ards肺复张的测定.pptxVIP

ARDS肺复张的测定会计学第1页/共87页第2页/共87页第3页/共87页内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinoni’s vs Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择 第4页/共87页ARDS病理生理ARDS病理生理特点Lung volume decreased markedly (TLC, VC, TV, FRC) ---alveolar edema ---pulmonary surfactant ---Interstitial pumonary edema depress brochiole and induce spasmCompliance reduced significantlyVentilation/perfusion mismatch ---intrapulmonary shunt and dead space like effects第5页/共87页ARDS病理生理肺容积减少—Small lung Baby LungCT scan70-80% 的肺野呈现高密度区分布：下垂部位(dependent field)提示：参与通气肺泡明显减少(20-30%) 肺损伤具有不均一性第6页/共87页ARDS病理生理A and C finding in the acute or exudative phaseB and DFinding in the fibrosing-alveolitis phase第7页/共87页ARDS病理生理肺容积/顺应性明显降低第8页/共87页ARDS病理生理肺顺应性明显降低顺应性曲线明显右下移位VolumeNORMALReduced range of volume excursion: Low complianceFlattening at low and high volumes: Lower and upper inflection pointsBigatello: Br J Anaest 1996ARDSPressure第9页/共87页ARDS病理生理Upper and Lower Inflection PointsVolumeLower呼气末肺泡塌陷吸气早期肺泡再开放Upper吸气末肺泡顺应性明显降低，肺泡过度膨胀Upper Inflection PointLower Inflection PointPressure第10页/共87页ARDS病理生理通气/血流失调肺泡塌陷：ARDS重力依赖区，炎症或不张区生理性低氧缩血管反应：障碍 第11页/共87页ARDS病理生理Imagine the Hardness to Blow up a Ballon ...spatial elastic limitationsLaplacian LaweasyhardIt needs higher initial pressures to overcome the surface tension to open up a bubble to wider diameters!第12页/共87页ARDS病理生理肺开放与保护性通气策略的基本内容Sustain inflation Sigh小潮气量通气—PHC, 避免肺泡过度膨胀最佳PEEP－避免剪切力(Shear force)性损害VolumePressure第13页/共87页ARDS病理生理Lung volume decreased markedlyAtelectraumaPEEPSI and SighOpen the lungKeep the lung openPrevent volutrauma第14页/共87页内容提要ARDS病理生理ARDS肺复张容积测定P-V曲线法等压法CT法：Gattinoni’s vs Rouby’sARDS肺复张测定应用明确肺不张的分布与特点评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用指导PEEP选择 第15页/共87页肺复张容积测定P－V曲线法 Step 1: 测量PEEP所致的?FRC(吸气末撤掉PEEP并延长呼气时间) ?FRC＝VE(ZEEP) － VE(PEEP)第16页/共87页肺复张容积测定 P－V曲线法Step 2: 分别描计ZEEP和PEEP的P－V曲线 Step 3: 肺复张容积：RV= V20(PEEP) + ?FRC ? V20(ZEEP)第17页/共87页肺复张容积测定等压法呼吸模式：BIPAP条件：Ph 20 cmH2O， PEEP分别为0 、5 、 10、15 cmH2O，