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Tongji Mechanical Ventilation ForumVentilation of Injured Lung肺损伤的机械通气Younsuck Koh, ck KohDepartment of Pulmonary and Critical Care Medicine

Asan Medical Center

University of Ulsan College of MedicineMechanical Force to the Alveoli during Ventilation机械通气过程中对肺泡的机械力•Stress:

Transpulmonary pressure

压力：跨肺压(airway pr-pl pr,

ΔPL)•Strain (ΔV/FRC)牵张（Ratio of volume change(ΔV) to the FRC）（肺容量的变化量与肺功能残气量的比值）Normal正常的肺泡ALI急性肺损伤的肺泡Why Do We Care for Protective Ventilation?为什么我们需要关注保护性肺通气？-Mechanical ventilation (MV) is

the way to let the ARF patients

to be survived.机械通气是挽救急性肾衰竭病人的方法之一。-MV can induce or aggravate

lung injury.

机械通气会导致或加重肺损伤。Safe Threshold between Strain and Stress in Healthy Pigs在健康猪的实验中得出的牵张力与压力关系的安全阈值Average stress–strain relationship computed from the fitting of individual recordings, available in 22 pigs.

Protti A, et al. Am J Respir Crit Care Med 2011;183:1354

Amplification of Wall Stress by HeterogeneousExpansion不均匀扩张导致的肺泡壁压力的扩增Alveolar VolumeEffective Pressure = Applied Pressure X2/3Atelectatic Volume肺泡容量有效压力= 设定压力X2/3肺塌陷容量Example（例如）:140 cm HHigh transalveolar pressure increases2O = 30 cm H2O X 102/3Mead J. et al : Stress distribution in lungs : A model of pulmonary elasticity.

transmicrovascular forces,

J Appl Physiol 28:596-608, 1970which could lead to

capillary stress fracture*.West JB, JAP, 1991;70;1731*

Gravity Effect on Alveoli in Supine仰卧位时重力对肺泡的影响]O2H10Normalmc[

e8ARDSruss力erp

加压6de叠so4pmirep2uS00Ventral2腹侧4681012Height (cm)Dorsal14背16侧Pelosi P et al. Am J Respir Crit Care Med 1994;149:8-13by the Courtesy of Gattinoni LPhysical Stretch Induces Inflammation

物理伸展诱发炎症Adopted from Tremblay LN, et al.

Ventilator-induced lung injury. In:

Physiological basis of ventilator

support. Marcel Dekker, 1998, 436Showing that ventilator-induced changes do not

remain confined to the lung.表明机械通气诱发的变化并不局限于肺What is Protective Ventilation?何谓“保护性肺通气”-The ventilation way to

lessen stress and strain to

the injured alveoli.是一种减少对损伤肺泡的压力和牵张力的通气策略-The ventilation way to

lessen VALI.

是一种减少呼吸机相关性肺损伤的通气策略Alveolar Area Pressure Curve for each of

the Three Alveolar Types三类肺泡的压力曲线Alveolar size change

with lung inflation:Tween lavage pigs,

in vivomicroscopy

Observation予以表面活性剂肺泡灌洗猪的体内实验，镜下：High Strain & Stress肺膨胀时肺泡容量的改变Nieman GF, et al. Crit Care Med 2003;31:1126Inappropriate MV Setting with Outcome of ALI不适当的机械通气带来急性肺损伤的后果Amato M, et al. NEJM 1998How Does Protect Lung in ALI?为什么要保护急性肺损伤患者的肺？-Reduce strain & stress of the

alveoli: Low VT减轻对肺泡的压力和牵张力：低潮气量-Avoid repeated open & closure of

the injured alveoli: PEEP, ARM避免损伤肺泡的反复张开、闭合：PEEP, ARM

EvidencesThe End-inspiratory Lung Volume

as a Determinants of Edema formation吸气末肺容量：肺水肿形成的决定因素High peak (45 cmH2O) positive inspiratory pressure high tidal volume ventilation (HiP-HiV) with those of negative

inspiratory airway pressure high tidal volume ventilation (iron lung ventilation = LoP-HiV) and of high peak (45

cmH2O) positive inspiratory pressure-low tidal volume ventilation (thoracoabdominal strapping = HiP-LoV).

Dreyfuss D, et al. Am Rev Respir Dis 1988; 137:1159-64The Recruitable Potential vs. Outcome of ARDSARDS的结局与可复张性的关系804 (12%)15 (44%)MRat ICU discharget70[no. of dead (%)]nem]t60surviveddeadthigui50recwe

40rg

nruol

30fl

lat20iaott

14 (41%)ne%10r2=0.46t[oP0p<0.0001-105 (15%)-2607080Non-aerated tissue [% total lung weight]Gattinoni L, et al. NEJM 2006, 354(17):1775-86By the Courtesy of Gattinoni L.

PEEP

as a Measure to

Prevent DerecuritmentPEEP：防止肺泡塌陷的方法VolumeSmall VTLIP (10 -15 cm H2O)PressureARDSnet Tidal Volume studyARDSnet潮气量研究Conventional Vt常规潮气量设置:

12 ml/kg, Pplat 50 cm H2O): MR 40 %Low Vt低潮气量设置:

6 ml/kg, Pplat < 30 cm H2O: MR 31 %504039.8)%31(

30ytilatro20M100N Engl J Med 2000: 342:1301The PEEP increase reduced opening and closinglung tissue in higher % of potentially recruitableLung.提高PEEP能够减少肺组织的开放与闭合，增加可复张肺组织的比例Caironi P, et al. Am J Respir Crit Care Med 2010; 181: 578–586High PEEP vs. Low PEEP in ALI with Low Tidal Volume急性肺损伤患者在小潮气量时高PEEP与低PEEP的比较N EnglJ Med. 2004: 351(4);327Low PEEP according to ARDSnet PEEP table

Tidal Hyperinflation during

Tidal Volume Low Ventilation in ARDSARDS患者小潮气量通气时的过度通气Terragni PP, et al. Am J Respir Crit Care Med 175; 160-66, 200720 Patientstidal inflation : 69.9 ±6.9%tidal hyperinflation : 8.1 ±5.4%(more protected)10 Patientstidal inflation : 23.1 ±14.4%tidal hyperinflation : 63.0 ±12.7%(less protected)Surfactant-depleted ALI

model in dogs (n= 10)Post PT Post ARM气的不均一性:coefficient of variance (SD/mean) of HU of 18 regionsPT（PEEP滴定法）ARM（肺复张）30 sec0.27 ±0.11 0.13 ±0.06 p= 0.02630 min0.22 ±0.10 0.13 ±0.06p= 0.042Lim CM, et al. Anesthesiology. 99(1):71-80, 2003RCT of ARM Efficacy with ARDSnet: AMCARDSnet中肺复张效能的随机对照研究：1)Decremental PEEP titration after ARM (ARM)肺复张后的PEEP递减滴定pressure limit 45 cm H2OPREARMDecremental PEEP titration2) ARDSnet Protocol (ARDSnet)FiO20.30.40.40.50.50.60.70.70.70.80.90.90.91PEEP558814161818-24(cm H20)Huh JW, et al. Critical Care 2009, 13:R22Alveolar Recruitment肺复张Volume肺容量ba-The Way to Make the Alveoli More HomogeneousAirway pressure气道压使肺泡更为均一-The way to decremental PEEP setting递减PEEP设置RCT of ARM Efficacy with ARDSnetARDSnet中肺复张效能的随机对照研究Allowed Pplat: 30 cmH20 in control, 40 cmH2O in ARM ts were censored at hospital discharge and at death in the2 analyses, respectively.平台压：对照组30 cmH20, 肺复张组40 cmH2O。患者分别在出院及死亡时进行检查。Meade, M. O. et al. JAMA 2008;299:e Variables 结果ARMARDSnet(n=30)(n=27)Barotrauma, %气压伤10.0 %11.1 %Ventilator day机械通气时间19.8±0.515.2±3.2ICU stay, dayICU住院天数22.5±4.225.8±7.628 d MR, %28天死亡率40.033.3Huh JW, et al. Critical Care 2009, 13:R22

Heterogeneity of lung aeration肺通

The 3rdway to PEEP SettingPEEP设定的第三种方法-Esophageal P. guided以食道压为指导:

1) PEEP: to achieve a transpulmonary p of 0-10 cm H2O

at end-expiration based on PaO2PEEP：使得基于动脉血氧分压得到的呼气末跨肺压为0-10 cm H2O2) VT: to keep transpulmonary p < 25 cm H2O at end

inspiration潮气量：确保吸气末跨肺压<25cm H20TalmorD, et al. N Engl J Med 2008;359:2095-104TalmorD, et al. N Engl J Med 2008;359:2095-104Respiratory Measurements at Baseline and at 24, 48, and 72 Hourse Control and Esophageal-Pressure–Guided thTalmorD, et al. N Engl J Med 2008;359:2095-104Stiff“Soft”“Soft”StiffELEwELEw255cmH2O1515EtotEtotCourtesy of L. Gattinoni

Ventilator Settings According to the Protocol.根据流程设定呼吸机参数TalmorD, et al. N Engl J Med 2008;359:2095-104* PEEP denotes applied positive end-expiratory D, et al. N Engl J Med 2008;359:2095-104Prone Positioning俯卧位通气

Prone position: PEEP-sparing effect俯卧位通气：PEEP-作用有限(Lim CM, et al. Eur Respir J 1999; 13:163)Low PEEPHigh PEEPSupineProneSupine ProneNM Blockade in ARDSARDS的神经肌肉阻断•340 patients with severe ARDS within previous 48 hrs presenting

to the ICU

340例严重ARDS患者在发病最初48小时内入住ICU•Random assignment:

cisatracurium besylate (178 patients) or

placebo (162 patients)随机分组：阿曲库铵组（178例患者）或安慰剂组（162例患者）•Severe ARDS:

PaO2/FiO2 < 150,PEEP > 5 cm H2OTidal volume 6 ~ 8 ml/kg (of pbw)严重ARDS：氧合指数< 150, PEEP > 5 cm H2O

潮气量6 ~ 8 ml/kg (of pbw)Papazian L, et al. N Engl J Med 2010;363:早期神经肌肉阻断NM Blockade at early stage低频率，小潮气量6ml/kgVT6m of Predicted B.W, Low f平台压<28cmH2OPplat< 28 cmH2OPEEPPEEP(ARDSnet)Optimal最佳的设置YesNoWeaningKeep the settingP脱机维持该设置FiOplatPaCO22ARM c Decremental Prone

PEEP settingventilationOthermeasures/APRV肺复张PEEP设置俯卧位通气其他方法/气道压变化通气ECMOHFOViLA/iNOAbroug et al. Critical Care 2011, 15:R6Abroug F, et al. Crit Care. 2011Outcome结果The hazard ratio for death

at 90 d in the cisatracurium gr0.68 (95% CI, 0.48 ~ 0.98)阿曲库铵组90天的死亡危险率The crude 90-day mortality:31.6% (95% CI, 25.2 ~ 38.8)

in the cisatracurium group

40.7% (95% CI, 33.5 ~ 48.4)

in the placebo group

(P = 0.08)阿曲库铵组90天死亡率为31.6%安慰机组90天死亡率为40.7%Papazian L, et al. N Engl J Med 2010;363:sions结论•VALI is associated with the outcome of ALI呼吸机相关性肺损伤与急性肺损伤的预后密切相关•VALI is more likely developed depending on the ALI

severity even under protective MV support.呼吸机相关性肺损伤很大程度上依赖于急性肺损伤的严重程度，即便在保护性通气策略下•Lung protective ventilation may be more beneficial in

patients at risk for ARDS.肺保护性通气可能对于有ARDS高危因素的病人更有益•Conservative fluid management after hemodynamic

stabilization should be considered.血流动力学稳定后推荐给予控制性液体管理