1、机械通气总论,机械通气,机械通气的应用,1,常用的机械通气模式,2,机械通气常见问题的处理,3,4,常见疾病的机械通气策略,机械通气,常用的机械通气模式,2,机械通气常见问题的处理,3,4,常见疾病的机械通气策略,机械通气的应用,1,机械通气的开始,机械通气的开始,1949 1950年Scandinavia脊髓灰质炎流行呼吸麻痹者死亡率80%1913年Janeway第一台定型呼吸机,机械通气的开始,1952年Denmark脊髓灰质炎流行Blegdam Hospital31名呼吸肌麻痹患者27名相继死亡麻醉科医生Bjan Ibsen气管插管,Mortality from Paralytic Po
2、lioLassen HCA. The Lancet 1:37-41,1953,July-Aug,机械通气的开始,75名病人手法通气24小时内动员250名医学生用手捏气囊260名护士参加床边护理消耗250筒氧气27名工人更换氧气筒死亡率从87%降低到40%以下,机械通气的开始,机械通气的开始,Mortality from Paralytic Polio:Lassen HCA. The Lancet 1:37-41,1953,July-Aug,Dec,Nov,Aug,Sept,Oct,机械通气的开始,负压呼吸机(“铁肺”)1928年Boston儿童医院无创通气首次用于临床20世纪40至50年代脊髓
3、灰质炎爆发流行时广泛使用正压呼吸机1955年麻省总医院首次使用有创通气现已成为机械通气的标准,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中的机械通气,机械通气的适应证急性呼吸功能衰竭66%ARDS8%慢性呼吸功能衰竭急性加重13%昏迷15%神经肌肉疾病 5%,Esteban A, Anzueto A, Alia I
4、, 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,ICU中的机械通气,人工气道气管插管75%经口气管插管96%经鼻气管插管 4%气管切开24%面罩 1%,Esteban A, Anzueto A, Alia I, et al. How Is Mechanical Ventilation Employed in the Inten
5、sive Care Unit? An International Utilization Review. Am J Respir Crit Care Med 2000; 161: 1450-1458,机械通气的比例,1. Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 1994; 106: 1188-1193; 2. Esteban A, Anzueto A, Alia I, et al.
6、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 mechanical ventilation. JAMA 2002; 287: 345-355,
7、机械通气,机械通气常见问题的处理,3,4,常见疾病的机械通气策略,机械通气的应用,1,常用的机械通气模式,2,呼吸模式,VCVPCVSIMVSIMV + PSVPSVCPAPBIPAPAPRV,PRVC/autoflow/VV+VS/VV+AutomodeVAPS/PAMRVASVPAV+/PPS,机械通气的常用模式,1. Esteban A, Alia I, Ibanez J, et al. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 1994; 106:
8、 1188-1193; 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 receiv
9、ing mechanical ventilation. JAMA 2002; 287: 345-355,呼吸机的参数设置,呼吸机的设置定容通气时的潮气量 9 ml/kg压力支持通气时压力支持水平19 cmH2O呼气末正压(PEEP) 5 cmH2O,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; 16
10、1: 1450-1458,选择不同机械通气模式,改善气体交换增加患者舒适性加速自主呼吸的恢复,呼吸模式介绍,如何开始吸气吸气如何进行如何结束吸气优点缺点,容量控制通气,Volume Control Ventilation(VCV),容量控制通气 参数的设置,参数潮气量(ml)或分钟通气量(l/min)吸气流速(l/min)呼吸频率(b/min)PEEP (cmH2O)FiO2 (%)吸呼比吸气末暂停时间(s)或吸气末暂停百分比(%)触发灵敏度,容量控制通气: 参数设置,如何开始吸气呼吸机或患者触发吸气如何进行恒定流速flow = Vt / Tinsp如何结束吸气设置吸气时间或潮气量,容量控制通
11、气: 吸气的开始,VIM,PIM,VIM,Tb = 60/f,The ventilator monitors time intervals from a specific event (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,
12、as shown in figure. Such a breath is called a ventilator-initiated mandatory (VIM) breath. If the patients inspiratory efforts generate a pressure or flow trigger before the breath cycle has elapsed, the ventilator delivers a PIM.,容量控制通气 吸气的开始,1,t,吸气相根据预置的呼吸频率或当患者触发时开始,吸气触发的方式及设置,压力触发(pressure trigg
13、er)-1 to -2 cmH2O流量触发(flow trigger)-1 to -3 lpm,吸气触发的方式 压力触发,P (cmH2O),呼气末气道压力下降= 患者开始吸气= 呼吸机开始送气,吸气触发的方式 压力触发,压力触发灵敏度的设置指气道压力较PEEP下降的水平0 20 cmH2O例如PEEP = 0 (10)Trigger sensitivity = -2即气道压力为-2 (8) cmH2O时呼吸机开始送气,吸气触发的方式 流量触发,呼气流量 吸气管路中气体流量,吸气管路,呼气管路,呼气末,吸气触发的方式 流量触发,呼气流量 90%的最小PEEP肺开放静态P-V曲线的低位转折点以上2 cmH2O,肺或胸廓限制性疾病,肺部疾患晚期肺纤维化晚期ARDS腹部疾患大量腹水其他胸廓异常脊柱后凸畸形,肺或胸廓限制性疾病,TV ,Palv,Physiologic dead space,Pleural pressure,Cardiac output SHOCK,PvO2,PaO2 ,MV PEEP,Palv PAP,V/Q mismatch or shunt,肺或胸廓限制性疾病,减少死腔通气的方法降低分钟通气量纠正低血容量,
