ARDS患者的肺復張 1 ARDS患者的肺復張 ARDS患者的肺復張 2 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 3 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 4 ARDS的肺保護性通氣策略 ARDS患者的肺復張 5 ARDS的肺保護性通氣策略 小潮氣量 6ml kgIBW 避免過度膨脹造成的容積傷 volutrauma 足夠的PEEP防止肺泡復張造成的剪切力損傷 atelectrauma ARDS患者的肺復張 6 肺泡塌陷與復張造成的剪切力 F PLx V0 V 2 3F 剪切力PL 跨肺壓V0 最初容積V 復張后容積如果 PL 30cmH2O V0 V 1 10則 F 140cmH2O MeadJ TakishimaT LeithD Stressdistributioninlungs amodelofpulmonaryelasticity JApplPhysiol1970 28 5 596 608 ARDS患者的肺復張 7 小潮氣量通氣的問題 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 ARDS患者的肺復張 8 小潮氣量通氣的問題 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 ARDS患者的肺復張 9 小潮氣量通氣的問題 RichardJC MaggioreSM JonsonB ManceboJ LemaireF BrochardL InfluenceofTidalVolumeonAlveolarRecruitment RespectiveRoleofPEEPandaRecruitmentManeuver AmJRespirCritCareMed2001 163 1609 1613 ARDS患者的肺復張 10 受損的肺組織如何復張 俯臥位足夠的PEEP足夠的潮氣量 和 或 嘆氣 肺復張手法減少水腫 最低可接受的FiO2 自主呼吸 ARDS患者的肺復張 11 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 12 肺泡的開放壓與閉合壓 ARDS患者的肺復張 13 PEEP不能使肺復張 ARDS患者的肺復張 14 LIP 僅僅是肺復張的開始 HicklingKG Thepressure volumecurveisgreatlymodifiedbyrecruitment AmathematicalmodelofARDSlungs AmJRespirCritCareMed1998 158 194 202 ARDS患者的肺復張 15 JonsonB RichardJC StrausC ManceboJ LemaireF BrochardL Pressure VolumeCurvesandComplianceinAcuteLungInjury EvidenceofRecruitmentAbovetheLowerInflectionPoint AmJRespirCritCareMed1999 159 1172 1178 低位轉折點之上仍有肺組織復張 ARDS患者的肺復張 16 肺泡的開放壓與閉合壓 ARDS患者的肺復張 17 肺泡開放壓與閉合壓 Paw cmH2O CrottiS MascheroniD CaironiP PelosiP RonzoniG MondinoM MariniJJ GattinoniL Recruitmentandderecruitmentduringacuterespiratoryfailure aclinicalstudy AmJRespirCritCareMed2001 164 131 140 ARDS患者的肺復張 18 ARDS的肺開放 EditorialOpenupthelungandkeepthelungopenB LachmannDept ofAnesthesiology ErasmusUniversityRotterdam TheNetherlands 1992 18 319 321 ARDS患者的肺復張 19 RM能夠使肺開放 RM PIP45cmH2O PEEP35cmH2Ox1min HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 ARDS患者的肺復張 20 肺復張能夠改善ARDS氧合 LapinskySE AubinM MehtaS BoiteauP SlutskyAS Safetyandefficacyofasustainedinflationforalveolarrecruitmentinadultswithrespiratoryfailure IntensiveCareMed1999 25 1297 1301 ARDS患者的肺復張 21 肺復張的各種方法 CPAP SI incrementalPEEPPCVSigh modified HFOV俯臥位 ARDS患者的肺復張 22 SI改善氧合 TugrulS AkinciO OzcanPE Ince S EsenF TelciL AkpirK CakarN Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome Focusingonpulmonaryandextrapulmonaryforms CritCareMed2003 31 738 744 SustainedInflation 45cmH2Ox30s ARDS患者的肺復張 23 SI改善氧合 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 SustainedInflation 30cmH2Ox30sTwicewith1mininterval ARDS患者的肺復張 24 嘆氣的設置 LimCM KohY ParkW ChinJY ShimTS LeeSD KimWS KimDS KimWD Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome Apreliminarystudy CritCareMed2001 29 1255 1260 充氣階段 每30秒PEEP增加5cmH2OVt減少2ml kg前2次呼吸除外直至Vt2ml kg PEEP25cmH2O暫停階段CPAP30cmH2Ofor30s放氣階段 ARDS患者的肺復張 25 嘆氣改善氧合 LimCM KohY ParkW ChinJY ShimTS LeeSD KimWS KimDS KimWD Mechanisticschemeandeffectofextendedsighasarecruitmentmaneuverinpatientswithacuterespiratorydistresssyndrome Apreliminarystudy CritCareMed2001 29 1255 1260 ARDS患者的肺復張 26 嘆氣對氧合及呼吸力學的影響 PelosiP CadringherP BottinoN PanigadaM CarrieriF RivaE LissoniA GattinoniL Sighinacuterespiratorydistresssyndrome AmJRespirCritCareMed1999 159 872 880 Sigh 3consecutivesighs minatPplat45cmH2O ARDS患者的肺復張 27 嘆氣的設置 PatronitiN FotiG CortinovisB MaggioniE BigatelloLM CeredaM PesentiA SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation Anesthesiology2002 96 788 94 Baseline PSVSigh BIPAPPEEPhigh 1 2xPIPpsvor35cmH2OTi s 3 5sf 1bpm ARDS患者的肺復張 28 嘆氣改善呼吸力學及氧合 PatronitiN FotiG CortinovisB MaggioniE BigatelloLM CeredaM PesentiA SighImprovesGasExchangeandLungVolumeinPatientswithAcuteRespiratoryDistressSyndromeUndergoingPressureSupportVentilation Anesthesiology2002 96 788 94 ARDS患者的肺復張 29 ARDS對RM的反應 VillagraA OchagaviaA VatusS MuriasG FernandezMF AguilarJL FernandezR BlanchL RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome AmJRespirCritCareMed2002 165 165 170 ARDS患者的肺復張 30 肺復張 CT的提示 HenzlerD MahnkenAH WildbergerJE RossaintR G ntherRW KuhlenR Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury EurRadiol2006 16 1351 1359 ARDS患者的肺復張 31 肺復張 CT的提示 HenzlerD MahnkenAH WildbergerJE RossaintR G ntherRW KuhlenR Multislicespiralcomputedtomographytodeterminetheeffectsofarecruitmentmaneuverinexperimentallunginjury EurRadiol2006 16 1351 1359 ARDS患者的肺復張 32 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 33 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復張 34 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復張 35 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復張 36 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復張 37 RMvs PEEP LimCM LeeSS LeeJS KohY ShimTS LeeSD KimWS KimDS KimWD MorphometricEffectsoftheRecruitmentManeuveronSaline lavagedCanineLungs AComputedTomographicAnalysis Anesthesiology2003 99 71 80 ARDS患者的肺復張 38 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 39 為什么肺復張作用不能持久 OczenskiW H rmannC KellerC LorenzlN KepkaA SchwarzS FitzgeraldRD RecruitmentManeuversafteraPositiveEnd expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome Anesthesiology2004 101 620 5 ARDS患者的肺復張 40 為什么肺復張作用不能持久 肺復張的方法 SI 50cmH2Ox30s作者認為 OczenskiW H rmannC KellerC LorenzlN KepkaA SchwarzS FitzgeraldRD RecruitmentManeuversafteraPositiveEnd expiratoryPressureTrialDoNotInduceSustainedEffectsinEarlyAdultRespiratoryDistressSyndrome Anesthesiology2004 101 620 5 ARDS患者的肺復張 41 RM PEEPvs RMvs PEEP LimCM JungH KohY LeeJS ShimTS LeeSD KimWS KimDS KimWD Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy etiologicalcategoryofdiffuselunginjury andbodypositionofthepatient CritCareMed2003 31 411 418 ARDS患者的肺復張 42 RM PEEPvs RMvs PEEP LimCM JungH KohY LeeJS ShimTS LeeSD KimWS KimDS KimWD Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy etiologicalcategoryofdiffuselunginjury andbodypositionofthepatient CritCareMed2003 31 411 418 RM PEEP RMonly ARDS患者的肺復張 43 RM后的PEEP ARDS患者的肺復張 44 RM后的PEEP能夠穩定肺泡 HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 ARDS患者的肺復張 45 RM后的PEEP能夠穩定肺泡 RM PIP45cmH2O PEEP35cmH2Ox1min PEEP5cmH2O PEEP10cmH2O HalterJM SteinbergJM SchillerHJ DaSilvaM GattoLA LandasS NiemanGF PositiveEnd ExpiratoryPressureafteraRecruitmentManeuverPreventsBothAlveolarCollapseandRecruitment Derecruitment AmJRespirCritCareMed2003 167 1620 1626 ARDS患者的肺復張 46 肺泡穩定能夠改善PaO2 McCannUG SchillerHJ GattoLA etal Alveolarmechanicsalterhypoxiculmonaryvasoconstriction CritCaremed2002 30 1315 1321 ARDS患者的肺復張 47 RM后的PEEP LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 ARDS患者的肺復張 48 RM PEEPvs PEEPonly LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 RM PEEP PEEPonly ARDS患者的肺復張 49 PEEP的設置 RM之后通常將PEEP設置在能夠維持PaO2 防止塌陷 的水平最初將PEEP設置為20cmH2O然后將FiO2減小到最低水平維持SpO290 95 每20 30分鐘降低PEEP2cmH2O直至患者SpO2下降 ARDS患者的肺復張 50 PEEP的設置 氧合下降前的PEEP水平防止大部分肺泡塌陷的PEEP一旦確認 則需重復肺復張操作 然后把PEEP和FiO2重新設置在上述水平對于多數ARDS患者 PEEP介于15 20cmH2O之間某些患者20cmH2O ARDS患者的肺復張 51 PEEP的設置 如果將PEEP設置于20cmH2O后 仍發現PaO2 FiO2顯著下降按照最初的PEEP設置25cmH2O重復肺復張然后按照上述方法調節FiO2和PEEP ARDS患者的肺復張 52 PEEP的設置 將PEEP從不必要的高水平逐漸降低不要將PEEP由低水平增加到高水平如同P V曲線所示 根據設置方法不同 同樣水平的PEEP所維持的肺容積不同如果在肺泡塌陷后設置PEEP 增加PEEP 則所設置的PEEP水平可以使肺容積減少 PaO2降低 ARDS患者的肺復張 53 PEEP FiO2的調整 推薦意見降低PEEP之前應當首先降低FiO2 以避免肺泡塌陷一般情況下FiO2應當減低到 0 45如果降低PEEP導致氧合下降應當重新設定PEEP肺泡塌陷時不應增加FiO2 ARDS患者的肺復張 54 肺復張后氧合穩定所需時間 TugrulS CakarN AkinciO OzcanPE DisciR EsenF TelciL TAkpir Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend expiratorypressureinacuterespiratorydistresssyndrome CritCareMed2005 33 995 1000 LIP 2 ARDS患者的肺復張 55 肺復張后氧合穩定所需時間 TugrulS CakarN AkinciO OzcanPE DisciR EsenF TelciL TAkpir Timerequiredforequilibrationofarterialoxygenpressureaftersettingoptimalpositiveend expiratorypressureinacuterespiratorydistresssyndrome CritCareMed2005 33 995 1000 ARDS患者的肺復張 56 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 57 不同RM方法的比較 基礎通氣方式VCV Vt10ml kg f20bpm I E1 2 FiO20 5肺復張 OdenstedtH LindgrenS OlegardC ErlandssonK LethvallS AnemanA StenqvistO LundinS Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復張 58 不同RM方法的比較 OdenstedtH LindgrenS OlegardC etal Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復張 59 不同RM方法的比較 OdenstedtH LindgrenS OlegardC ErlandssonK LethvallS AnemanA StenqvistO LundinS Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復張 60 不同RM方法的比較 對于灌洗造成的急性肺損傷模型緩慢低壓復張操作可以促進肺泡復張減少對循環系統的抑制避免對呼吸力學的不良影響 OdenstedtH LindgrenS OlegardC ErlandssonK LethvallS AnemanA StenqvistO LundinS Slowmoderatepressurerecruitmentmaneuverminimizesnegativecirculatoryandlungmechanicsideeffects evaluationofrecruitmentmaneuversusingelectricimpedancetomography IntensiveCareMed2005 31 1706 1714 ARDS患者的肺復張 61 不同RM方法的比較 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 Sustainedinflation45for40s IncrementalPEEPPIP35 PEEP8 35 PCVPIP45 PEEP16I E1 2 2min ARDS患者的肺復張 62 對于VILI模型PCV是最佳的RM方法其他模型結果相似 PEEP8 PEEP12 PEEP16 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 ARDS患者的肺復張 63 內容 小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 64 RM保護肺內皮而非肺泡上皮 試驗動物 大鼠模型制備 酸 pH1 5 吸入機械通氣 Vt6ml kgPEEP5cmH2OFiO21 0F60 70bpm復張操作 30cmH2Ox30sx2間隔1分鐘 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 ARDS患者的肺復張 65 RM保護肺內皮而非肺泡上皮 FrankJA McAuleyDF GutierrezJA DanielBM DobbsL MatthayMA Differentialeffectsofsustainedinflationrecruitmentmaneuversonalveolarepithelialandlungendothelialinjury CritCareMed2005 33 181 188 ARDS患者的肺復張 66 RM ARDS早期vs 晚期 VillagraA OchagaviaA VatusS MuriasG FernandezMF AguilarJL FernandezR BlanchL RecruitmentManeuversduringLungProtectiveVentilationinAcuteRespiratoryDistressSyndrome AmJRespirCritCareMed2002 165 165 170 ARDS患者的肺復張 67 原發性ARDS對RM反應不佳 Salinelavage Oleicacidinjury Pneumonia VanderKlootTE BlanchL YoungbloodAM WeinertC AdamsAB MariniJJ ShapiroRS NahumA RecruitmentManeuversinThreeExperimental ModelsofAcuteLungInjuryEffectonLungVolumeandGasExchange AmJRespirCritCareMed2000 161 1485 1494 SustainedinflationCPAP40 30CPAP60 30CPAP60 30 ARDS患者的肺復張 68 油酸損傷模型RM作用短暫 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 PEEP8 PEEP12 PEEP16 ARDS患者的肺復張 69 不同病因對RM的反應 LimCM AdamsAB SimonsonDA DriesDJ BroccardAF HotchkissJR MariniJJ Intercomparisonofrecruitmentmaneuverefficacyinthreemodelsofacutelunginjury CritCareMed2004 32 2371 2377 RM PEEP PEEPonly ARDS患者的肺復張 70 RM ARDSp與ARDSexp LimCM JungH KohY LeeJS ShimTS LeeSD KimWS KimDS KimWD Effectofalveolarrecruitmentmaneuverinearlyacuterespiratorydistresssyndromeaccordingtoantiderecruitmentstrategy etiologicalcategoryofdiffuselunginjury andbodypositionofthepatient CritCareMed2003 31 411 418 ARDS患者的肺復張 71 SI改善氧合 TugrulS AkinciO OzcanPE Ince S EsenF TelciL AkpirK CakarN Effectsofsustainedinflationandpostinflationpositiveendexpiratorypressureinacuterespiratorydistresssyndrome Focusingonpulmonaryandextrapulmonaryforms CritCareMed2003 31 738 744 SustainedInflation 45cmH2Ox30s ARDS患者的肺復張 72 嘆氣 ARDSp與ARDSexp PelosiP CadringherP BottinoN PanigadaM CarrieriF RivaE 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小潮氣量通氣的問題肺復張的理論與實踐肺復張與PEEP肺復張后的PEEP不同復張方法的差異肺復張的臨床適應癥肺復張的副作用肺復張存在的問題 ARDS患者的肺復張 80 肺泡開放壓與閉合壓 Paw cmH2O CrottiS MascheroniD CaironiP PelosiP RonzoniG MondinoM MariniJJ GattinoniL Recruitmentandderecruitmentduringacuterespiratoryfailure aclinicalstudy AmJRespirCritCareMed2001 164 131 140 即使使用足夠的PEEP也不能使所有肺單位開放 ARDS患者的肺復張 81 RM對哪些患者療效好 尚不清楚肺復張對哪類患者療效更好肺復張對早期ARDS ALI患者的效果更顯著隨著ARDS的進展 肺進入纖維增殖期肺復張就無法有效改善氧合氣壓傷的危險反而增加 ARDS患者的肺復張 82 RM對哪些患者療效好 ARDS的病因繼發性ARDS 全身性感染 創傷等 比原發性ARDS 肺炎 更容易復張目前的推薦意見在ARDS ALI病程早期進行肺復張無論ARDS的病因如何 ARDS患者的肺復張 83 肺復張操作的頻率 尚不清楚對某一患者進行肺復張操作的適宜頻率以下情況應進行肺復張操作病程早期當肺泡塌陷時例如呼吸機脫開 ARDS患者的肺復張 84 肺復張操作的頻率 對于ARDS患者脫離呼吸機能夠導致肺泡迅速塌陷 從而發生嚴重的低氧血癥為避免呼吸機脫開 建議采用密閉吸痰裝置特殊霧化裝置 ARDS患者的肺復張 85 肺復張操作的頻率 肺復張操作當觀察到SpO2持續降低 5min 時如果沒有觀察到氧合下降 則需要每日進行一次或兩次肺復張未知 ARDS患者的肺復張 86 總結 肺復張是肺保護性通氣策略的重要組成開放肺并維持肺開放是其理論基礎應用氣道高壓使塌陷肺泡開放應用足夠的PEEP維持肺泡開放肺復張對循環的影響肺復張尚未解決的問題壓力時間頻率適應癥 ARDS患者的肺復張 87 ARDS患者的肺復張 88 PEEP能否使肺復張 PEEP能夠防止肺泡塌陷 derecruitment 低水平的PEEP只能使很少的肺復張對于ARDS 將壓力持續維持在常用的PEEP水平 20cmH2O 只能使小部分肺組織復張 ARDS患者的肺復張 89 PEEP能否使肺復張 ARDS患者的肺復張貫穿于整個吸氣過程byHicklingAJRCCM1998TidalrecruitmentoccursbelowoptimalPEEP PEEPattheoptimallevelgenerallyresultsinadecreasedquasi staticcompliancewhenmeasuredontheventilatorbyJonsonetalAJRCCM1999 ARDS患者的肺復張 90 肺復張所需的壓力 正常潮氣量通氣也能使肺組織復張但是 大部分肺組織可能仍未充分復張在有限的吸氣時間內在目標氣道峰壓水平由于塌陷肺泡表面液體的粘滯性這些肺單位較高的表面張力間質組織的限制塌陷的肺組織需要較高的氣道壓力和較長的時間才能復張 ARDS患者的肺復張 91 Howhighapressure Howlongatime healthylung transpulmonarypressureof30cmH2OtorecruitatelectatichealthylungsGreavesetalJAP1990peakalveolarpressuresof40cmH2Ofor7to15secondstorecruitlungsofpreviouslyhealthynormalpatientsfollowing20minutesofgeneralanesthesiabyRothenetalBrJAnaesth1993 1998resolutionofatelectasisduringa40cmH2ORMhasatimeconstantof2 6secRothenetalBrJAnaesth1999 ARDS患者的肺復張 92 Howhighapressure Howlongatime healthylung Asaresultinpreviouslyhealthyindividualsthevastmajorityofatelectasiswouldberecruitedwithinabout7 8sec ARDS患者的肺復張 93 Howhighapressure Howlongatime animal peakairwaypressuresof55cmH2Ofor5 10mintoopencollapsedlunginaporcinemodelofARDSSjosrandetalICM1995tomaximallyrecruitlunginasheepsalinelavagelunginjuredmodel40cmH2OPEEP 20cmH2OPC Ppeak60cmH2O I Eof1 1 andarateof10bpmfor2minutesFujinoetalAJRCCM1999 ARDS患者的肺復張 94 Howhighapressure Howlongatime animal animalsrecruitedwith40cmH2OCPAPfor60secnotmaximallyrecruitedtofullyrecruitthelungmultiple 2 3 RMsrequiredevenatpeakpressuresof60cmH2O ARDS患者的肺復張 95 Howhighapressure Howlongatime patient peakairwaypressureof46cmH2OtorecruitcollapsedlunginARDSpatientsGattinonietalAJRCCM198635 40cmH2OCPAPfor30 40secpriortoestablishingalungprotectiveventilatorystrategywhenevermechanicalventilationwasdisruptedAmatoetalNEJM1998 ARDS患者的肺復張 96 Howhighapressure Howlongatime patient InapatientwithsepticARDSinitialrecruitmentmaneuverswith40cmH2OCPAPfor40secfailedPEEP40cmH2OPEEPandPCV20cmH2OatanI Eratioof1 1witharateof10bpmfor2minutestofullyrecruitthelungMedoffetalCCM2000 ARDS患者的肺復張 97 Howhighapressure Howlongatime patient ThesuccessofPCvsCPAPintheexamplesemphasizetherelationshipbetweenpressureandtimeFujinoetalAJRCCM1999MedoffetalCCM2000Theoptimalrelationshipbetweenthesetwovariablestomaximizeefficacyandmaintainsafetyremainsunclear ARDS患者的肺復張 98 Mechanismoflungrecruitment First theairwaysmustbeo