ARDS呼吸功能监测与通气策略抉择VIP免费

ARDS呼吸功能监测与通气策略抉择邱海波刘玲东南大学附属中大医院ICU内容提要•PhysiopathologiccourseofARDSandthedilemmainMechanicalventilation•OxygenationandShunt•Respiratorymechanics–Compliance(Elastance)andResistance–Stressindex–EsophagealPressure•Vd/VtTherapeutictargetofMVinARDS•Becomeevidentoverthepasttwodecades•MVitselfcanaugmentorcausepulmonarydamageShiftoftherapeutictargetofMVinARDS1970sNormalgasexchange1980-1990ProtectionofthelungfromVILINEnglJMed1972;287:799-806.Lancet1980;2:292-4.AmRevRespirDis1987;135:312-5.IntensiveCareMed1990;16:372-7.Thelung-protectionstrategy•Lungrecruitment-openthelung•UseofhigherPEEP---keeplungopen(avoidcollapse/recruitment)•Lowtidalvolumes(Pplat<30cmH2O)---avoidoverdistension•PreventregionalandglobalstressandstrainonthelungparenchymaAmJRespirCritCareMed.2008,178:346–355.SameMVstrategysutiableforeveryARDSpat??•MaybeNo.•PhysiologicaleffectsofRMandPEEPassociatedwithpatient’sindividualcharacteristics–Inflamattionspreadingfromcoredisease–Percentageofpotentiallyrecruitablelung–DifferentstagesofARDSNEnglJMed.2006,354;1775-86.JAMA.1994,271,1772-79.InflamattionspreadingfromcorediseasePossiblemodelLowerHigherHigherseveritymortalityCoredisease24%Inflammationspreading1LowerseveritymortalityPotentiallyrecruitablelungLowerpercentageofpotentiallyrecruitablelungHigherpercentageofpotentiallyrecruitablelungNEnglJMed.2006,354;1775-86•MortalityinRelationtothePercentageofpotentiallyRecruitableLung(PanelA)•PulmonaryanatomyaccordingtoCTFindingsinpatientswithHealthyLungs,PatientswithUnilateralPneumonia,andPatientswithAcuteLungInjuryorARDS(PanelB).NEnglJMed.2006,354;1775-86LowerVSHigherpercentageofpotentiallyrecruitablelung•Higherpercentageofpotentiallyrecruitablelung–Greatertotallungweights–Pooreroxygenation–Respiratory-systemcompliance–Higherlevelsofdeadspace–HigherratesofdeathNEnglJMed.2006,354;1775-86DifferentstagesofARDS•Pathologicstages•Earlyexudativephaseedema,bleeding,atelactasis,PMNandpltembolus,andmicroembolus•ProliferativephaseproliferationoftiveIIepitheliumcell•FibroticphaseProliferationoffibroblast•Heterogeneity：location,timecourse•Versatility:Pathologicchanges•Difficulttoassess•GattinoniL(1994)–EarlyARDS(MVupto1week):prevalentedema–IntermediateARDS(between1~2weeks):atransitionperiodduringedemabeginstobereabsorbedandproliferativeprocessesbegintooccur–LateARDS(morethan2weeks):fibrousprocessesClinicalstagesofARDSJAMA.1994,271,1772-79.EarlyVSLateARDS•84severARDSforunderwentextracoreslsupport(1979-1992)JAMA.1994,271,1772-79.EarlyInterLateMVL/minRRb/mnPaCO2mmHg010203040506070MVL/minRRb/mnPaCO2mmHgEarlyVSLateARDSJAMA.1994,271,1772-79.0102030405060EarlyInterLate7071727374757677787980PEEPQs/QtVd/VtCTscan,earlyVSlateARDSGattinoniLType1EarlyARDSWeek1IntermediateARDSWeek2LateARDSWeek<=3Type2Day1EarlyDay5Day12InterDay17Latediffusegroundglassopacification,rightgreaterthanleftinhomogeneousdiseaseandboththecraniocaudalandsternovertebralPartialclearingofboththediffusegroundglassopacificationandthegravity-dependentatelectasisgroundglassopacificationhasamorereticularpattern.apneumatoceleintheleftmidlungandincreasingatelectasisadjacenttoitAmJRespirCritCareMed.2001,164:1701–1711.EarlyandLate--Recruitability•N=17ARDSwithalungprotectivevent•EarlyARDS(n=9)vsLateARDS(n=8,>7d)•RM:PCV2minatPIP50cmH2O/PEEP>PUIPAmJRespirCritCareMed,2002...