单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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,呼吸机治疗的肺保护策略浙江大学医学院附属儿童医院,1,呼吸机相关性肺损伤,acute parenchymal lung injury and an acute inflammatory response,in the lung.,cytokines alveoli,and the systemic circulation multiple,organ dysfunction,mortality,呼吸机相关性肺损伤,2,呼吸机相关性肺损伤ventilator-induced lung injury,容量性损伤,Volutrauma（large gas volumes）,压力性损伤,Barotrauma（high airway pressure）,不张性损伤,Atelectotrauma（alveolar collapse and re-expansion）,生物性损伤,Biotrauma（increased inflammation,）,呼吸机相关性肺损伤ventilator-induced l,3,肺 损 伤 病 理,alveolar structural damage,pulmonary edema、inflammation、fibrosis,surfactant dysfunction,other organ dysfunction,exacerbate the disturbance of lung development,Semin Neonatol.2002 Oct;7(5):353-60.,肺 损 伤 病 理alveolar structural d,4,Approaches in the management of acute respiratory failure in children,protective ventilatory and potential protective,ventilatory modes,lower tidal volume and PEEP,permissive hypercapnia,high-frequency oscillatory ventilation,airway pressure release ventilation,partial liquid ventilation,improve oxygenation,recruitment maneuvers,prone positioning,kinetic therapy,reduce FiO,2,and facilitate gas exchange,inhaled nitric oxide and surfactant,Curr Opin Pediatr.2004 Jun;16(3):293-8.,Approaches in the management,5,Can mechanical ventilation strategies reduce chronic lung disease?,continuous positive airway pressure,permissive hypercapnia,patient-triggered ventilation,volume-targeted ventilation,proportional assist ventilation,high-frequency ventilation,Semin Neonatol.2003 Dec;8(6):441-8,Can mechanical ventilation str,6,小潮气量和呼气末正压,lower tidal volume and PEEP,小潮气量和呼气末正压,7,Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS,1202 patients,lower tidal volume(7ml/kg),low plateau pressure 30 cm H,2,O versus,tidal volume 10 to 15 ml/kg,Mortality at day 28,long-term mortality was uncertain,low and conventional tidal volume with plateau pressure 31 cm H,2,O was not significantly different,Cochrane Database Syst Rev.2004;(2):CD003844,Ventilation with lower tidal v,8,Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome,549 patients acute lung injury and ARDS,lower-PEEP group 8.33.2cmH,2,O,higher-PEEP group 13.23.5cmH,2,O(P0.001).,tidal-volume 6ml/kg,end-inspiratory plateau-pressure30cmH,2,O,The rates of death 24.9%27.5%(p=0.48),From day 1 to day 28,breathing was unassisted,14.510.4 days 13.810.6 days (p=0.5),clinical outcomes are similar whether lower or higher PEEP levels are used.,N Engl J Med.2004 Jul 22;351(4):327-36,.,Higher versus lower positive e,9,Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilation,Sprague-Dawley rats,negative control group,low pressures(PIP=12 cm H,2,O),rate=30,iT=0.5,1.0,1.5secs,experimental groups,high pressures(PIP=45 cm H,2,O),rate=10,iT=0.5,1.0,1.5 secs,lung compliance,PaO,2,/FiO,2,ratio,wet/dry lung weight,and dry lung/body weight,as inspiratory time increased,static lung compliance(p=.0002)and Pao,2,/Fio,2,(p=.001)decreased.Wet/dry lung weights(p.0001)and dry lung/body weights(p 0.05,0.05,0.05,0.05,0.05,两组胎龄、体重、病情严重程度比较胎龄（周）体重日龄AaDO,14,对照组（NPM,)：,应用人工呼吸机限压定时持续气流型，通气模式为IMV，持续脉搏血氧饱和度监测使其维持在8595%，每8h监测动脉血气一次，要求血气维持在正常范围内，PaO,2,40-70mmHg,PaCO,2,35-45mmHg,对照组（NPM)：,15,观察组（PM组）,：,1、肺力学监测仪(Bicore CP100)每812h 监测一次机械通气时肺力学参数,2、监测时要求患儿与呼吸机完全同步或无自主呼吸状态（必要时通过药物抑制呼吸）,3、肺力学监测仪的传感器置于近端接口,4、气管插管气漏率小于20%,5、每监测一次持续0.51h至数据稳定后记录监测的数据,观察组（PM组）：,16,NPM 组和PM组的评估指标,1.疾病极期，即生后2448h时呼吸机要求最高值，包括FiO,2,、PIP、PEEP、Ti、MAP、VR,2.VE、C,20,/C、TC（限于PM组），,3.记录血pH、PaO,2,、PaCO,2,、氧合指数（OI）,（OI=FiO,2,MAP/PaO,2,）,和心率、血压,4.呼吸机应用时间，用氧时间，住院天数，病死率，PDA，IVH和呼吸机相关性肺损伤的发生率。,NPM 组和PM组的评估指标,17,两组呼吸机参数比较,FiO,2,（%）,PIP,（cmH,2,O,),PEEP,（cmH,2,O,),MAP,（cmH,2,O,),Ti,(sec),VR,（次/分）,NPM,6019,30.53.4,5.60.8,14.93.4,0.750.1,399,PM,6218,26.71.7,5.40.6,11.92.0,0.450.1,4210,t,0.184,7.527,1.339,5.818,18.10,1.81,p,0.05,0.05,0.001,0.05,两组呼吸机参数比较FiO2 PIP（cmH2O)PE,18,呼吸治疗肺保护指南ppt课件,19,两组血气监测结果比较,PH,PaO,2,(mmHg),PaCO,2,(mmHg),HR,(次/分）,BP,(mmHg),OI,NPM,7.310.1,5717,4010,1448,404.6,1913,PM,7.30.04,5916,486.3,1456,393.6,147.7,t,0.289,0.516,4.663,0.798,0.942,2.011,p,0.05,0.05,0.05,0.05,0.05,两组血气监测结果比较PHPaO2PaCO2(mmHg)H,20,呼吸治疗肺保护指南ppt课件,21,两组呼吸机相关性肺损伤、PDA、IVH、呼吸机应用时间、用氧时间、住院天数、病死率比较,VALI%,PDA,%,IVH,%,IMV,(d),用氧时间(d),住院天数(d),病死率%,NPM,32,36,42,3.91.8,117,1914,14,PM,13.3,33.3,40,4.21.7,137,2211,8.3,t,0.867,1.474,1.22,5.57,0.09,0.05,0.9,p,0.05,0.05,0.05,0.05,0.05,0.05,两组呼吸机相关性肺损伤、PDA、IVH、呼吸机应用时间、用,22,结论,肺力学监测能指导正确应用呼吸机，降低呼吸机相关性肺损伤,从本研究结果推荐RDS呼吸机应用的参数为：PIP 25cmH,2,O左右，短Ti 0.30.5秒，应用适当的PEEP 5-7cmH,2,O治疗RDS，不影响氧合。,PaCO,2,的轻度增高（PaCO,2,45-60），IVH的发生未见增加。,结论肺力学监测能指导正确应用呼吸机，降低呼吸机相关性肺损伤,23,允许性高碳酸血症,Permissive hypercapnia,允许性高碳酸血症,24,Permissive hypercapnia-role in protective lung ventilatory strategies,First,we consider the evidence that protective lung ventilatory strategies improve survival and we explore current paradigms regarding the mechanisms u