ARDS患者的肺复张-nursing.pptVIP免费

ARDS患者的肺复张ALI/ARDS的定义ALI急性起病胸片对称的侵润影PaO2/FiO2300mmHgPAWP18mmHg或没有左心衰的证据ARDS急性起病胸片对称的侵润影PaO2/FiO2200mmHgPAWP18mmHg或没有左心衰的证据ARDS肺部形态学的改变PuybassetL,etal.Regionaldistributionofgasandtissueinacuterespiratorydistresssyndrome.I.Consequencesforlungmorphology.IntensiveCareMed2000;26:857-69.ARDS肺部形态学的改变ARDS患者健康对照CT平均密度(HU)-25621-6548组织容积(ml/m2BSA)31.61.716.70.8气体容积(ml/m2BSA)11.51.232.21.8胸腔内总容积(ml/m2BSA)43.02.349.02.5GattinoniL,etal.Relationshipsbetweenlungcomputedtomographicdensity,gasexchangeandPEEPinacuterespiratoryfailure.Anesthesiology1988;69:824-32.ARDS肺部形态学的改变PatronitiN,BellaniG,MaggioniE,ManfioA,MarcoraB,PesentiA.Measurementofpulmonaryedemainpatientswithacuterespiratorydistresssyndrome.CritCareMed2005;33:2547-2554ARDS肺部形态学的改变GATTINONI-3ZONES过度膨胀,“干”,“婴儿肺"湿,PEEP可使其复张塌陷或实变区域HEARTSPGattinoniL.JThoracImag1986;1(3):25ARDS肺部形态学的改变婴儿肺(BABYLUNG)的概念–通气的肺仅相当于正常肺的20–30%ARDS患者肺容积的减少并非意味胸腔内总容积的减少–仅仅是实变组织替代了气体GattinoniL,etal.Relationshipsbetweenlungcomputedtomographicdensity,gasexchangeandPEEPinacuterespiratoryfailure.Anesthesiology1988;69:824-32.气压伤(barotrauma)机械通气导致肺过度牵张所引起的肺损伤容积伤(volutrauma)NormalratlungsPIP45,5minPIP45,20mins剪切力损伤(atelectrauma)指由于肺泡反复塌陷和复张所造成的损伤肺泡塌陷时的剪切力损伤驱动压力30cmH2O时通气肺泡与不通气肺泡交界处的剪切力可高达140cmH2O(Mead1970)F=PLx(V0/V)2/3ARDS保护性肺通气策略机械通气时有两个肺损伤区域–肺容积过低可导致剪切力损伤–肺容积过高可导致肺泡过度牵张，引起容积伤FroeseAB,CritCareMed1997;25:906肺开放与ARDSEditorialEditorialOpenupthelungandkeepthelungopenOpenupthelungandkeepthelungopenB.LachmannB.LachmannDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlandsDept.ofAnesthesiology,ErasmusUniversityRotterdam,TheNetherlands(1992)18:319-321(1992)18:319-321肺泡...