【正文】 e and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003。o)穩(wěn)定能夠改善PaO2,McCann UG, Schiller HJ, Gatto LA, et al. Alveolar mechanics alter hypoxic ulmonary vasoconstriction. Crit Care med 2002。,RM + PEEP vs. PEEP only,Lim CM, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury. Crit Care Med 2004。),RM之后通常將PEEP設(shè)置在能夠維持(w233。zh236。,PEEP的設(shè)置(sh232。)于20 cmH2O后, 仍發(fā)現(xiàn)PaO2/FiO2顯著下降 按照最初的PEEP設(shè)置25 cmH2O重復(fù)肺復(fù)張 然后按照上述方法調(diào)節(jié)FiO2和PEEP,第五十一頁，共一百二十頁。n)所示, 根據(jù)設(shè)置方法不同, 同樣水平的PEEP所維持的肺容積不同 如果在肺泡塌陷后設(shè)置PEEP (增加PEEP), 那么所設(shè)置的PEEP水平可以使肺容積減少, PaO2降低,第五十二頁，共一百二十頁。,肺復(fù)張后氧合穩(wěn)定(wěnd236。ng)所需時間,Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, T Akpir. Time required for equilibration of arterial oxygen pressure after setting optimal positive endexpiratory pressure in acute respiratory distress syndrome. Crit Care Med 2005。ng),小潮氣量通氣的問題 肺復(fù)張的理論(lǐl249。nɡ)RM方法的比較,根底(jīchǔ)通氣方式 VCV: Vt 10 ml/kg, f 20 bpm, I:E 1:2, FiO2 0.5 肺復(fù)張:,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005。nɡ)RM方法的比較,Odenstedt H, Lindgren S, Olegard C, et al. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005。nɡ)RM方法的比較,Odenstedt H, Lindgren S, Olegard C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005。nɡ)RM方法的比較,對于灌洗造成的急性肺損傷模型 緩慢低壓復(fù)張操作可以 促進肺泡復(fù)張 減少對循環(huán)系統(tǒng)(x 31: 17061714,第六十頁，共一百二十頁。 32: 23712377,Sustained inflation 45 for 40 s,Incremental PEEP PIP 35, PEEP 8 35,PCV PIP 45, PEEP 16 I:E 1:2, 2 min,第六十一頁，共一百二十頁。 32: 23712377,第六十二頁，共一百二十頁。nt237。ngw249。)肺內(nèi)皮而非肺泡上皮,Frank JA, McAuley DF, Gutierrez JA, Daniel BM, Dobbs L, Matthay MA. Differential effects of sustained inflation recruitment maneuvers on alveolar epithelial and lung endothelial injury. Crit Care Med 2005。,原發(fā)性ARDS對RM反響(fǎny236。 32: 23712377,PEEP 8,PEEP 12,PEEP 16,第六十八頁，共一百二十頁。,RM: ARDSp與ARDSexp,Lim CM, Jung H, Koh Y, Lee JS, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient. Crit Care Med 2003。 31: 738744,Sustained Inflation: 45 cmH2O x 30 s,第七十一頁，共一百二十頁。 159: 872880,Sigh: 3 consecutive sighs/min at Pplat 45 cmH2O,第七十二頁，共一百二十頁。,RM不增加肺泡(f232。,第七十五頁，共一百二十頁。 98: 14328,第七十六頁，共一百二十頁。)的影響,Bein T, Kuhr LP, Bele S, Ploner F, Keyl C, Taeger K. Lung recruitment maneuver in patients with cerebral injury: effects on intracranial pressure and cerebral metabolism. Intensive Care Med 2002。ng),小潮氣量通氣的問題 肺復(fù)張的理論與實踐 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異(chāy236。g242。,RM對哪些患者(hu224。)的頻率,尚不清楚對某一患者進行肺復(fù)張操作的適宜頻率 以下情況應(yīng)進行肺復(fù)張操作 病程早期 當肺泡塌陷(tāxi224。,肺復(fù)張操作(cāozu242。),肺復(fù)張是肺保護性通氣策略的重要組成 開放肺并維持肺開放是其理論根底 應(yīng)用氣道高壓使塌陷肺泡開放 應(yīng)用足夠(z,PEEP能否(n233。,PEEP能否(n233。),正常潮氣量通氣(tōng q236。,How high a pressure? How long a time? animal,peak airway pressures of 55 cmH2O for 5 – 10 min to open collapsed lung in a porcine model of ARDS Sjosrand et al ICM 1995 to maximally recruit lung in a sheep saline lavage lung injured model 40 cmH2O PEEP, 20 cmH2O PC, Ppeak 60 cmH2O, I:E of 1:1, and a rate of 10 bpm for 2 minutes Fujino et al AJRCCM 1999,第九十三頁，共一百二十頁。,How high a pressure? How long a time? patient,The success of PC vs CPAP in the examples emphasize the relationship between pressure and time Fujino et al AJRCCM 1999 Medoff et al CCM 2000 The optimal relationship between these two variables to maximize efficacy and maintain safety remains unclear,第九十七頁，共一百二十頁。,Side Effects of RMs,hemodynamic compromise delayed until patients hemodynamically stable development of barotrauma the benefits and potential risks must be carefully weighed in patients with preexisting pulmonary cystic or bullous lung disease preexisting airleaks,第一百零一頁，共一百二十頁。,Performance of a RM,CPAP 40/60 PCV (2 min) PC 20 PEEP 40 F 10 I/E 1:1 PCV (30 min) PC 15 PEEP 20 F 20 I/E 1:1,Fujino Y, Goddon S, Dolhnikoff M, Hess D, Amato MBP。,Performance of a RM,If a CPAP of 40 cmH2O for 3040 sec insufficient to recruit the lung PCV 20 cmH2O with PEEP 30 cmH2O, I:E 1:1。,The PV Curve,On the inflation limb of the curve lower inflection point (Pflex) a region of changing slope in early inflation where lung recruitment begins the minimal PEEP necessary to prevent partial derecruitment of the lung during exhalation,第一百一十頁，共一百二十頁。,第一百一十四頁，共一百二十頁。 32: 23712377,第一百一十七頁，共一百二十頁。o)開放壓與閉合壓,,,0,10,20,30,40,50,0,5,10,15,20,25,30,35,40,45,50,Opening pressure,Closing pressure,Paw (cmH2O),Crotti S, Mascheroni D, Caironi P, Pelosi P, Ronzoni G, Mondino M, Marini JJ, Gattinoni L. Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 2001: 164: 131140.,第一百一十九頁，共一百二十頁。nzhě)的肺