ARDS患者的肺复张(下)

不同RM方法的比较
Sustained inflation 45 for 40 s
Incremental PEEP PIP 35, PEEP 8 - 35
PCV PIP 45, PEEP 16 I:E 1:2, 2 min
Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377
PEEP 8
对于VILI模型PCV是 最佳的RM方法
其他模型结果相似
Pቤተ መጻሕፍቲ ባይዱEP 12
PEEP 16
Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004; 32: 2371-2377
内容
小潮气量通气的问题 肺复张的理论与实践 肺复张与PEEP 肺复张后的PEEP 不同复张方法的差异 肺复张的临床适应症 肺复张的副作用 肺复张存在的问题
RM保护肺内皮而非肺泡上皮
试验动物: 大鼠
模型制备: 酸(pH 1.5)吸入
机械通气:
– Vt
6 ml/kg
– PEEP – FiO2 –F
不同RM方法的比较
Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714
内容
小潮气量通气的问题 肺复张的理论与实践 肺复张与PEEP 肺复张后的PEEP 不同复张方法的差异 肺复张的临床适应症 肺复张的副作用 肺复张存在的问题
不同RM方法的比较
基础通气方式
– VCV: Vt 10 ml/kg, f 20 bpm, I:E 1:2, FiO2 0.5
RM: ARDSp与ARDSexp
Lim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003; 31: 411-418
原发性ARDS对RM反应不佳
Saline lavage
Oleic acid injury Pneumonia
Sustained inflation 1. CPAP 40/30 2. CPAP 60/30 3. CPAP 60/30
Van der Kloot TE, Blanch L, Youngblood AM, Weinert C, Adams AB, Marini JJ, Shapiro RS, Nahum A. Recruitment Maneuvers in Three Experimental: Models of Acute Lung Injury Effect on Lung Volume and Gas Exchange. Am J Respir Crit Care Med 2000; 161: 1485-1494
稳肺 定复 所张 需后 时氧 间合
Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, T Akpir. Time required for equilibration of arterial oxygen pressure after setting optimal positive endexpiratory pressure in acute respiratory distress syndrome. Crit Care Med 2005; 33: 995-1000
叹气: ARDSp与ARDSexp
Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O
Pelosi P, Cadringher P, Bottino N, Panigada M, Carrieri F, Riva E, Lissoni A, Gattinoni L. Sigh in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159: 872-880
RM保护肺内皮而非肺泡上皮
Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Care Med 2005; 33: 181-188
不同RM方法的比较
对于灌洗造成的急性肺损伤模型 缓慢低压复张操作可以
– 促进肺泡复张 – 减少对循环系统的抑制 – 避免对呼吸力学的不良影响
Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714
SI改善氧合
Sustained Inflation: 45 cmH2O x 30 s
250
200
PaO2/FiO2
150
100
baseline
15 min
1 hr
ARDSp ARDSexp
4 hrs
6 hrs
Tugrul S, Akinci O, Ozcan PE, Ince, S, Esen F, Telci L, Akpir K, Cakar N. Effects of sustained inflation and postinflation positive endexpiratory pressure in acute respiratory distress syndrome: Focusing on pulmonary and extrapulmonary forms. Crit Care Med 2003; 31: 738-744
RM: ARDS早期 vs. 晚期
Villagra A, Ochagavia A, Vatus S, Murias G, Fernandez MF, Aguilar JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2002; 165: 165-170
5 cmH2O 1.0 60 – 70 bpm
复张操作:
– 30 cmH2O x 30 s x 2 – 间隔1分钟
Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Care Med 2005; 33: 181-188
SLRM PCRM ViCM
不
同
RM
方 法 的 比 较
Odenstedt H, Lindgren S, Olegard C, et al. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31: 1706-1714