肺复张与PEEP滴定.pptxVIP

肺复张与PEEP滴定 Between Yes and No, the frontier is thin. Good and Evil are mixed.Rouby JJ. Yin and Yang Am J Respir Crit Care Med 157.1721-1725 1998 ARDS attributable mortality Stapleton RD CHEST 2005; 128:525–532 肺损伤的机制 Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trialRanieri VM et al JAMA 1999 282: 54-61 Shear Force30cmH2OALVEOLARAIRWAY140cmH2OMead J. J Appl Physiol 1970; 28:596–608. Higher or lower PEEPN Engl J Med 2004 351(4):327-36 Recruitment Pressure(Pre) of RMModePre(cmH2O)Medoff BD. 2000PCV+PEEP60Barbas CS. 2004CPAP40Brower RG. 2004CPAP35-40Gattinoni L. 2006PCV+PEEP50 How Much PEEP is Enough? Open-Lung ApproachRM:a 40-second breathhold at 40 cm H2O airway pressure, on an FIO2 of 1.0.Plateau airway pressures not exceeding 40 cm H2O Recruitment Pressure(Pre) and UIPPercent0%25%50%75%100%01020Paw（cmH2O)3040RECUITMENT CURVEINSPIRATORY CURVEUIP 22.9±5.0Pre 24.6±5.5P0.05中华结核和呼吸杂志 2006;7:452-457 滴定式肺复张Albaiceta Am J Respir Crit Care Med 2004 170：1066–1072开放肺泡的 压力维持肺泡开放的 通气范围 Maximal alveolar recruitmentBorges JB.Am J Respir Crit Care Med 2006;174: 268–278 PCV+PEEPPCV1515151515PEEP2025303540BILEV ELPEEPhigh3540455055PEEPlow2025303540Mode of RM and titration RM pressure Goal of oxygenation parameterPaO2+PaCO2 ≥400 mm Hgthis formula matches a convenient threshold in quantitative CT analysis, indicating the presence of 5% collapsed lung mass, with good sensitivity/ specificityIncrements of PCO2 in the alveolar space decrease the alveolar PO2 in approximately a 1:1 ratio, especially under low shunt conditions (＜10%) HICKLING KG. Am J Respir Crit Care Med.2001;163: 69–78 Alveolar closing and Cmax(bde) of expiratory curvePercent0%25%50%75%100%Paw(cmH2O)010203040bde 11.9±2.4LIP 6.5±1.6UIP 17.4±4.0Pcl 11.3±2.5中华结核和呼吸杂志 2006;7:452-457 Tidal Hyperinflation during low tidal volume ventilation in ARDS□□□□30 pts, low tidal volume CTVTHGroupLess protected: VTH ≥40% More protec