stress-index：病理生理基础--课件

S STRESSTRESS INDEXINDEX病理生理基病理生理基础Ventilation in ALIBackgroundpALIALI是是ICUICU常见的危重病常见的危重病p病理生理特点病理生理特点 肺容积明显降低肺容积明显降低 肺顺应性明显下降肺顺应性明显下降 通气通气/血流比例失调血流比例失调p肺组织分布肺组织分布“不均一不均一”2ppt课件TIDAL recruitment end-expiration end-inspiration3ppt课件TIDAL hyperinflation end-expiration end-inspiration4ppt课件backgroundIntensive Care Med,2005,31:7767845ppt课件非重力依赖区过度膨胀非重力依赖区过度膨胀重力依赖区潮汐性塌陷复张重力依赖区潮汐性塌陷复张Best Practice&Research Clinical Anaesthesiology 2010;24:171-182.VILI立项依据6ppt课件Always opening and closingVILITidal collapseVT0 10 20 30 400 10 20 30 40 50%Paw(cmH2O)Closing pressureOpening pressureCrotti,et al Am J Respir Crit Care Med 2001;164:131-1407ppt课件HEARTSPPEEP-Keep the lung openLow VtRM Open lung BackgroundARDS病理生理变化病理生理变化肺保护性通气肺保护性通气8ppt课件机械通气患者病死率仍机械通气患者病死率仍高达高达37%Intensive Care Med 2009;35:816825.13,322 pats admitted to 299 ICUs from 35 countriesBackground9ppt课件6mlKg小潮气量小潮气量非重力依赖区肺泡依然过度膨胀非重力依赖区肺泡依然过度膨胀 Background中大医院重症医学科预试验中大医院重症医学科预试验10ppt课件重力依赖区通气不良和塌陷肺泡重力依赖区通气不良和塌陷肺泡明显增加明显增加 Background中大医院重症医学科预试验中大医院重症医学科预试验11ppt课件HEARTSPAt present：Lung Protective Ventilation Strategies非重力依赖区非重力依赖区肺泡过度膨胀肺泡过度膨胀 重力依赖区重力依赖区肺泡潮汐性塌陷复张肺泡潮汐性塌陷复张 BackgroundVILIVILI几乎无处不在几乎无处不在潮气量和潮气量和PEEPPEEP的设定依然矛盾重重的设定依然矛盾重重12ppt课件潮气量设置困难个体化难！潮气量设置困难个体化难！重症重症ARDS大量肺泡塌陷大量肺泡塌陷即使即使“小小”潮气量仍然导致潮气量仍然导致VILI潮气量应更小潮气量应更小VILI塌陷肺泡少塌陷肺泡少“小小”潮气量太小，肺泡通气无法保证，导致肺泡塌陷潮气量太小，肺泡通气无法保证，导致肺泡塌陷显然，显然，6mlKg的的“小小”潮气量不适合所有潮气量不适合所有ARDS13ppt课件The most controversial issue in ALI/ARDS pts Low PEEP to keep oxygenationHigh PEEP to keep lung open14ppt课件维持肺开放维持肺开放(Keep Lung Open)(Keep Lung Open)-最佳最佳PEEPPEEPPEEP水平不足水平不足肺泡反复塌陷、复张，产生剪切力肺泡反复塌陷、复张，产生剪切力 VILIPEEP水平过高水平过高肺泡过度膨胀，导致气压伤肺泡过度膨胀，导致气压伤 VILI最佳最佳PEEPPEEP改善通气改善通气/血流比例，纠正低氧血症血流比例，纠正低氧血症防止肺泡反复塌陷防止肺泡反复塌陷-复张和过度膨胀复张和过度膨胀减轻肺损伤、减轻炎症反应减轻肺损伤、减轻炎症反应立项依据立项依据立项依据立项依据15ppt课件Methods to titrate PEEP in ALI/ARDSBest PEEP(Suter,NEJM,1975)Super PEEP(Kirby,Chest,1975)Pflex(Amato,Am J Respir Crit Care Med,1995)Oxygenation scale(ARDSnet,NEJM,2000)Stress index(Ranieri,Anesthesiology,2000)Pmc(Goddon,Anesthesiology,2001)FRC+Cst(Lambermont,Critical Care,2008)Pes(Talmor,NEJM,2008)Increased recruitment strategy(Mercat,JAMA,2008)EIT(Meier,ICM,2008)Which one is best?16ppt课件滴定PEEP的最佳方法简便、床边快速安全可重复，为PEEP滴定提供可靠信息17ppt课件Stress index-Stress index-肺牵张指数肺牵张指数容量控制通气、恒定流速容量控制通气、恒定流速18ppt课件Stress index-Stress index-肺牵张指数肺牵张指数P-tP-t曲线吸气支：曲线回归方程曲线吸气支：曲线回归方程P=a*tP=a*tb b+c+c b b 值：肺牵张指数值：肺牵张指数描述曲线的形状，反映肺泡开放与塌陷程度的力学指标描述曲线的形状，反映肺泡开放与塌陷程度的力学指标Slutsky AS,Aneathiology,2000,93:1320-8 Grasso S,Crit Care Med,2004,32:10182719ppt课件Ranieri VM et al Anesthesiology 2000Stress index-Stress index-肺牵张指数肺牵张指数20ppt课件stress index=1 before RMstress index=1 after RM 0.6 stress index 0.8 0.8 stress index 11.1 stress index 1.31.3 stress index 1.5End InspirationEnd Expiration21ppt课件b b值与塌陷和过度膨胀值与塌陷和过度膨胀22ppt课件b b值与塌陷和过度膨胀值与塌陷和过度膨胀23ppt课件肺牵张指数指导肺牵张指数指导ARDSARDS患者患者PEEPPEEP的选择的选择14例ARDS患者实施肺复张后容量控制通气用回归法求得方程:P=a*tb+c.b为肺牵张指数。复张后调整PEEP使b1(0.6b0.8)b=1(0.9b1(1.1b1.3)与复张前比较，*P0.05;与复张后b1比较，#P0.05;与b=1比较，P0.05黄英姿，邱海波。中华医学杂志。2009,89:2739肺复张后肺复张后b=1b=1时，氧合、顺应性和肺复张容积明显改善时，氧合、顺应性和肺复张容积明显改善24ppt课件与基础状态比较与基础状态比较*P0.05；与氧合法比较；与氧合法比较P0.05；与肺牵张指数法比较与肺牵张指数法比较P0.05；与顺应性法比较；与顺应性法比较P0.05*不同方法选择最佳PEEP的比较 PEEP(cmH2O)25ppt课件PaO2/FiO2(mmHg)b b值滴定值滴定PEEPPEEP对氧合的影响对氧合的影响与基础状态比较，与基础状态比较，*P0.05*26ppt课件*与基础状态比较，与基础状态比较，*P0.05复复张张容容积积(ml)Cst(ml/cmH2O)b b值滴定值滴定PEEPPEEP对对复张容积和复张容积和CstCst的影响的影响27ppt课件THE STRESS INDEX CONCEPT:experimental data0.0 0.5 1.0 1.5 2.0.Ranieri VM et al Anesthesiology 20000.0 0.5 1.0 1.5 2.0.28ppt课件THE STRESS INDEX CONCEPT:experimental dataRanieri VM,Slutsky AS Anesthesiology 200029ppt课件BAL b=1 during SIventilationb=1 during SIventilationP 0.001b1 during NIHventilationb=1 during NIHventilationP 0.0541010IL-1 b=1b=1，炎症反应降低，炎症反应降低30ppt课件B B值滴定值滴定PEEPPEEP31ppt课件B B值反应肺顺应性的动态变化值反应肺顺应性的动态变化 btotal tot=1.00 but the algorithm is still able to distinguish b1=0.91 b2=1.11KleisTEK-Advanced Electronic Systems,Bari-Italy32ppt课件First phase:b1=0.91 Second phase:b2=1.11KleisTEK-Advanced Electronic Systems,Bari-ItalyB B值反应肺顺应性的动态变化值反应肺顺应性的动态变化33ppt课件B值滴定PEEP是最佳方法？简便、床边快速安全可重复，为PEEP滴定提供可靠信息34ppt课件35ppt课件