ARDS肺复张的临床实施.pptxVIP

ARDS RM的临床实施;;内容提要;30 kg 猪 肺灌洗复制ARDS模型 压力控制通气PCV Paw 13 cmH2O PEEP 5 cmH2O;肺容积明显降低 (a)肺泡水肿 (b)肺泡表面活性物质的消耗或不足 (c)肺间质水肿压迫远端细支气管 肺顺应性明显降低 通气/血流比例失调 肺内分流和死腔样通气;CT scan 70-80% 的肺野呈现高密度区 分布：下垂部位(dependent field) 提示： 1. 参与通气的肺泡区域明显减少(20-30%) 2. 肺损伤具有不均一性;肺顺应性明显降低;肺内分流增加;;内容提要;PEEP—肺复张与低氧血症改善;Pressure;DR--RM;;肺复张手法对重复去复张ARDS家兔 肺组织TNFαmRNA 表达的影响;;C.感染与肺不张;;ARDS－motor of MODS;腹部手术后肺不张及增加气道内正压的肺复张作用;Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.;Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.;临床研究: 塌陷肺泡越多, 病死率越高;Villar and Amato trial;内容提要;;;肺复张的常用方法;CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续20- 40s;内容提要;肺泡完全复张的临床标准;;;;Lower vs higher Percentage of Potentially Recruitable Lung;;内容提要;Prespective, randomized study: Effect of RM on ARDS;ARDS Trial Network, Crit Care Med 2003; 31(11):2592-2597;为什么RM改善氧合不明显？？;RM能够实现ARDS肺完全开放;麻醉导致的非炎症性肺泡塌陷;;肺泡复张的决定因素(3): 压力与时间;Multiple maneuvers--- 获得理想的复张效应;肺泡复张的决定因素(4):ARDS病程(早期　vs 后期) ;不同RM方法的肺复张效应不同;;An RM Can Profoundly Depress CO;RM Effect on CO Varies Among Injury Models;Effect of RM Method on CO in Pneumonia Model;肺泡复张的决定因素(6):肺泡过度膨胀;预测: ARDS肺复张效应;影响ARDS肺复张效应的因素;内容提要;RM导致的血流动力学改变;Prospective randomized cross-over study Pats with CABG RM (40 cmH2O X 10 s/20s Administered immediately after surgery and SVV 12% ;An RM Can Profoundly Depress CO;Prospective randomized cross-over study Pats with CABG RM (40 cmH2O X 10 s/20s ;RM循环干扰的机制：Effect of RM on RV afterload;Randomized, controlled, cross-over study Pig ARDS model by lung-lavage RM: 12s-s X 40 cm H2O OR 30-s X 40 cm H2O;Critical Care 2006, 10:R86;RM Effect on CO Varies Among Injury Models;Pigs with BAL vs LPS-induced ALI RM for 1 min vital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2O PCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kg;1.RM使三种 ARDS模型 CI均明显下降 2.CI盐酸组降低37% 油酸组 19% 生理盐水组 23% 3盐酸组5min后接近