ARDS呼吸功能监测与通气策略抉择VIP免费

邱海波刘玲东南大学附属中大医院ICU第一页，共六十六页。••OxygenationandShunt•Respiratorymechanics–Compliance(Elastance)andResistance–Stressindex–EsophagealPressure•Vd/Vt第二页，共六十六页。•Becomeevidentoverthepasttwodecades•MVitselfcanaugmentorcausepulmonarydamageShiftoftherapeutictargetofMVinARDS1970sNormalgasexchange1980-1990ProtectionofthelungfromVILINEnglJMed1972;287:799-806.Lancet1980;2:292-4.AmRevRespirDis1987;135:312-5.IntensiveCareMed1990;16:372-7.第三页，共六十六页。•Lungrecruitment-openthelung•UseofhigherPEEP---keeplungopen(avoidcollapse/recruitment)•Lowtidalvolumes(Pplat<30cmH2O)---avoidoverdistension•PreventregionalandglobalstressandstrainonthelungparenchymaAmJRespirCritCareMed.2008,178:346–355.第四页，共六十六页。•MaybeNo.•PhysiologicaleffectsofRMandPEEPassociatedwithpatient’sindividualcharacteristics–Inflamattionspreadingfromcoredisease–Percentageofpotentiallyrecruitablelung–DifferentstagesofARDSNEnglJMed.2006,354;1775-86.JAMA.1994,271,1772-79.第五页，共六十六页。PossiblemodelLowerHigherHigherseveritymortalityCoredisease24%Inflammationspreading1Lowerseveritymortality第六页，共六十六页。LowerpercentageofpotentiallyrecruitablelungHigherpercentageofpotentiallyrecruitablelungNEnglJMed.2006,354;1775-86第七页，共六十六页。•MortalityinRelationtothePercentageofpotentiallyRecruitableLung(PanelA)•PulmonaryanatomyaccordingtoCTFindingsinpatientswithHealthyLungs,PatientswithUnilateralPneumonia,andPatientswithAcuteLungInjuryorARDS(PanelB).NEnglJMed.2006,354;1775-86第八页，共六十六页。•Higherpercentageofpotentiallyrecruitablelung–Greatertotallungweights–Pooreroxygenation–Respiratory-systemcompliance–Higherlevelsofdeadspace–HigherratesofdeathNEnglJMed.2006,354;1775-86第九页，共六十六页。•Pathologicstages•edema,bleeding,atelactasis,PMNandpltembolus,andmicroembolus•proliferationoftiveIIepitheliumcell•Proliferationoffibroblast•Heterogeneity：location,timecourse•Versatility:Pathologicchanges第十页，共六十六页。•Difficulttoassess•GattinoniL(1994)–prevalentedema–atransitionperiodduringedemabeginstobereabsorbedandproliferativeprocessesbegintooccur–fibrousprocessesJAMA.1994,271,1772-79.第十一页，共六十六页。•84severARDSforunderwentextracoreslsupport(1979-1992)JAMA.1994,271,1772-79.EarlyInterLateMVL/minRRb/mnPaCO2mmHg010203040506070MVL/minRRb/mnPaCO2mmHg第十二页，共六十六页。JAMA.1994,271,1772-79.0102030405060EarlyInterLate7071727374757677787980PEEPQs/QtVd/Vt第十三页，共六十六页。GattinoniLEarlyARDSWeek1IntermediateARDSWeek2LateARDSWeek<=3第十四页，共六十六页。Day1EarlyDay5Day12InterDay17Latediffusegroundglassopacification,rightgreaterthanleftinhomogeneousdiseaseandboththecraniocaudalandsternovertebralPartialclearingofboththediffusegroundglassopacificationandthegravity-dependentatelectasisgroundglassopacificationhasamorereticularpattern.apneumatoceleintheleftmidlungandincreasingatelectasisadjacenttoitAmJRespirCritCareMed.2001,164:1701–1711.第十五页，共六十六页。•N=17ARDSwithalungprotectivevent•EarlyARDS(n=9)vsLateARDS(n=8,>7d)•RM:PCV2minatPIP50cmH2O/PEEP>PUIPAmJRespirCritCareMed,2002,165:165–170第十六页，共六十六页。•EarlyARDSischaracterizedbyedemaandintactlungstructure•Recruitabilityisfunctionoftheextentofedema•WithtimelungstructureisalteredassociatedwithincreaseddeadspaceandPCO2第十七页，共六十六页。•Inflammationspreading•Potentia...