ARDS患者的肺复张概要1.ppt

* 肺复张操作的频率 对于ARDS患者 脱离呼吸机能够导致肺泡迅速塌陷, 从而发生严重的低氧血症 为避免呼吸机脱开, 建议采用 密闭吸痰装置 特殊雾化装置 肺复张操作的频率 肺复张操作 当观察到SpO2持续降低( 5 min)时 如果没有观察到氧合下降, 则需要每日进行一次或两次肺复张 未知 总结 肺复张是肺保护性通气策略的重要组成 开放肺并维持肺开放是其理论基础 应用气道高压使塌陷肺泡开放 应用足够的PEEP维持肺泡开放 肺复张对循环的影响 肺复张尚未解决的问题 压力 时间 频率 适应症 PEEP能否使肺复张? PEEP能够防止肺泡塌陷(derecruitment) 低水平的PEEP只能使很少的肺复张 对于ARDS, 将压力持续维持在常用的PEEP水平( 20 cmH2O)只能使小部分肺组织复张 PEEP能否使肺复张? ARDS患者的肺复张贯穿于整个吸气过程 by Hickling AJRCCM 1998 Tidal recruitment occurs below optimal PEEP, PEEP at the optimal level generally results in a decreased quasi-static compliance when measured on the ventilator by Jonson et al AJRCCM 1999 肺复张所需的压力 正常潮气量通气也能使肺组织复张 但是, 大部分肺组织可能仍未充分复张 在有限的吸气时间内 在目标气道峰压水平 由于 塌陷肺泡表面液体的粘滞性 这些肺单位较高的表面张力 间质组织的限制 塌陷的肺组织需要较高的气道压力和较长的时间才能复张 How high a pressure?How long a time? - healthy lung transpulmonary pressure of 30 cmH2O to recruit atelectatic healthy lungs Greaves et al JAP 1990 peak alveolar pressures of 40 cmH2O for 7 to 15 seconds to recruit lungs of previously healthy normal patients following 20 minutes of general anesthesia by Rothen et al Br J Anaesth 1993, 1998 resolution of atelectasis during a 40 cmH2O RM has a time constant of 2.6 sec Rothen et al Br J Anaesth 1999 How high a pressure?How long a time? - healthy lung As a result in previously healthy individuals the vast majority of atelectasis would be recruited within about 7-8 sec How high a pressure?How long a time? - animal peak airway pressures of 55 cmH2O for 5 – 10 min to open collapsed lung in a porcine model of ARDS Sjosrand et al ICM 1995 to maximally recruit lung in a sheep saline lavage lung injured model 40 cmH2O PEEP, 20 cmH2O PC, Ppeak 60 cmH2O, I:E of 1:1, and a rate of 10 bpm for 2 minutes Fujino et al AJRCCM 1999 How high a pressure?How long a time? - animal animals recruited with 40 cmH2O CPAP for 60 sec not maximally recruited to fully recruit the lung multiple (2-3) RMs required even at peak pressures of 60 cmH2O How high a pressure?How long a time? - patient peak airway pressure of 46 cmH2O to r