北京協和醫院杜斌機械通氣患者壓力容積曲線機械通氣患者的壓力容積曲線第1頁呼吸系統壓力容積曲線反應肺和胸廓靜態機械力學特征了解患者病理生理學改變設置機械通氣參數機械通氣患者的壓力容積曲線第2頁靜態法(staticmethod)準靜態法(quasistatic)超大注射器法(super-syringetechnique)吸氣阻斷法(inspiratoryocclusiontechnique)低流量法(continuousinflationataconstantflow)PV曲線測定方法機械通氣患者的壓力容積曲線第3頁靜態PV曲線測定方法(I):超大注射器法測定前準備工作鎮靜+肌松測定前15分鐘預氧合FiO21.0PEEP0準備好1.5或3.0L超大注射器充滿經過濕化氧氣MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66機械通氣患者的壓力容積曲線第4頁靜態PV曲線測定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66機械通氣患者的壓力容積曲線第5頁靜態PV曲線測定方法(I):超大注射器法將患者脫離呼吸機數秒鐘使得肺完全排空，恢復至FRC將超大注射器連接氣管插管從FRC開始進行充氣每次向肺內注入50–100mL氣體等候3秒鐘以使壓力穩定經過壓力傳感器測定氣道壓力再次充氣50–100mL直至Paw到達40–50cmH2O，或注入氣體到達1.5L整個過程通常不超出90秒鐘MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66機械通氣患者的壓力容積曲線第6頁靜態PV曲線測定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66機械通氣患者的壓力容積曲線第7頁靜態PV曲線測定方法(I):超大注射器法MatamisD,LemaireF,HarfA,etal:Totalrespiratorypressurevolumecurvesintheadultrespiratorydistresssyndrome.Chest1984;86:58-66通常重復測定4次第1次結果舍棄對volumehistory進行校正后3次結果取平均值機械通氣患者的壓力容積曲線第8頁優點缺點測定PV曲線經典方法1980s金標準能夠測定吸氣支及呼氣支PV曲線測定時須脫離呼吸機充氣過程中肺容積降低充氣過程延長(>45s)消耗氧氣造成肺容積降低僅部分被生成CO2代償注射器中氧氣溫度和濕度影響測定結果使用未經加溫加濕氣體造成曲線左移靜態PV曲線測定方法(I):超大注射器法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare;4:91-100機械通氣患者的壓力容積曲線第9頁靜態PV曲線測定方法(II):吸氣阻斷法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89測定原理吸氣末平臺壓力反應肺泡壓力使用不一樣潮氣量能夠得到對應肺泡壓力機械通氣患者的壓力容積曲線第10頁靜態PV曲線測定方法(II):吸氣阻斷法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89測定前準備工作鎮靜+肌松呼吸機須具備功效吸氣末暫停呼氣末暫停平臺壓及呼氣末壓力顯示設置基礎通氣模式容量控制通氣模式恒定流量校正volumehistory機械通氣患者的壓力容積曲線第11頁靜態PV曲線測定方法(II):吸氣阻斷法LevyP,SimilowskiT,CorbeilC,etal:Amethodforstudyingthestaticvolume-pressurecurvesoftherespiratorysystemduringmechanicalventilation.JCritCare1989,4:83-89每次測定平臺壓力前應該恢復基礎通氣模式及設置使用呼氣末暫停測定PEEPi確保肺容積及呼氣末壓力恒定(volumehistory)每次測定時改變潮氣量經過改變呼吸頻率即吸氣時間增加或降低潮氣量保持吸氣流量不變隨機選擇潮氣量吸氣末阻斷數秒鐘后測定平臺壓力得到不一樣潮氣量所對應肺泡壓力并作圖機械通氣患者的壓力容積曲線第12頁靜態PV曲線測定方法(II):吸氣阻斷法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed;29:130-134機械通氣患者的壓力容積曲線第13頁靜態PV曲線測定方法(II):吸氣阻斷法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed;29:130-134機械通氣患者的壓力容積曲線第14頁靜態PV曲線測定方法(II):吸氣阻斷法BarberisL,MannoE,GuerinC.Effectofend-inspiratorypausedurationonplateaupressureinmechanicallyventilatedpatients.IntensiveCareMed;29:130-134機械通氣患者的壓力容積曲線第15頁Volumehistory對PV曲線測定影響TakeuchiM,SedeekKA,SchettinoGPP,etal.Peakpressureduringvolumehistoryandpressure-volumecurvemeasurementaffectsanalysis.AmJRespirCritCareMed;164:1225-1230機械通氣患者的壓力容積曲線第16頁Volumehistory對PV曲線測定影響NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed;32:1358-1364機械通氣患者的壓力容積曲線第17頁Volumehistory對PV曲線測定影響NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed;32:1358-1364機械通氣患者的壓力容積曲線第18頁Volumehistory對PV曲線測定影響NishidaT,SuchodolskiK,SchettinoGPP,etal.Peakvolumehistoryandpeakpressure-volumecurvepressuresindependentlyaffecttheshapeofthepressure-volumecurveoftherespiratorysystem.CritCareMed;32:1358-1364機械通氣患者的壓力容積曲線第19頁優點缺點患者無需脫離呼吸機能夠忽略氧氣消耗每次測定僅3秒鐘能夠在不一樣PEEP下測定PV曲線全部呼吸機均可使用耗時較長(約15分鐘)恢復基礎通氣設置測定PEEPi不能測定呼氣支PV曲線靜態PV曲線測定方法(II):吸氣阻斷法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare;4:91-100機械通氣患者的壓力容積曲線第20頁準靜態PV曲線測定方法(I):低流量法測定原理:順應性計算公式機械通氣患者的壓力容積曲線第21頁準靜態PV曲線測定方法(I):低流量法測定原理:順應性計算公式若V(t)恒定則克服阻力壓力差恒定此時氣道壓力與呼吸系統順應性呈負相關機械通氣患者的壓力容積曲線第22頁準靜態PV曲線測定方法(I):低流量法低流量法測定PV曲線:歷史演變Surattetal(JAP1980;Chest1981)吸氣流量0.60±0.10(0.40–0.65)L/secPV曲線順應性與靜態法相同Ranierietal(AmJRespirCritCareMed1994)低流量法PV曲線有利于確定PEEP造成肺泡復張及過分膨脹Servilloetal(AmJRespirCritCareMed1997); Luetal(AmJRespirCritCareMed1999)吸氣流量20–60lpm時,PV曲線斜率測定準確,但高估UIP和LIP機械通氣患者的壓力容積曲線第23頁準靜態PV曲線測定方法(I):低流量法SurattPM,OwensDH,KilgoreWT,HarryRR,HsiaoHS:Apulsemethodofmeasuringrespiratorysystemcompliance.JApplPhysiol1980,49:1116-1121SurattPM,OwensDH:Apulsemethodofmeasuringrespiratorysystemcomplianceinventilatedpatients.Chest1981,80:34-38RanieriVM,GiulianiR,FloreT,DambrosioM,Milic-EmiliJ:Volume–pressurecurveoftherespiratorysystempredictseffectsofPEEPinARDS:‘occlusion’versus‘constantflow’technique.AmJRespirCritCareMed1994,149:19-27ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282機械通氣患者的壓力容積曲線第24頁準靜態PV曲線測定方法(I):低流量法低流量法測定PV曲線:歷史演變Mankikianetal(CritCaremed1983)吸氣流量1.7lpm準靜態PV曲線與靜態法(超大注射器法)相同吸氣時間長達60sServilloetal(AmJRespirCritCareMed1997);吸氣流量15lpm時,準靜態PV曲線右移,但斜率不變高估UIP和LIPMankikianB,LemaireF,BenitoS,etal:Anewdeviceformeasurementofpulmonarypressure-volumecurvesinpatientsonmechanicalventilation.CritCareMed1983；11:897-901ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-163機械通氣患者的壓力容積曲線第25頁準靜態PV曲線測定方法(I):低流量法減去克服氣道阻力所需壓力深入降低吸氣流量Ptot=Ptrach+Pres(tube)Ptrach=Pel+Pres與吸氣阻斷法相比呼吸系統順應性,UIP和LIP均相同Paw=ΔPressure+PelΔPressure=FlowxRaw當吸氣流量≈0ΔPressure≈0Paw?Pel怎樣提升準靜態PV曲線準確性ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282機械通氣患者的壓力容積曲線第26頁準靜態PV曲線測定方法(I):低流量法JonsonB,RichardJC,StrausC,etal:Pressure–volumecurvesandcomplianceinacutelunginjury.AmJRespirCritCareMed1999,159:1172-1178機械通氣患者的壓力容積曲線第27頁準靜態PV曲線測定方法(I):低流量法KárasonS,S?ndergaardS,LundinS,WiklundJ,StenqvistO.Evaluationofpressure/volumeloopsbasedonintratrachealpressuremeasurementsduringdynamicconditions.ActaAnaesthesiolScand;44:571-577機械通氣患者的壓力容積曲線第28頁準靜態PV曲線測定方法(I):低流量法減去克服氣道阻力所需壓力深入降低吸氣流量Ptot=Ptrach+Pres(tube)Ptrach=Pel+Pres與吸氣阻斷法相比呼吸系統順應性,UIP和LIP均相同Paw=ΔPressure+PelΔPressure=FlowxRaw當吸氣流量≈0ΔPressure≈0Paw≈Pel怎樣提升準靜態PV曲線準確性ServilloG,SvantessonC,BeydonL,etal:Pressure–volumecurvesinacuterespiratoryfailure.Automatedlowflowinflationversusocclusion.AmJRespirCritCareMed1997,155:1629-1636LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282機械通氣患者的壓力容積曲線第29頁準靜態PV曲線測定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282呼吸機設置容量控制通氣模式吸氣流量恒定呼吸頻率 5lpmI:E 4:1VtFlow設置1500mL3lpm設置21500mL9lpm機械通氣患者的壓力容積曲線第30頁準靜態PV曲線測定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282機械通氣患者的壓力容積曲線第31頁準靜態PV曲線測定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282PEEPi呼氣流量從呼氣末數值下降至0克服氣道阻力所需壓力(Pres):吸氣流量開始恒定時所對應氣道壓力與PEEPi差值吸氣流量開始恒定LIP:初始階段順應性曲線與PV曲線斜率交點機械通氣患者的壓力容積曲線第32頁準靜態PV曲線測定方法(I):低流量法LuQ,VieiraS,RichecoeurJ,etal:Asimpleautomatedmethodformeasuringpressure-volumecurveduringmechanicalventilation.AmJRespirCritCareMed1999,159:275-282當吸氣流量設置為9lpm時PV曲線因阻力原因影響向右側移動高估LIP(統計學無差異)PV曲線斜率無差異機械通氣患者的壓力容積曲線第33頁優點缺點患者無需脫離呼吸機不影響肺容積測定時間較短每次測定僅需10秒鐘整個操作包含曲線分析僅需2分鐘能夠在不一樣PEEP下測定PV曲線需要特殊呼吸機吸氣流量較高時影響準確性PV曲線右移不能測定呼氣支PV曲線準靜態PV曲線測定方法(I):低流量法LuQ,RoubyJJ.Measurementofpressure-volumecurvesinpatientsonmechanicalventilation:methodsandsignificance.CritCare;4:91-100機械通氣患者的壓力容積曲線第34頁DraegerEvitaXLHamiltonGalileoGold/G5低流量法吸氣支和呼氣支PV曲線改良低流量法壓力改變速度很慢吸氣支和呼氣支PV曲線準靜態PV曲線測定方法(II):改良低流量法機械通氣患者的壓力容積曲線第35頁準靜態PV曲線測定方法(II):改良低流量法/.../PN%20689213_PV-Tool_WP_01-Validation_of_New_Method.pdfPiacentiniE,WysockiM,BlanchL.Anewautomatedmethodversuscontinuouspositiveairwaypressuremethodformeasuringpressure-volumecurvesinpatientswithacutelunginjury.IntensiveCareMed;35:565-570HamiltonGalileoGold采取改良低流量法測定吸氣與呼氣PV曲線與CPAP方法相同與低流量法相同機械通氣患者的壓力容積曲線第36頁低流量:HowLowisLow?目標:評價不一樣吸氣流量下測定準靜態PV曲線,其LIP,UIP,最大斜率及WOB是否存在差異研究對象:7名接收機械通氣ARDS患者方法:容量控制通氣模式吸氣流量1,2,5,10lpm吸氣時間從73±1.6sec到8.8±0.69sec結論:LIP無差異UIP和順應性有統計學差異GamaAM,MeyerEC,GaudencioAM,etal.Differentlowconstantflowscanequallydeterminethelowerinfectionpointinacuterespiratorydistresssyndromepatients.ArtifOrgans;25:882-889機械通氣患者的壓力容積曲線第37頁低流量:HowLowisLow?Figure1.Effectofinspiratoryflowonairwaypressuretraces.Thecurveontheleftwasobtainedbyusinga30L/minflow,thecurveontherightwith6L/min.Thecomponentrelatedtotheresistanceofflowthroughairwaysandtrachealcannula(ΔP1=Pmax?Pi)increaseswithhigherflows,whereasthecomponentrelatedtotheviscoelasticpropertiesoflungparenchyma(ΔP2=Pi?Pplat)remainsconstantinbothtracings.Thegoalinthelow-flowtechniqueforacquisitionofPVcurvesistouseaflowthatmakesΔP1negligible.Paw=airwaypressure,Pmax=maximumairwaypressure,Pi=pressureatthebeginningoftheinspiratorypause,Pplat=plateaupressureorpressureattheendoftheinspiratorypause.BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg;97:145-150機械通氣患者的壓力容積曲線第38頁低流量:HowLowisLow?BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg;97:145-150機械通氣患者的壓力容積曲線第39頁低流量:HowLowisLow?BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg;97:145-150機械通氣患者的壓力容積曲線第40頁低流量:HowLowisLow?BensenorFE,VieiraJE,AulerJOC.Guidelinesforinspiratoryflowsettingwhenmeasuringthepressure-volumerelationship.AnesthAnalg;97:145-150機械通氣患者的壓力容積曲線第41頁呼吸系統靜態PV曲線:WhatElse?(B)ThetrachealpressurePtrach(innerloop,dashedarea)iscalculatedpointbypoint.ThepressuredifferencebetweentheouterPAW/V-loopandtheinnerPtrach/V-loopmainlyrepresentstheflow-dependentresistivepressuredropacrosstheETT.ThePtrach/V-loopissubdividedintoeightslices(indicatedbyhorizontallines)andrespiratorymechanicsareanalysedseparatelyforeachslice.Theupperandlower5%ofthetidalvolume(VT)(i.e.slices1and8,respectively)areexcludedfromanalysis.Theremaining90%ofVTaredividedinto6slices.Onevolume-dependentdynamiccomplianceandresistanceoftherespiratorysystem(Crs,dynandRrs,dyn)arecalculatedperslice.(C)Qualityche