杨从山ARDS与肺血管通透性.pptVIP

ARDS与肺血管通透性 杨从山 东南大学附属中大医院ICU 东南大学急诊与危重病医学研究所 内容概要 ARDS诊断的困惑 肺血管通透性相关指标的测定 肺血管通透性指标对ARDS诊治的临床评估 ARDS/ALI诊断 急性呼吸窘迫综合征(ARDS)： ①急性起病；②PaO2/FiO2≤200 mmHg(不管PEEP水平)；③正位X线胸片显示双肺均有斑片状阴影；④肺动脉嵌顿压≤18 mmHg，或无左心房压力增高的临床证据。 急性肺损伤(ALI)： 如PaO2/FiO2≤300 mmHg且满足上述其它标准 Bernard GR, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med, 1994, 149:818 PAWP＞18 mmHg is common of ARDS CVP/PAWP增高不一定就是左心衰 高水平PEEP或气道平台压 针对休克的早期大量液体复苏 感染对心肌的抑制 腹内压的增高 肺血管阻力的增加(如COPD) 测量不当 ARDS与心源性肺水肿的鉴别诊断 肺水肿机制 Normal lung Starling定律与肺水肿 Starling公式 Qf=K×[(Pmv-Ppmv)-δ(πmv-πPmv) ] ?P=(Pmv-Ppmv)-δ(πmv-πPmv) 注：Qf 水分转移量； K 毛细血管滤过系数 Pmv 毛细血管内压；Ppmv 肺间质压 δ 蛋白质通过屏障系数 πmv 毛细血管内胶体渗透压 πPmv 肺间质胶体渗透压 ?P 毛细血管内外静水压与胶体渗透压差 肺泡－毛细血管膜 肺血管通透性(PVR)的测定 伊文思蓝(EBD)染料 荧光比色法 用于动物实验，它是经静脉注射伊文思蓝染料，30 min后，开胸取出肺，用甲酸胺提取伊文蓝并用荧光光度计定量测定伊文思蓝含量，并通过伊文蓝－甲酞胺溶液的荧光光谱和标准曲线来计算伊文思蓝含量来反映PVP 肺血管通透性(PVR)的测定 双核素体内标记技术 (67Ga-labeled transferrin and 99mTc-labeled red blood cells) Intensive Care Med, 2006，32(9): 1315-21 BALF蛋白含量(/血浆蛋白) PiCCO PiCCO反映肺水肿及通透性指标 Extravascular Lung Water: EVLW Pulmonary Vascular Permeability Index: PVPI (EVLW/PBV) EVLW/ITBV Katzenelson P, et al. Crit Care Med, 2004, 32(7):1550-4 Groeneveld AB . Intensive Care Med,2006, 32(9):1315-21 EVLWi/GEDVi Increased pulmonary capillary permeability and extravascular lung water after major vascular surgery Sixteen mechanically ventilated patients without heart failure were studied, within 3 h after major abdominal surgery. Extravascular lung water, intrathoracic, global end-diastolic and pulmonary blood volumes, 67Ga-transferrin pulmonary leak index and ventilatory and radiographic variables The pulmonary leak index was elevated in 11 patients and a supranormal extravascular lung water was associated with a hig