ards肺復(fù)張的測定-邱海波

1、急性呼吸窘迫綜合征肺復(fù)張的測定與應(yīng)用,邱海波東南大學(xué)附屬中大醫(yī)院東南大學(xué)急診與危重病研究所,內(nèi)容提要,ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinoni’s vs Rouby’sARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點(diǎn)評價(jià)SI or Sigh的肺復(fù)張作用 評價(jià)PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇,,Lung volume decreased markedly (TL

2、C, VC, TV, FRC) ---alveolar edema ---pulmonary surfactant ---Interstitial pumonary edema depress brochiole and induce spasmCompliance reduced significantlyVentilation/perfusion mismatch --

3、-intrapulmonary shunt and dead space like effects,ARDS病理生理特點(diǎn),ARDS病理生理,,,CT scan70-80% 的肺野呈現(xiàn)高密度區(qū)分布：下垂部位(dependent field)提示：參與通氣肺泡明顯減少(20-30%) 肺損傷具有不均一性,肺容積減少—Small lung Baby Lung,ARDS病理生理,A and C findi

4、ng in the acute or exudative phase,,,B and DFinding in the fibrosing-alveolitis phase,ARDS病理生理,肺容積/順應(yīng)性明顯降低,ARDS病理生理,Reduced range of volume excursion: Low complianceFlattening at low and high volume

5、s: Lower and upper inflection pointsBigatello: Br J Anaest 1996,,,Volume,Pressure,,,,,NORMAL,ARDS,,,,,,順應(yīng)性曲線明顯右下移位,肺順應(yīng)性明顯降低,ARDS病理生理,Upper and Lower Inflection Points,,,,,,,,Lower呼氣末肺泡塌陷吸氣早期肺泡再開放Upper吸氣末肺泡順應(yīng)性明顯降低，

6、肺泡過度膨脹,ARDS病理生理,Volume,Pressure,Lower Inflection Point,Upper Inflection Point,通氣/血流失調(diào),肺泡塌陷：ARDS重力依賴區(qū)，炎癥或不張區(qū)生理性低氧縮血管反應(yīng)：障礙,ARDS病理生理,Imagine the Hardness to Blow up a Ballon ...,easy,hard,spatial & elastic limitations,

7、Laplacian Law,It needs higher initial pressures to overcome the surface tension to open up a bubble to wider diameters!,ARDS病理生理,Sustain inflation Sigh小潮氣量通氣—PHC, 避免肺泡過度膨脹最佳PEEP－避免剪切力(Shear force)性損害,,,,Volume,P

8、ressure,,,,,,,,,肺開放與保護(hù)性通氣策略的基本內(nèi)容,,ARDS病理生理,,,Lung volume decreased markedly,,Atelectrauma,Keep the lung open,Open the lung,,Prevent volutrauma,,,,,,SI and Sigh,PEEP,,,ARDS病理生理,內(nèi)容提要,ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Ga

9、ttinoni’s vs Rouby’sARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點(diǎn)評價(jià)SI or Sigh的肺復(fù)張作用 評價(jià)PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇,,P－V曲線法,Step 1: 測量PEEP所致的?FRC(吸氣末撤掉PEEP并延長呼氣時(shí)間) ?FRC＝VE(ZEEP) － VE(PEEP),肺復(fù)張容積測定,P－V曲線法,St

10、ep 2: 分別描計(jì)ZEEP和PEEP的P－V曲線 Step 3: 肺復(fù)張容積：RV= V20(PEEP) + ?FRC ? V20(ZEEP),肺復(fù)張容積測定,等壓法,呼吸模式：BIPAP條件：Ph 20 cmH2O， PEEP分別為0 、5 、 10、15 cmH2O，Ti 6S測定：延長呼氣時(shí)間，測定ZEEP呼出氣量。在不同PEEP時(shí)吸氣末撤掉PEEP，延長呼氣時(shí)間，測定呼氣量,肺復(fù)張容積測定,

11、等壓法,肺復(fù)張容積測定,P-V曲線法與等壓法的比較,,肺復(fù)張容積測定,肺復(fù)張容積測定—P-V曲線法,等壓法雖然簡單，但準(zhǔn)確性較差 不能代替P-V曲線法目前肺復(fù)張容積的測定仍宜采用 P-V曲線法,肺復(fù)張容積測定,CT method,膈頂上1cm CT層面PEEP與ZEEP比較Gattinoni L. Am J Respir CCM, 1995, 151: 1807全肺掃描區(qū)別過度膨脹，膨脹，部分復(fù)張和塌陷區(qū)

12、Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,肺復(fù)張容積測定,CT法--Gattinoni,,肺復(fù)張容積測定,原理CT空氣=0Hu，CT水=?1000 HuCT值=?500Hu，肺組織50%空氣+50%水ARDS塌陷肺CT值?100Hu~?100Hu，塌陷肺泡復(fù)張 后，?100Hu~+100Hu內(nèi)肺組織減少方法ZEEP和PEEP通氣呼氣末CT掃描膈肌頂上

13、1cm計(jì)算CT值在?100 Hu ~ ?100 Hu范圍內(nèi)體素結(jié)果之差,Gattinoni L. Am J Respir CCM, 1995, 151: 1807,原理 充氣不良區(qū)(?100Hu~500Hu)、正常充氣區(qū)(?500Hu~ ?900Hu)、無充氣區(qū)(?100Hu~+100Hu)和過度充氣區(qū)(?900Hu~?1000Hu)。肺泡復(fù)張，充氣不良和正常充氣肺區(qū)體積增加 方法 ZEEP和PEEP呼氣末螺

14、旋CT，根據(jù)層面厚度計(jì)算不同CT值肺體積，肺復(fù)張后充氣不良與正常充氣肺組織體積增加值,肺復(fù)張容積測定,CT法-- Rouby,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,Gattinoni’s vs Rouby’s CT法比較,肺復(fù)張容積測定,CT methods: Rouby vs Gattinoni,Luiz M, Rouby JJ. Am J Respir CCM, 2

15、001,163:1444,肺復(fù)張容積測定,內(nèi)容提要,ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinoni’s vs Rouby’sARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點(diǎn)評價(jià)SI or Sigh的肺復(fù)張作用 評價(jià)PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇,,ARDS肺不張的影響因素---附加靜水壓,Hydrostatic pressure = (1 – [CT/-1000]) ? Hei

16、ght Maximum sternovertebral dimention of human thorax: 20cmH2OPEEP 20cmH2O不能使ARDS患者肺泡完全復(fù)張動(dòng)物ARDS,Mean Airway pressure 25 cm H2O,ARDS肺復(fù)張應(yīng)用,ARDS下肺氣體含量明顯降低,CT scan ARDS study group. AJRCCM, 2000,161:200

17、5,ARDS肺復(fù)張應(yīng)用,CT section lcated 5 cm below the carina No differences were observed in the percentage of lower lobes located beneath the heart in two groups,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺不張的影響因素---

18、heart lung interdependence,ARDS肺復(fù)張應(yīng)用,Cardiac mass and volume in ARDS,Cardiac mass was increased by 27% vs NS Mechanism of cardiac mass:Edema of cardiac wallRV dilation secondary to pul hypertensionHyperkinetic state

19、related to SIRS,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺復(fù)張應(yīng)用,心臟下肺葉氣體量明顯降低ARDS –73% vs NS –21%,Closed bar: Fraction of gas in lower lobes located beneath the heartOpen bar: lower lobes located outside the

20、heart,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺復(fù)張應(yīng)用,塌陷肺泡的分布,Local: Loss of aeration predominating in lower lobesDiffuse: Equal loss of aeration to the upper and lower lobes,ARDS肺復(fù)張應(yīng)用,Lung morphology patte

21、rn,Local DiffuseLIPNoYesNormally aerated 55?12% 24 ?12%Poorly aerated 23 ?8% 40 ?12%Distribution modal BimodalUnimodalPeak of CT distr-727Hu/27Hu7HuCompltot57 ?546 ? 11,Vieira SRR. A

22、JRCCM, 1999, 159: 1612,,,,ARDS肺復(fù)張應(yīng)用,Diffuse distribution,ARDS肺復(fù)張應(yīng)用,ARDS肺復(fù)張應(yīng)用,local distribution,內(nèi)容提要,ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinoni’s vs Rouby’sARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點(diǎn)評價(jià)VT和SI or Sigh對肺復(fù)張的影響 評價(jià)PEEP維持肺復(fù)張的

23、作用指導(dǎo)PEEP選擇,,SI前后綿羊復(fù)張容積的變化,*,*,與SI前相比，*P < 0.05,ARDS肺復(fù)張應(yīng)用,SI有效組綿羊肺氣體交換變化,*,*,與SI前相比，*P < 0.05,ARDS肺復(fù)張應(yīng)用,潮氣量對肺復(fù)張的影響,A:PEEP=0, B:PEEP=Pflex, C:at the end of inspiration,D:PEEP=Pflex as in C during expiration,Pelosi

24、P, Goldner M, Mckibben A, et al. Am J Respir Crit Care Med, 2001, 164, 131-140,ARDS肺復(fù)張應(yīng)用,小潮氣量通氣的局限性,Cretti S, Mascheroni D, Caironi P, et al. Am J Respir Crit Care Med, 2001, 164, 131-140,ARDS肺復(fù)張應(yīng)用,Mean Airway pressure

25、5 cm H2O,,CT Scan :ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺復(fù)張應(yīng)用,Mean Airway pressure 25 cm H2O,CT Scan :ARDS pig model 30 kg,,Optimized Lung Volume Strategy,ARDS肺復(fù)張應(yīng)用,Mean Airway Pressure 40 cm H2O,CT

26、 Scan :ARDS pig model 30 kg,,Optimized Lung Volume Strategy,ARDS肺復(fù)張應(yīng)用,不同VT的肺復(fù)張容積,*,*#,與6ml/kg組相比，*P < 0.05;與10 ml/kg相比， #P < 0.05,ARDS肺復(fù)張應(yīng)用,內(nèi)容提要,ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinoni’s vs Rouby’sARDS肺復(fù)張測定

27、應(yīng)用明確肺不張的分布與特點(diǎn)評價(jià)SI or Sigh的肺復(fù)張作用 評價(jià)PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇,,PEEP效應(yīng)的影響因素---附加靜水壓與心臟的影響,ARDS肺復(fù)張應(yīng)用,Rothen H. et al. Br J Anaesth 1993:71:788-795,Re-expansion of atelectasis during general anaethesia,A: CT scan at level of

28、 right disphragm B: CT scan 5cm above right diaphragm,ARDS肺復(fù)張應(yīng)用,PEEP誘導(dǎo)recruitment的分布,Puybasset L. ICM, 2000, 26:1215c,In lower lobes: Alv recruitment (ml) = 0.16 X End-expir lung volume(ml) –24ml,ARDS肺復(fù)張應(yīng)用,PEEP

29、導(dǎo)致overdistention的分布,Volume of overdistension(ml)=0.42?Parenchyma-900;-800(ml)–18ml,Puybasset L. ICM, 2000, 26:1215c,ARDS肺復(fù)張應(yīng)用,PEEP效應(yīng)的影響因素---塌陷肺泡的分布范圍,塌陷肺泡的范圍Efficiency of PEEP-induced alv recruitment highly corre

30、lated with the proportion of poorly and nonaerated lung parenchyma in ZEEP,Puybasset L. ICM, 2000,26:1215,ARDS肺復(fù)張應(yīng)用,Diffuse: Equal loss of aeration to the upper and lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺

31、復(fù)張應(yīng)用,Local: Loss of aeration predominating in lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺復(fù)張應(yīng)用,Effect of PEEP on recruitment and overdistention,,Puybasset L. ICM, 2000, 26:1215,ARDS肺復(fù)張應(yīng)用,PEEP效應(yīng)的影響因素---LIP的影響,

32、ARDS肺復(fù)張應(yīng)用,綿羊有無LIP組PEEP復(fù)張容積,ARDS肺復(fù)張應(yīng)用,有無LIP患者的復(fù)張容積,*,*#,*,*#?,與PEEP5 cmH2O相比，*P < 0.05與PEEP 10 cmH2O相比，#P < 0.05與LIP組比較，?P < 0.05,ARDS肺復(fù)張應(yīng)用,Effect of PEEP on recruitment and overdistention,In LIP/+: PEEP1=LIP+2

33、, PEEP2=LIP+7. In LIP/-: PEEP1=10, PEEP2=15,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺復(fù)張應(yīng)用,PEEP-induced alv recruitment,16pat with ARDSLIS 3Csts 39(ZEEP) CT scan Over -1000~-900 Normal -900~-500 Lo

34、w -500~-100 Ate –100~+100 PEEP 0 vs 15,,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,ARDS肺復(fù)張應(yīng)用,對象：17例穩(wěn)定ARDS患者VT=6ml/kg,PEEP=10cm/H2O肺復(fù)張方法：ZEEP, SI(40cmH2O,40s)，VT=6ml/kg, PEEP=Pflex+2cmH2O, PCV，PIP=15+PEEP，

35、調(diào)整PEEP為25、30、35、40、45cmH2O，CT比較非通氣區(qū)變化結(jié)果：PaO2從ZEEP的92.3mmHg上升至394mmHg，非通氣區(qū)從ZEEP的63.7%降至28.6%,VT-induced alv recruitment,ARDS肺復(fù)張應(yīng)用,VT-induced alv recruitment,ARDS肺復(fù)張應(yīng)用,內(nèi)容提要,ARDS病理生理ARDS肺復(fù)張容積測定P-V曲線法等壓法CT法：Gattinoni’s

36、vs Rouby’sARDS肺復(fù)張測定應(yīng)用明確肺不張的分布與特點(diǎn)評價(jià)SI or Sigh的肺復(fù)張作用 評價(jià)PEEP維持肺復(fù)張的作用指導(dǎo)PEEP選擇,,PEEP的選擇,氧分壓導(dǎo)向性PEEP選擇 PaO2 method DO2導(dǎo)向性PEEP選擇肺復(fù)張容積導(dǎo)向性PEEP選擇Recruitment volume method,ARDS肺復(fù)張應(yīng)用,,,,,,,,,open,closed,closed?,open,open

37、 up!,find closed!,re-open!,keep open!,airway pressure,time,,,氧分壓導(dǎo)向性PEEP選擇,ARDS肺復(fù)張應(yīng)用,Vazquez de Anda et al. Acta Anesth Scand 1998: 42:63-66,PEEP,PIP,ARDS肺復(fù)張應(yīng)用,對象：17例ARDS患者，VT=6ml/kg, PEEP=10cm/H2OPEEP選擇方法：PCV，PIP=15+PEE

38、P，每2min調(diào)PEEP 25、30、35、40、45cmH2O，至FiO2為100% PaO2+PaCO2>400mmHg，每15-20min降低PEEP，至PaO2較前一次降低>5%, PEEP水平為前一次PEEP結(jié)果：PaO2+PaCO2從178.4?76.5mmHg升至487.8 ? 139.1mmHg，維持肺復(fù)張PEEP水平為22?4cmH2O,V.N.Okamoto et al. Unpublished da

39、ta, 2003,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,對象：47例早期ARDS患者，VCV，VT=8ml/kg， PEEP=10cm/H2O，RR20次/分，I：E=1：1分組與方法： ARM+PEEP組：ARM實(shí)施方法為逐步增加PEEP至15、

40、 20、25、30cm/H2O(extended sigh)， 結(jié)束后PEEP設(shè)為15cm/H2O ARM組：ARM后PEEP仍為10cm/H2O PEEP組：基礎(chǔ)通氣模式,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,

41、31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,Lim CM, Jung H,

42、Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺復(fù)張應(yīng)用,氧分壓導(dǎo)向性PEEP選擇,DO2導(dǎo)向性PEEP選擇,ARDS傳統(tǒng)的通氣策略----經(jīng)驗(yàn)性PEEP缺點(diǎn)：缺乏科學(xué)依據(jù)ARDS肺保護(hù)性通氣策略----最佳PEEP優(yōu)點(diǎn)：獲得最大的DO2，同時(shí)考慮PEEP 對循環(huán)和呼吸的影響，LIP+2cmH2O 為最佳PEEP,ARD

43、S肺復(fù)張應(yīng)用,邱海波, 郭鳳梅, 周韶霞等. 中華內(nèi)科雜志, 2001, 9,PEEP不足大量肺泡難以復(fù)張,,,LIP：塌陷肺泡開始復(fù)張壓力，不是全部塌陷肺泡復(fù)張壓力,ARDS肺復(fù)張應(yīng)用,LIP—Start of recruitment,Recruitment occurs along the entire PV curve, even beyond UIP,Gattinoni L. AJRCCM, 2001, 164: 131,A

44、RDS肺復(fù)張應(yīng)用,PEEP and Survoval,A post hoc analysis, 53 patients,Barbas CSV, Medeiros DM, Magaldi RB, et al. Am J Respir Crit Care Med, 2002, 165: A218,ARDS肺復(fù)張應(yīng)用,PEEP—肺復(fù)張與低氧血癥改善,Gattinoni L, Caironi P, Pelosi P, et al. Am

45、 J Respir Crit Care Med, 2001, 164:1701-1711,ARDS肺復(fù)張應(yīng)用,ARDS綿羊不同PEEP復(fù)張容積,ARDS肺復(fù)張應(yīng)用,ARDS患者不同PEEP復(fù)張容積,*,*#,與PEEP5cmH2O相比較，*P < 0.05;與PEEP5cmH2O相比較，#P < 0.05;,ARDS肺復(fù)張應(yīng)用,ARDS早期PEEP的調(diào)整 肺復(fù)張容積與DO2的結(jié)合,ARDS肺復(fù)張應(yīng)用,,不同通氣模式對肺N

46、F-?B的影響,,1、2、3、4、5和6分別為正常、ARDS、HVZP、LVBP、LVHP、NVBP組,1 2 3 4 5 6,基礎(chǔ)研究,不同通氣模式對肺TNF?-mRNA表達(dá)的影響,1 2 3 4 5 6,,1、2、3、4、5和6分別為正常、ARDS、LVBP、LVHP、NVBP和HVZP組,基礎(chǔ)研究,不同通氣模式對肺組織TNF?的影響,基礎(chǔ)研究,不同通氣模式對肺組織MPO的影響,與對照組比較，*

47、P<0.05；與ARDS組比較，△ P<0.05，與LVBP組比較，＃P < 0.05；與HVZP組比較，▲ P<0.05,基礎(chǔ)研究,不同通氣模式對肺組織MDA的影響,與對照組比較，* P<0.05；與ARDS組比較，△ P<0.05，與LVBP組比較，＃P < 0.05；比較，▲ P<0.05,基礎(chǔ)研究,Bedside assessment of lung morphology

48、 (PEEP=5cmH2O),Diffuse,Chest X-rayDiffuse Predominating/CT scan / White lungs in lower lobesSlope of PV 50ml/cmH2OLIP>530cmH2OPEEP trial10-15-20-255-8-10-12,,Local,,,總 結(jié),ARDS肺復(fù)張