ARDS患者的肺复张课件.ppt

How high a pressure?How long a time? - patient peak airway pressure of 46 cmH2O to recruit collapsed lung in ARDS patients Gattinoni et al AJRCCM 1986 35 – 40 cmH2O CPAP for 30 – 40 sec prior to establishing a lung protective ventilatory strategy whenever mechanical ventilation was disrupted Amato et al NEJM 1998 How high a pressure?How long a time? - patient In a patient with septic ARDS initial recruitment maneuvers with 40 cmH2O CPAP for 40 sec failed PEEP 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 Medoff et al CCM 2000 How high a pressure?How long a time? - patient The success of PC vs CPAP in the examples emphasize the relationship between pressure and time Fujino et al AJRCCM 1999 Medoff et al CCM 2000 The optimal relationship between these two variables to maximize efficacy and maintain safety remains unclear Mechanism of lung recruitment First, the airways must be opened in order to recruit collapsed lung Airway opening occurs by either moving the meniscus formed by fluid lining the airway toward the periphery or overcoming the parenchyma tethering present in actual collapsed airway Mechanism of lung recruitment Second, the collapsed alveoli must be opened collapsed injured lung units with increased surface tension require very high pressures to establish sufficient lateral stress to open the lung Mead et al JAP 1970 What is clear is that the optimal method of lung recruitment insuring maximal efficacy and safety has not been determined Side Effects of RMs hemodynamic compromise delayed until patients hemodynamically stable development of barotrauma the benefits and potential risks must be carefully weighed in patients with preexisting pulmonary cystic or bullous lung disease preexisting airleaks Monitoring of Patients arterial pressure pulse rate and rhythm SpO2 if compromise develops the recruitment maneuver aborted Performance of a RM FIO2 increased to 1.0 for 5-10 minutes befo