ARDSPP李文雄PPT推荐.pptx
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ARDSPP李文雄PPT推荐.pptx
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1334-1349.,diffusealveolardamagewithneutrophils,macrophages,erythrocytes,hyalinemembranes,andproteinrichedemafluidinthealveolarspaces,capillaryinjury,anddisruptionofthealveolarepithelium,RadiologicalandpathophysiologicalalterationofARDS,ApatchyperipheraldistributionProgresstodiffusebilateralinvolvementwithgroundglasschangesBilateralpatchyopacitiesinmostlymiddleandlowerlungzones,Alveolarfilling,consolidation,andatelectasisoccurpredominantlyindependentlungzones,whereasotherareasmayberelativelyspared.itprogressestofibrosingalveolitiswithpersistenthypoxemia,increasedalveolardeadspace,andafurtherdecreaseinpulmonarycompliance.Pulmonaryhypertension,owingtoobliterationofthepulmonarycapillarybed,maybesevereandmayleadtorightventricularfailure,From“babylung”to“spongelung”,Schemarepresentationofspongemodel.InARDSthe“tissue,”likelyedemaintheearlyphase,isalmostdoubledineachlunglevelcomparedwithnormal,indicatingthenongravitationaldistributionofedema.Theincreasedmass,however,causesanincreasedsuperimposedpressure(SP;
cmH2O),whichinturnleadstoa“gassqueezing”fromthemostdependentlungregions.SuperimposedpressureisexpressedascmH2O.,PelosiP,DAndreaL,VitaleGetal(1994)Verticalgradientofregionallunginflationinadultrespiratorydistresssyndrome.AmJRespirCritCareMed149:
813,附加压力与胸膜腔内压,PelosiPetal.AmJRespirCritCareMed2001;
164
(1):
122-30.,TheARDSLung,RoubyIntensiveCareMed2000,ARDS:
为什么需要RM(recruitmentmaneuvers)?
MVVILI,MV可导致肺的形态学和生理学变化StressandstrainShearforcestress=PLPL=PAW-PplStrain=dV/V0dV:
肺容积的变化(Vt)Vo:
静息肺容积(FRC),Stress(PL)=K(specificlungeleastance)strain(dV/Vo),MVVILI,DynamicStrain=Vt/FRCStaticStrain=Vpeep/FRCGlobalstrain=(Vt+Vpeep)/FRC,IntrathoracicPressuresandLungStretching,Slutsky,AS.NEnglJMed2013;
369:
2126-36.,MVVILI,大VT的危害肺过度膨胀抑制或使表面活性物质失活牵张肺泡上皮细胞和血管内皮细胞激活炎症反应诱发MODSVT降低的后果肺泡萎陷膨胀不全的肺泡和末端小气道周期性开放与闭合Shearforce:
主要发生在充气与非充气肺单位的连接处,PhuaJ.AmJRespirCritCareMed2009,179:
220227.OecklerRA.EurRespirJ2007,30:
12161226.TheAcuteRespiratoryDistressSyndromeNetworkNEnglJMed2000,342(18):
13011308.PelosiP,etal.AmJRespirCritCareMed2001,164:
122130.,ShearForce(Atelectasis),30cmH2O,ALVEOLAR,AIRWAY,140cmH2O,MeadJ.JApplPhysiol1970;
28:
596608.,Theinterstitialpressurewasamplifiedupto140cmH2O(V0/V=1/10)Betweenthehyperinflatedandthenormalalveoliandbetweenthecontinuouslyrecruited-derecruitedalveoliandthenormallyexpandedregions,F=PLx(V0/V)2/3,F=PLx(V0/V)2/3,LungInjuryCausedbyForcesGeneratedbyVentilationatLowandHighLungVolumes,Whenventilationoccursatlowlungvolumes,lunginjurycanbecausedbytheopeningandclosingoflungunits(atelectrauma)aswellasbyothermechanisms.Thisinjuryismagnifiedwhenthereisincreasedlunginhomogeneity,asshownoncomputedtomography(PanelA),especiallyinpatientswiththeacuterespiratorydistresssyndrome(ARDS)whohavesurfactantdysfunction,pulmonaryedema,andatelectasis.Inaddition,ventilationmaybeveryinhomogeneous,astatusthatmaybepartiallyorfullyreversedbytheuseofpositiveend-expiratorypressure(PEEP),asshowninaventilatedexvivoratlung.Athighlungvolumes,overdistentioncanleadtogrossbarotrauma(airleaks)(PanelB).,Macroscopicaspectofventilator-inducedlunginjury,Intactratsweremechanicallyventilatedwitheitheranormaltidalvolume(left)orwithahightidalvolumefor5min(middle)or20min(right).After5min,therewereonlyfocalcongestivezones.After20min,lunglesionsaresevereasshownbymarkedenlargementandcongestion.Trachealedemafluidfillsthecannula.,设置PEEP降低ShearForce,PutativemechanismsofVILI:
effectsofPEEP,IntensiveCareMed(2015)41:
20762086.,The“babylung”atend-inspiration,UpperPercentageofinspiratorycapacity(blacklines;
solidblacklinealsopercentageofrecruitment)andpercentageofderecruitment(dashedgrayline)asfunctionofairwaypressure.LowerFrequencydistributionofopeningpressureasfunctionofairwaypressure(solidline)andofclosingpressure(dashedline).VerticallinesExampleofairwaypressuresusedduringmechanicalventilation,plateaupressure25cmH2O(solidline)andPEEP10cmH2O(dashedline).At25cmH2Oairwaypressurenearly60%inspiratorycapacity,40%oflungunitsarestillclosed.At10cmH2OPEEPnearly35%undergoesopeningandclosing.(DatafromCrottietal.),CrottiS,MascheroniD,CaironiPetal(2001)Recruitmentandderecruitmentduringacuterespiratoryfailure:
aclin-icalstudy.AmJRespirCritCareMed164:
131140,RMandPEEPsetting,ARDS的通气策略,肺保护性通气策略吸氧浓度(FiO2)小潮气量限制气道平台压小VT和限制Pplat预防肺和远隔脏器损伤恰当的呼气末正压(PEEP)PEEP的设置适当的PEEP降低shearforce高PEEPvs低PEEP的作用不确定允许性高碳酸血症限制驱动压(15cmH2O)?
Effectsofpronepositioningonoxygenation,PP改善氧合降低肺内Qs/Qt改善VA/Q过去的想法Qs/Qt下降血流转向通气好的区域或通气重新转向灌注好
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