mechanicalventilationofcopd杜斌

1、COPD的機械通氣的機械通氣Vt, FiO2, what else?北京協(xié)和醫(yī)院杜斌COPD患者的肺泡過度充盈患者的肺泡過度充盈Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004; 350: 2689-97時間常數(shù)時間常數(shù)( ) = R x C測定肺組織充盈或排空的速度反映肺組織對壓力變化的反應(yīng)速度時間常數(shù)時間常數(shù)( )Time/Tau吸氣相吸氣相呼氣相呼氣相Pressure時間常數(shù)時間常數(shù)( )PA(t) = (Pplat - PEEP) e-k

2、tk = 1/ =1/(R x C)V(t) = Vt x e-ktk = 1/ =1/(R x C)時間常數(shù)時間常數(shù)( )時間常數(shù)成人(正常值)2 x 0.10 = 0.20”術(shù)后氣管插管成人患者5 x 0.06 = 0.30”COPD成人患者15 x 0.06 = 0.90”ARDS成人患者8 x 0.03 = 0.24”ARDS患兒5 x 0.01 = 0.05”Tau呼出氣容積殘余容積00%100%163%37%395%5%599.9%0.1%動態(tài)過度充盈動態(tài)過度充盈: DHIinspexpTimeTidal volumeTrapped gasLung VolumeFRCObstruc

3、ted LungsNormal Stiff Lungs機械通氣的適應(yīng)證機械通氣的適應(yīng)證: COPD呼吸肌疲勞且瀕臨呼吸停止盡管進行充分的保守治療, PaCO2仍進行性升高勞累和(或)高碳酸血癥導致意識狀態(tài)惡化高濃度吸氧治療無效的低氧血癥痰液清除障礙導致病情惡化呼吸驟停COPD患者的病理生理改變患者的病理生理改變內(nèi)源性PEEP過高n肺泡過度膨脹n胸腔內(nèi)壓過高 回心血量減少 休克機械通氣時的機械通氣時的PEEPiVt 10 12 ml/kg, f 12 15 bpm, I:E 1:2 3診斷No.PEEPi (范圍)發(fā)生率COPD452.6 2245/45 (100%)CF1111/1 (100%

4、)Asthma313.5 203/3 (100%)ARDS281.0 8.115/28 (58%)CPE101.0 6.08/10 (80%)Other101.0 4.15/10 (50%)DHI和和PEEPi的影響因素的影響因素內(nèi)在因素內(nèi)在因素外部因素外部因素呼吸力學附加氣流阻力氣流阻力氣管插管管徑過細呼氣氣流受限呼吸機管路和相關(guān)裝置呼吸系統(tǒng)順應(yīng)性呼吸機設(shè)置呼吸方式呼吸頻率呼吸頻率I:ETi/Ttot潮氣量潮氣量吸氣末暫停DHI和和PEEPi的影響因素的影響因素內(nèi)在因素內(nèi)在因素外部因素外部因素呼吸力學附加氣流阻力氣流阻力氣管插管管徑過細呼氣氣流受限呼吸機管路和相關(guān)裝置呼吸系統(tǒng)順應(yīng)性呼吸機設(shè)置

5、呼吸方式呼吸頻率呼吸頻率I:ETi/Ttot潮氣量潮氣量吸氣末暫停機械通氣參數(shù)的設(shè)置機械通氣參數(shù)的設(shè)置: COPD潮氣量吸氣流速吸呼比 / 吸氣時間 / 呼氣時間呼吸頻率COPD: 不同吸氣氣流的比較不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation

6、. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較波形(均值 SD)呼吸機參數(shù)恒定氣流1正弦波減速氣流恒定氣流2Vt, ml562 67558 65566 59571 72RR, bpm18.2 1.718.6 1.418.4 1.918.5 1.3MV, lpm10.4 1.610.3 1.510.6 1.610.7 1.8Ti/Ttot0.29 0.040.28 0.030.29 0.040.28 0.03平均吸氣流速, lpm38 537 739 738 6Shieh Ching Yang, MD, FCCP; and Sze Piao

7、 Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較波形(均值 SD)呼吸力學參數(shù)恒定氣流1正弦波減速氣流恒定氣流2PIP, cmH2O47.1 11.547.8 10.839.5 9.746.6 11.0Paw, cmH2O7.6 4.27.2

8、4.88.4 4.58.4 3.9Pplat, cmH2O20.2 9.119.6 10.618.9 8.821.4 10.4Vd/Vt, %58.4 5.254.5 6.348.6 5.557.6 4.9Cst, ml/cmH2O35.3 8.935.8 11.236.6 9.337.2 9.7Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COP

9、D Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較波形(均值 SD)恒定氣流1正弦波減速氣流恒定氣流2pH7.44 0.047.44 0.077.43 0.067.44 0.04PaO2/FiO2, mmHg236 73231 65223 70227 67PaCO2, mmHg45 1045 1037 946 12A-aDO2, mmHg133.1 36.5136.4 34.2156.3 33.7134.4 35.3HR, bpm106.1 18.1108.3 2

10、0.2105.3 18.9109.9 20.5MAP, mmHg92 2388 1888 2190 19Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較波形(均值

11、SD)參數(shù)恒定氣流1正弦波減速氣流恒定氣流2WOB, J/L0.92 0.160.88 0.180.75 0.150.92 0.18Raw, cmH2O/L/s12.6 3.112.4 3.611.2 2.412.5 3.3VO2, ml/min384 53389 60377 49382 52VCO2, ml/min274 52280 47273 56276 55癥狀評分54.5 13.458.6 11.942.7 12.356.1 12.8Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Wa

12、veforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較結(jié)論COPD患者機械通氣的最佳吸氣氣流為減速氣流通過選擇適宜的吸氣氣流, 有可能改善上述患者的通氣Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms o

13、n Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD機械通氣策略機械通氣策略降低內(nèi)源性PEEP的方法n外源性PEEP ?n延長呼氣時間u增加吸氣流速u縮短吸氣末暫停u降低呼吸頻率呼氣流速呼氣流速PalvPEEPFlow = P / Raw= (Palv PEEP) / RawFlowPEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Ef

14、fect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6CompliancePEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Ana

15、lg 2005; 100: 1112-6Compliance P Flow PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑PEEPPEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expira

16、tory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6PEEP半徑半徑流速流速? P 流速流速 PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 11

17、12-6PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flo

18、w During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑 Flow PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The

19、 Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑 PEEPPEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth A

20、nalg 2005; 100: 1112-6PEEP半徑半徑 流速流速 P 流速流速 COPD穩(wěn)定期患者穩(wěn)定期患者(n = 9)年齡(yr)70 FEV1 (%pred)30 FVC (%pred)53 RV (%pred)186 FEV1/VC (%)44 TLC (%pred)103 TLCO (%pred)46 PaO2 PaCO2 ODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung vol

21、ume in severe stable COPD. Thorax 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, B

22、ersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stab

23、le COPD. Thorax 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy

24、RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 20

25、02;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539總結(jié)對于處于穩(wěn)定期的嚴重COPD患者, 應(yīng)用高水平的CPAP能夠n降低PEEPi及肌肉活動指標n肺容積顯著增加COPD急性期患者急性期患者(n = 10)Gurin C, Fournie

26、r G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498年齡(yr)64 6身高(cm)167 6體重(kg)72 21體重(%pred)96 27FiO2 (%)48 9 COPD急性期急性期: PEEPPEEP (cmH2O)051015PEEPt, cmH2O8.4 4.810.0 3.912.3 2.416.9 1.8PEEPi, cmH2O7.1 3.93.7 3.31.8

27、1.80.8 1.2FRC, L0.54 0.420.74 0.481.03 0.421.50 0.51Rint, rs, cmH2O s/L9.2 3.68.1 2.77.3 2.77.2 3.0Rrs, cmH2O s/L7.7 1.88.5 1.89.5 2.79.7 3.3Rrs, cmH2O s/L17 3.916.7 2.716.8 3.016.9 3.6Est,rs, cmH2O/L12.7 3.012.9 3.312.9 3.315.5 4.5Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory r

28、esistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498COPD急性期急性期: PEEPGurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR,

29、 Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528RR 6 bpmRR 9 bpmCOPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR,

30、Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carva

31、lho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek

32、RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, V

33、elasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato

34、MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical

35、responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to posi

36、tive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528結(jié)論對于部分氣道梗阻的患者而言, 應(yīng)用控制通氣過程中, 設(shè)置外源性PEEP能夠緩解過度充盈基礎(chǔ)疾病, 機械力學指標或呼吸機設(shè)置均無法預測上述結(jié)果逐漸增加PEEP并觀察平臺壓力改變, 是減少副作用的合理方法Assessment of Pulmonary HyperinflationTimeTidal volumeTrapped gasLung

37、VolumeFRCTidal vol.Tidal hyper-inflationApneaTidal VentilationCOPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370Tins

38、p RR Texp PEEPi COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370患者基礎(chǔ)情況(n = 10)基本情況均值 SE年齡, yr68.3 2.9體重, kg82.9 5.

39、9身高, cm173.5 2.1FEV1, L1.21 0.12FEV1, %pred39.7 4.3FEV1/FVC, %pred40.9 3.5FRC, L6.5 0.8TLC, L8.9 0.7PaO2, mmHg72 3PaCO2, mmHg38 1COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pu

40、lmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-137016.1 19.0 20.8 7.0 6.3 6.4 2.1 2.4 2.3 COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respi

41、r Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370為何需要設(shè)置吸氣末暫停為何需要設(shè)置吸氣末暫停Pressure

42、FlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduring thePlateau Phase為何需要設(shè)置吸氣末暫停為何需要設(shè)置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNo PENDELLUFTbecause of constant flow flowCOPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflatio

43、n Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時間縮短吸氣時間機械通氣患者常常呼吸頻數(shù), 肺過度充盈n提高吸氣流速, 可以縮短吸氣時間, 盡管呼吸頻率加快, 但能夠延長呼氣時間, 降低呼吸做功n延長吸氣暫停能夠降低呼吸頻率, 卻引發(fā)肺過度充盈, 呼吸做功增加Laghi F, Segal J, Choe WK, Tobi

44、n MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370嚴重氣流梗阻患者的處理嚴重氣流梗阻患者的處理增加流量不能顯著延長呼氣時間(TE)VtRRflowTTOTTITETE0.515 604.000.503.50-提示降低分鐘通氣量對于減少內(nèi)源性PEEP的重要作用延長呼氣時間治療哮喘持續(xù)狀態(tài)延