肺复张术与急性呼吸窘迫综合症（一）  

Recruitment Maneuver and Acute Respiratory Distress Syndrome

作　　者：杨自建[1] 张翔宇[1] 

机构地区：[1]同济大学附属上海市第十人民医院外科重症监护病房,上海200072

出　　处：《麻醉与监护论坛》2006年第4期204-206,共3页Forum of Anesthesia and Monitoring

摘　　要：机械通气是纠正急性呼吸窘迫综合征严重低氧血症的主要方法，但是同样可以诱发或加重急性肺损伤。肺复张术的实施可以有效预防或减轻呼吸机相关性肺损伤，改善氧合。肺复张术涉及两个步骤：1）应用充分的吸气压力打开萎陷的肺泡，从而减少肺内分流，改善氧合；2）应用恰当的PEEP维持已经复张的肺泡处于开放状态，防止再次萎陷及由此引起的萎陷伤。目前临床上使用的肺复张术主要有三种：1）控制性肺膨胀法；2）PEEP递增法；3）PVC法。判断肺复张的方法有直接法和间接法，氧饱和度是较为方便的方法，可以根据氧饱和度的变化逐步调定PEEP。经过恰当解读的静态压力-容量环是一种很实用的判断肺复张状态的工具。既往认为压力容量环吸气相低位拐点上2厘米是较为理想的PEEP，但是目前认为在曲线呼吸相拐点上厘米设定PEEP更为合理。如肺复张术失败，氧饱和度随着肺复张术的实施反而下降，应考虑到肺内分流，心内分流存在，并进行相应检查、处理。肺复张术是否可以提高ARDS患者的生存率仍然存在争议，需要进一步研究。Mechanical ventilation is the main method correct severe hypoxemia in acute lung injury and acute respiratory distress syndrome （ALI /ARDS） patients, but can induce or exacerbate the syndrome either Recruitment maneuver is the major measure in the management of ALI /ARDS ta prevenl ventilator reduced lung injury and ameliorate oxygenation. Recruitment maneuver entail two components to open the collapsed lung using sufficient respiratory pressure （to reduce the intraputrnonary shunt and to ameliorate oxygenation） and to keep the lung open with optimal PEEP after recruitment （to prevent redecruitmen and atelectrauma）.Three methods involved in recruitment maneuver can be applied to ALI/ARDS： sustained inflation, stepwise recruitment strategy and pressure control ventiation, except other ancillary measures. Titrate optimal PEEP based on oxygenation saturation is more applicable clinically If appropriately used static pressure - volume curve （PV curve） is a useful tool in assessment of the status of lung aeration and provide some information in recruiting collapsed lung and maintaining recruited lung open. Contrary to previous standard to set ＇optimal PEEP＇at 2 cm above lower inflection point in the inflation limb of PV curve, it is considered more rational to set＇optimal PEEP＇ according to inflection point in the deflation limb of PV curve, in case of failure of recruitment or deterioration of oxygenation during recruitment maneuver, increase of intrapulmonary shunt or intra-cardiac shunt should be considered. So far. whether or not recruitment maneuver could increase the survivor rate of ALI/ARDS patients remains controversial and needs to be further explored.

关 键 词：机械通气 急性肺损伤 急性呼吸窘迫综合征 肺复张术 呼气末正压 肺分流 心内分流 压力容量环 

分 类 号：R563.8[医药卫生—呼吸系统]