心脏病患者的正压通气─心肺相互作用.

北京协和医院杜斌心脏病患者的正压通气:心肺相互作用利益冲突无机械通气是心脏病患者常用的治疗手段美国6个州共6,469,674名住院患者180,326(2.8%)接受机械通气AMI1.7%心脏功能不全18.4%全球20个国家361个ICU中15,757名患者5,183(33%)接受机械通气急性呼衰68.8%原因术后20.8%肺炎13.9%充血性心衰10.4%全身性感染8.8%创伤7.9%WunschH,Linde-ZwirbleWT,AngusDC,etal.TheepidemiologyofmechanicalventilationintheUnitedStates.CritCareMed2010;38:1947-1953EstebanA,AnzuetoA,FrutosF,etal.Characteristicsandoutcomesinadultpatientsreceivingmechanicalventilation.A28-dayinternationalstudy.JAMA2002;287:345-355自主呼吸及机械通气对心血管的影响ShekerdemianL,BohnD.Cardiovasculareffectsofmechanicalventilation.ArchDisChild1999;80:475-480正压通气胸腔内压肺容积前负荷后负荷心率心肌收缩力正压通气对心血管的影响ScharfSM,CaldiniP,IngramRH.Cardiovasculareffectsofincreasingairwaypressureinthedog.AmJPhysiol1977;232:H35-H43胸腔内压改变的血流动力学影响ThoraxVenousReturnLVEjection自主呼吸对LV充盈的影响Lemaire,etal.Anesthesiol1988;69:171-179胸腔内负压的剧烈波动可导致肺水肿哮喘持续状态上气道梗阻肺水肿StalcupandMellins.NEnglJMed1977;297:592-596KanterandWatchko.AmJDisChil1984;138:356-358Lukeetal.Pediatrics1966;37:762-768Oswaltetal.JAMA1977;238:1833-1835Miroetal.Chest1989;96:1430-1431NPPE的发病机制UpperAirwayObstructionMullerManeuverITPmorenegativePulm.bloodvolumePulm.arterialpressureTransudationPulmonaryEdemaCapillarypermeabilityPulm.capillarydamagePulm.arterialconstrictionSystemicvasoconstrictionCNSHypoxiaLVafterloadPulm.venouspressurePericapillaryhydrostaticpressureCOITP升高能够降低LV后负荷，增加心输出量β-受体阻滞剂诱导的急性心功能衰竭（犬模型）Pinskyetal.JApplPhysiol1983;54:950-955Pinskyetal.JApplPhysiol1985;58:1189-1198合并CHF的心肌病患者Pinsky&Summer.Chest1983;84:370-375急性心功能衰竭犬模型心动周期特异性ITP增加Pinskyetal.JApplPhysiol1986;60:604-612预防低血容量下CO下降Matuschaketal.JApplPhysiol1986;61:44-53急性二尖瓣返流的犬模型Steinetal.JApplPhysiol1990;69:2120-2125ITP改变对LV射血的影响ITP下降能够增加LV射血压，增加LV后负荷ITP升高能够降低LV射血压，降低LV后负荷Buda,Pinsky,etal.NEnglJMed1979;301:453-459Pinsky,etal.JApplPhysiol1983;54:950-955LVPV曲线，MVO2和心脏做功的关系StrokeWorkElastance-DefinedPotentialWorkThehiddenmechanicalworkoftheLVSugaH,HayashiT,ShirahataM.Ventricularsystolicpressure-volumeareaaspredictorofcardiacoxygenconsumption.AmJPhysiol1981;240:H39-H44LV压力─容积面积(PVA)VendelinM,BovendeerdPHM,EngelbrechtJ,etal.Optimizingventricularfibers:uniformstrainorstress,butnotATPconsumption,leadstohighefficiency.AmJPhysiol2002;283:H1072-H1081LVVolumeStrokeWorkPELVVolumePVALVPressureATP/MVO2PVALVPV曲线，MVO2和心脏做功的关系LVVolumeLVPressureABLVVolumeLVPressureABMVO2AMVO2B两个P/V环：每搏功相同PVA及MVO2不同正压通气对LV前负荷和后负荷的影响DenaultAY,GorcsanJ,PinskyMR.Dynamiceffectsofpositive-pressureventilationoncanineleftventricularpressure-volumerelations.JApplPhysiol2001;91:298-308正压通气对LV前负荷和后负荷的影响DenaultAY,GorcsanJ,PinskyMR.Dynamiceffectsofpositive-pressureventilationoncanineleftventricularpressure-volumerelations.JApplPhysiol2001;91:298-308正压通气对LV前负荷和后负荷的影响DhainautJF,DevauxJY,MonsallierJF,etal.MechanismsofdecreasedleftventricularpreloadduringcontinuouspositivepressureventilationinARDS.Chest1986;90:74-80LV收缩力正常时ITPITPIncreasedLVEjectionPressureIncreasedLVPreloadDecreasedLVEjectionPressureDecreasedLVPreloadPinskyMR.Thehemodynamicconsequencesofmechanicalventilation:anevolvingstory.IntensiveCareMed1997;23:493-503LV收缩力降低时ITPITPIncreasedLVEjectionPressureIncreasedLVPreloadDecreasedLVEjectionPressureDecreasedLVPreloadPinskyMR.Thehemodynamicconsequencesofmechanicalventilation:anevolvingstory.IntensiveCareMed1997;23:493-503无创CPAP和BiPAP能够减轻心脏应激CPAP能够减轻急性心源性肺水肿(ACPE)患者的心脏缺血Rasanenetal.AmJCardiol55:296-300,1985如果CPAP能够消除ACPE患者的胸腔内负压，才能发挥有益作用Rasanenetal.Chest87:158-62,1985面罩CPAP可避免ACPE患者气管插管Berstenetal.NEnglJMed325:1825-30,1991面罩BiPAP以及PSV可改善ACPE患者氧合，避免气管插管Massipetal.Lancet356:2126-32,2000Giacominietal.Chest123:2057-61,2003Navaetal.AmJRespirCritCareMed168:1432-7,2003Ferreretal.AmJRespirCritCareMed168:1438-44,2003CPAP和BiPAP对ACPE具有相似的有益作用Parketal.CritCareMed32:2407-15,2005面罩BiPAP能够改善OSA患者的左心室功能Kanekoetal.NEnglJMed348:1233-41,2003急性心梗时的CPAPRasanenetal.Chest1985；87:158-162CPAP对CHF患者ITP的影响NaughtonMT,RahmanA,HaraK,etal.Effectofcontinuouspositiveairwaypressureonintrathoracicandleftventriculartransmuralpressuresinpatientswithcongestiveheartfailure.Circ1995;91:1725-1731CPAP对CHF患者ITP的影响NaughtonMT,RahmanA,HaraK,etal.Effectofcontinuouspositiveairwaypressureonintrathoracicandleftventriculartransmuralpressuresinpatientswithcongestiveheartfailure.Circ1995;91:1725-1731CPAP改善CHF患者的LV功能24名合并CHF的OSA患者夜间CPAPx1mthvs.对照组夜间CPAP组病情改善OSA发作减少收缩压降低(126to116mmHg)心率减慢(68to63bpm)LV射血分数改善(25to34%)LV收缩末内径减小(55to53mm)Kanekoetal.NEnglJMed2003;348:1233-1241CPAP改善CHF患者的LV功能Kanekoetal.NEnglJMed2003;348:1233-1241ACPE时的面罩CPAP39名ACPE患者随机分为面罩CPAP组或氧疗组(FiO20.4)研究持续24h30分钟后呼吸频率及PaCO2下降24h时两组患者生理指标相似气管插管比例CPAP组0/20对照组7/19Berstenetal.NEnglJMed1991;325:1825-1830ACPE时的面罩CPAPBerstenetal.NEnglJMed1991;325:1825-1830CPAPO2ACPE的无创通气Masip,etal.Lancet2000;356:2126-2132Control(n=18)NIPSV(n=19)ACPE的无创通气Masip,etal.Lancet2000;356:2126-2132ACPE的无创机械通气FerrerM,EsquinasA,LeonMetal.Noninvasiveventilationinseverehypoxemicrespiratoryfailure:arandomizedclinicaltrial.AmJRespirCritCareMed2003;168:1438-1444ACPE的无创机械通气FerrerM,EsquinasA,LeonMetal.Noninvasiveventilationinsevere