COPD的機械通氣培訓課件1

COPD的機械通氣COPD患者的肺泡過度充盈SutherlandER,CherniackRM.ManagementofChronicObstructivePulmonaryDisease.NEnglJMed2004;350:2689-972COPD的機械通氣時間常數(shù)()=RxC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速度3COPD的機械通氣時間常數(shù)()Time/Tau吸氣相呼氣相Pressure4COPD的機械通氣時間常數(shù)()PA(t)=(Pplat-PEEP)e-kte=2.718k=1/=1/(RxC)V(t)=Vtxe-kte=2.718k=1/=1/(RxC)5COPD的機械通氣時間常數(shù)()時間常數(shù)成人(正常值)2x0.10=0.20”術后氣管插管成人患者5x0.06=0.30”COPD成人患者15x0.06=0.90”ARDS成人患者8x0.03=0.24”ARDS患兒5x0.01=0.05”Tau呼出氣容積殘余容積00%100%163%37%395%5%599.9%0.1%6COPD的機械通氣動態(tài)過度充盈:DHIinspexpTimeTidalvolumeTrappedgasLungVolumeFRCObstructedLungsNormalStiffLungs7COPD的機械通氣機械通氣的適應證: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8COPD的機械通氣COPD患者的病理生理改變內源性PEEP過高肺泡過度膨脹胸腔內壓過高回心血量減少休克9COPD的機械通氣機械通氣時的PEEPi

Vt10–12ml/kg,f12–15bpm,I:E1:2–3診斷No.PEEPi(范圍)發(fā)生率COPD452.6–2245/45(100%)CF1111/1(100%)Asthma313.5–203/3(100%)ARDS281.0–8.115/28(58%)CPE101.0–6.08/10(80%)Other101.0–4.15/10(50%)10COPD的機械通氣DHI和PEEPi的影響因素內在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裝置呼吸系統(tǒng)順應性呼吸機設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11COPD的機械通氣DHI和PEEPi的影響因素內在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裝置呼吸系統(tǒng)順應性呼吸機設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12COPD的機械通氣機械通氣參數(shù)的設置:COPD潮氣量吸氣流速吸呼比/吸氣時間/呼氣時間呼吸頻率…13COPD的機械通氣COPD:不同吸氣氣流的比較ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210414COPD的機械通氣COPD: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,ml56267558655665957172RR,bpm18.21.718.61.418.41.918.51.3MV,lpm10.41.610.31.510.61.610.71.8Ti/Ttot0.290.040.280.030.290.040.280.03平均吸氣流速,lpm385377397386ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210415COPD的機械通氣COPD: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,cmH2O47.111.547.810.839.59.746.611.0Paw,cmH2O7.64.27.24.88.44.58.43.9Pplat,cmH2O20.29.119.610.618.98.821.410.4Vd/Vt,%58.45.254.56.348.65.557.64.9Cst,ml/cmH2O35.38.935.811.236.69.337.29.7ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210416COPD的機械通氣COPD: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2pH7.440.047.440.077.430.067.440.04PaO2/FiO2,mmHg23673231652237022767PaCO2,mmHg451045103794612A-aDO2,mmHg133.136.5136.434.2156.333.7134.435.3HR,bpm106.118.1108.320.2105.318.9109.920.5MAP,mmHg9223881888219019ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210417COPD的機械通氣COPD:不同吸氣氣流的比較波形(均值SD)參數(shù)恒定氣流1正弦波減速氣流恒定氣流2WOB,J/L0.920.160.880.180.750.150.920.18Raw,cmH2O/L/s12.63.112.43.611.22.412.53.3VO2,ml/min38453389603774938252VCO2,ml/min27452280472735627655癥狀評分54.513.458.611.942.712.356.112.8ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210418COPD的機械通氣COPD:不同吸氣氣流的比較結 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ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210419COPD的機械通氣COPD機械通氣策略降低內源性PEEP的方法外源性PEEP?延長呼氣時間增加吸氣流速縮短吸氣末暫停降低呼吸頻率20COPD的機械通氣呼氣流速PalvPEEPFlow =P/Raw =(Palv–PEEP)/RawFlow21COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6Compliance22COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6CompliancePFlow23COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半徑PEEP24COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP半徑流速?P流速25COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-626COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-627COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半徑28COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半徑Flow29COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半徑PEEP30COPD的機械通氣PEEP與呼氣流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP半徑流速P流速31COPD的機械通氣COPD穩(wěn)定期患者(n=9)年齡(yr) 707.3FEV1(%pred) 30

9.5FVC(%pred) 53

13.6RV(%pred) 186

33.1FEV1/VC(%) 44

11.6TLC(%pred) 103

8.7TLCO(%pred) 46

25.4PaO2(kPa) 7.4

0.4PaCO2(kPa) 7.1

1.1pH 7.40

0.00O’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53932COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53933COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53934COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53935COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53936COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53937COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53938COPD的機械通氣COPD穩(wěn)定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539總結對于處于穩(wěn)定期的嚴重COPD患者,應用高水平的CPAP能夠降低PEEPi及肌肉活動指標肺容積顯著增加39COPD的機械通氣COPD急性期患者(n=10)GuérinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2001;18:491-498年齡(yr) 646身高(cm) 167

6體重(kg) 72

21體重(%pred) 96

27FiO2(%) 48

9Vt(L) 0.74

0.09PIF(L/s) 0.65

0.12Tinsp(s) 1.13

0.15Texp(s) 3.42

0.57RR(bpm) 13.5

1.540COPD的機械通氣COPD急性期:PEEPPEEP(cmH2O)051015PEEPt,cmH2O8.44.810.03.912.32.416.91.8PEEPi,cmH2O7.13.93.73.31.81.80.81.2FRC,L0.540.420.740.481.030.421.500.51Rint,rs,cmH2Os/L9.23.68.12.77.32.77.23.0Rrs,cmH2Os/L7.71.88.51.89.52.79.73.3Rrs,cmH2Os/L173.916.72.716.83.016.93.6Est,rs,cmH2O/L12.73.012.93.312.93.315.54.5GuérinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2001;18:491-49841COPD的機械通氣COPD急性期:PEEPGuérinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2001;18:491-49842COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-1528RR6bpmRR9bpm43COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152844COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152845COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152846COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152847COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152848COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152849COPD的機械通氣COPD:PEEP與呼氣流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-1528結 論對于部分氣道梗阻的患者而言,應用控制通氣過程中,設置外源性PEEP能夠緩解過度充盈基礎疾病,機械力學指標或呼吸機設置均無法預測上述結果逐漸增加PEEP并觀察平臺壓力改變,是減少副作用的合理方法50COPD的機械通氣AssessmentofPulmonaryHyperinflationTimeTidalvolumeTrappedgasLungVolumeFRCTidalvol.Tidalhyper-inflationApneaTidalVentilation51COPD的機械通氣COPD:縮短吸氣時間LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-1370Tinsp

RRTexpPEEPi52COPD的機械通氣COPD:縮短吸氣時間LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-1370患者基礎情況(n=10)基本情況均值SE年齡,yr68.32.9體重,kg82.95.9身高,cm173.52.1FEV1,L1.210.12FEV1,%pred39.74.3FEV1/FVC,%pred40.93.5FRC,L6.50.8TLC,L8.90.7PaO2,mmHg723PaCO2,mmHg38153COPD的機械通氣COPD:縮短吸氣時間LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137016.11.019.01.420.81.57.01.36.31.16.41.12.10.22.40.22.30.254COPD的機械通氣COPD:縮短吸氣時間LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137056COPD的機械通氣為何需要設置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduringthePlateauPhase57COPD的機械通氣為何需要設置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNoPENDELLUFTbecauseofconstantflowflow58COPD的機械通氣COPD:縮短吸氣時間LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137059COPD的機械通氣COPD:縮短吸氣時間機械通氣患者常常呼吸頻數(shù),肺過度充盈提高吸氣流速,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LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137060COPD的機械通氣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) Vt RR flow TTOT TI TE

TE 0.5 15 60 4.00 0.50 3.50 -- 0.5 15 120 4.00 0.25 3.75 0.25 0.5 14 60 4.30 0.50 3.80 0.30 0.5 12 60 5.00 0.50 4.50 1.00提示降低分鐘通氣量對于減少內源性PEEP的重要作用61COPD的機械通氣延長呼氣時間治療哮喘持續(xù)狀態(tài)目的:評價哮喘持續(xù)狀態(tài)患者降低呼吸頻率對動態(tài)過度充盈(DHI)的影響氣道平臺壓患者:12名因嚴重哮喘接受機械通氣患者設置:定容通氣,潮氣量613100mL,吸氣流速794L/