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呼吸机治疗的肺保护策略.ppt
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    呼吸机治疗的肺保护策略

    浙江大学医学院附属儿童医院

    施丽萍

    呼吸机相关性肺损伤

    ? acute parenchymal lung injury and an acute inflammatory response in the lung.

    ? cytokines →alveoli and the systemic circulation →multiple organ dysfunction

    ? mortality↑

    呼吸机相关性肺损伤

    ventilator-induced lung injury

    ? 容量性损伤

    Volutrauma(large gas volumes )

    ? 压力性损伤

    Barotrauma(high airway pressure )

    ? 不张性损伤

    Atelectotrauma(alveolar collapse and re-expansion)

    ? 生物性损伤

    Biotrauma(increased inflammation )

    肺 损 伤 病 理

    ? alveolar structural damage

    ? pulmonary edema、 inflammation、 fibrosis

    ? surfactant dysfunction

    ? other organ dysfunction

    ? exacerbate the disturbance of lung development

    Semin Neonatol. 2002 Oct;7(5):353-60.

    Approaches in the management of acute respiratory failure in children

    protective ventilatory and potential protective

    ventilatory modes

    lower tidal volume and PEEP

    permissive hypercapnia

    high-frequency oscillatory ventilation

    airway pressure release ventilation

    partial liquid ventilation

    improve oxygenation

    recruitment maneuvers

    prone positioning

    kinetic therapy

    reduce FiO2 and facilitate gas exchange

    inhaled nitric oxide and surfactant

    Curr Opin Pediatr. 2004 Jun;16(3):293-8.

    Can mechanical ventilation strategies reduce chronic lung disease?

    ? continuous positive airway pressure

    ? permissive hypercapnia

    ? patient-triggered ventilation

    ? volume-targeted ventilation

    ? proportional assist ventilation

    ? high-frequency ventilation

    Semin Neonatol. 2003 Dec;8(6):441-8

    小潮气量和呼气末正压

    lower tidal volume and PEEP

    Ventilation with lower tidal volumes versus traditional tidal volumes in adults for ALI and ARDS

    ? 1202 patients

    ? lower tidal volume (≤7ml/kg)

    low plateau pressure ≤30 cm H2O versus

    ? tidal volume 10 to 15 ml/kg

    ? Mortality at day 28 ?

    ? long-term mortality was uncertain

    ? low and conventional tidal volume with plateau pressure ≤31 cm H2O was not significantly different

    Cochrane Database Syst Rev. 2004;(2):CD003844

    Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome

    ? 549 patients acute lung injury and ARDS

    ? lower-PEEP group 8.3±3.2cmH2O

    higher-PEEP group 13.2±3.5cmH2O (P<0.001).

    ? tidal-volume 6ml/kg

    end-inspiratory plateau-pressure≤30cmH2O

    ? The rates of death 24.9 % 27.5 % (p=0.48)

    From day 1 to day 28, breathing was unassisted

    14.5±10.4 days 13.8±10.6 days (p=0.5)

    ? clinical outcomes are similar whether lower or higher PEEP levels are used.

    N Engl J Med. 2004 Jul 22;351(4):327-36.

    Increasing inspiratory time exacerbates ventilator-induced lung injury during high-pressure/high-volume mechanical ventilation

    ? Sprague-Dawley rats

    ? negative control group ......

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