【正文】 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。,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。,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。),肺復(fù)張是肺保護(hù)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(zg242。,第七十五頁，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。ngw249。 31: 17061714,第六十頁，共一百二十頁。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。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。),RM之后通常將PEEP設(shè)置在能夠維持(w233。ngg242。y242。n) 肺復(fù)張與PEEP 肺復(fù)張后的PEEP 不同復(fù)張方法的差異 肺復(fù)張的臨床適應(yīng)癥 肺復(fù)張的副作用 肺復(fù)張存在的問題,第三十二頁，共一百二十頁。ng),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。 29: 12551260,充氣階段, 每30秒 PEEP增加5 cmH2O Vt減少(jiǎnshǎo)2 ml/kg 前2次呼吸除外 直至Vt 2 ml/kg, PEEP 25 cmH2O 暫停階段 CPAP 30 cmH2O for 30 s 放氣階段,第二十四頁，共一百二十頁。 167: 16201626,第十九頁，共一百二十頁。,肺泡(f232。,小潮氣量通氣(tōng q236。,內(nèi)容(n232。ir243。)的問題,Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of Tidal Volume on Alveolar Recruitment: Respective Role of PEEP and a Recruitment Maneuver. Am J Respir Crit Care Med 2001。ip224。,肺復(fù)張能夠(n233。,嘆氣(t224。 165: 165170,第二十九頁，共一百二十頁。,RM vs. PEEP,Lim CM, Lee SS, Lee JS, Koh Y, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD. Morphometric Effects of the Recruitment Maneuver on Salinelavaged Canine Lungs: A Computed Tomographic Analysis. Anesthesiology 2003。ng)不能持久?,Oczenski W, H246。u)穩(wěn)定肺泡,Halter JM, Steinberg JM, Schiller HJ, DaSilva M, Gatto LA, Landas S, Nieman GF. Positive EndExpiratory Pressure after a Recruitment Maneuver Prevents Both Alveolar Collapse and Recruitment/Derecruitment. Am J Respir Crit Care Med 2003。ich237。,PEEP/FiO2的調(diào)整(ti225。 31: 17061714,第五十七頁，共一百二十頁。,不同(b249。): 大鼠 模型制備: 酸(pH 1.5)吸入 機(jī)械通氣: Vt 6 ml/kg PEEP 5 cmH2O FiO2 1.0 F 60 – 70 bpm 復(fù)張操作: 30 cmH2O x 30 s x 2 間隔1分鐘,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。 31: 411418,第七十頁，共一百二十頁。,肺復(fù)張對(duì)內(nèi)臟(n232。u)的PEEP也不能使所有肺單位開放,第八十頁，共一百二十頁。g242。,How high a pressure? How long a time? animal,animals recruited with 40 cmH2O CPAP for 60 sec not maximally recruited to fully recruit the lung multiple (23) RMs required even at peak pressures of 60 cmH2O,第九十四頁，共一百二十頁。 rate 10/min for 2 min If this is ineffective PCV 20 cmH2O with PEEP 40 cmH2O, I:E 1:1, rate 10/min for 2 min a small drop in CO and an increase in PAP in some animals, with a complete return to pre RM homodynamic status within 10 min in all animals studied Fujino et al AJRCCM 1999,第一百零七頁，共一百二十頁。,內(nèi)容(n232。ip224。,Performance of a RM,whether to use pressures beyond 40 cmH2O still unclear animal data imply that pressures up to 60 cmH2O are safe though these pressures must still be considered experimental and applied very cautiously under well monitored conditions Fujino et al AJRCCM 1999,第一百零六頁，共一百二十頁。,How high a pressure? How long a time? healthy lung,As a result in previously healthy individuals the vast majority of atelectasis would be recruited within about 78 sec,第九十二頁，共一百二十頁。,總結(jié)(zǒngji233。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.,即使使用足夠(z 29: 218225,第七十四頁，共一百二十頁。 32: 23712377,RM + PEEP,PEEP only,第六十九頁，共一百二十頁。)肺內(nèi)皮而非肺泡上皮,試驗(yàn)動(dòng)物(d242。tǒng)的抑制 防止對(duì)呼吸力學(xué)的不良影響,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。 t243。),將PEEP從不必要的高水平逐漸降低 不要將PEEP由低水平增加到高水平 如同PV曲線(qūxi224。zh236。,RM后的PEEP能夠(n233。,為什么肺復(fù)張作用(zu242。ji224。,ARDS對(duì)RM的反響(fǎny23