17杨从山-ARDS与肺血管通透性.ppt

17杨从山-ARDS与肺血管通透性.ppt

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ARDS与肺血管通透性与肺血管通透性杨从山杨从山东南大学附属中大医院东南大学附属中大医院ICU东南大学急诊与危重病医学研究所东南大学急诊与危重病医学研究所内容概要内容概要nARDS诊断的困惑诊断的困惑n肺血管通透性相关指标的测定肺血管通透性相关指标的测定n肺血管通透性指标对肺血管通透性指标对ARDS诊治的临床评估诊治的临床评估pH7.359PO276.4mmHg（FiO250%）CVP15mmHgLac6.5mmol/LARDS/ALI诊断n急性呼吸窘迫综合征（ARDS）：

急性起病；PaO2/FiO2200mmHg（不管PEEP水平）；正位X线胸片显示双肺均有斑片状阴影；肺动脉肺动脉嵌顿压嵌顿压18mmHg，或无左心房压力增高的临床证据。

n急性肺损伤（ALI）：

如PaO2/FiO2300mmHg且满足上述其它标准BernardGR,etal.TheAmerican-EuropeanConsensusConferenceonARDS.Definitions,mechanisms,relevantoutcomes,andclinicaltrialcoordination.AmJRespirCritCareMed,1994,149:

818PAWP18mmHgiscommonofARDSNEnglJMed，2006,354:

2213-24n29pats：

PAWP18mmHgn97%patswithPAWP18mmHghadanormalorelevatedcardiacindex.1001patients,513assignedtoPAC,488toCVCCVP/PAWP增高不一定就是左心衰增高不一定就是左心衰n高水平PEEP或气道平台压n针对休克的早期大量液体复苏n感染对心肌的抑制n腹内压的增高n肺血管阻力的增加（如COPD）n测量不当ARDS与心源性肺水肿的鉴别诊断与心源性肺水肿的鉴别诊断对于有基础心脏病史，合并感染、休克时鉴别诊断非常困难对于有基础心脏病史，合并感染、休克时鉴别诊断非常困难肺水肿机制HydrostaticpulmonaryedemapulmonaryoedemaPermeabilitypulmonaryedemaCardiogenicpulmonaryedema（CPE）ALI/ARDSThedefinitionofALI/ARDSshouldincludethefunctionalfeatureoflunginjury,i.e.anincreasedpulmonarymicrovascularpermeability.NormallungNEnglJMed,2005,353:

2788-96Starling定律与肺水肿定律与肺水肿nStarling公式公式Qf=K（Pmv-Ppmv）-（mv-Pmv）P=（Pmv-Ppmv）-（mv-Pmv）注：

Qf水分转移量；K毛细血管滤过系数Pmv毛细血管内压；Ppmv肺间质压蛋白质通过屏障系数mv毛细血管内胶体渗透压Pmv肺间质胶体渗透压P毛细血管内外静水压与胶体渗透压差肺泡毛细血管膜肺泡毛细血管膜ARDS液体和蛋白液体和蛋白肺血管通透性肺血管通透性（PVR）的测定的测定n伊文思蓝伊文思蓝（EBD）染料染料荧光比色法荧光比色法用于动物实验，它是经静脉注射伊文思蓝染料，30min后，开胸取出肺，用甲酸胺提取伊文蓝并用荧光光度计定量测定伊文思蓝含量，并通过伊文蓝甲酞胺溶液的荧光光谱和标准曲线来计算伊文思蓝含量来反映PVP肺血管通透性肺血管通透性（PVR）的测定的测定n双核素体内标记技术双核素体内标记技术（67Ga-labeledtransferrinand99mTc-labeledredbloodcells）IntensiveCareMed,2006，32（9）:

1315-21nBALF蛋白含量（/血浆蛋白）nPiCCOCentralVenousCatheterArterialthermodilutioncatheterInjectatetemperaturesensorcablePCCIAP13.0316.28TB37.0AP14011792（CVP）5SVRI2762PCCI3.24HR78SVI42SVV5%dPmx1140（GEDI）625TemperatureinterfacecablePressurecablePiCCO反映肺水肿及通透性指标nExtravascularLungWater:

EVLWnPulmonaryVascularPermeabilityIndex:

PVPI（EVLW/PBV）PulmonaryVascularPermeabilityIndex（PVPI）HydrostaticpulmonaryedemaPermeabilitypulmonaryedemaPVPI=PBVEVLWnormalelevatedelevatedPVPI=PBVEVLWelevatedelevatednormalPVPI=PBVEVLWnormalnormalnormalPBVPBVPBVNormalLungnEVLW/ITBVKatzenelsonP,etal.CritCareMed,2004,32（7）:

1550-4GroeneveldAB.IntensiveCareMed,2006,32（9）:

1315-21nEVLWi/GEDViIntensiveCareMed,2000,26:

180-187IncreasedpulmonarycapillarypermeabilityandextravascularlungwateraftermajorvascularsurgerynSixteenmechanicallyventilatedpatientswithoutheartfailurewerestudied,within3haftermajorabdominalsurgery.nExtravascularlungwater,intrathoracic,globalend-diastolicandpulmonarybloodvolumes,67Ga-transferrinpulmonaryleakindexandventilatoryandradiographicvariablesnThepulmonaryleakindexwaselevatedin11patientsandasupranormalextravascularlungwaterwasassociatedwithahighpulmonaryleakindexEuropeanJournalofAnaesthesiology2006,23:

3641EuropeanJournalofAnaesthesiology2006,23:

3641AccuratecharacterizationofextravascularlungwaterinARDSDesign:

Prospective,observationalcohortstudySetting:

MedicalandsurgicalICUsattwoacademichospitalsCritCareMed2008;36:

18031809IndexingEVLWtoPBWorAdjBWreducesthenumberofARDSpatientswithnormalEVLWCritCareMed2008;36:

18031809nDesign:

RetrospectivereviewofcasesnPatients:

48criticallyillpatsventilatedforARFBilateralinfiltratesonchestradiographPaO2/FiO2300mmHgEVLWI12ml/kgIntervention:

Pulmonarypermeability：

PVPIandEVLWi/GEDViCauseofpulmonaryedema：

determinedby3expertsMeasurementsandresults:

EVLWi/GEDVi3.01021.21021.41020.4102*PVPIcanbehelpfulfordistinguishinghydrostaticpulmonaryedemaandARDSCut-offvalue=3Se=85%Sp=100%ROC-PVPI:

0.920.04UnderlyingetiologiesofARDSpandARDSexpEurRespirJ,2003,22:

Suppl.42,48s56sDothedataobtainedbyPiCCOsystemenabletodifferentiatedirect/indirectALI/ARDS?

nTenpatients,fourwithdirectALI/ARDS（twoaspirationandtwopneumonia）andsixwithindirectALI/ARDS（sepsisinduced）.Allpatientsweremechanicallyventilated.nOnehundredandtwentymeasurementswereavailableforanalysisCriticalCare2006,10（Suppl1）:

P326PI（permeabilityindex）=EVLW/ITBVnConclusion:

EVLWIandPVPImonitoringisofclinicalvaluetosomedegreeinearlydiagnosisofhydrostaticpulmonaryedemaandpermeabilitypulmonaryedema.MaLJandQinYZ,ZhongguoWeiZhongBingJiJiuYiXue,2008;20

（2）:

111-4ComparisonofTwoFluid-ManagementStrategiesinAcuteLungInjuryNEnglJMed2006,354:

2564-75TheconservativestrategyoffluidmanagementisbetterNEnglJMed2006,354:

2564-75EVLWcorrelatedwellwithsurvival373criticallyillpatients,Retrospectiveanalysis.SakkaSG,etal.Chest2002,122:

20802086Extravascularlungwaterinsepsis-associatedARDSCritCareMed2008;36:

6973EVLWpisbetterforidentificationofnonsurvivorsAUCwere0.9880.019,0.8690.112,0.8510.113,and0.6430.137forEVLW