LungProtectiveMechanicalVentilation

肺保護性機械通氣

Adoption&discussion張翔宇急救重癥科上海同濟大學上海市第十人民醫院LungprotectivestrategyVentilatorInducedLungInjury,VILILungprotectivestrategyPEEPVTRecruitmentManeuver,RMPIP=?Pplateau=?Mode?VentilatorInducedLungInjury

VILIOverdistentionBarotraumaVolutraumaRecruitment/DerecruitmentInjuryTranslocationofCellsBiotraumaVILI：

Recruitment/DerecruitmentInjury

PIP=14,PEEP=0PIP=45,PEEP=10PIP=45,PEEP=0Webb&TierneyARRD1974;110;556VentilationStrategies&BALCytokinesTremblay,Valenza,Ribeiro,Li,SlutskyJClinicalInvestigation99:944-52,199773MVHP1510HVZPCcontrol40identicaldV/dtVT(cc/kg)PEEPcmH2O15MVZP1002001,2001,400*§§CMVHPMVZPHVZPTNF-a,pg/ml50倍！VentilatoryStrategyandBALCytokinesTremblay,Valenza,Ribeiro,Li,SlutskyJClinicalInvestigation99:944-52,1997*

p<0.05vs.C,MVHP,MVZP&p<0.05vs.C,MVHP#

p<0.05vs.CArthurSSlutskySerumCytokinesinAcidAspirationModel

Chiumello,Pristine,SlutskyAJRCCM1999;160:109-16Vt,ml/kgPEEP,cmH2OHVZPHVPLVZPLVP16165555CytokinesinHumans

StuberetalIntCareMed2002;28:834-841JAMA289:2104-2112,2003SystemicEffectsofVILI

ImaietalJAMA289:2104-2112,2003BiophysicalInjuryshear

overdistentioncyclicstretchDintrathoracicpressurealveolar-capillarypermeabilitycardiacoutputorganperfusionBiochemicalInjury(Biotrauma)mfcytokines,complement,PGs,LTs,ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistalOrganDysfunctionMechanicalVentilationSlutsky,TremblayAmJRespCritCareMed.1998;157:1721-5DEATHProtectthelungs?PEEP=?VT=?PIP=?Pplateau=?RM?PEEP=?PEEP/FiO2combination?X!ARDSnet,2000,NEJM,2000;18:1301中華醫學會重癥醫學分會急性肺損傷/急性呼吸窘迫綜合征診斷與治療指南（2006）推薦意見7：對ARDS患者實施機械通氣時應采用肺保護性通氣策略，氣道平臺壓不應超過30-35cmH2O（推薦級別：B級）推薦意見8：可采用肺復張手法促進ARDS患者塌陷肺泡復張，改善氧合（推薦級別：E級）ALI/ARDS指南：

中華內科雜志,2007,46(5):430-435推薦意見9：應使用能防止肺泡塌陷的最低PEEP，有條件情況下，應根據靜態P-V曲線低位轉折點壓力+2cmH2O來確定PEEP（推薦級別：C級）推薦意見10：ARDS患者機械通氣時應盡量保留自主呼吸（推薦級別：C級）推薦意見11：若無禁忌證，機械通氣的ARDS患者應采用30-45度半臥位（推薦級別：B級）推薦意見12：常規機械通氣治療無效的重度ARDS患者，若無禁忌證，可考慮采用俯臥位通氣（推薦級別：D

SSC2008CritCareMed2008Vol.36,No.1SSC2008推薦對ALI/ARDS病人應用6ml/kg（預測體重）的目標潮氣量。（1B）推薦對ALI/ARDS病人進行平臺壓監測，對于被動通氣的病人初始平臺壓目標設定在≤30cmH2O;檢測平臺壓時應當考慮到胸廓的順應性。（1C）推薦對ALI/ARDS病人在必要降低平臺壓或減少潮氣量時施行允許性高碳酸血癥（PaCO2水平高于病前）。（1C）SSC20084.推薦設定PEEP以阻止張開的肺在呼氣末塌陷。（1C）5.建議在有經驗的單位，對于需要可能有害的FiO2和平臺壓的ALI/ARDS病人在沒有不良后果高風險的條件下應用俯臥位通氣。（2C）6a.除非有禁忌，推薦機械通氣的病人床頭抬高減少誤吸風險，防止呼吸機相關性肺炎

。（1B）6b.建議床頭抬高30～45o.（2C）7.建議無創通氣（NIV）只能在少數輕中度低氧的、血流動力學穩定的、易于喚醒的、能夠自我呼吸道保護的、能自主咳痰的、能很快恢復的ALI/ARDS病人考慮應用。SSC20088.推薦制定一套適當的脫機方案，當患者還須滿足以下條件時常規對機械通氣患者施行自主呼吸試驗以評估脫離機械通氣的能力，：①可喚醒，②血流動力學穩定（不用升壓藥），③沒有新的潛在嚴重疾患，④只需低通氣量和低PEEP，⑤面罩或鼻導管給氧可滿足吸氧濃度要求。應選擇低水平壓力支持、持續氣道正壓（CPAP，≈5cmH2O）或T管進行自主呼吸試驗（1A）。9.不推薦對ALI/ARDS患者常規應用肺動脈導管（1A）。10.對已有ALI且無組織低灌注證據的患者，推薦保守補液策略，以減少機械通氣和住ICU天數（1C）。潮氣量

VT6ml/kgPplateau<PuipPplateau<30cmH2O肺復張術Lungrecruitmentmaneuver,RMSIPCStepwiseRMRecruitmentManeuverMassachusettsGeneralHospitalPerformanceofRM@MGH30cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell35cmH2OCPAPfor30to40secIfunresponsivebuttoleratedwell40cmH2OCPAPfor30to40secAllow15to20minutesbetweenRMPerformanceofRM@MGHSetFIO2at1.0Wait10minutesInsureappropriatesedationMayneedtodomultipleRMsMonitoringduringRM(MGH)TheRMshouldbeabortedif:MAP<60mmHgordecreasesby>20mmHgSpO2<88%Heartrate>130or<60/minuteNewarrhythmiasAmatoNEJM1998;338:34735–40cmH2OCPAPfor30to40secAtenrollmentAfterventilatordisconnectNoseverehemodynamiccompromiseNobarotraumaAmato:2004ChinaFULLRECRUITMENT: PaO2+PaCO2>400mmHgAmatoARDSprotocolRecruitFIO2=1TitratePEEPTitratePdrivingWAIT(<15)FIO2≤30%(HighPEEP+PSV)WAITFIO2≤30%(HighPEEP+PSV)DecreasePSdownto8DecreasePEEPdownto12NIMV(CPAP=12,PS=8)PEEP/FIO2target

(≈8～14cmH2O)PEEPatPFLEX

(≈14～18cmH2O)PEEPenoughtofullyavoid airwaycollapse

(≈16～26cmH2O)Amato:2004China張翔宇的方法

所有患者均行有創動脈壓持續監測

SpO2持續監測

CVP持續監測清醒患者適當鎮靜復張術（RM）前排除氣壓傷排除肺氣腫患者

Protocol

Mode:PEEP+PCVorPEEP+PSVPEEP:increment2cmH2OInterval:2minPEEPtarget:16/1stRM,20/2ndRM,26~30/3rdRMPIPmax:45cmH2OAbortifABPorSpO2startfallRestinterval:15～30minMayrepeattwiceaday結果心臟外科術后低氧患者有效：100%PaO2/FiO2improve：110%±36%

無并發癥多發傷并發ALI/ARDS患者有效：92%PaO2/FiO2improve：86%±32%無并發癥軍團菌病1例，無效，出現氣壓傷

RM一次，PEEPmax:22,PIPmax:32縱隔氣腫臨床觀察252例次RM有93次血壓短暫降低（37%）出現血壓下降的PEEP水平為6～23cmH2O,平均13.9cmH2OPEEP降低之后動脈恢復到原來水平所有病人有創持續血壓監測1例經心超證實卵圓孔未閉，在PEEP=6時發生右向左分流，同時SpO2下降張翔宇，等，中國危重病急救醫學，2007，19（9）CritCareMed2007Vol.35,No.1

FernandoSuarez-Sipmann,etalUseofdynamiccomplianceforopenlungpositiveend-expiratorypressuretitrationinanexperimentalstudyEighthealthypigsLunglavagesCTsliceswereobtained2cmcranialoftherightdiaphragmaticdomeProtocolResultSuarez-Sipmann’sclusiondynamiccomplianceidentifiedthebeginningoflungcollapseinapigmodel.thecontinuousmonitoringofdynamiccompliancemightbecomeavaluablebedsidetoolforeasilyidentifyingthelevelofPEEPthatpreventsend-expiratorylungcollapse？？？Bob’snewprotocol2007PerformanceofRMSetFIO2at1.0AllowtimeforstabilizationInsureappropriatesedationInsurehemodynamicstabilityBob’snewprotocolPerformanceofRM-PCVPressurecontrolventilation:PEEP20-30cmH2OPeakInspirPress40-50cmH2OInspirTime:1to3secRate:8to20/minTime1to3minSetPEEPat20,ventilateVC,VT4to6ml/kgPBW,increaserate,avoidauto-PEEPMeasuredynamiccomplianceDecreasePEEP2cmH2OBob’snewprotocolPerformanceofRM-PCVMeasuredynamiccomplianceRepeatuntilmaxcompliancedeterminedOptimalPEEPmaxcompPEEP+2to3cmH2ORepeatrecruitmentmaneuverandsetPEEPattheidentifiedsettings,adjustventilationAfterPEEPandventilationsetandstabilized,decreaseFIO2untilPO2intargetrangeIfresponseispoor,repeatRM,PEEP25,PeakPressure45Ifresponseispoor,repeatRM,PEEP30,PeakPressure50Bob’snewprotocol2007LungRecruitmentPerformearlyinARDSIdealapproachtoRMmostlikelyPC,limitedpatientdataavailableusingPC!WorksbetterinextrapulmonarythanprimaryARDS?Moredifficulttorecruitthelungthestifferthechestwall!Startwithlowpressure,increaseastoleratedandneeded!IfbenefitlostafterRM,PEEPinadequate!Bob’snewprotocolAcomparisonofmethodstoidentifyopen-lungPEEP.

CaramezMP,KacmarekRM,etal

InthisanimalmodelofARDS,dynamictidalrespiratorycompliance,maximumPaO2,maximumPaO2+PaCO2,minimumshunt,inflationlowerPflexandPmci,iyieldsimilarvaluesforPEEPfollowingarecruitmentmaneuver.IntensiveCareMed.2009Apr;35(4):740-7.

Patients(n=549)

ARDS/ALI

Pplat(cmH2O)

<30

PEEP(cmH2O)

12.9±4

8.4±4

RR(b/min)30

TV

(ml/Kg) <6

TheNIHrandomizedmulticenterstudyassessingtheeffectonmortalityoflowvshighPEEPinARDS

NewEnglJMed2004;351:327-336NIHPEEPselectedaccordingtoaTabletoachieveminimalphysiologicaloxygenation(88-95%)

Patients(n=983)

ARDS/ALI

Pplat(cmH2O)

<30

PEEP(cmH2O)

16.3±3

RR(b/min)

30

TV

(ml/Kg)

<6

9.1±4TheLOVS:LungOpenVentilationCanadianStudy

CanadianTrial

OxygenationwasbetterinHighPEEPCompliancewasbetterinHighPEEPLessrescuetherapiesinHighPEEP0,40,50,60,70,80,910102030405060DaysafterrandomizationProbabilityofsurvivalLowPEEPHighPEEPPEEPselectedaccordingtoatabletoachieveminimalphysiologicaloxygenation+RMStewartTetalJAMA.2008;299(6):637-645

Patients(n=752)

ARDS/