1、ARDS RM的临床实施,邱海波东南大学附属中大医院东南大学急诊与危重病医学研究所,BP 70/50，HR 170, cvp 8. NE 5 PHE 5 FiO2 70%, PEEP 12 Ph24 SaO2 90%,ARDS常见的临床综合征,内容提要,病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素,30 kg 猪肺灌洗复制ARDS模型压力控制通气PCVPaw 13 cmH2O PEEP 5 cmH2O,ARDS-肺泡塌陷广泛存在,肺容积明显降低(a)肺泡水肿 (b)肺泡表面活性物质的消耗或不足(c)肺间质水肿压迫远端细支气管肺顺应性明显降低通气/血流比例失调
2、肺内分流和死腔样通气,ARDS的病理生理,CT scan70-80% 的肺野呈现高密度区分布：下垂部位(dependent field)提示：1. 参与通气的肺泡区域明显减少(20-30%) 2. 肺损伤具有不均一性,肺容积减少Small lung Baby Lung,肺顺应性明显降低,Reduced range of volume excursion: Low complianceFlattening at low and high volumes: Lower and upper inflection points,Volume,Pressure,NORMAL,ARDS,顺应性曲线明显向右
3、下移位,肺内分流增加,肺泡塌陷：ARDS重力依赖区 炎症或不张区生理性低氧缩血管反应：障碍,HEART,SP,ARDS-Gattinoni分区,1.过度通气区或“干区” “baby lung2. 可复张区或湿区3. 实变区,内容提要,病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素,PEEP肺复张与低氧血症改善,Gattinoni L, Caironi P, Pelosi P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711,A .低氧血症,Pressure,Volume,Pressure wedge,S
4、hear force,B. 剪切力(Shear force),DR-RM,盐水灌肺制造家兔ARDS模型,低流速法测定LIP水平,肺保护通气3h,Vt6ml/kg,PEEP=LIP,DR后予SI的RM,DR后予PCV的RM,每小时的0、10、20、30、40分钟将呼吸机脱开1分钟制造肺泡的重复去复张(DR),动物处死，取肺病理检查、测湿/干重比、测TNF-mRNA表达、转录因子NF-B的活性 、MPO及MDA活性,对照组,ARDS组,LP组,DR组,PCV组,SI组,动物准备,1,2,3,4,5,6,1、2、3、4、5和6泳道分别为正常、ARDS、DR、LP、SI和PCV组,肺复张手法对重复去复
5、张ARDS家兔肺组织NF-B 活性的影响,肺复张手法对重复去复张ARDS家兔 肺组织TNFmRNA 表达的影响,0,1,2,3,4,5,6,1、2、3、4、5和6泳道分别为Normal、ARDS、LP、DR、SI和PCV组0泳道为分子质量标准,肺复张手法对重复去复张ARDS 家兔PaO2 的影响,C.感染与肺不张,全麻-肺不张的发生率 90%择期腹部手术：肺不张肺部感染9.6%择期心脏手术：肺不张肺部感染5.7%肥胖病人手术：25%-30%发生肺不张肺部感染,CHEST 1997; 111:564-71,Qiu Haibo. Chin J Emerg Med, 2001, 10(5): 293
6、-294,气压伤 生物伤启动炎症反应,炎症介质移位细菌毒素移位,MODS/MOF,D.气压伤、生物伤与MODS,From Slusky,ARDSmotor of MODS,邱海波. 中华急诊医学杂志, 2001, 10(5): 293-294,Biotrauma Barotrauma initiate a cascade of proinfla mediators,肺是炎症细胞激活和聚积的重要场所肺实质细胞可释放炎症介质,Mediator translocationBacteria and LPS translocation,MODS/MOF,腹部手术后肺不张及增加气道内正压的肺复张作用,将大
7、鼠常规镇静肌松,通气参数 : Vt 8 ml/kg; f 38 40 / min; PEEP 1 cm H2O; FiO2 0.21,剖腹术(series1),非剖腹术 (series2),复张组: 复张方法： (PEEP 增加到 8 cm H2O，10个呼吸周期, 每 30 分钟一次). PEEP 降至2 cm H2O 通气,无复张组 : 0 PEEP 不采取任何肺复张手法,Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.,肺泡塌陷与复张对预后影响的实验研究,Duggan M. Am J Respir Crit Care M
8、ed. 2003, 167: 1633-1640.,Duggan M. Am J Respir Crit Care Med. 2003, 167: 1633-1640.,持续肺泡塌陷-预后不良,临床研究: 塌陷肺泡越多, 病死率越高,N Engl J Med 2006;354:1775-86,Villar and Amato trial,Villar J. Crit Care Med 2006; 34:1311,内容提要,病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素,20,40,60,80,100,Pressure cmH2O,10,20,30,40,60,5
9、0,Total Lung Capacity %,R = 22%,R = 81%,R = 100%,R = 93%,肺复张是压力依赖性过程,0,0,R = 0%,R = 59%,From Pelosi et alAJRCCM 2001,1/5 of “Recruitable” Units,肺复张是压力依赖性过程, 40 SECONDS,肺复张的常用方法,控制性肺膨胀(SI)PEEP递增法压力控制法(PCV),45 for 40 s,35 Peak,45/16 and 1:2 for 120 s,PCV Advantages-Same Recruiting Pressure-Repeated Ma
10、neuvers-Lower Mean Pressure-Preserved Ventilation,CPAP模式: PS 0, PEEP 30-40 cmH2O, 20-50s 2. BIPAP: Ph /PL 30-40cmH2O, 20-50s 3. Insp Hold: 将吸气保持键按住，持续20- 40s,控制性肺膨胀(SI)法,内容提要,病理生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素,肺泡完全复张的临床标准,氧合标准CT标准EIT标准,肺泡完全复张的临床标准-PaO2/FiO2,PaO2/FiO2400 PaO2 + PaCO2 400 2.PaO2/
11、FiO2 降低5%,PaO2 + PaCO2 400 (at 100% oxygen): 维持肺开放的可靠指标达到PaO2 + PaCO2 400时： CT显示只有5% 的肺泡塌陷 PaO2 + PaCO2 400对塌陷肺泡的预测： ROC曲线下面积 0.943,Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006,肺泡完全复张的临床标准-CT,肺泡完全复张的临床标准-CT,Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2
12、006,动脉氧合与塌陷肺组织重量明显呈负相关 (R = 0.91),Lower vs higher Percentage of Potentially Recruitable Lung,ARDS塌陷肺泡都能重新开放吗?,N Engl J Med 2006;354:1775-86,PEEP 5cmH2O Ppla 20cmH2O,PEEP 17cmH2O Ppla 40cmH2O,PEEP 25cmH2O Ppla 40cmH2O,PEEP 25cmH2O Ppla 60cmH2O,Correspondence: Amato, N Engl J Med 2006, 355:319,内容提要,病理
13、生理特点肺泡塌陷的危害如何实施肺复张?肺复张疗效的判断影响肺复张实施的因素,Prespective, randomized study: Effect of RM on ARDS,Prespective, randomized crossover study34 ICU at 19 hospRM: CPAP over 510 s to 35 cm H2OPEEP: FIO2/PEEPstep to maintain SpO2 8895%.,CCM, 2003, 31(11): 2592-7,肺泡复张的决定因素(1): 肺内 vs 肺外源性ARDS,ARDS Trial Network, Cri
14、t Care Med 2003; 31(11):2592-2597,Starting Conditions For the ARDSnet Recruiting Trial,Primary,为什么RM改善氧合不明显？,病人的特点：入组时Ppla 26.4肺内原因ARDS占65%,Paw cmH2O,%,0,5,10,15,20,25,30,35,40,45,50,0,10,20,30,40,50,Crotti et al. AJRCCM 2001.,PPLAT,PRECRUIT,Opening Pressures: Primary ARDS,RM能够实现ARDS肺完全开放,实现 open th
15、e lung and keep the lung open in the 24/26 pats,Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006,麻醉导致的非炎症性肺泡塌陷,肺泡复张的决定因素(2): 病理特征,Rothen HU. Dynamics of reexpansion of atelectasis during general anaesthesia. Br J Anaesth1999; 82: 5516,Superimposed,Pressure,(modified from Gattin
16、oni),Regional Spectrum of Opening Pressures,肺泡复张的决定因素(3): 压力与时间,实现 open the lung and keep the lung open in the 24/26 pats,Borges JB, , Amato MBP.Am J Respir Crit Care Med Vol 174. pp 111, 2006,Multiple maneuvers- 获得理想的复张效应,Fujino et al, Crit Care Med 2001; 29(8):1579-1586,肺泡复张的决定因素(4):ARDS病程(早期vs 后期
17、),N=17 ARDS with a lung protective ventEarly ARDS (n=9) vs Late ARDS (n=8, 7d)RM: PCV 2min at PIP 50cmH2O/PEEP PUIP,Am J Respir Crit Care Med, 2002, 165:165170,不同RM方法的肺复张效应不同,PCV,Volume increments at 15 min Post-RM in VILI Model,Paw cmH2O,%,Opening and Closing Pressures,0,5,10,15,20,25,30,35,40,45,5
18、0,0,10,20,30,40,50,5 patients,ALI / ARDS,From Crotti et alAJRCCM 2001.,Some units cantbe kept open by any reasonable PEEP!,肺泡复张的决定因素(5): 循环耐受情况,An RM Can Profoundly Depress CO,Averaged Data from 3 Models,S-C Lim, et al 2004,RM Effect on CO Varies Among Injury Models,Averaged data for 3 RM Methods,PN
19、M,VILI,S-C Lim, CCM 2004,Effect of RM Method on CO in Pneumonia Model,SI,PCV,S-C Lim, CCM 2004,肺泡复张的决定因素(6):肺泡过度膨胀,Clinical exp of Gattinonii,低可复张的ARDS患者Higher PEEP: little benefit and may actually be harmful. 多数肺泡( 60 %)处于开放状态高PEEP和肺复张对开放的肺泡可能是有害的高可复张的ARDS患者the use of higher PEEP levels seems appro
20、priate In our daily practicePEEP 15 cmH2OPEEP 150 mlNonrecruiters: 150 ml,影响ARDS肺复张效应的因素,Am J Respir Crit Care Med Vol 171. pp 10021008, 2005,影响复张响应的预测因素 (原发病No effect)PEEP - PaO2/FiO2PEPP - ComplPEEP - Stress index (b),内容提要,RM的病理生理基础与实施RM造成的循环问题突破RM的循环限制,RM导致的血流动力学改变,ARDS pats n=10 SI的实施：30cmH2O，20
21、s SI时PAP、CVP、PAWP、PVRI和RVSWI均显著增加(P 12%,RM面临的循环困境,LMRs: 40 cmH2O for 10 s or 20 s CO reduction 50%LV end-diastolic area 45%Mean arterial pressure drop 20%Of course, hemodynamic status return stable within 3min,Intensive Care Med (2005) 31:11891194,An RM Can Profoundly Depress CO,Averaged Data from 3
22、 Models,S-C Lim, et al 2004,CO降低的原因ContractilityAfterloadPreload,Prospective randomized cross-over studyPats with CABGRM (40 cmH2O X 10 s/20s,RM循环干扰的机制： Effect of RM on LV preload,Intensive Care Med (2005) 31:11891194,TEE: transgastric ED short axis view of the LVA before a 10s LRMB at the end of a
23、10-s LRMC before a 20s LRMD at the end of a 20-s LRM,RM循环干扰的机制：Effect of RM on RV afterload,Increase in RV afterloadAlveolar overdistention of aerated lung areasHypoxic vasoconstriction in atelectatic lung areas,Atelectasis causes vascular leak and lethal right ventricular failure in uninjured rat l
24、ungs. Am J Respir Crit Care Med 2003, 167:1633-1640.Ventilation above closing volume reduces pulmonary vascular resistance hysteresis. Am J Respir Crit Care Med 1998, 158:1114-1119.,Randomized, controlled, cross-over studyPig ARDS model by lung-lavageRM: 12s-s X 40 cm H2O OR 30-s X 40 cm H2O,RM循环干扰的
25、机制：Effect of RM on Leftward septal shift,Echocardiogram: via the short axis end-diastolic view of the RV and LV,Before RM and at the end of a 30-s RM,Intensive Care Med (2006) 32:585594,Critical Care 2006, 10:R86,Effect of RM on LV,Effect of RMContractility and Afterload (SVR): NOTPreload: decrease,
26、Pig with ARDS by repeated lung lavageConventional MV (CMV): PEEP 5 cmH2O +Vt 810 ml/kg. No RMOLC ventilation: RM for PaO2/FiO2 60 kPa. Vt 68 ml/kg,RM Effect on CO Varies Among Injury Models,Averaged data for 3 RM Methods,PNM,VILI,S-C Lim, CCM 2004,突破循环限制血流动力学干扰 vs ARDS病因(a),Pigs with BAL vs LPS-indu
27、ced ALIRM for 1 minvital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2OPCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kg,Intensive Care Med (2005) 31:112120,Aortic blood flow (ABF)Mesenteric blood flow (QPV),突破循环限制血流动力学干扰 vs ARDS病因(a),1.RM使三种 ARDS模型 CI均明显下降2.C
28、I盐酸组降低37% 油酸组 19% 生理盐水组 23%3盐酸组5min后接近 RM前水平,不同病因的ARDS vs RM对CI的影响,Effect of RM Method on CO in Pneumonia Model,SI,PCV,S-C Lim, CCM 2004,突破循环限制血流动力学干扰 vs RM方法(b),HCI吸入复制模型CI降低程度不同PCV: 降低25%SI: 降低46%IP: 降低39%,RM方法不同对CI的影响,Pigs with BAL vs LPS-induced ALIRM for 1 minvital capacity manoeuvres (ViCM) at
29、 SI30 OR SI40 cmH2OPCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kg,Intensive Care Med (2005) 31:112120,Aortic blood flow (ABF)Mesenteric blood flow (QPV),突破循环限制血流动力学干扰 vs RM方法(b),突破循环限制血流动力学干扰 vs RM方法(b),Intensive Care Med (2006) 32:585594,突破循环限制血流动力学干扰 vs Vol
30、ume expansion(c),Volume status in pats with ARDS,Intensive Care Med (2006) 32:585594,Pigs with ARDS, RM for 1 minvital capacity manoeuvres (ViCM) at SI30 OR SI40 cmH2OPCRM with peak airway pressure PIP/PEEP30/15 OR 40/20 Volume expansion: dextran 8 ml/kg,Intensive Care Med (2005) 31:112120,Aortic bl
31、ood flow (ABF)Mesenteric blood flow (QPV),突破循环限制血流动力学干扰 vs Volume expansion(c),Randomized, controlled, cross-over studyPig ARDS model by lung-lavageRM: 12s-s X 40 cm H2O OR 30-s X 40 cm H2OVolume status: under hypovolemia, normovolemia and hypervolemia,Effect of volume status on Leftward septal shif
32、t,Echocardiogram Screen: via the short axis end-diastolic view of the left and right ventriclesBefore RM and at the end of a 30-s RM,Intensive Care Med (2006) 32:585594,突破循环限制血流动力学干扰 vs Volume/septal shift (d),hypovolemia, normovolemia and hypervolemia,突破循环限制血流动力学干扰 vs Volume/septal shift (d),Anesth
33、etized pigsA bronchial blocker was inserted in the right lower lobe, which was selectively lavaged to create a dense lobar collapse. Randomized into two groupsSelective lung RM (using the inner lumen of the bronchial blocker)General lung RMRM 40cmH2O for 30 s,突破循环限制血流动力学干扰 vs Selective RM (e),Before
34、 (A) and after (B) selective lobar recruitment,ANESTH ANALG 2006;102:150410,突破循环限制血流动力学干扰 vs Selective RM (e),ANESTH ANALG 2006;102:150410,Hemodynamic effectSelective RM: no circulatory changesGeneral lung RM: mABP decreased significantly by 36 (21, 41) mm HgCO decreased by 2.1 (1.6, 2.5) L/min LVED
35、 area decreased by 4.4 (3.5, 4.5) cm2.,Transthoracic end-diastolic short axis view of the LV at baseline (A), after recovery (B), at the end of a selectiveLRM (C), and at the end of a general LRM (D),突破循环限制血流动力学干扰 vs Selective RM/Low volume (e),Anesth Analg 2007;105:729 34,Hemodynamic effectNormovol
36、emia and 20% hypovolemia: no circ changes40% hypovolemia: CO: unchangedmABP(mmHg) Before RM: 48 End of RM: 40 (P0.05)3 min after RM: 47,Anesthetized pigsA bronchial blocker was inserted in the right lower lobeS-LRM 40cmH2O for 30 sat normovolemia,after venesection of 20% of the blood volume,after venesection of 40% of the blood volume,塌陷肺泡一定要用肺复张打开吗？,全身麻醉可导致肺泡塌陷,Morbidlyobese,Non-obese,肺泡塌陷24h后明显改善,Anesth Analg 2002;95:1788 92,小结,肺复张是ARDS降低肺不张, 减少肺内分流的重要手段塌陷肺泡是否能够开放受多种因素影响肺复张的方法(手段, 压力,时间,次数)原发病(pul vs non-pul)与病理特征ARDS病程肺泡过度膨胀(VILI)与循环干扰多数ARDS患者通过高条件的肺复张可实现塌陷肺泡的复张,
