%Dres M，Teboul JL，Anguel N，et al.Extravascular lung water，B-type natriuretic peptide，andblood volume contraction enable diagnosis of weaning-induced pulmonary edema,Crit Care Med,2014,42:1882-1889.Teboul JL.Weaning-induced cardiac dysfunction:where are we today?Intensive Care Med,2014,40:1069-1079.3发病机制胸腔内压右房压右心输出左室前负荷右心前负荷左室周围负压左室克服负压收缩力左室后负荷撤机时呼吸做功情绪紧张心肌耗氧4有研究发现，有部分患者在SBT后期出现二尖瓣反流，可能会影响左室的前后负荷。一些应用超声心动图研究强调，左室舒张功能异常在撤机相关肺水肿的发生过程扮演了重要角色。Gerbaud E,Erickson M,Grenouillet-Delacre M,et al.Echocardiographic evaluation and N-terminal pro-brainnatriuretic peptide measurement of patients hospitalized for heart failure during weaning from mechanical ventilation.Minerva Anestesiol,2012,78:415-425.Moschietto S,Doyen D,Greh L,et al.Transthoracic echocardiography with Doppler tissue imaging predicts weaning failure from mechanical ventilation:evolution of the left ventricle relaxation rate during a spontaneous breathing trial is the key factor in weaning outcome.Crit Care,2012,16:R81.5SBT寻找证据明确诊断。诊断怀疑撤机相关肺水肿三步骤6计划撤机寻找证据明确诊断。可疑撤机相关肺水肿SBTSBT成功SBT失败是否发现撤机失败的非心脏因素否是！T形管试验比压力支持对心脏功能影响更大，诊断撤机相关肺水肿更敏感Thill AW,Richard J-CM,Brochard L.The decision to extubate in the intensive care unit.Am J Respir Crit Care Med,2013,187:1294-1302.7肺动脉导管寻找证据明确诊断（1）诊断PAWP升高18mmHg有创、置管不常用8寻找证据明确诊断（2）诊断多普勒测量二尖瓣口舒张早期血流峰值流速EE/A与E/Ea舒张晚期血流峰值流速A二尖瓣环舒张早期峰值运动速度EaE/A与E/Ea-左室充盈压9BNP和NT-proBNP寻找证据明确诊断（3）诊断研究发现，SBT之前的基线水平不能预测撤机相关肺水肿，SBT期间血BNP升高12%预测撤机相关肺水肿敏感性76%，特异性78%Dres M，Teboul JL，Anguel N，et al.Extravascular lung water，B-type natriuretic peptide，andblood volume contraction enable diagnosis of weaning-induced pulmonary edema,Crit Care Med,2014,42:1882-1889.10EVLW寻找证据明确诊断（4）诊断以EVLW14%作为诊断撤机相关肺水肿的标准，其敏感性为67%，特异性100%Dres M，Teboul JL，Anguel N，et al.Extravascular lung water，B-type natriuretic peptide，andblood volume contraction enable diagnosis of weaning-induced pulmonary edema,Crit Care Med,2014,42:1882-1889.对已经监测PICOO患者观察SBT前后EVLW变化对诊断撤机相关肺水肿很有帮助Dres M，Teboul JL，Monnet X.Weaning the cardiac patient fromo mechanical ventilation.Curr Opin Crit Care,2014,20:493-498.11血红蛋白和血浆蛋白浓度寻找证据明确诊断（5）诊断之前研究显示，血浆蛋白浓度升高6%以及血红蛋白浓度升高6.5%，诊断撤机相关肺水肿敏感性87%和93%，特异性95%和77%Dres M，Teboul JL，Anguel N，et al.Extravascular lung water，B-type natriuretic peptide，andblood volume contraction enable diagnosis of weaning-induced pulmonary edema,Crit Care Med,2014,42:1882-1889.最近研究再次证实，血浆蛋白浓度及血红蛋白浓度升高5%，诊断敏感性87%和93%，特异性95%和77%Teboul JL.Weaning-induced cardiac dysfunction:where are we today?Intensive Care Med,2014,40:1069-1079.12肺动脉导管EVLW升高14%超声心动图血标本血浆蛋白浓度及血红蛋白浓度升高56%PAWP升高18mmHgE/A与E/Ea比值升高BNP升高12%诊断13容量管理：清除液体尤其是累积正液体患者，可以BNP为指导减轻前后负荷：收缩压升高予以硝酸盐减轻后负荷：慢性高血压予ACEI，肥厚性心肌病予钙通道阻滞剂改善心肌供血：之前SBT时曾出现心肌缺血则予以相应治疗治疗SBT期间14无明确定义，发生率47.6%小结治疗：容量管理、心脏功能支持诊断：动脉导管、超声、EVLW、BNP、血浆蛋白及血红蛋白浓度15Thanks for listening162024/5/8 周三17.