17杨从山-ARDS与肺血管通透性.ppt

1、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pH 7.359 PO2 76.4 mmHg(FiO2 50%)CVP 15mmHg Lac 6.5mmol/LARDS/ALI诊断n急性呼吸窘迫综合征(ARDS)：急性起病；PaO2/FiO2200 mmHg(不管PEEP水平)；正位X线胸片显示双肺均有斑片状阴影；肺动

2、脉肺动脉嵌顿压嵌顿压18 mmHg，或无左心房压力增高的临床证据。n急性肺损伤(ALI)：如PaO2/FiO2300 mmHg且满足上述其它标准 Bernard GR,et al.The American-European Consensus Conference on ARDS.Definitions,mechanisms,relevant outcomes,and clinical trial coordination.Am J Respir Crit Care Med,1994,149:818PAWP18 mmHg is common of ARDSN Engl J Med，2006,3

3、54:2213-24n 29 pats：PAWP 18 mmHgn 97%pats with PAWP 18 mmHg had a normal or elevated cardiac index.1001 patients,513 assigned to PAC,488 to CVCCVP/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，

4、合并感染、休克时鉴别诊断非常困难肺水肿机制Hydrostaticpulmonary edemapulmonary oedemaPermeabilitypulmonary edemaCardiogenic pulmonary edema(CPE)ALI/ARDSThe definition of ALI/ARDS should include the functional feature of lung injury,i.e.an increased pulmonary microvascular permeability.Normal lungN Engl J Med,2005,353:278

5、8-96Starling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，30 min后，开胸取出肺，用甲

6、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-labeled transferrin and 99mTc-labeled red blood cells)Intensive Care Med,2006，32(9):1315-21n BALF蛋白含量(/血浆蛋白)nPiCCOCentral Venous CatheterArterial thermodilution catheter Injectate temperatur

7、e sensor cable PCCIAP13.03 16.28 TB37.0AP 140117 92(CVP)5SVRI 2762PCCI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625 Temperature interface cable Pressure cable PiCCO反映肺水肿及通透性指标nExtravascular Lung Water:EVLWnPulmonary Vascular Permeability Index:PVPI(EVLW/PBV)Pulmonary Vascular Permeability Index (PVPI)Hyd

8、rostaticpulmonary edemaPermeabilitypulmonary edemaPVPI=PBVEVLWnormalelevatedelevatedPVPI=PBVEVLWelevatedelevatednormalPVPI=PBVEVLWnormalnormalnormalPBVPBVPBVNormal LungnEVLW/ITBV Katzenelson P,et al.Crit Care Med,2004,32(7):1550-4 Groeneveld AB.Intensive Care Med,2006,32(9):1315-21 nEVLWi/GEDViInten

9、sive Care Med,2000,26:180-187Increased pulmonary capillary permeability and extravascular lung water after major vascular surgerynSixteen mechanically ventilated patients without heart failure were studied,within 3 h after major abdominal surgery.nExtravascular lung water,intrathoracic,global end-di

10、astolic and pulmonary blood volumes,67Ga-transferrin pulmonary leak index and ventilatory and radiographic variablesnThe pulmonary leak index was elevated in 11 patients and a supranormal extravascular lung water was associated with a high pulmonary leak indexEuropean Journal of Anaesthesiology 2006

11、,23:3641European Journal of Anaesthesiology 2006,23:3641Accurate characterization of extravascular lung water in ARDSDesign:Prospective,observational cohort studySetting:Medical and surgical ICUs at two academic hospitalsCrit Care Med 2008;36:18031809Indexing EVLW to PBW or AdjBW reduces the number

12、of ARDS patients with normal EVLWCrit Care Med 2008;36:18031809nDesign:Retrospective review of cases nPatients:48 critically ill pats ventilated for ARF Bilateral infiltrates on chest radiograph PaO2/FiO2 300 mm Hg EVLWI 12 ml/kgIntervention:Pulmonary permeability：PVPI and EVLWi/GEDVi Cause of pulmo

13、nary edema：determined by 3 experts Measurements and results:EVLWi/GEDVi 3.01021.2102 1.41020.4102*PVPI can be helpful for distinguishing hydrostatic pulmonary edema and ARDSCut-off value=3 Se=85%Sp=100%ROC-PVPI:0.920.04Underlying etiologies of ARDSp and ARDSexp Eur Respir J,2003,22:Suppl.42,48s56sDo

14、 the data obtained by PiCCO system enable to differentiate direct/indirect ALI/ARDS?nTen patients,four with direct ALI/ARDS(two aspiration and two pneumonia)and six with indirect ALI/ARDS(sepsis induced).All patients were mechanically ventilated.nOne hundred and twenty measurements were available fo

15、r analysisCritical Care 2006,10(Suppl 1):P326PI(permeability index)=EVLW/ITBVnConclusion:EVLWI and PVPI monitoring is of clinical value to some degree in early diagnosis of hydrostatic pulmonary edema and permeability pulmonary edema.Ma LJ and Qin YZ,Zhongguo Wei Zhong Bing Ji Jiu Yi Xue,2008;20(2):

16、111-4 Comparison of Two Fluid-ManagementStrategies in Acute Lung InjuryN Engl J Med 2006,354:2564-75The conservative strategy of fluid management is betterN Engl J Med 2006,354:2564-75EVLW correlated well with survival 373 critically ill patients,Retrospective analysis.Sakka SG,et al.Chest 2002,122:20802086Extravascular lung water in sepsis-associated ARDSCrit Care Med 2008;36:6973EVLWp is better for identification of nonsurvivorsAUC were 0.9880.019,0.8690.112,0.8510.113,and 0.643 0.137 for EVLW