肺保护机械通气seminar2008.ppt

Ventilator Induced Lung InjuryVILI Overdistention Barotrauma Volutrauma Recruitment/Derecruitment Injury Translocation of Cells Biotrauma Overdistention Barotrauma Volutrauma VILI： Recruitment/Derecruitment Injury Translocation of Cells Translocation of Cells disrupt the alveolar epithelium tears in capillary endothelium Biotruama? Magaret Parker, MD, FCCM.(SCCM Chair 2004) Arthur S Slutsky Serum Cytokines in Acid Aspiration ModelChiumello, Pristine, Slutsky AJRCCM 1999;160:109-16 Cytokines in HumansStuber et al Int Care Med 2002;28:834-841 ARDS Mortality Decreased Abruptly Shanghai ARDS Study Group. 15 ICUs in 12 university hospitals in Shanghai In-hospital mortality of ARDS patients were 68.5% and 90-day mortality of ARDS patients were 70.4%, Protect the lungs? PEEP=? VT=? PIP=? Pplateau=? RM ? Mode ? Protect the lungs? How? PEEP too low: Recruitment/Derecruitment Injury Pplateau too high: Overdistention Barotrauma Volutrauma MARCELO AMATO, M.D.,et al. (N Engl J Med 1998;338:347-54.) EFFECT OF A PROTECTIVE-VENTILATION STRATEGY ON MORTALITY IN THE ACUTE RESPIRATORY DISTRESS SYNDROME METHODSStudy Population Marcelo BP Amato, MD PV curve (static) P-V curve Methodology The supersyringe technique Post-Operative Atelectasis Healthy Lung 40 cmH2O peak alveolar pressure held for 7-15 sec needed to reopen lung Rothen Br J Anaesth 1993;71:788 Rothen Br J Anaesth 1998;81:681 Rothen Br J Anaesth 1999;82:551 Recruitment Maneuver Massachusetts General Hospital Performance of RM @ MGH 30 cmH2O CPAP for 30 to 40 sec If unresponsive but tolerated well 35 cmH2O CPAP for 30 to 40 sec If unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 sec Allow 15 to 20 minutes between RM Performance of RM @ MGH Set FIO2 at 1.0 Wait 10 minutes Insure appropriate sedation May need to do multiple RMs Monitoring during RM (MGH) The RM should be aborted if: MAP 60 mmHg or decreases by 20 mmHg SpO2 88% Heart rate 130 or 60/ minute New arrhy