• 新疆醫(yī)科大學(xué)第一附屬醫(yī)院ICU（新疆烏魯木齊 830054）;

近年來, 小潮氣量、呼氣末正壓( PEEP) 通氣及肺復(fù)張的肺保護(hù)性通氣策略已普遍被人們接受, 并越來越多的應(yīng)用于 ALI/ARDS 患者。但由此造成的呼吸機(jī)相關(guān)性肺損傷 ( VALI) , 及其對循環(huán)系統(tǒng)的不良反應(yīng)也逐步引起人們的重視, 如何選擇最佳PEEP 成為關(guān)注的熱點(diǎn)。Suter 等[ 1] 于 1975 年首先提出最佳PEEP( optimal PEEP) 的概念, 認(rèn)為既能改善氧合, 又能減少VALI 的PEEP 為最佳PEEP。過去我們通常認(rèn)為在FiO2 ≤ 60% 條件下, 使PaO2 ≥ 60 mm Hg ( 1 mmHg = 0. 133 kPa) 的最低PEEP 為最佳PEEP, 另有學(xué)者利用氧代謝選擇最佳PEEP, 認(rèn)為能達(dá)到最大氧輸送 ( maximal oxygen transport) 的最低PEEP, 才為最佳PEEP[ 2] 。許多學(xué)者認(rèn)為壓力-容積曲線( P-V 曲線) 吸氣支的吸氣支下拐點(diǎn)( lower inflection point, LIP) 為肺泡復(fù)張的結(jié)束, 將PEEP 設(shè)置在LIP + 2 cmH2O( 1 cmH2O= 0. 098 kPa) 附近可以避免肺泡塌陷。近年來隨著大量的臨床和動物實(shí)驗(yàn)的開展, 舊的理論逐漸被推翻, 出現(xiàn)了更多尋找最佳PEEP 的方法, 本文就ALI/ARDS 患者機(jī)械通氣時(shí)PEEP 選擇方法的研究進(jìn)展作一綜述。

引用本文： 陳淑萍,于湘友. ALI/ARDS患者機(jī)械通氣時(shí)最佳PEEP選擇的研究進(jìn)展. 中國呼吸與危重監(jiān)護(hù)雜志, 2009, 09(5): 511-514. doi: 復(fù)制

1. Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med, 1975, 292: 284-289.
2. Hickling KG. Reinterpreting the pressure-volume curve in patients with acute respiratory distress syndrome. Curr Opin Crit Care, 2002 , 8: 32-38.
3. Hickling KG. The pressure-volume curve is greatly modified by recruitment . A mathematical model of ARDS lungs. Am J Respir Crit Care Med, 1998, 158: 194-202.
4. Albaiceta GM, Taboada T. Parra D, et al. Tomographic study of the inflection points of the pressure-volume curve in acute lung injury. Am J Respir Crit Care Med, 2004, 170: 1066-1072.
5. 陳宇清, 周新. 急性呼吸窘迫綜合征的壓力-容積曲線及其臨床應(yīng)用. 中國呼吸與危重監(jiān)護(hù)雜志, 2007, 6: 314-320.
6. LaFollette R, Hojnowski K, Norton J, et al. Using pressure-volume curves to set proper PEEP in acute lung injury. Nurs Crit Care, 2007, 12: 231-241.
7. ·513· ? 2002-2009 Editorial Department of Chinese Journal of Respiratory and Critical Care Medicine. All rights reserved. Http://www.cjrccm.com 19 Rylander C, H　gman M, Perchiazzi G, et al. Functional residual capacity and respiratory mechanics as indicators of aeration and collapse in experimental lung injury. Anesth Analg, 2004,98: 782-789.
8. Hickling KG. Best compliance during a decremental, but not incremental, positive end-expiratory pressure trial is related to open- Lung positive end-expiratory pressure. Am J Respir Crit Care Med, 2001, 163: 69-78.
9. Koefoed-Nielsen J, Andersen G, Barklin A, et al. Maximal hysteresis: a new method to set positive end-expiratory pressure in acute lung injury? Acta Anaesthesiol Scand, 2008 , 52 : 641-649.
10. Syring RS, Otto CM, Spivack RE, et al. Maintenance of endexpiratory recruitment with increased respiratory rate after salinelavage lung injury. J Appl Physiol, 2007, 102: 331-339.
11. , No.
12. Gattinoni L, Caironi P, Carlesso E. How to ventilate patients with acute lung injury and acute respiratory distress syndrome. Curr Opin Crit Care, 2005, 11: 69-76.
13. Toth I, Leiner T, Mikor A, et al. Hemodynamic and respiratory changes during lung recruitment and descending optimal positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. Crit Care Med, 2007, 35: 787-793.
14. Borges JB, Okamoto VN, Matos GF, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med, 2006, 174: 268-278.
15. Meier T, Luepschen H, Karsten J, et al. Assessment of regional lung recruitment and derecruitment during a PEEP trial based on electrical impedance tomography. Intensive Care Med, 2008, 34 : 543-550.
16. Henzler D, Pelosi P, Dembinski R, et al. Respiratory compliance but not gas exchange correlates with changes in lung aeration after a recruitment maneuver: an experimental study in pigs with saline lavage lung injury. Crit Care, 2005, 9: R471-R482.
17. Suarez-Sipmann F, B　hm SH, Tusman G, et al. Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study. Crit Care Med, 2007 , 35: 214 -221.
18. 邱海波, 許紅陽, 楊毅, 等. 呼氣末正壓對急性呼吸窘迫綜合征肺復(fù)張容積及氧合影響的臨床研究. 中國危重病急救醫(yī)學(xué), 2004, 16: 993-204.
19. Grasso S, Terragni P, Mascia L, et al. Airway perssure-time curve porfile ( stress index ) detects tidal recruitment /hyperinflation in experimental acute lung injury. Crit Care Med, 2004 , 32: 1018 - 1027.
20. 邱海波, 陳永銘, 楊毅, 等. 肺牽張指數(shù)指導(dǎo)不同原因急性呼吸窘迫綜合征復(fù)張后呼氣末正壓選擇的實(shí)驗(yàn)研究. 中華外科雜志, 2006, 44: 1181-1184. 中國呼吸與危重監(jiān)護(hù)雜志2009 年9 月第8 卷第5 期Chin J Respir Crit Care Med, September 2009, Vol.
21. Lambermont B, Ghuysen A, Janssen N, et al. Comparison of functional residual capacity and static compliance of the respiratory system during a positive end-expiratory pressure ( PEEP) ramp procedure in an experimental model of acute respiratory distress syndrome. Crit Care, 2008, 12: R91.
22. Tusman G, Suarez-Sipmann F, B　hm SH, et al. Monitoring dead space during recruitment and PEEP titration in an experimental model. Intensive Care Med, 2006, 32: 1863-1871.
23. Carvalho AR, Jandre FC, Pino AV, et al. Positive end-expiratory pressure at minimal respiratory elastance represents the best compromise between mechanical stress and lung aeration in oleic acid induced lung injury. Crit Care, 2007, 11: R86.
24. Pássaro CP, Silva PL, Rzezinski AF, et al. Pulmonary lesion induced by low and high positive end-expiratory pressure levels during protective ventilation in experimental acute lung injury. Crit Care Med. , 2009, 37: 1011-1017.
25. Pelosi P, D′Onofrio D, Chiumello D, et al. Pulmonary and extrapulmonary acute respiratory distress syndrome are different. Eur Respir J, 2003, 42: 48s-56s.
26. Villar J. Positive end-expiratory pressure or no positive endexpiratory pressure: is that the question to be asked? Crit Care, 2003, 7: 192.
  1. 1. Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med, 1975, 292: 284-289.
  2. 2. Hickling KG. Reinterpreting the pressure-volume curve in patients with acute respiratory distress syndrome. Curr Opin Crit Care, 2002 , 8: 32-38.
  3. 3. Hickling KG. The pressure-volume curve is greatly modified by recruitment . A mathematical model of ARDS lungs. Am J Respir Crit Care Med, 1998, 158: 194-202.
  4. 4. Albaiceta GM, Taboada T. Parra D, et al. Tomographic study of the inflection points of the pressure-volume curve in acute lung injury. Am J Respir Crit Care Med, 2004, 170: 1066-1072.
  5. 5. 陳宇清, 周新. 急性呼吸窘迫綜合征的壓力-容積曲線及其臨床應(yīng)用. 中國呼吸與危重監(jiān)護(hù)雜志, 2007, 6: 314-320.
  6. 6. LaFollette R, Hojnowski K, Norton J, et al. Using pressure-volume curves to set proper PEEP in acute lung injury. Nurs Crit Care, 2007, 12: 231-241.
  7. 7. ·513· ? 2002-2009 Editorial Department of Chinese Journal of Respiratory and Critical Care Medicine. All rights reserved. Http://www.cjrccm.com 19 Rylander C, H　gman M, Perchiazzi G, et al. Functional residual capacity and respiratory mechanics as indicators of aeration and collapse in experimental lung injury. Anesth Analg, 2004,98: 782-789.
  8. 8. Hickling KG. Best compliance during a decremental, but not incremental, positive end-expiratory pressure trial is related to open- Lung positive end-expiratory pressure. Am J Respir Crit Care Med, 2001, 163: 69-78.
  9. 9. Koefoed-Nielsen J, Andersen G, Barklin A, et al. Maximal hysteresis: a new method to set positive end-expiratory pressure in acute lung injury? Acta Anaesthesiol Scand, 2008 , 52 : 641-649.
  10. 10. Syring RS, Otto CM, Spivack RE, et al. Maintenance of endexpiratory recruitment with increased respiratory rate after salinelavage lung injury. J Appl Physiol, 2007, 102: 331-339.
  11. 11. , No.
  12. 12. Gattinoni L, Caironi P, Carlesso E. How to ventilate patients with acute lung injury and acute respiratory distress syndrome. Curr Opin Crit Care, 2005, 11: 69-76.
  13. 13. Toth I, Leiner T, Mikor A, et al. Hemodynamic and respiratory changes during lung recruitment and descending optimal positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. Crit Care Med, 2007, 35: 787-793.
  14. 14. Borges JB, Okamoto VN, Matos GF, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med, 2006, 174: 268-278.
  15. 15. Meier T, Luepschen H, Karsten J, et al. Assessment of regional lung recruitment and derecruitment during a PEEP trial based on electrical impedance tomography. Intensive Care Med, 2008, 34 : 543-550.
  16. 16. Henzler D, Pelosi P, Dembinski R, et al. Respiratory compliance but not gas exchange correlates with changes in lung aeration after a recruitment maneuver: an experimental study in pigs with saline lavage lung injury. Crit Care, 2005, 9: R471-R482.
  17. 17. Suarez-Sipmann F, B　hm SH, Tusman G, et al. Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study. Crit Care Med, 2007 , 35: 214 -221.
  18. 18. 邱海波, 許紅陽, 楊毅, 等. 呼氣末正壓對急性呼吸窘迫綜合征肺復(fù)張容積及氧合影響的臨床研究. 中國危重病急救醫(yī)學(xué), 2004, 16: 993-204.
  19. 19. Grasso S, Terragni P, Mascia L, et al. Airway perssure-time curve porfile ( stress index ) detects tidal recruitment /hyperinflation in experimental acute lung injury. Crit Care Med, 2004 , 32: 1018 - 1027.
  20. 20. 邱海波, 陳永銘, 楊毅, 等. 肺牽張指數(shù)指導(dǎo)不同原因急性呼吸窘迫綜合征復(fù)張后呼氣末正壓選擇的實(shí)驗(yàn)研究. 中華外科雜志, 2006, 44: 1181-1184. 中國呼吸與危重監(jiān)護(hù)雜志2009 年9 月第8 卷第5 期Chin J Respir Crit Care Med, September 2009, Vol.
  21. 21. Lambermont B, Ghuysen A, Janssen N, et al. Comparison of functional residual capacity and static compliance of the respiratory system during a positive end-expiratory pressure ( PEEP) ramp procedure in an experimental model of acute respiratory distress syndrome. Crit Care, 2008, 12: R91.
  22. 22. Tusman G, Suarez-Sipmann F, B　hm SH, et al. Monitoring dead space during recruitment and PEEP titration in an experimental model. Intensive Care Med, 2006, 32: 1863-1871.
  23. 23. Carvalho AR, Jandre FC, Pino AV, et al. Positive end-expiratory pressure at minimal respiratory elastance represents the best compromise between mechanical stress and lung aeration in oleic acid induced lung injury. Crit Care, 2007, 11: R86.
  24. 24. Pássaro CP, Silva PL, Rzezinski AF, et al. Pulmonary lesion induced by low and high positive end-expiratory pressure levels during protective ventilation in experimental acute lung injury. Crit Care Med. , 2009, 37: 1011-1017.
  25. 25. Pelosi P, D′Onofrio D, Chiumello D, et al. Pulmonary and extrapulmonary acute respiratory distress syndrome are different. Eur Respir J, 2003, 42: 48s-56s.
  26. 26. Villar J. Positive end-expiratory pressure or no positive endexpiratory pressure: is that the question to be asked? Crit Care, 2003, 7: 192.

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