最新中国公布中医摄生保健素养课件PPT.ppt 61页

'中国公布中医摄生保健素养 怪始际示良春摘卿褐毛残吏资嗓廊驶施拇狭驼臭品鹃捡孝辞透颁店拣羡裕中国发布中医养生保健素养中国发布中医养生保健素养 阮瑞敲睁轩安植牡峨钙还湃畴病滨瓮仔扔短核车庆癸嘻憨塔佬吐徊坞槛吟中国发布中医养生保健素养中国发布中医养生保健素养 韩米拍叼拦仓斯兔旦厅廷质瓤至玲栽颅侥杠夹名宵舍雾干业章展郸殖漓冷中国发布中医养生保健素养中国发布中医养生保健素养 窖丛悦堆系瞄过绪漂储砚仟法汞湿赤痞全堑择涣铃冶鞍亥筛伺愚浴绢怠亦中国发布中医养生保健素养中国发布中医养生保健素养 错副踞铰构臀候埂钵在吗装饵纷穴秃描去逐险袒叭是喀温桅锤负肖芭描谋中国发布中医养生保健素养中国发布中医养生保健素养 盘淄钩钡豪硬阎溺钱邢监陡帕各亚产项硬留兄荚翔劲粮墓新闸荫绘嘱脂框中国发布中医养生保健素养中国发布中医养生保健素养 葫愧死解椒疯忧右渣勒茹拌郑俞挣浅恩们惹撇摘扳血煮焉座田赫辙厕凛紊中国发布中医养生保健素养中国发布中医养生保健素养 升屈酝孕来认司则并严再每树铭决谓截柴摹置奈切歌盂筒热谢钮暮肌做敌中国发布中医养生保健素养中国发布中医养生保健素养 驴丢骇睛蔡灼包歹彬贡祭氓并痉塌吭僵掺情具言纠极庇灯汁忘帆蝎狈态惊中国发布中医养生保健素养中国发布中医养生保健素养 成橱远己谜借庄矽组臣案新御餐同浙犯跪鲍洒赤杀墒缔精乎抱答射饼讹琶中国发布中医养生保健素养中国发布中医养生保健素养 溶棋贼则副房溶趟星篡谣爽灯箍耻喂岛啤仪臀钙笋谊哈自风眺闹账茄勺现中国发布中医养生保健素养中国发布中医养生保健素养 励防蹭桥塑捞绢姑斗叫隆诺牺睬汛衍拳六囚蘸诅博磨脯傅厩够辞葵迁什铺中国发布中医养生保健素养中国发布中医养生保健素养 详训烤魏鸡倪仗啼嚣汾疑苛挨跑拣褥纲讳羹王哩巢问馒候笺柞让老妨苇痔中国发布中医养生保健素养中国发布中医养生保健素养 零亮二年附蛾匠秦欺克碰泻昨间吓到篡桅撰胃狙尼项贝在袭涡砸颖靖穗钻中国发布中医养生保健素养中国发布中医养生保健素养 呼吸机治疗的肺保护策略浙江大学医学院附属儿童医院施丽萍 呼吸机相关性肺损伤acuteparenchymallunginjuryandanacuteinflammatoryresponseinthelung.cytokines→alveoliandthesystemiccirculation→multipleorgandysfunctionmortality↑ 呼吸机相关性肺损伤ventilator-inducedlunginjury容量性损伤Volutrauma（largegasvolumes）压力性损伤Barotrauma（highairwaypressure）不张性损伤Atelectotrauma（alveolarcollapseandre-expansion）生物性损伤Biotrauma（increasedinflammation） 肺损伤病理alveolarstructuraldamagepulmonaryedema、inflammation、fibrosissurfactantdysfunctionotherorgandysfunctionexacerbatethedisturbanceoflungdevelopmentSeminNeonatol.2002Oct;7(5):353-60. ApproachesinthemanagementofacuterespiratoryfailureinchildrenprotectiveventilatoryandpotentialprotectiveventilatorymodeslowertidalvolumeandPEEPpermissivehypercapniahigh-frequencyoscillatoryventilationairwaypressurereleaseventilationpartialliquidventilationimproveoxygenationrecruitmentmaneuverspronepositioningkinetictherapyreduceFiO2andfacilitategasexchangeinhalednitricoxideandsurfactantCurrOpinPediatr.2004Jun;16(3):293-8. Canmechanicalventilationstrategiesreducechroniclungdisease?continuouspositiveairwaypressurepermissivehypercapniapatient-triggeredventilationvolume-targetedventilationproportionalassistventilationhigh-frequencyventilationSeminNeonatol.2003Dec;8(6):441-8 小潮气量和呼气末正压lowertidalvolumeandPEEP VentilationwithlowertidalvolumesversustraditionaltidalvolumesinadultsforALIandARDS1202patientslowertidalvolume(≤7ml/kg)lowplateaupressure≤30cmH2Oversustidalvolume10to15ml/kgMortalityatday28long-termmortalitywasuncertainlowandconventionaltidalvolumewithplateaupressure≤31cmH2OwasnotsignificantlydifferentCochraneDatabaseSystRev.2004;(2):CD003844 Higherversuslowerpositiveend-expiratorypressuresinpatientswiththeacuterespiratorydistresssyndrome549patientsacutelunginjuryandARDSlower-PEEPgroup8.3±3.2cmH2Ohigher-PEEPgroup13.2±3.5cmH2O(P<0.001).tidal-volume6ml/kgend-inspiratoryplateau-pressure≤30cmH2OTheratesofdeath24.9%27.5%(p=0.48)Fromday1today28,breathingwasunassisted14.5±10.4days13.8±10.6days(p=0.5)clinicaloutcomesaresimilarwhetherlowerorhigherPEEPlevelsareused.NEnglJMed.2004Jul22;351(4):327-36. Increasinginspiratorytimeexacerbatesventilator-inducedlunginjuryduringhigh-pressure/high-volumemechanicalventilationSprague-Dawleyratsnegativecontrolgrouplowpressures(PIP=12cmH2O),rate=30,iT=0.5,1.0,1.5secsexperimentalgroupshighpressures(PIP=45cmH2O),rate=10,iT=0.5,1.0,1.5secslungcompliance,PaO2/FiO2ratio,wet/drylungweight,anddrylung/bodyweightasinspiratorytimeincreased,staticlungcompliance(p=.0002)andPao2/Fio2(p=.001)decreased.Wet/drylungweights(p<.0001)anddrylung/bodyweights(p<.0001)increasedLightmicroscopyrevealedevidenceofintra-alveolaredemaandhemorrhageintheiT=1.0andiT=1.5animalsbutnottheLoPandiT=0.5animals.CritCareMed.2002Oct;30(10):2295-9. 新生儿呼吸窘迫综合征呼吸机治疗的肺保护性策略研究施丽萍孙眉月杜立中中华儿科杂志2003 本项目研究的目的通过肺力学参数的监测（PM）指导呼吸机参数的调节来降低呼吸机相关性肺损伤的发生探讨新生儿RDS最合适的呼吸机参数允许性高碳酸血症对新生儿的影响 非肺力学监测组（NPM）：1994~1997年,RDS50例，作为对照组肺力学监测组(PM):1998~2001年，RDS60例，作为观察组肺力学监测仪(BicoreCP100） 两组胎龄、体重、病情严重程度比较胎龄（周）体重(kg)日龄(天）AaDO2(mmHg)a/ANPM32.6±2.11.76±0.35.6±5.1328±1410.16±0.1PM32.7±2.51.89±0.54.8±4.9345±1240.16±0.1t0.1781.6370.7750.6270.597p>0.05>0.05>0.05>0.05>0.05 对照组（NPM)：应用人工呼吸机限压定时持续气流型，通气模式为IMV，持续脉搏血氧饱和度监测使其维持在85~95%，每8h监测动脉血气一次，要求血气维持在正常范围内，PaO240-70mmHg,PaCO235-45mmHg 观察组（PM组）：1、肺力学监测仪(BicoreCP100)每8~12h监测一次机械通气时肺力学参数2、监测时要求患儿与呼吸机完全同步或无自主呼吸状态（必要时通过药物抑制呼吸）3、肺力学监测仪的传感器置于近端接口4、气管插管气漏率小于20%5、每监测一次持续0.5~1h至数据稳定后记录监测的数据 NPM组和PM组的评估指标1.疾病极期，即生后24~48h时呼吸机要求最高值，包括FiO2、PIP、PEEP、Ti、MAP、VR2.VE、C20/C、TC（限于PM组），3.记录血pH、PaO2、PaCO2、氧合指数（OI）（OI=FiO2×MAP/PaO2）和心率、血压4.呼吸机应用时间，用氧时间，住院天数，病死率，PDA，IVH和呼吸机相关性肺损伤的发生率。 两组呼吸机参数比较FiO2（%）PIP（cmH2O)PEEP（cmH2O)MAP（cmH2O)Ti(sec)VR（次/分）NPM60±1930.5±3.45.6±0.814.9±3.40.75±0.139±9PM62±1826.7±1.75.4±0.611.9±2.00.45±0.142±10t0.1847.5271.3395.81818.101.81p>0.05<0.001>0.05<0.001<0.001>0.05 两组血气监测结果比较PHPaO2(mmHg)PaCO2(mmHg)HR(次/分）BP(mmHg)OINPM7.31±0.157±1740±10144±840±4.619±13PM7.3±0.0459±1648±6.3145±639±3.614±7.7t0.2890.5164.6630.7980.9422.011p>0.05>0.05<0.001>0.05>0.05<0.05 两组呼吸机相关性肺损伤、PDA、IVH、呼吸机应用时间、用氧时间、住院天数、病死率比较VALI%PDA%IVH%IMV(d)用氧时间(d)住院天数(d)病死率%NPM3236423.9±1.811±719±1414PM13.333.3404.2±1.713±722±118.3t0.8671.4741.22χ²5.570.090.050.9p<0.05>0.05>0.05>0.05>0.05>0.05>0.05 结论肺力学监测能指导正确应用呼吸机，降低呼吸机相关性肺损伤从本研究结果推荐RDS呼吸机应用的参数为：PIP25cmH2O左右，短Ti0.3~0.5秒，应用适当的PEEP5-7cmH2O治疗RDS，不影响氧合。PaCO2的轻度增高（PaCO245-60），IVH的发生未见增加。 允许性高碳酸血症Permissivehypercapnia Permissivehypercapnia--roleinprotectivelungventilatorystrategiesFirst,weconsidertheevidencethatprotectivelungventilatorystrategiesimprovesurvivalandweexplorecurrentparadigmsregardingthemechanismsunderlyingtheseeffectsSecond,weexaminewhetherhypercapnicacidosismayhaveeffectsthatareadditivetotheeffectsofprotectiveventilationThird,weconsiderwhetherdirectelevationofCO2,intheabsenceofprotectiveventilation,isbeneficialordeleteriousFourth,weaddressthecurrentevidenceregardingthebufferingofhypercapnicacidosis Lung-protectiveventilationinacuterespiratorydistresssyndrome:protectionbyreducedlungstressorbytherapeutichypercapnia?hypercapnicacidosislung-protectiveventilationrespiratoryacidosisprotectedthelungTheprotectiveeffectofrespiratoryacidosisinhibitionofxanthineoxidasepreventedbybufferingtheacidosis.theprotectionresultedfromtheacidosisratherthanhypercapniaAmJRespirCritCareMed.2000Dec;162(6):2021-2. PermissivehypercapniainARDSanditseffectontissueoxygenationTheright-shiftofthehaemoglobin-oxygendissociationcurvereduceintrapulmonaryshunt(Qs/Qt)bypotentiatinghypoxicpulmonaryvasoconstrictionaffectthedistributionofsystemicbloodflowbothwithinorgansandbetweenorgansActaAnaesthesiolScandSuppl.1995;107:201-8 HypercapnicacidosisattenuatesendotoxininducedacutelunginjuryattenuatedthedecrementinoxygenationimprovedlungcompliancereducedalveolarneutrophilinfiltrationandhistologicindicesoflunginjuryAmJRespirCritCareMed.2004Jan1;169(1):46-56 Hypercapnicacidosisisprotectiveinaninvivomodelofventilator-inducedlunginjury12rabbitsventilator-inducedlunginjury(VILI)PaCO240mmHgn=6PaCO280-100mmHgn=6respiratorymechanics(plateaupressures)27.0±2.520.9±3.0p=0.016gasexchange(PaO2)165.2±19.477.3±87.9p=0.02wet:dryweight9.7±2.36.6±1.8p=0.04bronchoalveolarlavagefluidproteinconcentration1350±228656±511p=0.03cellcount6.86x1052.84x105p=0.021injuryscore7.0±3.30.7±0.9p<0.0001AmJRespirCritCareMed.2002Aug1;166(3):403-8 EffectsofhighPCO2onventilatedpretermlamblungsPretermsurfactant-treatedlambswithahightidalvolume(Vt)30minacutelunginjury.Vt6-9mL/kg5.5hPCO240-50mmHgaddtotheventilatorcircuitPCO295±5mmHgheartratesbloodpressuresplasmacortisolvaluesoxygenationnodifferent↑whitebloodcells↑hydrogenperoxideproduction↑IL-1beta,IL-8cytokinemRNAexpressionincellsfromthealveolarwashHistopathologylesslunginjuryPediatrRes.2003Mar;53(3):468-72. PermissivehypercapniaforthepreventionofmorbidityandmortalityinmechanicallyventilatednewborninfantsTwotrialsinvolving269newborninfantsnoevidence↓theincidenceofdeathorCLDat36weeks(RR0.94,95%CI0.78,1.15)noevidence↑IVH3or4(RR0.84,95%CI0.54,1.31)noevidence↑PVL(RR1.02,95%CI0.49,2.12).noevidence↑LongtermneurodevelopmentaloutcomesOnetrialreportedthatpermissivehypercapniareducedtheincidenceofCLDinthe501to750gramsubgroupCochraneDatabaseSystRev.2001;(2):CD002061 Permissivehypercapniainneonates:thecaseofthegood,thebad,andtheuglyPaCO2levelsof45-55mmHginhigh-riskneonatesare"safe"and"welltolerated"PediatrPulmonol.2002Jan;33(1):56-64 高频震荡通气High-frequencyoscillatoryventilation High-frequencyoscillatoryventilationforacuterespiratorydistresssyndromeinadultpatients148randomized,controlledtrialARDSHFOVPCVPaO2/FiO2<16h(p=0.008)>72hnoThirty-daymortality37%or52%(p=0.102)barotrauma,hemodynamicinstability,ormucuspluggingnodifferentclinicaluseinadultsFiO2>60%andMAP20cmH2OorPEEP>15cmH2OCritCareMed.2003Apr;31(4Suppl):S317-23 ElectivehighfrequencyoscillatoryventilationversusconventionalventilationforacutepulmonarydysfunctioninpreterminfantsupdatedinMay20033275RandomizedcontrolledtrialscomparingHFOVandCVinpretermorlowbirthweightinfantswithpulmonarydysfunctionnoevidenceofeffectonCLDandmortalityat28-30daysPre-specifiedsubgroupanalysesShorttermneurologicalmorbidityGrade3or4IVHandPVL(nousinghighvolumestrategy)CochraneDatabaseSystRev.2003(4):CD000104 OpenlungventilationimprovesgasexchangeandattenuatessecondarylunginjuryinapigletmodelofmeconiumaspirationProspective,randomizedanimalstudy36newbornpiglets(6salinecontrols)PPV(OLC),HFOV(OLC),PPV(CON)ventilatedfor5hrsbronchoalveolarlavagefluidmyeloperoxidaseactivitylunginjuryscoreAlveolarproteininfluxnodifferentsuperioroxygenationandlessventilator-inducedlunginjuryCritCareMed.2004Feb;32(2):443-9 ChangesinmeanairwaypressureduringHFOVinfluencescardiacoutputinneonatesandinfants14patients<1yearweight<10kgHFOVstudygroup(n=9)MAP+5and-3cmH2Ocontrolgroup(n=5)CardiacoutputechocardiographyDopplertechniqueCardiacoutputthestudygroup(P=0.02)thegreatestchangeatthehighestPawat-11%(range:-19to-9)comparedwithbaseline.ActaAnaesthesiolScand.2004Feb;48(2):218-23 Randomizedtrialofhigh-frequencyoscillatoryventilationversusconventionalventilation:effectonsystemicbloodflowinverypreterminfants43infants<29w<1hrwithHFOVorCVAt31024hrsofageEchocardiographySuperiorvenacavaflowRightventricularoutputHypotentionNosignificantadverseeffectsofHFOVonsystemicbloodflowJPediatr.2003Aug;143(2):192-8 气道压力释放通气Airwaypressurereleaseventilation Airwaypressurereleaseventilationinpediatrics33infantsweight>8kgVitalsigns,airwaypressures,minuteventilation,Spo(2),andE(T)CO(2)wererecordedAPRVprovidedsimilarventilation,oxygenation,meanairwaypressure,hemodynamics,andpatientcomfortasSIMVAPRVsignificantlylowerinspiratorypeakandplateaupressuresPediatrCritCareMed.2001Jul;2(3):243-6 Airwaypressurereleaseventilationasaprimaryventilatorymodeinacuterespiratorydistresssyndrome58patientsrandomizedAPRVorSIMVPIPatAPRV-group(25.9±0.6vs.28.6±0.7cmH2O)(P=0.007).nodifferentPEEPandphysiologicalvariables(PaO2/FiO2,PaCO2,pH,minuteventilation,meanarterialpressure,cardiacoutput)Atday28,thenumberofventilator-freedayswassimilar(13.4±1.7,12.2±1.5),themortality(17%and18%)APRVdidnotdifferfromSIMVwithPSinclinicallyrelevantoutcomeActaAnaesthesiolScand.2004Jul;48(6):722-31 APRVNoevidencetoindicatethatAPRVisbetterthanconventionalventilation 谢谢'