呼吸机治疗的肺保护策略浙江大学医学院附属儿童医院施丽萍呼吸机相关性肺损伤•acuteparenchymallunginjuryandanacuteinflammatoryresponseinthelung.•cytokines→alveoliandthesystemiccirculation→multipleorgandysfunction•mortality↑呼吸机相关性肺损伤ventilator-inducedlunginjury•容量性损伤Volutrauma（largegasvolumes）•压力性损伤Barotrauma（highairwaypressure）•不张性损伤Atelectotrauma（alveolarcollapseandre-expansion）•生物性损伤Biotrauma（increasedinflammation）肺损伤病理•alveolarstructuraldamage•pulmonaryedema、inflammation、fibrosis•surfactantdysfunction•otherorgandysfunction•exacerbatethedisturbanceoflungdevelopmentSeminNeonatol.2002Oct;7(5):353-60.ApproachesinthemanagementofacuterespiratoryfailureinchildrenprotectiveventilatoryandpotentialprotectiveventilatorymodeslowertidalvolumeandPEEPpermissivehypercapniahigh-frequencyoscillatoryventilationairwaypressurereleaseventilationpartialliquidventilationimproveoxygenationrecruitmentmaneuverspronepositioningkinetictherapyreduceFiO2andfacilitategasexchangeinhalednitricoxideandsurfactantCurrOpinPediatr.2004Jun;16(3):293-8.Canmechanicalventilationstrategiesreducechroniclungdisease?•continuouspositiveairwaypressure•permissivehypercapnia•patient-triggeredventilation•volume-targetedventilation•proportionalassistventilation•high-frequencyventilationSeminNeonatol.2003Dec;8(6):441-8小潮气量和呼气末正压lowertidalvolumeandPEEPVentilationwithlowertidalvolumesversustraditionaltidalvolumesinadultsforALIandARDS•1202patients•lowertidalvolume(≤7ml/kg)lowplateaupressure≤30cmH2Oversus•tidalvolume10to15ml/kg•Mortalityatday28•long-termmortalitywasuncertain•lowandconventionaltidalvolumewithplateaupressure≤31cmH2OwasnotsignificantlydifferentCochraneDatabaseSystRev.2004;(2):CD003844Higherversuslowerpositiveend-expiratorypressuresinpatientswiththeacuterespiratorydistresssyndrome•549patientsacutelunginjuryandARDS•lower-PEEPgroup8.3±3.2cmH2Ohigher-PEEPgroup13.2±3.5cmH2O(P<0.001).•tidal-volume6ml/kgend-inspiratoryplateau-pressure≤30cmH2O•Theratesofdeath24.9%27.5%(p=0.48)Fromday1today28,breathingwasunassisted14.5±10.4days13.8±10.6days(p=0.5)•clinicaloutcomesaresimilarwhetherlowerorhigherPEEPlevelsareused.NEnglJMed.2004Jul22;351(4):327-36.Increasinginspiratorytimeexacerbatesventilator-inducedlunginjuryduringhigh-pressure/high-volumemechanicalventilation•Sprague-Dawleyrats•negativecontrolgrouplowpressures(PIP=12cmH2O),rate=30,iT=0.5,1.0,1.5secs•experimentalgroupshighpressures(PIP=45cmH2O),rate=10,iT=0.5,1.0,1.5secs•lungcompliance,PaO2/FiO2ratio,wet/drylungweight,anddrylung/bodyweight•asinspiratorytimeincreased,staticlungcompliance(p=.0002)andPao2/Fio2(p=.001)decreased.Wet/drylungweights(p<.0001)anddrylung/bodyweights(p<.0001)increased•Lightmicroscopyrevealedevidenceofintra-alveolaredemaandhemorrhageintheiT=1.0andiT=1.5animalsbutnottheLoPandiT=0.5animals.CritCareMed.2002Oct;30(10):2295-9.新生儿呼吸窘迫综合征呼吸机治疗的肺保护性策略研究施丽萍孙眉月杜立中中华儿科杂志2003本项目研究的目的•通过肺力学参数的监测（PM）指导呼吸机参数的调节来降低呼吸机相关性肺损伤的发生•探讨新生儿RDS最合适的呼吸机参数•允许性高碳酸血症对新生儿的影响•非肺力学监测组（NPM）：1994~1997年,RDS50例，作为对照组•肺力学监测组(PM):1998~2001年，RDS60例，作为观察组•肺力学监测仪(BicoreCP100）两组胎龄、体重、病情严重程度比较胎龄（周）体重(kg)日龄(天）AaDO2(...
