邱海波东南大学附属中大医院ICU东南大学急诊与危重病医学研究所ARDS肺复张的实施科学与艺术的困惑内容提要•肺保护性通气策略不能解决解决的问题•肺泡塌陷的病理生理后果•肺复张的临床实施–Proneposition–Spontaneousbreathing–HighVTandsigh–RMARDSnet:小潮气量通气LowTidalLowTidalVolumesVolumesTraditionalTidalTraditionalTidalVolumesVolumesP-P-valuevalueDeathbeforedischargehomeandDeathbeforedischargehomeandbreathingwithoutassistant(%)breathingwithoutassistant(%)31.039.80.007BreathingwithoutassistancebyBreathingwithoutassistancebydays(%)days(%)65.755.0<0.001NOofventilatorfreedaysNOofventilatorfreedaysDay1-28Day1-2812±1110±110.007Boratrauma,Day1-28(%)Boratrauma,Day1-28(%)10110.43NOofdayswithoutfailureofNOofdayswithoutfailureofnonpulmonaryorgansorsystemsnonpulmonaryorgansorsystemsDay1-28Day1-2815±1112±110.006ARDSNet.NEnglJMed.2000May4;342(18):1301-8.Lowtidalvolume:morealvcollapse小Vt不能复张塌陷肺泡，加重低氧血症实施肺保护性通气策略至少15~25%患者需提高FiO2邱海波,刘大为,陈德昌等.中华麻醉学杂志,1998,18:202-205CollapsedairwayV1V2PressureVolumeV1V1+V2OpeningpressureNormalARDSPEEPadjustmentLIPLIP：：塌陷肺泡开始复张的压力塌陷肺泡开始复张的压力不是全部塌陷肺泡复张的压力不是全部塌陷肺泡复张的压力PEEPnotenough:morealvkeepcollapse30kgPigPostLavagePCVPaw13cmH2OPEEP5cmH2OExperimentalstudy-PigwithARDS许红阳，邱海波.ARDS绵羊肺复张容积测定方法的比较.中国危重病急救医学，2004,16:413.邱海波.PEEP对ARDS肺复张容积及氧合影响的临床研究.中国危重病急救医学，2004,16:399.ClinicalTrial－11ARDSpats0100200300400复张容积(ml)-PaO2/FiO2051015PEEP(cmH2O)肺复张容积PaO2/FiO2内容提要•肺保护性通气策略不能解决解决的问题•肺泡塌陷的病理生理后果•肺复张的临床实施–Proneposition–Spontaneousbreathing–HighVTandsigh–RMA.HypoxamiaA.HypoxamiaB.ShearforcesB.ShearforcesC.SurfactantsinactivateC.SurfactantsinactivateD.BiotraumaandMODSD.BiotraumaandMODSPathophysiologyPathophysiologyConsolidationandalvcollapseA.低氧血症肺泡塌陷：ARDS重力依赖区炎症或不张区生理性低氧缩血管反应：障碍HowDoesExcessiveMechanicalStressInflametheLung?“Shear”Verbruggeetal.CritCareMed1999;27：779Ventilator-associatedlunginjuryVentilator-associatedlunginjury012345Control7/045/1045/0PurineProtein•Purine:amarkerofATPbreakdownandVILI•42SDrats•PCV6min•PCVPre/PEEP•BALFpurineandproteinLachmann.ICM,1994;20:6-11Lachmann.ICM,1994;20:6-11Intra-alveolarproteinsinactivatealvsurfactantinaIntra-alveolarproteinsinactivatealvsurfactantinadose-dependentwaydose-dependentway1mgsurfactant1mgsurfactant==inhibitoryeffectof1mgplasmaproteininhibitoryeffectof1mgplasmaproteinC.Surfactant灭活Surfactantmoveaway•Whenlungregionscollapseatend–expiration,surfactantmoleculesmoveawayfromthealvsurfacetowardterminalbronchioles•and•cannotbereusedduringnextinflationRoubyJJ.AmJRespirCritCareMed,2001,165:1182D.预防Biotrauma和MODSMariniJJ,GattinoniL.Ventilatorymanagementofacuterespiratorydistresssyndrome:aconsensusoftwoCritCareMed.2004Jan;32(1):250-5.“Stretch”“Shear”AirwayTrauma内容提要•肺保护性通气策略不能解决解决的问题•肺泡塌陷的病理生理后果•肺复张的临床实施–Proneposition–Spontaneousbreathing–HighVTandsigh–RM俯卧位通气的病理生理特征•改善通气过程胸膜腔压力梯度顺应性胸壁–促进分泌物的清除ClosingClosingpressurepressureClosingClosingpressurepressure11.10%66.70%100%85.70%0.00%25.00%50.00%75.00%100.00%PPV0.5hPPV2h百分率ARDSp组ARDSexp组TimecourseofProneonPaO2/FiO2between...
