急性呼吸窘迫综合征9ppt课件.pptVIP

In the case of Acute Respiratory Distress Syndrome patients or patient with Acute Lung Injury, one can observe on a “Lower Inflexion Point”. The main reason for this can be explained as follow: - on the above picture, when the insufflation starts,only the alveoli “V1” are inflated. There total volume is V1. The alveoli “V2” are not recruited because of the collapsed airway; - but after a given level of pressure, this airway is opened and the alveoli “V2” can be inflated. Above this opening pressure, the total volume is “V1+V2”, and so, it is easy to understand that the compliance is greater. The PEEP level should be adjusted just above this LIP to recruit the maximum number of alveoli. The above ARDS grey curve, plot in ZEEP, will give the physician an indication of how to set the external PEEP: it is said that a good value should be: Pressure at the LIP + 2 hPa. After having applied the PEEP to the patient for a certain amount of time, one can observe that: 1. The volume in the lungs at PEEP pressure (red curve) is higher than the volume in the chest at the same pressure level on the ARDS grey curve; 2. The slope of the curve during PEEP is lower than the slope during ZEEP. The first point can be explained by the recruiting effect of the PEEP. The second point can be explained by the fact during ZEEP, the alveoli are being recruited little by little all along the inflation. In other words, the slope during ZEEP is not representative to the compliance of the thoracic system. 根据压力-容积曲线(P-V曲线)选择 PEEP选择的方法 经验性选择 Collapsed airway V1 V2 Pressure Volume V1 V1 + V2 Opening pressure Normal ARDS PEEP adjustment 根据P-V曲线选择 PEEP effect V1 V2 Pressure Volume V1 V1 + V2 Opening pressure Normal ARDS Adjusted PEEP Recruiting effect 根据P-V曲线选择 开始时给患者一个较低PEEP(一般5cmH2O)，此时FiO2可以高一些(80%～100%)，氧合不理想可以增加PEEP(2cmH2O/次)，直至达到一个比较理想的氧合。增加PEEP压迫要注意气道压的变化。 经验性选择 不恰当的呼吸机参数，特别是过高的气道压容易造成机械通气相关性肺损伤(VILI) 。VILI的发生率约为4%～15%，其中大部分发生在ARDS患者。 由此，对ARDS患者应该实施肺保护性通气策略，主要内容包括： 小VT通气、允许高碳酸血症。 适当PEEP