呼吸机相关性肺损伤郑州ppt课件.pptVIP

Volume, ml 800 600 400 200 0 0 20 40 DPL 0 20 40 Pao 0 20 40 DPes cm H2O Limitation of Plateau Pressure Heterogenous Involvement Lung and Chest Wall Involvement 2. 容量伤(Volutrauma）: Dreyfuss, 1988 (rats) , ARDS Network, 2000 The aerated, ventral regions (‘baby lung’)-Volutrama NEJM 2001;344:1986 6 cc/kg versus 12 cc/kg 6 cc/kg versus 12 cc/kg 31% Mortality with small tidal volumes (low plateau pressure) 38.9% Mortality in conventional tidal volume group (higher plateau pressures) 332 patients without ARDS 9 ml/kg 9-12 ml/kg 12 ml/kg ALI?ARDS 17% 22 % 33% ----- Doctor induced ARDS 低潮气量保护正常肺 Development of ARDS and Tidal Volume For every 1cc/kg above 6cc/kg, odds ratio of ALI increased 1.3 3. 剪切伤（Atelectrauma）: Atelectasis The consolidation and atelectasis The interface between the two areas-Atelectrauma Alveolar Collapsing-Reopening Injury ZEEP PEEP Airway Pressure 1000 800 600 400 200 0 0 10 20 30 40 Pressure, cm H2O NEJM 2001;344:1986 0 2 4 6 Protective Ventilation 600 400 200 0 Seconds Volume, ml 0 2 4 6 Conventional Ventilation 800 600 400 200 0 Volume, ml Alveolar overdistention Alveolar collapse Gattinoni et al, AJRCCM 1998;158:3 PEEP Effect: Influence of ARDS Etiology Pulmonary Cause Non Pulmonary Cause 15 10 5 0 Change in Volume, L Change in Static Total Respiratory System Pressure, cm H2O 0 40 10 30 20 0 0.8 0.4 1.2 1.6 PEEP 0 10 20 30 40 Best PEEP: CO, PaO2 , FiO2 FiO2 0.3 0.4 0.5 0.6-0.7 0.8-0.9 PEEP 5 5-8 8-10 10-12 14-18 NHLB ARDS clinical trials network, 2004, NEJM 549 patients, 28 days PEEP 8 vs. 13cmH2O, No difference Best PEEP Effect of PEEP in ARDS Randomized 549 ARDS/ALI patients ARDS Network NEJM 2004; 351(4): 327 0 10 20 30 40 50 0.0