ARDS诊治进展PPT课件.ppt

;ARDS的病理生理定义;ARDS的病因; ARDS的发生机制？;1 肺间质 2 肺泡;失活表面活性物质;;1.感染性肺水肿 (pulmonary edema due to infection);ARDS肺水肿的 成分： 富含蛋白 细胞碎片 未激活的PS 中性粒细胞 巨噬细胞 炎症介质 ......; ARDS的病理生理; ARDS的临床诊断？;;;An early PEEP/FIO2 trial identifies different degrees of lung injury in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med.?2007； 15;176(8):795-804. ; 29%ARDS患者PAWP≥18mmHg（或CVP升高）, 而其中97%PAWP升高的ARDS患者中有正常的心脏功能。结论：PAWP或CVP升高不能作为ARDS的排除标准。;Berlin Definition 2012 柏林定义;Berlin Definition of ARDS; ARDS的治疗策略？;ARDS的治疗原则;延误使用有效抗生素增加重症肺炎死亡率;ARDS的治疗原则;ARDS的治疗原则;ARDS的治疗原则;Ventilator Induced Lung Injury，VILI;OverdistentionBarotrauma Volutrauma;;;; ARDS的保护性通气策略？;Oxidant injury- keep FiO2 60 Barotrauma- keep alveolar inflation pressures 35 cm H2O Volutrauma- Baby lung concept or stretch injury Atelectrauma- repeated opening and closing Biotrauma- release of inflammatory mediators and bacterial translocation OPEN GENTLY AND KEEP THEM OPEN 温柔的打开肺泡，并保持开放;传统的肺保护性通气策略;LUNG PROTECTIVE VENTILATION WITH LOW TIDAL VOLUME;;提纲：临床探讨的通气模式与参数;2000年 《NEJM》， 861名成人ARDS患者 治疗组：小潮气量（4-6ml/kg）,限制压力（平台压30cmH2O），允许性高碳酸血症但保持pH大于7.3 显著改善预后 病死率 39.8%―→31% 自主呼吸天数 10天―→12天 首次为小潮气量通气模式提供可靠的循证医学证据 ;平台压的调整策略（跨肺压、驱动压）;787 patients from ARDS Network study;;;Ventilation Using the Best PEEPPrevention of Atelectrauma（最佳PEEP）;VCV vs PCV 定容与定压 ;RECRUITMENT 肺复张;RECRUITMENT MANEUVER;Variations in Patients: Some Need Higher PEEP Than Others;Current evidence suggests that that RMs should not be routinely used on all ARDS patients unless severe hypoxemia persists or as a rescue maneuver to overcome severe hypoxemia, to open the lung when setting PEEP, or following evidence of acute lung derecruitment such as a ventilator circuit disconnect 结论：RM不常规用在所有的ARDS患者，除非持续的严??低氧血症，或者做为严重低氧血症的一种肺开放手段（设置PEEP），或者由于管路断开出现急性肺陷闭;;Computed tomography scan of the lungs showing ARDS when the patient is lying supine (left) and prone (right).;Prone Positioning;The Prone-Supine II Study is the largest clinical trial (N 5342)