-如何实现ARDS肺复张-方法与影响因素摘要.ppt

* * * * * * * * * * * Although PaO2/FiO2 Or PaO2 + PaCO2 >400 (FiO2 100%) is a relable indicator for lung recruitment, the procedure is complex and there is no continuous blood gas monitor in china To find new procedure to evaluate/titrate PEEP is necessary. * * * * * * * * * * * * * * * * * * * * Paw [cmH2O] % Opening and Closing Pressures 0 5 10 15 20 25 30 35 40 45 50 0 10 20 30 40 50 Opening pressure Closing pressure 5 patients, ALI / ARDS From Crotti et al AJRCCM 2001. Some units can’t be kept open by any reasonable PEEP! 肺泡复张的决定因素(5): 循环耐受情况 An RM Can Profoundly Depress CO Averaged Data from 3 Models S-C Lim, et al 2004 RM Effect on CO Varies Among Injury Models Averaged data for 3 RM Methods PNM VILI S-C Lim, CCM 2004 Effect of RM Method on CO in Pneumonia Model SI PCV S-C Lim, CCM 2004 肺泡复张的决定因素(6):肺泡过度膨胀 Clinical exp of Gattinonii 低可复张的ARDS患者 Higher PEEP: little benefit and may actually be harmful. 多数肺泡(> 60 %)处于开放状态 高PEEP和肺复张对开放的肺泡可能是有害的 高可复张的ARDS患者 the use of higher PEEP levels seems appropriate In our daily practice PEEP >15 cmH2O PEEP <10 cmH2O Gattinoni L. Eur Respir J Suppl 2003;47:15s-25s. Grasso S. Am J Respir Crit Care Med 2005;171:1002-8. 预测: ARDS肺复张效应 N=19 ARDS Higher PEEP vs lower PEEP on RV Am J Respir Crit Care Med Vol 171. pp 1002–1008, 2005 Higher PEEP strategy induced alv recruitment Recruiters: >150 ml Nonrecruiters: <150 ml 影响ARDS肺复张效应的因素 Am J Respir Crit Care Med Vol 171. pp 1002–1008, 2005 影响复张响应的预测因素 (原发病　No effect) PEEP ----- PaO2/FiO2 PEPP ----- Compl PEEP ----- Stress index (b) 小结 肺复张是ARDS降低肺不张, 减少肺内分流的重要手段 塌陷肺泡是否能够开放受多种因素影响 肺复张的方法(手段, 压力,时间,次数) 原发病(pul vs non-pul)与病理特征 ARDS病程 肺泡过度膨胀(VILI)与循环干扰 多数ARDS患者通过高条件的肺复张可实现塌陷肺泡的复张 并不是ARDS的所有塌陷肺泡均需要复张 * * * * But the lung protective ventilation strategies is not enough for ARDS ARDS animal and clinical study show that there are a lot of consolidation in dependent zone when lung protective ventilation strategies was used * * * In a low ARDS, the comp