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!!!
:
, -,
-, -
3 : ()
-
II
III
, ,
IV
VI
2
2
(
FRC)
(pO2/FiO2) , 50
mmHg
R
-
,
- - upper inflection point
(UIP) - 30-40 c H2O 20-40
?
(Sighs)?
PEEP?
, PEEP
,
( !)
10 1000-1200 ,
PEEP 10-12 cm H2O
pO2/FiO2
10
20
30
Pressure [cmH2O]
40
50
60
(< 30 c H20 6 /)
Amato, AJRCCM 1995;152:1835-1846
Amato, NEJM 1998; 338:347-354
ARDS Network N Engl J Med 2000;342:1301-08
(Inflection Points)
0.6
0.4
0.2
B
-40
-20
20
40
( )
-, -,
-
? (2 > 55
Hg)
( 2 = 60 Hg, Sat O2 = 89%)
,
. ! :
1.
Hipcrates
(6 / 8 /, Vt Noli Nocere
P )?
plat
2.
(, )?
3.
,
?
4.
5.
6.
1.
?11
1.
VT 6 /?
-
ARDS study
VT=12 /
Eichacker et al. Am J Respir Crit Care Med 2002;
166:1510-1514
Stewart et al. N Engl J Med 1998; 338: 355-361
Brochard et al. Am J Respir Crit Care Med 1998; 158:
1831-1838
2.
!
3.
, ?
-
.
4.
?
:
,
, ,
,
30 cm H20
Lung
A
Lung
Lung
B
Lung
-20
B
Lung
B
,
-20
-20
,
Vt?
6 ml/kg?
,
Vt?
?
,
,
6.
?
, =
(FRC) - APRV ? HFO? ARDS Network?
MAP,
, HFO & APRV
,
APRV & ARDS Network
30
cmH20
Pressure
20
10
0
APRV
HFO
ARDS Network
7. ?
open lung rest
-, -, -