呼吸机相关性肺损伤：机理与防治.pptx

4/29/2021,#,弥散性肺损伤影响到气血屏,障,肺泡渗出,炎症反应和表面活,性,物质变,化,高死亡率,(40%),病残率,长远生活,质,量明显下降和高花,费,USA:,每年,200,000,病人,75,000,人死亡和,3,500,000,住院天数,Goss,et,al,2003.,Ware,et,al,2000.,Bachofen,et,al 1982 Rubenfeld,2005,ALI/ARDS:,“,肺受袭,”,ARDS,治疗,:,小潮气量通,气,Brower et al,NEJM,1999,ACCP J,club,2001,急性肺损伤,急性呼吸窘迫综合征,炎症反应,机械,化学,生物,+,渗透性的肺水肿及结果,急性肺损伤病理生,理,毛细压力失,常,酸的误,吸,直,接,SARS,流感病毒,呼吸道合胞病毒,卡氏肺孢子虫肺,炎,非直,接,SIRS,再灌注,IL2,TRALI,呼吸膜损伤,直接肺损伤病理生,理,非直接肺损伤,:,中性粒细胞调,节,Abraham,E.,Neutrophils,and,acute,lung,injury.,Crit,Care Med 2003;31(4,Suppl):S195-9,机械损伤,:,毛细压力失,常,J.B.,West Am J,Physiol Lung,Cell,Mol Physiol,2003;,肺泡,-,毛细血管膜,:,表面 厚度 拉力,1000,ft,2,0.2,microns,35 cm,H,2,O,不同吸气压力导致的肺泡扩,张,Paw 35,cm,H,2,O,Paw 12,cm,H,2,O,按照高危因素分组的,ALI/ARDS,发病,率,Ferguson ND,Frutos-Vivar F,Esteban A,et al.Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward:a prospective observational study.,Crit,Care.,Sep 4,2007;11(5):R96,危险因,素,“,修饰,”,长期或大量饮,酒,糖尿,病,吸,烟,低蛋白血,症,酸中,毒,既往肺疾病,史,二,次,“,打击,”:,通气肺损伤,(VALI),FIO,2,（,高浓度吸氧,）,RBC,Platelet,&,FFP,transfusion,（,输血）,Cardiac,dysfunction/fluid,（,心功能失常）,Gajic O,Dara SI,Mendez JL,Adesanya AO,F,Crit,Care Med.2004,Sep;32(9):1817-24,ICU,获得的,ALI,危险因,素,:,呼吸机设,置,Gajic O,Frutos-Vivar,F,Esteban A,Hubmayr RD,Anzueto,A,Intensive Care,Med.,2005,Jul;31(7):922-6,A,R,DS,NO,ARDS,I,C,U,获得的,A,RDS,风险因素,13,14,1,6,18,19,456789,10,1,Vt,mL/kg,PBW,13,14,1,6,18,19,456789,10,1,Vt,mL/kg,PBW,NOT,SAFE,NOT,SAFE,Ventilator,settings,%,ARDS,M,o,rtalit,y,33%,9.6%,28.3%,18%,ALI,预,防,证,实,风险因素,OR,95%,CI,P,value,任何输血,2.14,1.24,to,3.75,0.008,输血可能,1.00,0.43,to,2.31,0.992,肺炎,6.89,4.37,to,10.95,0.001,误吸,2.07,1.11,to,3.88,0.023,脓毒血证,4.95,3.28,to,7.53,20ml/kg),高气道峰压、高平台压、高水平的,P,EE,P,及大潮气,量,都应视为,VILI,的风险因素,。

易发气压伤的临床状,态,ALI/ARDS,患者进行大潮气量,（,12ml/kg,）,通,气,应用高水平,PEEP,（,15cmH2O,）,高水平气道峰压（,5060cmH2O,）,ARDS,患者病程的晚期（,23,周,）,严重的气道阻塞性疾,病,ARDS,患者并发肺部感染,时,PCP,和病毒性肺,炎,肺结核合并肺大,疱,VI,L,I,发生的微观机,制,VILI,时肺毛细血管通透性增高的机,理,机械牵,拉,肺表面活性物质灭活,剪切力,（,stress,force),，,使血管跨壁压明显增高而引 起孔样牵张,（,pore,stretching,）,或血管的牵拉衰竭,（,capilary stress,failure,）,炎症细胞及细胞因子的参,与,TNF-a,、,IL-1,、,IL-6,、,MIP-2,等，,气压伤的临床表,现,临床症,状,突然或进行性的气道峰压和平台压增,高,出现低血压或心血管功能衰,竭,突然出现烦躁和呼吸窘迫，人机对,抗,胸部影像学发,现,一侧胸腔肺容积增,大,深沟征（膈肌或肋膈角下移,）,一侧肺或部分肺透亮度增,加,重视影床旁学检,测,淋巴瘤化疗后肺部并发,症,病情介,绍,男性，,40,岁,2011,年,1,月,16,日因肛周脓肿入,院,2011-1-17,行肛周脓肿切开引,流,术后当日夜间体温,38.9,度,术后,1,周持续发热,38,度左,右,呼吸困难进行性加,重,2011-1-24,日气管插,管,美罗培南,+,替考拉宁,+,伏立康唑,痰涂片,G+,球菌,痰培养多次为,MDR,不动杆菌，一次为光滑念珠菌,2011-1-2,2,2011-1-24,2011-1-3,1,甲强龙,80m,g/d,40,39.,5,39,泼尼松,38.,5,38,37.,5,37,36.,5,36,40,39.,5,39,38.,5,38,37.,5,37,111111111111111,/,1,/,1,/,1,/,1,/,1,111111111,/,1,2,7,2,8,2,9,3,0,3,1,1,/,2,/,3,/,4,/,5,/,6,/,7,/,8,/,9,/,1,0,1,/,1,/,1,/,1,/,1,/,2,/,2,/,2,/,2,/,2,/,2,/,2,/,2,/,2,/,2,/,3,0,2,5,2,0,1,5,1,0,5,0,01,/27/,11,01,/28/,11,01,/29/,11,01,/30/,11,01,/31/,11,02,/01/,11,02,/02/,11,02,/03/,11,02,/04/,11,02,/05/,11,02,/06/,11,02,/07/,11,02,/08/,11,02,/09/,11,02,/10/,11,舒普,深,美,平,替考拉,宁,斯,沃,伏立康唑 口服万古霉,素,40,39.,5,39,泼尼松,38.,5,38,37.,5,37,36.,5,36,40,39.5,39,38.5,38,37.5,37,1/,27/1,1,1/,28/1,1,1/,29/1,1,1/,30/1,1,1/,31/1,1,2/,1/11,2/,2/11,2/,3/11,2/,4/11,2/,5/11,2/,6/11,2/,7/11,2/,8/11,2/,9/11,2/,10/1,1,舒普,深,美,平,替考拉,宁,斯,沃,伏立康唑 口服万古霉,素,气,胸,。