2015年ARDS-通气策略(宋立强)课件.pptVIP

;ARDS的病理生理定义; ARDS的发生机制？;1 肺间质 2 肺泡;;1.感染性肺水肿 (pulmonary edema due to infection);ARDS肺水肿的 成分： 富含蛋白 细胞碎片 未激活的PS 中性粒细胞 巨噬细胞 炎症介质 ......;Apex; ARDS的临床诊断？;;;An early PEEP/FIO2 trial identifies different degrees of lung injury in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med.?2007； 15;176(8):795-804. ; 29%ARDS患者PAWP≥18mmHg（或CVP升高）, 而其中97%PAWP升高的ARDS患者中有正常的心脏功能。结论：PAWP或CVP升高不能作为ARDS的排除标准。;Berlin Definition 2012 柏林定义; 传统机械通气的肺损伤？;Ventilator Induced Lung Injury，VILI;OverdistentionBarotrauma Volutrauma;;Translocation of Cells By BUBBLE;;; ARDS的保护性通气策略？;Oxidant injury- keep FiO2 60 Barotrauma- keep alveolar inflation pressures 35 cm H2O Volutrauma- Baby lung concept or stretch injury Atelectrauma- repeated opening and closing Biotrauma- release of inflammatory mediators and bacterial translocation OPEN GENTLY AND KEEP THEM OPEN 温柔的打开肺泡，并保持开放;传统的肺保护性通气策略;;提纲：临床探讨的通气模式与参数;肺通气保护策略在儿童ARDS中的应用;PLATEAU PRESSURES 低平台压;;平台压的调整策略;;;;流程图;;小潮气量+高PEEP;;;;;;研究结论;VCV vs PCV 定容与定压 ;RCT multicenter, 79 patients with ARDS PCV (n-37) versus VCV (n=42). P plat ≤ 35 cm H2O No difference in mortality trend to more renal failure in VCV group BUT patients in VCV group had a higher in-house mortality related to higher number of extra-pulmonary organ failures (78% vs 51%) （TV 8cc/kg of weight）;RECRUITMENT 肺复张;Current evidence suggests that that RMs should not be routinely used on all ARDS patients unless severe hypoxemia persists or as a rescue maneuver to overcome severe hypoxemia, to open the lung when setting PEEP, or following evidence of acute lung derecruitment such as a ventilator circuit disconnect 结论：RM不常规用在所有的ARDS患者，除非持续的严重低氧血症，或者做为严重低氧血症的一种肺开放手段（设置PEEP），或者由于管路断开出现急性肺陷闭;;Computed tomography scan of the lungs showing ARDS when the patient is lying supine (left) and prone (right).;The Prone-Supine II Study is the largest clinical trial (N 5342) in adult ARDS patients, conducted in 23 centers in Italy and 2 in Spain 20 hours/day Similar 28-day mortal