肺保护机械通气seminarppt课件

Lung Protective Mechanical Ventilation肺 保 护 性 机 械 通 气Adoption 110;556 Ventilation Strategies 160:109-162D Graph 2 TIME (hours)0 1 2 3 4 TNF-a(pg/ml) 0100200300400500 600700800 HVZPHVPLVZPLVPLVPR 2D Graph 1 TIME (hours)0 1 2 3 4 MIP-2 (pg/ml) 0100020003000 40005000 HVZPHVPLVZPLVPLVPR* * * * (4) (3) (4) (3) Vt, ml/kgPEEP, cmH2OHVZP HVP LVZP LVP16 16 5 55 5 Cytokines in HumansStuber et al Int Care Med 2002;28:834-841 JAMA 289:2104-2112,2003 Systemic Effects of VILIImai et al JAMA 289:2104-2112,2003 BiophysicalInjury shear overdistention cyclic stretch D intrathoracicpressure alveolar-capillarypermeability cardiac output organ perfusionBiochemical Injury (Biotrauma)cytokines, complement,PGs, LTs, ROS,proteasesbacteriaEpithelium/interstitiumneutrophilsDistal Organ DysfunctionMechanical Ventilation Slutsky, Tremblay Am J Resp Crit Care Med. 1998;157:1721-5DEATH Protect the lungs? PEEP=? VT=? PIP=? Pplateau=? RM ? PEEP=? PEEP/FiO2 combination? X! 中 华 医 学 会 重 症 医 学 分 会急 性 肺 损 伤 /急 性 呼 吸 窘 迫 综 合 征 诊 断 与 治 疗指 南 （ 2006）推荐意见7：对ARDS患者实施机械通气时应采用肺保护性通气策略，气道平台压不应超过30-35cmH2O（推荐级别：B级）推荐意见8：可采用肺复张手法促进ARDS患者塌陷肺泡复张，改善氧合（推荐级别：E级） ALI/ARDS指南： 中华内科杂志,2007, 46(5):430-435推荐意见9：应使用能防止肺泡塌陷的最低PEEP，有条件情况下，应根据静态P-V曲线低位转折点压力+2cmH2O来确定PEEP（推荐级别：C级）推荐意见10：ARDS患者机械通气时应尽量保留自主呼吸（推荐级别：C级）推荐意见11：若无禁忌证，机械通气的ARDS患者应采用30-45度半卧位（推荐级别：B级）推荐意见12：常规机械通气治疗无效的重度ARDS患者，若无禁忌证，可考虑采用俯卧位通气（推荐级别：D SSC 2008Crit Care Med 2008 Vol. 36, No. 1 SSC 20081.推荐对ALI/ARDS病人应用6ml/kg（预测体重）的目标潮气量。（1B）2.推荐对ALI/ARDS病人进行平台压监测，对于被动通气的病人初始平台压目标设定在30cmH2O;检测平台压时应当考虑到胸廓的顺应性。（1C）3.推荐对ALI/ARDS病人在必要降低平台压或减少潮气量时施行允许性高碳酸血症（PaCO2水平高于病前）。（1C） SSC 20084. 推荐设定PEEP以阻止张开的肺在呼气末塌陷。（1C）5. 建议在有经验的单位，对于需要可能有害的FiO2和平台压的ALI/ARDS病人在没有不良后果高风险的条件下应用俯卧位通气。（2C）6a. 除非有禁忌，推荐机械通气的病人床头抬高减少误吸风险，防止呼吸机相关性肺炎 。（1B）6b. 建议床头抬高3045.（2C）7. 建议无创通气（NIV）只能在少数轻中度低氧的、血流动力学稳定的、易于唤 醒的、能够自我呼吸道保护的、能自主咳痰的、能很快恢复的ALI/ARDS病人考虑应用。 SSC 20088. 推荐制定一套适当的脱机方案，当患者还须满足以下条件时常规对机械通气患者施行自主呼吸试验以评估脱离机械通气的能力，：可唤醒，血流动力学稳定（不用升压药），没有新的潜在严重疾患，只需低通气量和低PEEP，面罩或鼻导管给氧可满足吸氧浓度要求。应选择低水平压力支持、持续气道正压（CPAP，5cmH2O）或T管进行自主呼吸试验（1A）。9. 不推荐对ALI/ARDS患者常规应用肺动脉导管（1A）。10. 对已有ALI且无组织低灌注证据的患者，推荐保守补液策略，以减少机械通气和住ICU天数（1C）。 潮 气 量 VT 6 ml/kg Pplateau Puip Pplateau 30cmH2O 肺 复 张 术Lung recruitment maneuver, RM SI PC Stepwise RM Recruitment ManeuverMassachusetts General Hospital Performance of RM MGH30 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 35 cmH2O CPAP for 30 to 40 secIf unresponsive but tolerated well 40 cmH2O CPAP for 30 to 40 secAllow 15 to 20 minutes between RM Performance of RM MGHSet FIO2 at 1.0Wait 10 minutesInsure appropriate sedationMay need to do multiple RMs Monitoring during RM (MGH)The RM should be aborted if:MAP 20 mmHgSpO2 130 or 400 mmHg Amato Amato: 2004 China 张 翔 宇 的 方 法 所 有 患 者 均 行 有 创 动 脉 压 持 续 监 测 SpO2持 续 监 测 CVP持 续 监 测 清 醒 患 者 适 当 镇 静 复 张 术 （ RM） 前 排 除 气 压 伤 排 除 肺 气 肿 患 者 Protocol Mode: PEEP+PCV or PEEP+PSV PEEP: increment 2 cmH2O Interval: 2 min PEEP target: 16/1st RM, 20/2nd RM, 2630/3rd RM PIPmax: 45 cmH2O Abort if ABP or SpO2 start fall Rest interval: 1530 min May repeat twice a day 结 果 心 脏 外 科 术 后 低 氧 患 者 有 效 ： 100% PaO2/FiO2 improve： 110% 36% 无 并 发 症 多 发 伤 并 发 ALI/ARDS患 者 有 效 ： 92% PaO2/FiO2 improve： 86% 32% 无 并 发 症 军 团 菌 病 1例 ， 无 效 ， 出 现 气 压 伤 RM一 次 ， PEEPmax: 22, PIPmax: 32 纵 隔 气 肿 临床观察252例次RM有93次血压短暂降低（37%）出现血压下降的PEEP水平为623cmH2O,平均13.9cmH2OPEEP降低之后动脉恢复到原来水平所有病人有创持续血压监测1例经心超证实卵圆孔未闭，在PEEP=6时发生右向左分流，同时SpO2下降 张翔宇，等，中国危重病急救医学，2007，19（9） Crit Care Med 2007 Vol. 35, No. 1Fernando Suarez-Sipmann, et al Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental studyEight healthy pigsLung lavagesCT slices were obtained 2 cm cranial of the right diaphragmatic dome Protocol Result Suarez-Sipmanns clusiondynamic compliance identified the beginning of lung collapse in a pig model.the continuous monitoring of dynamic compliance might become a valuable bedside tool for easily identifying the level of PEEP that prevents end-expiratory lung collapse？ Performance of RMSet FIO2 at 1.0Allow time for stabilizationInsure appropriate sedationInsure hemodynamic stability Performance of RM - PCV Pressure control ventilation: PEEP 20-30 cmH2O Peak Inspir Press 40-50 cmH2O Inspir Time: 1 to 3 sec Rate: 8 to 20/ min Time 1 to 3 min Set PEEP at 20, ventilate VC, VT 4 to 6 ml/kg PBW, increase rate, avoid auto-PEEP Measure dynamic compliance Decrease PEEP 2 cm H 2O Performance of RM - PCV Measure dynamic compliance Repeat until max compliance determined Optimal PEEP max comp PEEP+2 to 3 cm H2O Repeat recruitment maneuver and set PEEP at the identified settings, adjust ventilation After PEEP and ventilation set and stabilized, decrease FIO2 until PO2 in target range If response is poor, repeat RM, PEEP 25, Peak Pressure 45 If response is poor, repeat RM, PEEP 30, Peak Pressure 50 Lung RecruitmentPerform early in ARDSIdeal approach to RM most likely PC, limited patient data available using PC!Works better in extra pulmonary than primary ARDS?More difficult to recruit the lung the stiffer the chest wall!Start with low pressure, increase as tolerated and needed!If benefit lost after RM, PEEP inadequate! A comparison of methods to identify open-lung PEEP.Caramez MP, Kacmarek RM, et al In this animal model of ARDS, dynamic tidal respiratory compliance, maximum PaO2, maximum PaO2 + PaCO2, minimum shunt, inflation lower Pflex and Pmci,i yield similar values for PEEP following a recruitment maneuver. Intensive Care Med. 2009 Apr;35(4):740-7. New Engl J Med 2004; 351: 327-336NIH PEEP selected according to a Table to achieve minimal physiological oxygenation (88-95%) 6 9.1 4The LOVS: Lung Open Ventilation Canadian Study CanadianTrial Oxygenation was better in High PEEP Compliance was better in High PEEP Less rescue therapies in High PEEP0,40,50,60,70,80,91 0 10 20 30 40 50 60Days after randomizationProbability of survival Low PEEPHigh PEEP PEEP selected according to a table to achieve minimal physiological oxygenation + RMStewart T et al JAMA. 2008;299(6):637-645 6 7.4 4French Trial“Express” PEEP selected to avoid overdistension or to achieve maximal recruitmentPEEP set for PEEP tot 5-9 cmH2O PEEP set for Plat 28-30 cmH2O Oxygenation was better in Max distension Higher ventilation free days in Max distension Higher organ failure free days in Max distension Mercat A et al JAMA. 2008;299(6):646-655 Critical Care 2009, 13:R22 Younsuck Koh, et al Critical Care 2009, 13:R22 Younsuck Koh, et al Efficacy of positive end-expiratory pressure titration after thealveolar recruitment manoeuvre in patients with acute respiratorydistress syndrome. Younsuck Koh, et al Critical Care 2009, 13:R22 MARCELO AMATO, M.D.,et al. (N Engl J Med 1998;338:347-54.) Mechanical Ventilation Guided by Esophageal Pressure in Acute Lung Injury N Engl J Med 2008;359:2095-104. N Engl J Med 2008;359:2095-104 N Engl J Med 2008;359:2095-104 N Engl J Med 360;8 February 19, 2009 N Engl J Med 359;20, november 13, 2008 Effect of the chest wall on pressurevolume curve analysis of acuterespiratory distress syndrome lungsConclusions: This method of “correcting” the total respiratorysystem P-V curve for the chest wall allows for calculation of anairway pressure that would place the lung at a desired volume onits P-V curve. For most patients, the chest wall had little influenceon the total respiratory system P-V curve. However, there werepatients in whom the chest wall did potentially have clinicalsignificance.atory system P-V curve. Crit Care Med 2008; 36:2980 2985 Crit Care Med 2008; 36:2980 2985Dean Hess, et al. Animal Lab at JinShan 2009 Prospective Dreagers new idea EIT in process of developWe hope it work before RMInformation provided by EITafter RMPatient ventilated with same tidal volumes before and after RM (both images with same color scale) max.min. Reference webs: