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1、急性呼吸窘迫综合征肺复张的测定与应用,邱海波 东南大学附属中大医院 东南大学急诊与危重病研究所,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,Lung volume decreased markedly (TLC, VC, TV, FRC) -alveolar edema -pulmonary surfactant -Interstitial pumonary edema depres
2、s brochiole and induce spasm Compliance reduced significantly Ventilation/perfusion mismatch -intrapulmonary shunt and dead space like effects,ARDS病理生理特点,ARDS病理生理,CT scan 70-80% 的肺野呈现高密度区 分布：下垂部位(dependent field) 提示： 参与通气肺泡明显减少(20-30%) 肺损伤具有不均一性,肺容积减少Small lung Baby Lung,ARDS病理生理,A and C finding in
3、the acute or exudative phase,B and D Finding in the fibrosing-alveolitis phase,ARDS病理生理,肺容积/顺应性明显降低,ARDS病理生理,Reduced range of volume excursion: Low compliance Flattening at low and high volumes: Lower and upper inflection points Bigatello: Br J Anaest 1996,Volume,Pressure,NORMAL,ARDS,顺应性曲线明显右下移位,肺顺应
4、性明显降低,ARDS病理生理,Upper and Lower Inflection Points,Lower 呼气末肺泡塌陷 吸气早期肺泡再开放 Upper 吸气末肺泡顺应性明显 降低，肺泡过度膨胀,ARDS病理生理,Volume,Pressure,Lower Inflection Point,Upper Inflection Point,通气/血流失调,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,ARDS病理生理,Imagine the Hardness to Blow up a Ballon .,easy,hard,spatial & elastic limit
5、ations,Laplacian Law,It needs higher initial pressures to overcome the surface tension to open up a bubble to wider diameters!,ARDS病理生理,Sustain inflation Sigh 小潮气量通气PHC, 避免肺泡过度膨胀 最佳PEEP避免剪切力(Shear force)性损害,Volume,Pressure,肺开放与保护性通气策略的基本内容,ARDS病理生理,Lung volume decreased markedly,Atelectrauma,Keep th
6、e lung open,Open the lung,Prevent volutrauma,SI and Sigh,PEEP,ARDS病理生理,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,PV曲线法,Step 1: 测量PEEP所致的FRC(吸气末撤掉PEEP并延长呼气时间) FRCVE(ZEEP) VE(PEEP),肺复张容积测定,PV曲线法,Step 2: 分别描计ZEEP和PEE
7、P的PV曲线 Step 3: 肺复张容积： RV= V20(PEEP) + FRC V20(ZEEP),肺复张容积测定,等压法,呼吸模式：BIPAP 条件：Ph 20 cmH2O， PEEP分别为0 、5 、 10、15 cmH2O，Ti 6S 测定：延长呼气时间，测定ZEEP呼出气量。在不同PEEP时吸气末撤掉PEEP，延长呼气时间，测定呼气量,肺复张容积测定,等压法,肺复张容积测定,P-V曲线法与等压法的比较,肺复张容积测定,肺复张容积测定P-V曲线法,等压法虽然简单，但准确性较差 不能代替P-V曲线法 目前肺复张容积的测定仍宜采用 P-V曲线法,肺复张容积测定,CT method,膈顶上
8、1cm CT层面 PEEP与ZEEP比较 Gattinoni L. Am J Respir CCM, 1995, 151: 1807 全肺扫描 区别过度膨胀，膨胀，部分复张和塌陷区 Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,肺复张容积测定,CT法-Gattinoni,肺复张容积测定,原理 CT空气=0Hu，CT水=1000 Hu CT值=500Hu，肺组织50%空气+50%水 ARDS塌陷肺CT值100Hu100Hu，塌陷肺泡复张 后，100Hu+100Hu内肺组织减少 方法 ZEEP和PEEP通气呼气末CT扫描 膈肌顶上1cm 计算CT
9、值在100 Hu 100 Hu范围内体素结果之差,Gattinoni L. Am J Respir CCM, 1995, 151: 1807,原理 充气不良区(100Hu500Hu)、正常充气区(500Hu 900Hu)、无充气区(100Hu+100Hu)和过度充气区(900Hu1000Hu)。肺泡复张，充气不良和正常充气肺区体积增加 方法 ZEEP和PEEP呼气末螺旋CT，根据层面厚度计算不同CT值肺体积，肺复张后充气不良与正常充气肺组织体积增加值,肺复张容积测定,CT法- Rouby,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,Gatt
10、inonis vs Roubys CT法比较,肺复张容积测定,CT methods: Rouby vs Gattinoni,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,肺复张容积测定,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,ARDS肺不张的影响因素-附加静水压,Hydrostatic pressure = (1 CT/-100
11、0) Height Maximum sternovertebral dimention of human thorax: 20cmH2O PEEP 20cmH2O不能使ARDS患者肺泡完全复张 动物ARDS,Mean Airway pressure 25 cm H2O,ARDS肺复张应用,ARDS下肺气体含量明显降低,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺复张应用,CT section lcated 5 cm below the carina No differences were observed in the percen
12、tage of lower lobes located beneath the heart in two groups,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺不张的影响因素 -heart lung interdependence,ARDS肺复张应用,Cardiac mass and volume in ARDS,Cardiac mass was increased by 27% vs NS Mechanism of cardiac mass: Edema of cardiac wall RV dilation secondar
13、y to pul hypertension Hyperkinetic state related to SIRS,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺复张应用,心脏下肺叶气体量明显降低 ARDS 73% vs NS 21%,Closed bar: Fraction of gas in lower lobes located beneath the heart Open bar: lower lobes located outside the heart,CT scan ARDS study group. AJRCCM, 20
14、00,161:2005,ARDS肺复张应用,塌陷肺泡的分布,Local: Loss of aeration predominating in lower lobes Diffuse: Equal loss of aeration to the upper and lower lobes,ARDS肺复张应用,Lung morphology pattern,Local Diffuse LIP No Yes Normally aerated 5512% 24 12% Poorly aerated 23 8% 40 12% Distribution modal Bimodal Unimodal Pea
15、k of CT distr -727Hu/27Hu 7Hu Compltot 57 5 46 11,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,Diffuse distribution,ARDS肺复张应用,ARDS肺复张应用,local distribution,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价VT和SI or Sigh对肺复张的影响 评价PEEP维持肺复张的作用 指导PEEP选择,SI前后绵羊复张容积的
16、变化,*,*,与SI前相比，*P 0.05,ARDS肺复张应用,SI有效组绵羊肺气体交换变化,*,*,与SI前相比，*P 0.05,ARDS肺复张应用,潮气量对肺复张的影响,A:PEEP=0, B:PEEP=Pflex, C:at the end of inspiration, D:PEEP=Pflex as in C during expiration,Pelosi P, Goldner M, Mckibben A, et al. Am J Respir Crit Care Med, 2001, 164, 131-140,ARDS肺复张应用,小潮气量通气的局限性,Cretti S, Masc
17、heroni D, Caironi P, et al. Am J Respir Crit Care Med, 2001, 164, 131-140,ARDS肺复张应用,Mean Airway pressure 5 cm H2O,CT Scan : ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,Mean Airway pressure 25 cm H2O,CT Scan : ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,Mean Airway
18、 Pressure 40 cm H2O,CT Scan : ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,不同VT的肺复张容积,*,*#,与6ml/kg组相比，*P 0.05;与10 ml/kg相比， #P 0.05,ARDS肺复张应用,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,PEEP效应的影响因素 -
19、附加静水压与心脏的影响,ARDS肺复张应用,Rothen H. et al. Br J Anaesth 1993:71:788-795,Re-expansion of atelectasis during general anaethesia,A: CT scan at level of right disphragm B: CT scan 5cm above right diaphragm,ARDS肺复张应用,PEEP诱导recruitment的分布,Puybasset L. ICM, 2000, 26:1215c,In lower lobes: Alv recruitment (ml) =
20、 0.16 X End-expir lung volume(ml) 24ml,ARDS肺复张应用,PEEP导致overdistention的分布,Volume of overdistension(ml)=0.42Parenchyma-900;-800(ml)18ml,Puybasset L. ICM, 2000, 26:1215c,ARDS肺复张应用,PEEP效应的影响因素 -塌陷肺泡的分布范围,塌陷肺泡的范围 Efficiency of PEEP-induced alv recruitment highly correlated with the proportion of poorly a
21、nd nonaerated lung parenchyma in ZEEP,Puybasset L. ICM, 2000,26:1215,ARDS肺复张应用,Diffuse: Equal loss of aeration to the upper and lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,Local: Loss of aeration predominating in lower lobes,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,Effect of PEEP
22、on recruitment and overdistention,Puybasset L. ICM, 2000, 26:1215,ARDS肺复张应用,PEEP效应的影响因素 -LIP的影响,ARDS肺复张应用,绵羊有无LIP组PEEP复张容积,ARDS肺复张应用,有无LIP患者的复张容积,*,*#,*,*#,与PEEP5 cmH2O相比，*P 0.05 与PEEP 10 cmH2O相比，#P 0.05 与LIP组比较，P 0.05,ARDS肺复张应用,Effect of PEEP on recruitment and overdistention,In LIP/+: PEEP1=LIP+2,
23、 PEEP2=LIP+7. In LIP/-: PEEP1=10, PEEP2=15,Vieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,PEEP-induced alv recruitment,16pat with ARDS LIS 3 Csts 39(ZEEP) CT scan Over -1000-900 Normal -900-500 Low -500-100 Ate 100+100 PEEP 0 vs 15,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,ARDS肺复张应用,对象：17例稳定AR
24、DS患者VT=6ml/kg,PEEP=10cm/H2O 肺复张方法：ZEEP, SI(40cmH2O,40s)，VT=6ml/kg, PEEP=Pflex+2cmH2O, PCV，PIP=15+PEEP，调整PEEP为25、30、35、40、45cmH2O，CT比较非通气区变化 结果：PaO2从ZEEP的92.3mmHg上升至394mmHg，非通气区从ZEEP的63.7%降至28.6%,VT-induced alv recruitment,ARDS肺复张应用,VT-induced alv recruitment,ARDS肺复张应用,内容提要,ARDS病理生理 ARDS肺复张容积测定 P-V曲线
25、法 等压法 CT法：Gattinonis vs Roubys ARDS肺复张测定应用 明确肺不张的分布与特点 评价SI or Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,PEEP的选择,氧分压导向性PEEP选择 PaO2 method DO2导向性PEEP选择 肺复张容积导向性PEEP选择Recruitment volume method,ARDS肺复张应用,open,closed,closed?,open,open up!,find closed!,re-open!,keep open!,airway pressure,time,氧分压导向性PEEP选择,ARDS肺
26、复张应用,Vazquez de Anda et al. Acta Anesth Scand 1998: 42:63-66,PEEP,PIP,ARDS肺复张应用,对象：17例ARDS患者，VT=6ml/kg, PEEP=10cm/H2O PEEP选择方法：PCV，PIP=15+PEEP，每2min调PEEP 25、30、35、40、45cmH2O，至FiO2为100% PaO2+PaCO2400mmHg，每15-20min降低PEEP，至PaO2较前一次降低5%, PEEP水平为前一次PEEP 结果：PaO2+PaCO2从178.476.5mmHg升至487.8 139.1mmHg，维持肺复张P
27、EEP水平为224cmH2O,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺复张应用,氧分压导向性PEEP选择,V.N.Okamoto et al. Unpublished data, 2003,ARDS肺复张应用,氧分压导向性PEEP选择,对象：47例早期ARDS患者，VCV，VT=8ml/kg， PEEP=10cm/H2O，RR20次/分，I：E=1：1 分组与方法： ARM+PEEP组：ARM实施方法为逐步增加PEEP至15、 20、25、30cm/H2O(extended sigh)， 结束后PEEP设为15cm/H2O ARM组：ARM
28、后PEEP仍为10cm/H2O PEEP组：基础通气模式,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,Lim CM, Jung H, Koh Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,Lim CM, Jung H, Koh
29、 Y, et al. Crit Care Med, 2003,31:411-418,ARDS肺复张应用,氧分压导向性PEEP选择,DO2导向性PEEP选择,ARDS传统的通气策略-经验性PEEP 缺点：缺乏科学依据 ARDS肺保护性通气策略-最佳PEEP 优点：获得最大的DO2，同时考虑PEEP 对循环和呼吸的影响，LIP+2cmH2O 为最佳PEEP,ARDS肺复张应用,邱海波, 郭凤梅, 周韶霞等. 中华内科杂志, 2001, 9,PEEP不足大量肺泡难以复张,LIP：塌陷肺泡开始复张压力，不是全部塌陷肺泡复张压力,ARDS肺复张应用,LIPStart of recruitment,Rec
30、ruitment occurs along the entire PV curve, even beyond UIP,Gattinoni L. AJRCCM, 2001, 164: 131,ARDS肺复张应用,PEEP and Survoval,A post hoc analysis, 53 patients,Barbas CSV, Medeiros DM, Magaldi RB, et al. Am J Respir Crit Care Med, 2002, 165: A218,ARDS肺复张应用,PEEP 肺复张与 低氧血症改善,Gattinoni L, Caironi P, Pelosi
31、 P, et al. Am J Respir Crit Care Med, 2001, 164:1701-1711,ARDS肺复张应用,ARDS绵羊不同PEEP复张容积,ARDS肺复张应用,ARDS患者不同PEEP复张容积,*,*#,与PEEP5cmH2O相比较，*P 0.05; 与PEEP5cmH2O相比较，#P 0.05;,ARDS肺复张应用,ARDS早期PEEP的调整 肺复张容积与DO2的结合,ARDS肺复张应用,不同通气模式对肺NF-B的影响,1、2、3、4、5和6分别为正常、ARDS、HVZP、LVBP、LVHP、NVBP组,1 2 3 4 5 6,基础研究,不同通气模式对肺 TNF
32、-mRNA表达的影响,1 2 3 4 5 6,1、2、3、4、5和6分别为正常、ARDS、LVBP、LVHP、NVBP和HVZP组,基础研究,不同通气模式对肺组织TNF的影响,基础研究,不同通气模式对肺组织MPO的影响,与对照组比较，* P0.05；与ARDS组比较， P0.05，与LVBP组比较，P 0.05；与HVZP组比较， P0.05,基础研究,不同通气模式对肺组织MDA的影响,与对照组比较，* P0.05；与ARDS组比较， P0.05，与LVBP组比较，P 0.05；比较， P0.05,基础研究,Bedside assessment of lung morphology (PEEP
33、=5cmH2O),Diffuse,Chest X-ray Diffuse Predominating /CT scan / White lungs in lower lobes Slope of PV 50ml/cmH2O LIP 5 30cmH2O PEEP trial 10-15-20-25 5-8-10-12,Local,总 结,ARDS肺复张应用,The Right PEEP level does not allow to reduce FiO2 bellow 0.6,Prone position trial. If failure iNO trial (5-10ppm). If failure If failure ECOM,ARDS肺复张应用,Thanks for your attention,