第二十二章 急性肺损伤（ALI）急性呼吸窘迫综合征（ARDS）.ppt课件

PATHOPHYSIOLOGY

非心源性高通透性肺水肿 　Non-cardiac pulmonary edema with increased permeability 肺呼吸功能改变 　Changes of lung respiratory function 肺循环功能改变 　Changes of lung circulatory function

PATHOPHYSIOLOGY

Inflammatory Response

Inflammatory Response

Acute alveolar and endothelial damage

Vascular permeability

Lung water

protein

Gas exchange

increase

decrease

Inflammatory Mediators in ARDS

Cytokines Interleukins Tumor necrosis factor Interforns Complement proteins Contact activation proteins Bradykinin Coagulation proteins Thrombin Fibrin degradation products

Progtaglandins Leukotrienes Vasoactive peptides Serotonin Histamine Platelet-activating factors

From Foner BJ, Norwood S, Taylor RW: The acute repiratory distress syndrome In: Critical Care. 3rd ed. Civetta JM, Taylor RW, Kirby RR(Eds). Philadelphia, Lippincott-RA##Ven, 1997, pp 1825～1839

PATHOPHYSIOLOGY

Pulmonary edema formation and microcirculatory injU##Ry:

Pulmoanry edema formation Endothelial injU##Ry Epithelial injU##Ry Ventilator induced pulmoary edema

PATHOPHYSIOLOGY

Histologic changes SU##Rfactant Alteration Lung mechanics and Gas exchange Extrapulmonary organ failU##Re

Components and Individual Values of the Lung InjU##Ry Score

Component Value Chest roentgenogram score No alveolar consolidation 0 Alveolar consolidation confined to 1 quadrant 1 Alveolar consolidation confined to 2 quadrant 2 Alveolar consolidation confined to 3 quadrant 3 Alveolar consolidation in all 4 quadrant 4 Hypoxemia score PaO2/FiO2 >300 0 PaO2/FiO2 225～299 1 PaO2/FiO2 175～224 2 PaO2/FiO2 100～174 3 PaO2/FiO2 <100 4 PEEP score PEEP ≤5 cmH2O 0 PEEP 6～8 cmH2O 1 PEEP 9～11 cmH2O 2 PEEP 12～14 cmH2O 3 PEEP ≥15 cmH2O 4

The final value is obtained by dividing the aggregate sum by the number of components that were used. No lung injU##Ry: 0 Mild to moderate: 0.1～2.5 Severe: >2.5

From MU##Rray JF, Mathay MA, Luce JM, et al: An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988;138:720.

临床分期

ARDS分期： 第一期：原发病临床表现 第二期：轻度呼吸困难 第三期：呼吸窘迫 第四期：严重呼吸窘迫

§4. Diagnosis Criteria

ALI: PaO2/FiO2≤300 (whatever PEEP) 　Bilateral infiltrates on chest radiograph PAWP≤18mmHg or no clinical findings suggestive of increased LAP ARDS: PaO2/FiO2≤200 (whatever PEEP) Bilateral infiltrates on chest radiograph PAWP≤18mmHg or no clinical findings suggestive of increased LAP

From Bernard GR, Artigas A, Brigham KL, et al: The American-EU##Ropean consensus conference on ARDS definitions. Am J Respir Crit Care Med 1994;149:818

患者，女性，63，误吸。38mmHg, 100% 9h后： 56mmHg, 50% 13h后： 65mmHg, 50% 20h后： 79mmHg, 50% 34h后： 73mmHg, 50%

§5. 治疗 therapy or treatment

积极治疗原发疾病　　　7. 部分液体通气 控制感染　　　　　　　8. 表面活性物质替代 机械通气支持　　　　　9. 免疫疗法的应用 降低肺血管阻力　　　 10. 营养代谢支持疗法　肾上腺糖皮质激素　　 12. 循环功能的支持 体外膜肺氧合

Fluid Therapy

Conventional Approach: Aims of resuscitation in ARDS: Attain normal vital signs while PAWPis kept as low as possible. Fluid restriction and diU##Retic administration. (1)Input and output records of large amount of fluids given befor the diagnosis of ARDS was given. (2)Clinical evidence of excessive fluid retention, such as peripheral edema. (3)Clinical radiologic evidence of pulmoary congestive and edema (4)Improvement in arterial blood gas values after diU##Retic therapy