機(jī)械通氣總論

1、機(jī)械通氣總論機(jī)械通氣總論機(jī)械通氣機(jī)械通氣機(jī)械通氣的應(yīng)用1常用的機(jī)械通氣模式2機(jī)械通氣常見(jiàn)問(wèn)題的處理34常見(jiàn)疾病的機(jī)械通氣策略機(jī)械通氣機(jī)械通氣常用的機(jī)械通氣模式2機(jī)械通氣常見(jiàn)問(wèn)題的處理34常見(jiàn)疾病的機(jī)械通氣策略機(jī)械通氣的應(yīng)用1機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始1949 1950年Scandinavian脊髓灰質(zhì)炎流行n呼吸麻痹者死亡率80%1913年 Janewayn第一臺(tái)定型呼吸機(jī)機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始1952年 Denmarkn脊髓灰質(zhì)炎流行nBlegdam Hospitalu31名呼吸肌麻痹患者u27名相繼死亡n麻醉科醫(yī)生Bjan Ibsen氣管插管Mortal

2、ity from Paralytic PolioLassen HCA. The Lancet 1:37-41,1953機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始75名病人手法通氣24小時(shí)內(nèi)n動(dòng)員250名醫(yī)學(xué)生用手捏氣囊n260名護(hù)士參加床邊護(hù)理n消耗250筒氧氣n27名工人更換氧氣筒n死亡率從87%降低到40%以下機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始Mortality from Paralytic Polio:Lassen HCA. The Lancet 1:37-41,1953Mechanical Ventilation機(jī)械通氣的開(kāi)始機(jī)械通氣的開(kāi)始負(fù)壓呼吸機(jī)(“鐵肺”)n1928年Bo

3、ston兒童醫(yī)院無(wú)創(chuàng)通氣首次用于臨床n20世紀(jì)40至50年代脊髓灰質(zhì)炎爆發(fā)流行時(shí)廣泛使用正壓呼吸機(jī)n1955年麻省總醫(yī)院首次使用有創(chuàng)通氣n現(xiàn)已成為機(jī)械通氣的標(biāo)準(zhǔn)The iron lung created negative pressure in abdomen as well as the chest, decreasing cardiac output.Iron lung polio ward at Rancho Los Amigos Hospital in 1953.ICU中的機(jī)械通氣中的機(jī)械通氣機(jī)械通氣的適應(yīng)證急性呼吸功能衰竭66%nARDS8%慢性呼吸功能衰竭急性加重 13%昏迷15%

4、神經(jīng)肌肉疾病 5%Esteban A, Anzueto A, Alia I, et al. How Is Mechanical Ventilation Employed in the Intensive Care Unit? An International Utilization Review. Am J Respir Crit Care Med 2000; 161: 1450-1458ICU中的機(jī)械通氣中的機(jī)械通氣人工氣道氣管插管75%n經(jīng)口氣管插管96%n經(jīng)鼻氣管插管 4%氣管切開(kāi)24%面罩 1%Esteban A, Anzueto A, Alia I, et al. How Is Me

5、chanical Ventilation Employed in the Intensive Care Unit? An International Utilization Review. Am J Respir Crit Care Med 2000; 161: 1450-1458機(jī)械通氣的比例機(jī)械通氣的比例1. Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 1994; 106: 1188

6、-1193; 2. Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the Intensive Care Units? An international utilization review. Am J Respir Crit Care Med 2000; 161: 1450-1458; 3. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving m

7、echanical ventilation. JAMA 2002; 287: 345-355機(jī)械通氣機(jī)械通氣機(jī)械通氣常見(jiàn)問(wèn)題的處理34常見(jiàn)疾病的機(jī)械通氣策略機(jī)械通氣的應(yīng)用1常用的機(jī)械通氣模式2呼吸模式呼吸模式VCVPCVSIMVSIMV + PSVPSVCPAPBIPAPAPRVPRVC/autoflow/VV+VS/VV+AutomodeVAPS/PAMRVASVPAV+/PPS機(jī)械通氣的常用模式機(jī)械通氣的常用模式Esteban (1992)Esteban (1996)Esteban (1998)VCV55%47%53%PCV1%5%SIMV26%6%8%SIMV + PSV8%25%15%

8、PSV8%15%4%其他模式2%7%15%1. Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 1994; 106: 1188-1193; 2. Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the Intensive Care Units? An international ut

9、ilization review. Am J Respir Crit Care Med 2000; 161: 1450-1458; 3. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation. JAMA 2002; 287: 345-355呼吸機(jī)的參數(shù)設(shè)置呼吸機(jī)的參數(shù)設(shè)置呼吸機(jī)的設(shè)置定容通氣時(shí)的潮氣量 9 ml/kg壓力支持通氣時(shí)壓力支持水平19 cmH2O呼氣末正壓(PEEP) 5 cmH2OEsteban A

10、, Anzueto A, Alia I, et al. How Is Mechanical Ventilation Employed in the Intensive Care Unit? An International Utilization Review. Am J Respir Crit Care Med 2000; 161: 1450-1458選擇不同機(jī)械通氣模式選擇不同機(jī)械通氣模式改善氣體交換增加患者舒適性加速自主呼吸的恢復(fù)呼吸模式介紹呼吸模式介紹如何開(kāi)始吸氣吸氣如何進(jìn)行如何結(jié)束吸氣優(yōu)點(diǎn)缺點(diǎn)容量控制通氣容量控制通氣Volume Control Ventilation(VCV)容量控

11、制通氣容量控制通氣 參數(shù)的設(shè)置參數(shù)的設(shè)置參數(shù)潮氣量(ml)或分鐘通氣量(l/min)吸氣流速(l/min)呼吸頻率(b/min)PEEP (cmH2O)FiO2 (%)吸呼比吸氣末暫停時(shí)間(s)或吸氣末暫停百分比(%)觸發(fā)靈敏度容量控制通氣容量控制通氣: 參數(shù)設(shè)置參數(shù)設(shè)置如何開(kāi)始吸氣n呼吸機(jī)或患者觸發(fā)吸氣如何進(jìn)行n恒定流速flow = Vt / Tinsp如何結(jié)束吸氣n設(shè)置吸氣時(shí)間或潮氣量容量控制通氣容量控制通氣: 吸氣的開(kāi)始吸氣的開(kāi)始TbTbTbVIMPIMVIMTb = 60/fThe ventilator monitors time intervals from a specific e

12、vent (for example, triggering a PIM or the transition from inspiration to exhalation.) During A/C in the absence of patient effort, the ventilator delivers one inspiration at the beginning of every breath period, as shown in figure. Such a breath is called a ventilator-initiated mandatory (VIM) brea

13、th. If the patients inspiratory efforts generate a pressure or flow trigger before the breath cycle has elapsed, the ventilator delivers a PIM.容量控制通氣容量控制通氣 吸氣的開(kāi)始吸氣的開(kāi)始1t1.吸氣相根據(jù)預(yù)置的呼吸頻率或當(dāng)患者觸發(fā)時(shí)開(kāi)始吸氣觸發(fā)的方式及設(shè)置吸氣觸發(fā)的方式及設(shè)置壓力觸發(fā)(pressure trigger)n-1 to -2 cmH2O流量觸發(fā)(flow trigger)n-1 to -3 lpm吸氣觸發(fā)的方式吸氣觸發(fā)的方式 壓力觸發(fā)壓力

14、觸發(fā)P (cmH2O)呼氣末氣道壓力下降= 患者開(kāi)始吸氣= 呼吸機(jī)開(kāi)始送氣吸氣觸發(fā)的方式吸氣觸發(fā)的方式 壓力觸發(fā)壓力觸發(fā)壓力觸發(fā)靈敏度的設(shè)置指氣道壓力較PEEP下降的水平n0 20 cmH2O例如nPEEP = 0 (10)nTrigger sensitivity = -2n即氣道壓力為-2 (8) cmH2O時(shí)呼吸機(jī)開(kāi)始送氣吸氣觸發(fā)的方式吸氣觸發(fā)的方式 流量觸發(fā)流量觸發(fā)呼氣流量呼氣流量 吸氣管路中氣體流量吸氣管路中氣體流量吸氣管路呼氣管路呼氣末吸氣觸發(fā)的方式吸氣觸發(fā)的方式 流量觸發(fā)流量觸發(fā)呼氣流量呼氣流量 90%的最小PEEP肺開(kāi)放n靜態(tài)P-V曲線的低位轉(zhuǎn)折點(diǎn)以上2 cmH2O肺或胸廓限制性疾病肺或胸