Stressindex

病理生理基礎(chǔ)VentilationinALIBackgroundALI是ICU常見的危重病病理生理特點

肺容積明顯降低

肺順應(yīng)性明顯下降

通氣/血流比例失調(diào)肺組織分布“不均一”2ppt課件TIDALrecruitmentend-expirationend-inspiration3ppt課件TIDALhyperinflationend-expirationend-inspiration4ppt課件backgroundIntensiveCareMed,2005,31:776–7845ppt課件非重力依賴區(qū)過度膨脹

重力依賴區(qū)潮汐性塌陷復(fù)張BestPractice&ResearchClinicalAnaesthesiology2010;24:171-182.VILI立項依據(jù)6ppt課件Alwaysopeningandclosing－－VILI●●●●●●●●●●●●●●●●●●●TidalcollapseVT01020304001020304050%Paw(cmH2O)●Closingpressure●OpeningpressureCrotti,etalAmJRespirCritCareMed2001;164:131-140●●●●●●●●●7ppt課件HEARTSPPEEP--KeepthelungopenLowVtRMOpenlung

BackgroundARDS病理生理變化－－肺保護性通氣8ppt課件機械通氣患者病死率仍高達37%IntensiveCareMed2009;35:816–825.13,322patsadmittedto299ICUsfrom35countriesBackground9ppt課件6ml／Kg－－小潮氣量

非重力依賴區(qū)肺泡依然過度膨脹Background中大醫(yī)院重癥醫(yī)學(xué)科－－預(yù)試驗10ppt課件重力依賴區(qū)通氣不良和塌陷肺泡明顯增加Background中大醫(yī)院重癥醫(yī)學(xué)科－－預(yù)試驗11ppt課件HEARTSPAtpresent：LungProtectiveVentilationStrategies非重力依賴區(qū)肺泡過度膨脹

重力依賴區(qū)肺泡潮汐性塌陷復(fù)張

BackgroundVILI幾乎無處不在潮氣量和PEEP的設(shè)定依然矛盾重重12ppt課件潮氣量設(shè)置困難－－個體化難！

重癥ARDS－－大量肺泡塌陷即使“小”潮氣量仍然導(dǎo)致VILI潮氣量應(yīng)更小VILI－－塌陷肺泡少“小”潮氣量太小，肺泡通氣無法保證，導(dǎo)致肺泡塌陷顯然，6ml／Kg的“小”潮氣量不適合所有ARDS13ppt課件ThemostcontroversialissueinALI/ARDSptsLowPEEPtokeepoxygenationHighPEEPtokeeplungopen14ppt課件維持肺開放(KeepLungOpen)

----最佳PEEPPEEP水平不足肺泡反復(fù)塌陷、復(fù)張，產(chǎn)生剪切力

VILIPEEP水平過高肺泡過度膨脹，導(dǎo)致氣壓傷

VILI最佳PEEP改善通氣/血流比例，糾正低氧血癥防止肺泡反復(fù)塌陷-復(fù)張和過度膨脹減輕肺損傷、減輕炎癥反應(yīng)立項依據(jù)15ppt課件MethodstotitratePEEPinALI/ARDSBestPEEP(Suter,NEJM,1975)SuperPEEP(Kirby,Chest,1975)Pflex(Amato,AmJRespirCritCareMed,1995)Oxygenationscale(ARDSnet,NEJM,2000)Stressindex(Ranieri,Anesthesiology,2000)Pmc(Goddon,Anesthesiology,2001)FRC+Cst(Lambermont,CriticalCare,2008)Pes(Talmor,NEJM,2008)Increasedrecruitmentstrategy(Mercat,JAMA,2008)EIT(Meier,ICM,2008)…Whichoneisbest?16ppt課件滴定PEEP的最佳方法簡便、床邊快速安全可重復(fù)，為PEEP滴定提供可靠信息17ppt課件Stressindex---肺牽張指數(shù)容量控制通氣、恒定流速18ppt課件Stressindex---肺牽張指數(shù)P-t曲線吸氣支：曲線回歸方程P=a*tb+cb值：肺牽張指數(shù)描述曲線的形狀，反映肺泡開放與塌陷程度的力學(xué)指標SlutskyAS,Aneathiology,2000,93:1320-8GrassoS,CritCareMed,2004,32:1018–2719ppt課件RanieriVMetalAnesthesiology2000Stressindex---肺牽張指數(shù)20ppt課件stressindex=1beforeRMstressindex=1afterRM0.6<stressindex<0.80.8<stressindex<11.1<stressindex<1.31.3<stressindex<1.5EndInspirationEndExpiration21ppt課件b值與塌陷和過度膨脹22ppt課件b值與塌陷和過度膨脹23ppt課件肺牽張指數(shù)指導(dǎo)ARDS患者PEEP的選擇14例ARDS患者實施肺復(fù)張后容量控制通氣用回歸法求得方程:P=a*tb+c.b為肺牽張指數(shù)。復(fù)張后調(diào)整PEEP使b<1(0.6<b<0.8)b=1(0.9<b<1.1)b>1(1.1<b<1.3)與復(fù)張前比較，*P<0.05;與復(fù)張后b<1比較，#P<0.05;與b=1比較，ΔP<0.05黃英姿，邱海波。中華醫(yī)學(xué)雜志。2009,89:2739肺復(fù)張后b=1時，氧合、順應(yīng)性和肺復(fù)張容積明顯改善24ppt課件與基礎(chǔ)狀態(tài)比較*P<0.05；與氧合法比較＃P<0.05；與肺牽張指數(shù)法比較△P<0.05；與順應(yīng)性法比較▲P<0.05

****△△＃不同方法選擇最佳PEEP的比較

PEEP(cmH2O)25ppt課件PaO2/FiO2(mmHg)b值滴定PEEP對氧合的影響與基礎(chǔ)狀態(tài)比較，*P<0.05****26ppt課件*與基礎(chǔ)狀態(tài)比較，*P<0.05復(fù)張容積(ml)Cst(ml/cmH2O)b值滴定PEEP對復(fù)張容積和Cst的影響27ppt課件THESTRESSINDEXCONCEPT:experimentaldata0.00.51.01.52.0.RanieriVMetalAnesthesiology20000.00.51.01.52.0.28ppt課件THESTRESSINDEXCONCEPT:experimentaldataRanieriVM,SlutskyASAnesthesiology200029ppt課件BALb=1duringSIventilationb=1duringSIventilationP<0.001b≠1duringNIHventilationb=1duringNIHventilationP<0.0541010IL-1

b=1，炎癥反應(yīng)降低30ppt課件B值滴定PEEP31ppt課件B值反應(yīng)肺順應(yīng)性的動態(tài)變化btotaltot=1.00butthealgorithmisstillabletodistinguish

b1=0.91b2=1.11KleisTEK-AdvancedElectronicSystems,Bari-Ita