呼吸機(jī)波形分析中文分析

1、1會(huì)計(jì)學(xué)呼吸機(jī)波形分析中文分析呼吸機(jī)波形分析中文分析機(jī)械通氣波形概述機(jī)械通氣波形概述1常見機(jī)械通氣波形常見機(jī)械通氣波形2特殊參數(shù)波形特殊參數(shù)波形3異常波形解析異常波形解析4第1頁(yè)/共86頁(yè)熟練的ICU醫(yī)師通過(guò)呼吸機(jī)波形評(píng)估病人肺的狀態(tài)如同心臟科醫(yī)師通過(guò)心電圖評(píng)估心臟狀態(tài) 了解病人目前的通氣狀態(tài) 分析機(jī)械通氣過(guò)程中出現(xiàn)的問(wèn)題第2頁(yè)/共86頁(yè)壓縮空氣壓縮氧氣空氧混合器吸氣閥吸氣吸氣流量流量傳感傳感器器濕化器氣道氣道壓力壓力傳感傳感器器病人呼氣呼氣流量流量傳感傳感器器呼氣閥單向活瓣第3頁(yè)/共86頁(yè)呼氣流速傳感器Expiratory FlowTransducer呼氣流速傳感器Expiratory Fl

2、owTransducer第4頁(yè)/共86頁(yè).SECLPM123456120VPawVT第5頁(yè)/共86頁(yè)最常見的波形形態(tài)為:方波(square), 斜波(ramp), 和正弦波(sine)square AscendingrampDecsendingrampsine第6頁(yè)/共86頁(yè)TIMETIME方波:代表一個(gè)恒定不變或設(shè)定的參數(shù)壓力控制模式的壓力波形流速恒定的容控模式的流速波形斜波:代表一個(gè)不斷變化的差數(shù)主要受肺力學(xué)特性的影響分為遞增波和遞減波TIME正弦波:見于自主通氣第7頁(yè)/共86頁(yè)TP TPTVTVFTF TPressure ModesVolume ModesVolume Control S

3、IMV (Vol. Control)Pressure ControlPRVCSIMV (PRVC)SIMV (Press. Control)Pressure SupportVolume Support第8頁(yè)/共86頁(yè)第9頁(yè)/共86頁(yè)P(yáng)ressure mode壓力波形常為方波吸氣時(shí)壓力持續(xù)不變Volume mode壓力波形常為斜波Paw (cm H2O)Time (sec)第10頁(yè)/共86頁(yè)可用于評(píng)估:TP第11頁(yè)/共86頁(yè)Time (sec)Paw (cm H2O)Patient Triggered01020PEEP +5應(yīng)用PEEP后整個(gè)壓力波形的基線將抬高若為病人自主觸發(fā)的通氣整個(gè)波形前將

4、有一個(gè)負(fù)向波 第12頁(yè)/共86頁(yè)Time (sec)Paw (cm H2O)Begin InspirationPIPBegin ExpirationPplateau整個(gè)曲線下面積代表整個(gè)曲線下面積代表平均氣道壓（平均氣道壓（ Pmean ） Pmean=(A+B+C)/TimeABCA= 氣道阻力 (Raw)B= 肺泡擴(kuò)張所需壓力PIP= Peak Inspiratory PressureInspiratory holdPplateau = Plateau Pressure第13頁(yè)/共86頁(yè)Time (sec)Paw (cm H2O)PIPPPlatHigh RawPIPPPlat不變不變No

5、rmalHigh FlowPIP TiPPlat不不變變氣道阻力或流速的增加導(dǎo)致 PIP 升高但Pplat 不變第14頁(yè)/共86頁(yè)Time (sec)Paw (cm H2O)PIPPPlatNormalPIPPPlatLow ComplianceHigh VTPIP TiPPlat肺順應(yīng)性下降或潮氣量的升高導(dǎo)致Pplat升高但 PIP 和 Pplat 之間的差值不變第15頁(yè)/共86頁(yè)Time (sec)Paw (cm H2O)01020Expiratory “hold” appliedAuto-PEEP =4 Set PEEP=5 Total-PEEP =14使用呼氣暫停后，尚未呼出的陷閉氣體

6、將導(dǎo)致壓力波形升高高于基線水平，形成auto-PEEP可接受的 auto-PEEP 應(yīng) 5cm H2O第16頁(yè)/共86頁(yè)Time (sec)容量時(shí)間波形一般呈“山尖”狀：如果設(shè)定吸氣暫停時(shí)間或使用吸氣暫停功能后波形頂部將出現(xiàn)平臺(tái)LITERSVT第17頁(yè)/共86頁(yè)可用于評(píng)估:TimeV第18頁(yè)/共86頁(yè)Time (sec)Begin InspirationBegin ExpirationExhaled volume returnsto baselineVolume Inspiratory Tidal VolumeLITERSVT第19頁(yè)/共86頁(yè)Time (sec)Loss of volume如

7、果呼氣支曲線未能回到基線，則可能存在氣體陷閉或漏氣（可見于氣管插管氣囊漏氣，呼吸機(jī)管路漏氣，交通性氣胸行胸腔置管引流后）LITERSVT第20頁(yè)/共86頁(yè)P(yáng)ressure mode流速波為斜波Volume mode在恒流時(shí)流速波為方波，流速保持不變123456Time (sec)120-120FlowL/min現(xiàn)代呼吸機(jī)在容量控制通氣時(shí)亦允許使用多種預(yù)設(shè)計(jì)的流速波形（如減速斜波）第21頁(yè)/共86頁(yè)可用于評(píng)估:TIMEF第22頁(yè)/共86頁(yè)Time(sec)Time(sec)VolumePressureConstant flowDecelerating flow達(dá)到相同的潮氣量減速流速模式所需的氣

8、道峰壓更低，優(yōu)于恒定流速模式PawcmH2OL/minFlow第23頁(yè)/共86頁(yè)Time (sec)L/min123456120-120Flow流速Expiratory flow doesnt return to baselineNormalStart of next breath如果呼氣相流速曲線在下次吸氣前無(wú)法回到基線，則可能存在氣體陷閉 (可見于肺氣腫病人，吸呼時(shí)間比設(shè)置不當(dāng))第24頁(yè)/共86頁(yè)之氣管擴(kuò)張藥物起效的表現(xiàn)有： 呼氣峰流速的上升呼氣支曲線更快回到基線Time (sec)120-120FlowL/minshort exp. timeincreased Peak FlowPre-

9、BronchodilatorPost-Bronchodilator第25頁(yè)/共86頁(yè)如何區(qū)別壓力模式和容量模式？Remember the letter “P”. In Pressure modesThe Pressure waveformhas a Plateau.TP TPTVTVFTF TPressure ModesVolume Modes第26頁(yè)/共86頁(yè)在壓力限制、控制模式中，流速曲線一般會(huì)回到基線位置而在壓力支持模式中，流速曲線不會(huì)回到基線位置 TPTVF TPressure Modes第27頁(yè)/共86頁(yè)LITERSVTPawcmH2OInspirationExpirationY軸表

10、示容積 X軸表示壓力吸氣支走形向上呼氣支走形向下環(huán)形的底部將位于 PEEP 水平PEEP第28頁(yè)/共86頁(yè)LITERSVTPawcmH2OInspirationExpiration自主呼吸時(shí)曲線為順時(shí)針向正壓通氣時(shí)曲線為逆時(shí)針向第29頁(yè)/共86頁(yè)VP可用于判斷:第30頁(yè)/共86頁(yè)LITERSVTPawcmH2ODynamic Compliance(Cdyn)PV曲線起點(diǎn)端和頂端的連線的斜率代表動(dòng)態(tài)肺順應(yīng)性(Cdyn)Cdyn = volume/pressure第31頁(yè)/共86頁(yè)VTPIPPEEPPPlatSlopeComplianceC =Pplat - PEEPtidal volume切點(diǎn)

11、TIMEPLITERSVTPawcmH2O第32頁(yè)/共86頁(yè)LITERSVTPawcmH2OPaw (cm H2O)Time(sec)壓力限制/控制/支持模式下吸氣時(shí)壓力受限或保持不變，PV近似為方形第33頁(yè)/共86頁(yè)P(yáng)awcmH2OVTPaw risesWith little or no change in VT“鳥嘴征鳥嘴征”LITERS壓力持續(xù)上升而容積變化較小，形成 “鳥嘴征”應(yīng)降低潮氣量或吸氣壓力第34頁(yè)/共86頁(yè)LITERSVTPawcmH2O呼氣阻力增加:氣道痰栓支氣管痙攣 吸氣阻力增加：氣管插管變形病人咬管隨氣道阻力的增加，PV曲線將變寬其中呼氣阻力的增加更為常見第35頁(yè)/共8

12、6頁(yè)LITERSPawcmH2OVTLITERSPawcmH2OVTIncreased ComplianceDecreased Compliance常見于: 肺氣腫，表面活性劑治療后常見于: ARDS, CHF,肺不張第36頁(yè)/共86頁(yè)P(yáng)awcmH2OVTLITERSPV環(huán)的呼氣支曲線未回到基線水平提示漏氣存在第37頁(yè)/共86頁(yè)LITERSVTPawcmH2OLower Inflection PointUpper Inflection Point(Third Inflection Point)低位拐點(diǎn)代表大多數(shù)塌陷肺泡的開放點(diǎn)（肺復(fù)張）ARDS的保護(hù)性肺通氣建議PEEP應(yīng)設(shè)置于地位拐點(diǎn)之上第3

13、8頁(yè)/共86頁(yè)InspirationExpirationFlow(L/min)LITERSVTY軸表示流速，X軸表示容積吸氣支位于X軸上方并且其波形與流速時(shí)間波形一致呼氣支位于X軸下方，反應(yīng)被動(dòng)呼氣的情況PIF PEF Vt第39頁(yè)/共86頁(yè)FV可用于評(píng)估：第40頁(yè)/共86頁(yè)FVTFTFFVFV曲線吸氣支波形與相應(yīng)的流速時(shí)間波形一致第41頁(yè)/共86頁(yè)InspirationExpirationFlow(L/min)LITERSVT呼氣支曲線未回到起始點(diǎn)如果存在漏氣，F(xiàn)V環(huán)無(wú)法回到起始點(diǎn)。這一現(xiàn)象同樣可見于氣體陷閉時(shí)。第42頁(yè)/共86頁(yè)FVFVReduced Peak Flowscooping 導(dǎo)

14、致小氣道梗阻的疾病下呼氣支曲線呈現(xiàn)出內(nèi)凹的“勺形”，常見于哮喘、肺氣腫等導(dǎo)致呼氣阻力升高的疾病。第43頁(yè)/共86頁(yè)第44頁(yè)/共86頁(yè)P(yáng)aw (cm H2O)Time在吸氣相達(dá)到設(shè)定的氣道壓力或峰流速所需時(shí)間為上升時(shí)間用于評(píng)估在壓力支持通氣下呼吸機(jī)的支持是否滿足病人吸氣需求第45頁(yè)/共86頁(yè)如果上升時(shí)間過(guò)短，可見壓力波形上見一突起部，稱為壓力“波峰”需要減慢呼吸機(jī)送氣閥的開放，增加上升時(shí)間如果上升時(shí)間過(guò)長(zhǎng)，壓力波形將變得光滑且傾斜，將降低呼吸機(jī)氣流的輸出并且可能無(wú)法滿足病人的吸氣需求需加快送氣閥的開放，降低上升時(shí)間TimePaw (cm H2O)too fasttoo slowpressure

15、spike第46頁(yè)/共86頁(yè)第47頁(yè)/共86頁(yè)當(dāng)吸氣流速下降至某一特定水平時(shí)吸氣終止Inspiration endsTime(sec)PawcmH2OL/minFlowTime(sec)第48頁(yè)/共86頁(yè)Time (sec)120-120FlowL/min100% of PatientsPeak Inspiratory Flow100%75%50%30%上圖中，呼吸機(jī)的設(shè)置為：當(dāng)流速下降至峰流速的30%時(shí)吸氣終止第49頁(yè)/共86頁(yè)A 切換流速的百分比設(shè)置過(guò)高，切換提早出現(xiàn)導(dǎo)致吸氣時(shí)間過(guò)短（潮氣量不足）B 切換流速的百分比設(shè)置過(guò)低，導(dǎo)致吸氣時(shí)間過(guò)長(zhǎng)迫使病人主動(dòng)呼氣（增加呼吸功），壓力波形上出現(xiàn)呼

16、氣“波峰”PawcmH2OL/minFlowTime (sec)Time (sec)100%60%10%Exhalation spikeAB第50頁(yè)/共86頁(yè)第51頁(yè)/共86頁(yè)改善氣道狹窄，增加吸氣流速，減少吸氣時(shí)間，使用PEEPTPTFTVPVFV第52頁(yè)/共86頁(yè)治療氣道痙攣，吸引氣道，更換氣管插管或呼氣濾器，使用牙墊，降低峰流速TPPIPPPlat不不變變TFVPFV第53頁(yè)/共86頁(yè)v 順應(yīng)性增加原因 肺氣腫 表面活性劑使用PVTPIPPPlatP順應(yīng)性下順應(yīng)性下降降順應(yīng)性增順應(yīng)性增加加第54頁(yè)/共86頁(yè)檢查呼吸機(jī)管路可能的漏氣位置TVPVFV第55頁(yè)/共86頁(yè)第56頁(yè)/共86頁(yè)Tri

17、gger dyssynchronyFlow dyssynchronyCycle dyssynchrony 觸發(fā)不觸發(fā)不同步同步流量流量/容容量量 不同不同步步切換不切換不同步同步第57頁(yè)/共86頁(yè)50%以上以上Eur Respir J 2002; 20: S603第58頁(yè)/共86頁(yè)Kondili et al.patient with severe COPD ventilated with PSV第59頁(yè)/共86頁(yè)損傷肌纖維超損傷肌纖維超微結(jié)構(gòu)微結(jié)構(gòu)降低肌力降低肌力第60頁(yè)/共86頁(yè)Eur Respir J 1999; 13: 87382PSVV-ACV第61頁(yè)/共86頁(yè)Br J Anaesth

18、 2003; 91:106119吸氣過(guò)早切換吸氣過(guò)早切換為呼氣為呼氣第62頁(yè)/共86頁(yè)1234Ti固定不固定不變變Ti取決于取決于預(yù)設(shè)和病預(yù)設(shè)和病人人Am J Respir Crit Care Med 2002;165: 9727第63頁(yè)/共86頁(yè)VPFV第64頁(yè)/共86頁(yè)因?yàn)槲鼩饬魉僭O(shè)置過(guò)低，壓力時(shí)間曲線的吸氣支下移Time(sec)Time(sec)PawcmH2OL/minFlow增加流速，減少吸氣時(shí)間，增加設(shè)定的呼吸頻率調(diào)整觸發(fā)敏感度，改成以支持通氣為主的通氣模式，如PSV對(duì)于神經(jīng)系統(tǒng)損傷病人給予充分鎮(zhèn)靜第65頁(yè)/共86頁(yè)第66頁(yè)/共86頁(yè)Time (sec)RawPawcmH2OQu

19、estion: An increase in airway resistance causes _to increase and _ to remain the same?Answer: PIP increases, Pplat remains the same第67頁(yè)/共86頁(yè)Question: This flow pattern indicates what?Answer: Air trapping (auto-PEEP)Time (sec)L/min123456120-120FlowNormal第68頁(yè)/共86頁(yè)120-120FlowL/minPre-BronchodilatorPost

20、-BronchodilatorQuestion: To assess improvement after a breathing treatment you should see what?Time (sec)Answer: Improved peak flow and shorter expiratory time第69頁(yè)/共86頁(yè) TPTVF TThe flow waveform doesnt return to baselineInterpret the mode:Is it a Volume or Pressure mode?Is it a Control (rate) or Supp

21、ort mode?The pressure waveform has a plateau第70頁(yè)/共86頁(yè)Question: What does this loop indicate?Answer: Decreased lung compliance. (ARDS, CHF, Atelectasis)LITERSPawcmH2OVT第71頁(yè)/共86頁(yè)P(yáng)awcmH2OVTPaw risesWith little or no change in VT“beaking”LITERSQuestion: What is occurring when there is a bird beak appear

22、ance on the P/V loop?Answer: Lung overdistention. Pressure continues to increase, while volume remains the same.第72頁(yè)/共86頁(yè)Question: When the expiratory side of the loop doesnt return to baseline, this indicates what?Answer: There is a leak. (ETT cuff, vent circuit)InspirationExpirationFlow(L/min)LITE

23、RSVT第73頁(yè)/共86頁(yè)FVFVQuestion: What is the term used for the part of the loop indicated by the arrow?Answer: This is known as “scooping”. Its caused by airway obstruction.第74頁(yè)/共86頁(yè)Question: The red portion of the waveform indicates that rise time is what?Answer: It indicates that the rise time is too slowPaw (cm H2O)Time第75頁(yè)/共86頁(yè)Question: This pressure support breath is set to cycle of at 30% of the patients _.Answer: Peak Inspiratory FlowTime (sec)120-120FlowL/min100%30%第76頁(yè)/共86頁(yè)第