【正文】 4,第二十八頁，共一百二十頁。 16: 13511359,第三十頁，共一百二十頁。ng),小潮氣量通氣的問題 肺復張的理論與實踐(sh237。 99: 7180,第三十五頁，共一百二十頁。n)與實踐 肺復張與PEEP 肺復張后的PEEP 不同復張方法的差異 肺復張的臨床適應癥 肺復張的副作用 肺復張存在的問題,第三十八頁，共一百二十頁。ng)不能持久?,肺復張的方法? SI: 50 cmH2O x 30 s 作者(zu242。,RM后的PEEP,第四十三頁，共一百二十頁。,肺泡(f232。,PEEP的設置(sh232。r232。zh236。 33: 9951000,= LIP + 2,第五十四頁，共一百二十頁。,不同(b249。,不同(b249。n x236。x237。,RM保護(bǎoh249。,RM: ARDS早期(zǎoqī) vs. 晚期,Villagra A, Ochagavia A, Vatus S, Murias G, Fernandez MF, Aguilar JL, Fernandez R, Blanch L. Recruitment Maneuvers during Lung Protective Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2002。ngyīn)對RM的反響,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。n q236。o)過度膨脹,Bugedo G, Bruhn A, Hernandez G, et al. Lung computed tomography during a lung recruitment maneuver in patients with acute lung injury. Intensive Care Med 2003。,肺復張對腦氧代謝(d224。,肺泡開放(kāif224。n)意見 在ARDS/ALI病程早期進行肺復張 無論ARDS的病因如何,第八十二頁，共一百二十頁。) 當觀察到SpO2持續(xù)降低( 5 min)時 如果沒有觀察到氧合下降, 那么需要每日進行一次或兩次肺復張 未知,第八十五頁，共一百二十頁。y,How high a pressure? How long a time? healthy lung,transpulmonary pressure of 30 cmH2O to recruit atelectatic healthy lungs Greaves et al JAP 1990 peak alveolar pressures of 40 cmH2O for 7 to 15 seconds to recruit lungs of previously healthy normal patients following 20 minutes of general anesthesia by Rothen et al Br J Anaesth 1993, 1998 resolution of atelectasis during a 40 cmH2O RM has a time constant of 2.6 sec Rothen et al Br J Anaesth 1999,第九十一頁，共一百二十頁。,Mechanism of lung recruitment,Second, the collapsed alveoli must be opened collapsed injured lung units with increased surface tension require very high pressures to establish sufficient lateral stress to open the lung Mead et al JAP 1970,第九十九頁，共一百二十頁。 29:15791586,第一百零五頁，共一百二十頁。,The PV Curve,these two “points〞 identify the range of PEEP needed in ARDS Pflex = the minimum PMCEX = the maximum Ideally, a complete PV should be preformed on all patients identifying these points to allow accurate setting of PEEP,第一百一十二頁，共一百二十頁。,肺泡(f232。Hickling KG. The pressurevolume curve is greatly modified by recruitment. A mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998: 158: 194202.。ir243。,第一百一十六頁，共一百二十頁。,What is Successful Recruitment?,PaO2/FIO2 ratio 300 mmHg,第一百零八頁，共一百二十頁。,Performance of a RM,FIO2 increased to 1.0 for 510 minutes before RM sedation generally required to insure passive inflation during the recruitment period 30 cmH2O CPAP for 3040 sec during the first RM followed by careful assessment of the results,第一百零三頁，共一百二十頁。,How high a pressure? How long a time? patient,peak airway pressure of 46 cmH2O to recruit collapsed lung in ARDS patients Gattinoni et al AJRCCM 1986 35 – 40 cmH2O CPAP for 30 – 40 sec prior to establishing a lung protective ventilatory strategy whenever mechanical ventilation was disrupted Amato et al NEJM 1998,第九十五頁，共一百二十頁。nchuān)于整個吸氣過程 by Hickling AJRCCM 1998 Tidal recruitment occurs below optimal PEEP, PEEP at the optimal level generally results in a decreased quasistatic compliance when measured on the ventilator by Jonson et al AJRCCM 1999,第八十九頁，共一百二十頁。u)的PEEP維持肺泡開放 肺復張對循環(huán)的影響 肺復張尚未解決的問題 壓力 時間 頻率 適應癥,第八十六頁，共一百二十頁。,肺復張操作(cāozu242。,RM對哪些患者(hu224。,內容(n232。iz224。ir243。,SI改善(gǎish224。 161: 14851494,Sustained inflation CPAP 40/30 CPAP 60/30 CPAP 60/30,第六十七頁，共一百二十頁。 33: 181188,第六十四頁，共一百二十頁。ir243。 t243。,不同(b249。,不同(b249。,內容(n232。ozhěng),推薦意見 降低PEEP之前應當首先降低FiO2, 以防止肺泡塌陷 一般情況下 FiO2應當減低到 0.45 如果降低PEEP導致氧合下降 應當重新(ch243。),如果將PEEP設置(sh232。)PaO2 (防止塌陷)的水平 最初將PEEP設置為20 cmH2O 然后將FiO2減小到最低水平 維持SpO2 90 – 95% 每20 – 30分鐘降低PEEP 2 cmH2O 直至患者SpO2下降,第四十九頁，共一百二十頁。,RM后的PEEP,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。 167: 16201626,第四十四頁，共一百二十頁。,RM + PEEP vs. RM vs. PEEP,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。rmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment Maneuvers after a Positive Endexpiratory Pressure Trial Do Not Induce Sustained Effects in Early Adult Respiratory Distress Syndrome. Anesthesiology 2004。 99: 7180,第三十七頁，共一百二十頁。 99: 7180,第三十三頁，共一百二十頁。nther RW, Kuhlen R. Multislice spiral computed tomography to determine the effects of a recruitment maneuver in experimental lung injury. Eur Radiol 2006。,肺復張 – CT的提示(t237。n q236。n q236。,SI改善(gǎish224。ngg242。ng)壓與閉合壓,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.,第十七頁，共一百二十頁。o)的開放壓與閉合壓,第十二頁，共一百二十頁。u)的FiO2 (?) 自主呼吸(?),第十頁，共一百二十頁。 163: 16091613,第七頁，共一百二十頁。ng)造成的容積傷(volutrauma) 足夠的PEEP 防止肺泡復張造成的剪切力損傷(atelectrauma),第五頁，共一百二十頁。ng),小潮氣量通氣的問題(w232。nzhě)的肺復張,北京協(xié)和醫(yī)院,第一頁，共一百二十頁。n) 肺復張與PEEP 肺復張后的PEEP 不同復張方法的差異 肺復張的臨床適應癥 肺復張的副作用 肺復張存在的問題,第二頁，共一百二十頁。,ARDS的肺保護性通氣(tōng q236。 28(5): 596608,第六頁，共一百二十頁。