ARDS肺复张的临床实施课件-新.pptVIP

Paw [cmH2O] % Opening and Closing Pressures 0 5 10 15 20 25 30 35 40 45 50 0 10 20 30 40 50 Opening pressure Closing pressure 5 patients, ALI / ARDS From Crotti et al AJRCCM 2001. Some units can’t be kept open by any reasonable PEEP! 肺泡复张的决定因素(5): 循环耐受情况 An RM Can Profoundly Depress CO Averaged Data from 3 Models S-C Lim, et al 2004 RM Effect on CO Varies Among Injury Models Averaged data for 3 RM Methods PNM VILI S-C Lim, CCM 2004 Effect of RM Method on CO in Pneumonia Model SI PCV S-C Lim, CCM 2004 肺泡复张的决定因素(6):肺泡过度膨胀 Clinical exp of Gattinonii 低可复张的ARDS患者 Higher PEEP: little benefit and may actually be harmful. 多数肺泡( 60 %)处于开放状态 高PEEP和肺复张对开放的肺泡可能是有害的 高可复张的ARDS患者 the use of higher PEEP levels seems appropriate In our daily practice PEEP 15 cmH2O PEEP 10 cmH2O Gattinoni L. Eur Respir J Suppl 2003;47:15s-25s. Grasso S. Am J Respir Crit Care Med 2005;171:1002-8. 预测: ARDS肺复张效应 N=19 ARDS Higher PEEP vs lower PEEP on RV Am J Respir Crit Care Med Vol 171. pp 1002–1008, 2005 Higher PEEP strategy induced alv recruitment Recruiters: 150 ml Nonrecruiters: 150 ml 影响ARDS肺复张效应的因素 Am J Respir Crit Care Med Vol 171. pp 1002–1008, 2005 影响复张响应的预测因素 (原发病　No effect) PEEP ----- PaO2/FiO2 PEPP ----- Compl PEEP ----- Stress index (b) 内容提要 RM的病理生理基础与实施 RM造成的循环问题 突破RM的循环限制 RM导致的血流动力学改变 ARDS pats n=10 SI的实施：30cmH2O，20s SI时 PAP、CVP、PAWP、PVRI和RVSWI均显著增加(P 0.05) MAP ：4例患者略升高，3例降低，3例不变 邱海波, 谭焰. 江苏医药，2003, 29: 84-87 肺复张手法对重复去复张ARDS 家兔PaO2 的影响 C.感染与肺不张 全麻---肺不张的发生率 90% 择期腹部手术：肺不张—肺部感染9.6% 择期心脏手术：肺不张—肺部感染5.7% 肥胖病人手术：25%--30%发生肺不张／肺部感染　　 CHEST 1997; 111:564-71 Qiu Haibo. Chin J Emerg Med, 2001, 10(5): 293-294 气压伤 — 生物伤 启动炎症反应 炎症介质移位 细菌毒素移位 MODS/MOF D.气压伤、生物伤与MODS From Slusky ARDS－motor of MODS 邱海波. 中华急诊医学杂志, 2001, 10(5): 293-294 Biotrauma — Barotrauma initiate a cascade of proinfla mediators 肺是炎症细胞激活和聚积的重要场所 肺实质细胞可释放炎症介质 Mediator translocation Bacteria and LPS translocation MODS/MOF 腹部手术后肺不张及增加气道内正压的肺复张作用 将大鼠常规镇静肌松 通气参数 : Vt 8 ml/kg; f 38 ~