呼吸机相关性肺损伤2014-11-22郑州_PPT课件.ppt

欧阳彬 SICU 中山大学附属第一医院, 广州;机械通气挽救了无数患者的生命;但机械通气同时导致了 呼吸机相关性肺损伤（VALI） 呼吸机诱导膈肌萎缩(VIDD) 呼吸机相关性肺炎(VAP) 呼吸机相关性不适（VAUE）; Inflammation Hemorrhage Edema Fibrosis Pulmonary dysfunction Systemic effects ;1. 炎症（Inflammation）;Tidal Volume 7 ml/kg for 2hrs;3. 水肿（Edema）;VT 20;肺纤维化 （Lung Fibrosis）;PaO2 (mmHg);6. 全身效应（Systemic Effects）;;TGFb1 and TGFb2 up-regulation found in rat serum of VILI;机械通气导致肺损伤的机制探讨;The Mechanism of Inflammation;The Mechanism of Inflammation ----Studies in lung epithelial cells;The Mechanism of Inflammation ----Studies in lung epithelial cells;The Mechanism of Inflammation ----Studies in lung epithelial cells;;;The Mechanism of Inflammation ----Fibroblasts;The Mechanism of Inflammation --Oxidant Injury; 压力伤（Barotrauma） Pneumothorax and emphysema, PIP 50 cmH2O 容量伤（Volutrauma）: Dreyfuss, 1988 (rats) , ARDS Network, 2000 剪切伤（Atelectrauma）: Atelectasis 生物伤（Biotrauma）: Cytokines (IL-8, IL-10, IL-6, TNFa, TGFb), Oxidants;Barotrauma Pneumothorax and emphysema, PIP 50 cmH2O;14 Peak 0 PEEP;The aerated, ventral regions (‘baby lung’)-Barotrauma; 压力伤的减轻: Pneumothorax and emphysema, PIP 50 cmH2O 吸气平台压（IPP）：30-35cmH2O 气道峰压（PIP）：平台压+气道阻力 在容控通气时, 设定压力限制 压力支持(PS)带来的损伤PEEP 跨肺压的意义更大;Volume, ml;2. 容量伤(Volutrauma）: Dreyfuss, 1988 (rats) , ARDS Network, 2000;NEJM 2001;344:1986;6 cc/kg versus 12 cc/kg;6 cc/kg versus 12 cc/kg;332 patients without ARDS 9 ml/kg 9-12 ml/kg 12 ml/kg ALI?ARDS 17% 22 % 33% ----- Doctor induced ARDS ;Development of ARDS and Tidal Volume;3. 剪切伤（Atelectrauma）: Atelectasis;;;; 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