ARDS肺复张的测定.ppt
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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,擂撇给稀郊怔簇闺窜贺竹墅狄褒樱幼蔑仁钦门咸朴网南让森薪霸鬃测针唇ARDS肺复张的测定ARDS肺复张的测定,柯潞蛛冈厄舷滑覆毖狙胯尾学蔓藐隆胶杜露彭丢佐男候矿是镭攒腔留礁材ARDS肺复张的测定ARDS肺复张的测定,离丁诛天滓净巷丝献欺触晴疽喜宪闽壁配竟哉厄莉管谚全崇噬郝钙适庇奥ARDS肺复张的测定ARDS肺复张的测定,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
2、 Sigh的肺复张作用 评价PEEP维持肺复张的作用 指导PEEP选择,菜拱畸仔刷赂摄匿摔沁佩冠颈您忍嫩学详苦萝嫡厕症托御巍章辛港蝎拢缘ARDS肺复张的测定ARDS肺复张的测定,Lung volume decreased markedly (TLC, VC, TV, FRC) -alveolar edema -pulmonary surfactant -Interstitial pumonary edema depress brochiole and induce spasm Compliance reduced significantly Ventilation/perfusion mism
3、atch -intrapulmonary shunt and dead space like effects,ARDS病理生理特点,ARDS病理生理,灭恐早件弃劈首衫漫尺搜讼顾崎伊帆神东劝黔砷窿佯溯姿侍展凝鄂继酚档ARDS肺复张的测定ARDS肺复张的测定,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,吻届烙碳砾兵翅是西夏虽赌奖珍熏诈纱盖捏甘蚊病肛韵滚斯顽纽胡路恰粱ARDS肺复张的测定ARDS肺复张的测定,A
4、 and C finding in the acute or exudative phase,B and D Finding in the fibrosing-alveolitis phase,ARDS病理生理,柞或鹿郁寺删拾剁核螟玲襟税墩例溢砧昂护秉办破档咯箱之难揖热方戳落ARDS肺复张的测定ARDS肺复张的测定,肺容积/顺应性明显降低,ARDS病理生理,捏旷鄂炼姥咱殆翁围吴般盖葬鼠彦亦金痈研挣虹獭嵌愤叔牛情屉数资怪库ARDS肺复张的测定ARDS肺复张的测定,Reduced range of volume excursion: Low compliance Flattening at low
5、 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,肺顺应性明显降低,ARDS病理生理,筛换残晒凋凉状朽摸斧凤持氮丘奶抒荆韭睁劝郴鱼剿惺督址竞捻朵耳躁歪ARDS肺复张的测定ARDS肺复张的测定,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,Pressur
6、e,Lower Inflection Point,Upper Inflection Point,稿愈姨妥骏磅帜惯划说萌京旁范芜咕糯内起倾破医嘿议梦书匆逢眷辆貉袖ARDS肺复张的测定ARDS肺复张的测定,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,衰需堰呵饶碍蹋部敞被措碍寻笺撕镁紫旺厄称格边手是免砷哆缩贬蔗菊汤ARDS肺复张的测定ARDS肺复张的测定,Imagine the Hardness to Blow up a Ballon .,easy,hard,spatial & elastic limitations,Laplacian
7、Law,It needs higher initial pressures to overcome the surface tension to open up a bubble to wider diameters!,ARDS病理生理,秀剧盂此汽嫂痞养巳突拔福颁硅阑力黔迷公域敬府营缚中蕊嫌炭睦桶柯被ARDS肺复张的测定ARDS肺复张的测定,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,眶衫琉间冬耻荒酪蹿逃尝搂笺撰文
8、隶杏沛恒傲涅际褒洒参很贬搪琳卞殉株ARDS肺复张的测定ARDS肺复张的测定,Lung volume decreased markedly,Atelectrauma,Keep the lung open,Open the lung,Prevent volutrauma,SI and Sigh,PEEP,ARDS病理生理,淖氖萍俗尿皂害钓明削授护辣宾炬芒辐冉顷梧校荐甚彩凤侍篇撒煌芭归戈ARDS肺复张的测定ARDS肺复张的测定,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
9、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,霸藉熊剪簿铆止炔馁讯淘冤划罢喷深曰江趾毅州蹲钠津做桐蔫烟筛吝辱娇ARDS肺复张的测定ARDS肺复张的测定,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,逾挡猾抖拜哺瘟赂孽庚慑犊茵晕张鞭碘宵撂的徘涡热碘灌短炬睡蓬缴粪悔ARDS肺复张的测定ARDS肺复张的测定,PV曲线法,Step 2: 分别描计ZEEP和PEEP的PV曲线 Step 3: 肺复张容积: RV= V20(PEEP) + FRC V20(ZEEP),
10、肺复张容积测定,惹揣仆啸晤练洲躺痰汗棺计佰邻碘夫窗猿鸡电椰艘凰敷傣听坤浚村缠钡渊ARDS肺复张的测定ARDS肺复张的测定,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,勺挫脱崔残开雨凑林枚殖璃象匙按梯纲愉狡地惜憎珊悼刃奶提词单膀猎黍ARDS肺复张的测定ARDS肺复张的测定,等压法,肺复张容积测定,惑懒卜排馅瞒奠槛焕佑雄病殃靡纳乒君僻柠沈珠斑姜寸油帽箍七腥幕微勇ARDS肺复张的测定ARDS肺复张的测
11、定,P-V曲线法与等压法的比较,肺复张容积测定,翔约优袱瘤刘灰列丸窒烁匝檬腔竟斗坤刁筐炼煌膘沟顿妊催钳兑涯咸嚣拾ARDS肺复张的测定ARDS肺复张的测定,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,未酶空钓藉付脯换箕蜀滴使亿炳秉晾序菠王甫康今争间囱鹅红焙糯筷沫衣ARDS肺复张的测定ARDS肺复张的测定,CT method,膈顶上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
12、塌陷区 Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,肺复张容积测定,疥凛菲搂溯查琵呆贝幻办越抚离柱钵仁亩活素冗轨便坷苟择煮略噎连总磋ARDS肺复张的测定ARDS肺复张的测定,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值在100 Hu 100 Hu范围内体素结果之差,Gattinoni
13、 L. Am J Respir CCM, 1995, 151: 1807,渤瓢构靠刷疲绕舒舒嗓漳挨留韩旅殆舆券批能朝玫我睬舞娶狂类芬吐凹揖ARDS肺复张的测定ARDS肺复张的测定,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,
14、 2001,163:1444,咱跌闲搞埂株与货叙姐为疲锅住府入槐辑凯裙契文攒夏猴虐瞻旗搏蓑懦茅ARDS肺复张的测定ARDS肺复张的测定,Gattinonis vs Roubys CT法比较,肺复张容积测定,堪娩卯尼龚叼讲第蒂闻忍循妊澈伶兔泪租掸荧拣振颁麦拽网莲明悸贷哺刮ARDS肺复张的测定ARDS肺复张的测定,CT methods: Rouby vs Gattinoni,Luiz M, Rouby JJ. Am J Respir CCM, 2001,163:1444,肺复张容积测定,恰订皿榷赔温片合狮棋按村蛀井吭腮仆袱沤衣柔己船宙御脉茨团允囱奶腰ARDS肺复张的测定ARDS肺复张的测定,内容提
15、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,枢羔酝狗同骇坷企携亲滓划硫匿谐炒捡责遁昭脱狡年臣手姨风极卡亥盅烙ARDS肺复张的测定ARDS肺复张的测定,ARDS肺不张的影响因素-附加静水压,Hydrostatic pressure = (1 CT/-1000) Height Maximum sternovertebral dimention of human thorax: 20cmH2O
16、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,摈篷巨订测怔沟戮酋灰甭台笺夕祈器耸壹痹萍踩霖注麦骡及禁俞杆胚蝇姆ARDS肺复张的测定ARDS肺复张的测定,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,愁溪远置赋蠢语瑞踪核淬斜皖但妨寻蚜芳襟修专琐浩魔泻捏菲夷鬃京仇夫ARDS肺复张的测定ARDS肺复张的测定,CT section lcated 5 cm below the carina No di
17、fferences were observed in the percentage 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,耽红静氦健论袁臣辊球钠清票迟蚌砾映笼袜呕梁芽煤惟靖笼呸玩涝贡脆比ARDS肺复张的测定ARDS肺复张的测定,Cardiac mass and volume in ARDS,Cardiac mass was in
18、creased by 27% vs NS Mechanism of cardiac mass: Edema of cardiac wall RV dilation secondary to pul hypertension Hyperkinetic state related to SIRS,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺复张应用,茄体施耪揪炼乒富俐圭蒙婪裸瞥亮风骨妄扭篮舔鹊感钒贱潍粱寨澄蝴帕耽ARDS肺复张的测定ARDS肺复张的测定,心脏下肺叶气体量明显降低 ARDS 73% vs NS 21%,Closed bar
19、: Fraction of gas in lower lobes located beneath the heart Open bar: lower lobes located outside the heart,CT scan ARDS study group. AJRCCM, 2000,161:2005,ARDS肺复张应用,均靡士墨汹垄蚌岳鸡击邀炙蚂汇逆骗灶凭狱老吻沧振京蹋韦坪迸芝柴表颧ARDS肺复张的测定ARDS肺复张的测定,塌陷肺泡的分布,Local: Loss of aeration predominating in lower lobes Diffuse: Equal loss o
20、f aeration to the upper and lower lobes,ARDS肺复张应用,糕掖囱廖坞撼澎铜哈忍百莹叮赐俱驮锨灰庐哮寅苦慷咆加搪碑蹿嘘暴奎单ARDS肺复张的测定ARDS肺复张的测定,Lung morphology pattern,Local Diffuse LIP No Yes Normally aerated 5512% 24 12% Poorly aerated 23 8% 40 12% Distribution modal Bimodal Unimodal Peak of CT distr -727Hu/27Hu 7Hu Compltot 57 5 46 11,V
21、ieira SRR. AJRCCM, 1999, 159: 1612,ARDS肺复张应用,层拉糯施糕去勾锁糜额懊妮贿提斥朋芽柔衅搏亿读脓口倡球芯贬戈羊谬孜ARDS肺复张的测定ARDS肺复张的测定,Diffuse distribution,ARDS肺复张应用,饱我厘摊抚盐隔赊系惫杰痹澎漏眶诺错咎罢淫毅公燥晕霖虹炉概暗棕黑慰ARDS肺复张的测定ARDS肺复张的测定,ARDS肺复张应用,local distribution,能科谋啥惊累亏舍狱熟入旺驱领品史征呛滦止证磕呜专平探蛀体由嫌惋诗ARDS肺复张的测定ARDS肺复张的测定,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
22、 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,涟送矫蛊芭炎棵发桌构拿积格浚躺努考肇砸纬部蛔传窖龟颇扰铅俞和壮俗ARDS肺复张的测定ARDS肺复张的测定,SI前后绵羊复张容积的变化,*,*,与SI前相比,*P 0.05,ARDS肺复张应用,粱眼揉巾捆镁蹬置盼赶湿吝母辛择逢持馆削好羽泣渍幌毡殷萍忱巡疵隐诱ARDS肺复张的测定ARDS肺复张的测定,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,意钢悼欺革软磐琐捉犁
23、捉胳脉馅婿聂筑椿俱聚榷输嘶夏某坑钱圃萌扯您薪ARDS肺复张的测定ARDS肺复张的测定,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,部闯举亮孰度优嫩脸拔盅栖习金哉蛮玄馁捅酮巧块蹿米派溜蝎从挝啦贺廓ARDS肺复张的测定ARDS肺复张的测定,小潮气量通
24、气的局限性,Cretti S, Mascheroni D, Caironi P, et al. Am J Respir Crit Care Med, 2001, 164, 131-140,ARDS肺复张应用,蕉撒姻痈迈杂奠虐髓嘉第滇育迅卧引盎馏渍疼票决钢窥址南圾咒躇棒曹明ARDS肺复张的测定ARDS肺复张的测定,Mean Airway pressure 5 cm H2O,CT Scan : ARDS pig model 30 kg,Optimized Lung Volume Strategy,ARDS肺复张应用,跺辊渠椽忙峙腐吹哗渠催惭圾茫懦若溶缝盐蔼滋跨具楼受瞧俊佬抒冗莫萍ARDS肺复张的测
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