高流量氧療應(yīng)用及進(jìn)展

1、新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM經(jīng)鼻高流量氧療經(jīng)鼻高流量氧療HFNCHFNC應(yīng)用應(yīng)用概況與進(jìn)展概況與進(jìn)展徐林根2018年9月7日新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM感覺真的很好！新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM我們的實(shí)踐我們的實(shí)踐n我們比較早推廣經(jīng)鼻高流量氧療n2015年從2臺(tái)邁瑞呼吸機(jī)上開始n至少有10臺(tái)機(jī)器可以同時(shí)開始做n實(shí)踐中太多病

2、人獲益讓我們信心倍增nARDSnAECOPDn拔管后n新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMCOPD急性發(fā)作,二型呼吸衰竭，曾經(jīng)氣管切開機(jī)械通氣數(shù)十天，后每次都是HFNC使用后好轉(zhuǎn)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM直腸穿孔，膿毒性休克，ARDS,譫妄，進(jìn)入ICU。氧療加基礎(chǔ)治療后好轉(zhuǎn)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM新昌縣中醫(yī)院新昌縣中醫(yī)院XI

3、NCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM經(jīng)歷了肺炎ARDS，通過氧療現(xiàn)狀態(tài)還不錯(cuò)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM入院PCO2 115mmhg氧療后改善新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM入院PCO2 130mmhg氧療后改善新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM經(jīng)鼻高流量氧療（經(jīng)鼻高流量氧療（

4、HFNC）nhigh-flow nasal cannula nHeated Humidified High-Flow Nasal Oxygen nHigh-Flow Nasal OxygennNasal high flow Oxygen鼻導(dǎo)管、氧療、高流量、加溫加濕鼻導(dǎo)管、氧療、高流量、加溫加濕新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM常見氧療裝置常見氧療裝置1256347新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM常見氧療裝置的問題-鼻導(dǎo)管

5、氧濃度計(jì)算（忽略了病人）氧流量氧流量(lpm)FiO2FiO2 = 0.21 + 0.04 x L氧流量氧流量(lpm)?新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM常見氧療裝置的問題常見氧療裝置的問題-鼻導(dǎo)管鼻導(dǎo)管優(yōu)點(diǎn)：n價(jià)格便宜n使用方便n耐受良好缺點(diǎn)：n吸入氧濃度不固定n患者很難達(dá)到高的吸入氧濃度n受病人呼吸方式影響大新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM儲(chǔ)氧面罩儲(chǔ)氧面罩(非重復(fù)吸入非重復(fù)吸入)n= 普通面罩 + 儲(chǔ)氧氣囊n儲(chǔ)氧氣囊

6、與面罩之間有單向活瓣n面罩上也有單向活瓣n（傳統(tǒng)高流量）新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM問題問題-儲(chǔ)氧面罩儲(chǔ)氧面罩(非重復(fù)吸入非重復(fù)吸入)優(yōu)點(diǎn)nFiO2 接近100%n非插管及機(jī)械通氣條件下提供最高的FiO2缺點(diǎn)nFiO2 接近100%n無法使用濕化無法使用濕化n需要密閉n影響進(jìn)食及交談n無法進(jìn)行霧化治療新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM有氧中毒的危險(xiǎn)有氧中毒的危險(xiǎn)n對(duì)肺臟的危害n纖毛功能障礙n肺不張n通氣血流比失調(diào)n過度

7、炎癥反應(yīng)n肺水腫n間質(zhì)纖維化n對(duì)心臟的危害n減少心輸出量n增加外周血管阻力n減少冠脈血流量健康受試者健康受試者呼吸困難肺活量降低纖毛功能障礙FiO2 98%30-74 HoursFiO2 100%24 HoursFiO2 90-95%3 Hours新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM理想氧療裝置理想氧療裝置n氧濃度精確調(diào)節(jié)n充分濕化n舒適n有機(jī)械通氣的部分功效減低患者做功新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM經(jīng)鼻高流量氧療（經(jīng)鼻高

8、流量氧療（HFNC）n鼻導(dǎo)管氧療鼻導(dǎo)管氧療n相對(duì)舒適相對(duì)舒適n充分的加溫加濕（充分的加溫加濕（37，44mg/L）n促進(jìn)分泌物的移動(dòng)和排出n高流量（4060L/分）n保證氧濃度穩(wěn)定n沖刷和呼氣末正壓n降低呼吸系統(tǒng)代謝消耗新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM高流量氧療設(shè)備的結(jié)構(gòu)（邁瑞高流量氧療設(shè)備的結(jié)構(gòu)（邁瑞SV300）：四大部分）：四大部分一、空氧混合器：提供從21%100%的穩(wěn)定氧濃度二、主動(dòng)加溫加濕器：使氣流維持生理溫濕度三、加熱單回路：使管路內(nèi)氣流保持恒溫四、氧療鼻塞：安全舒適一二三四新昌縣中醫(yī)院新昌縣中

9、醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM高流量氧療的生理機(jī)理：四大效應(yīng)高流量氧療的生理機(jī)理：四大效應(yīng)n穩(wěn)定的供氧濃度（靠能夠提供足夠快的流速）穩(wěn)定的供氧濃度（靠能夠提供足夠快的流速）n呼氣末正壓效應(yīng)n主動(dòng)加溫加濕的氣道效應(yīng)n死腔沖刷效應(yīng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM經(jīng)鼻高流量氧療（經(jīng)鼻高流量氧療（HFNC）提供穩(wěn)定氧濃度）提供穩(wěn)定氧濃度n裝置輸出流量大于吸氣流量n吸入氧濃度相對(duì)穩(wěn)定 n幾乎不受呼吸方式影響氣體流量：氣體流量：8-60 L/min，

10、FiO2 0.21-1.0新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM穩(wěn)定的供氧濃度與吸入氣流速密切相關(guān)穩(wěn)定的供氧濃度與吸入氣流速密切相關(guān)不夠部分空氣補(bǔ)充新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM氧濃度與吸入氣流速關(guān)系n流量到60，氧濃度基本一致n流量20和40時(shí)，氧濃度受潮氣量影響FiO2 0.3FiO2 0.5FiO2 0.7新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF

11、TCM高流量氧療的生理機(jī)理：四大效應(yīng)高流量氧療的生理機(jī)理：四大效應(yīng)n穩(wěn)定的供氧濃度n呼氣末正壓效應(yīng)呼氣末正壓效應(yīng)n主動(dòng)加溫加濕的氣道效應(yīng)n死腔沖刷效應(yīng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMHFNC的的PEEP效應(yīng)受流速于口腔閉合與否影響效應(yīng)受流速于口腔閉合與否影響Groves, N. Aust Crit Care. 2007新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMHFNC 增加增加EELVn與低流量氧療對(duì)比，HFNC顯著增加了可達(dá)25

12、.6%的呼末肺容積新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM高流量氧療的生理機(jī)理：四大效應(yīng)高流量氧療的生理機(jī)理：四大效應(yīng)n穩(wěn)定的供氧濃度n呼氣末正壓效應(yīng)n主動(dòng)加溫加濕的氣道效應(yīng)主動(dòng)加溫加濕的氣道效應(yīng)n死腔沖刷效應(yīng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM合適的濕化使氣道清除能力加強(qiáng)合適的濕化使氣道清除能力加強(qiáng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM流量影響濕化效

13、果（原理同氧濃度）流量影響濕化效果（原理同氧濃度）n設(shè)置流量超過病人自主呼吸流量，才能保持絕對(duì)濕度穩(wěn)定n病人潮氣量越大，這種現(xiàn)象越明顯Chikata, Respir Care. 2014 Aug;59(8):1186-90.新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM高流量氧療的生理機(jī)理：四大效應(yīng)高流量氧療的生理機(jī)理：四大效應(yīng)n穩(wěn)定的供氧濃度n呼氣末正壓效應(yīng)n主動(dòng)加溫加濕的氣道效應(yīng)n死腔沖刷效應(yīng)死腔沖刷效應(yīng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF

14、TCM死腔沖刷效應(yīng)死腔沖刷效應(yīng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM呼氣相死腔沖刷呼氣相死腔沖刷大部分CO2已被沖刷稀釋呼氣結(jié)束，吸氣即將開始。這段氣體將被重復(fù)吸入新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn3D模型核素氪示蹤試驗(yàn)，可見氣體沖刷的時(shí)間效應(yīng)和流量效應(yīng)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn鼻腔前段的沖刷效果比后段更明顯n流速加大，沖刷效果增強(qiáng)

15、n1L/min的流速大致對(duì)應(yīng)1.8ml/s的沖刷容積新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM操作路徑操作路徑n氧濃度調(diào)節(jié)n氣體流量調(diào)節(jié)n濕化目標(biāo)設(shè)定n回路建立連接新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMHFNC的臨床具體操作的臨床具體操作n需要調(diào)節(jié)的主要參數(shù)就是流量和氧濃度n流量n初始設(shè)置流量35L/minn如果呼吸頻率沒有下降，則按5-10L/min往上加n如果患者不能耐受，則按5-10L/min往下減n氧濃度n根據(jù)氧合情況調(diào)整氧濃度

16、新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn原則上優(yōu)先調(diào)整流量，但是在緊急情況下可優(yōu)先調(diào)整氧濃度以快速獲得滿意氧合n撤離n如患者在流量20L/min，氧濃度50%情況下能耐受，可撤離HFNC新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM呼吸機(jī)氧療的連接步驟呼吸機(jī)氧療的連接步驟1. 通過管路將吸氣支路的過濾器與濕化器入口連接2. 通過帶加熱功能的呼吸管路將濕化器出口于鼻塞導(dǎo)管相連3. 呼氣端口不連接管路新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG H

17、OSPITAL OF TCMXINCHANG HOSPITAL OF TCM氧療鼻導(dǎo)管的使用氧療鼻導(dǎo)管的使用注意注意請(qǐng)確保鼻塞導(dǎo)管的大小合適且不要堵塞鼻孔在連接病人前，請(qǐng)檢查系統(tǒng)的流速設(shè)置及送氣系統(tǒng)已經(jīng)加熱新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn室溫25時(shí)，基本沒有冷凝水n室溫20時(shí)，冷凝水逐漸累積n調(diào)高流速可減少冷凝水形成室溫室溫25室溫室溫20新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn室溫25，流量20、40、60L/min時(shí)，一

18、天蒸餾水消耗量分別為1.2L，2.4L和3.5L。n室溫20，流量20、40、60L/min時(shí)，一天蒸餾水消耗量分別為1.4L，3.0L和3.5L。室溫室溫25室溫室溫20室溫越低流量越大消耗蒸餾水越大室溫越低流量越大消耗蒸餾水越大新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM臨床應(yīng)用范圍臨床應(yīng)用范圍n一型呼衰n二型呼衰n氣管插管前預(yù)充氧n氣管插管拔管后n急性左心衰n姑息性治療n纖支鏡操作n霧化吸入新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMNE

19、JM, 2015一型呼衰：證據(jù)明確，應(yīng)用廣泛一型呼衰：證據(jù)明確，應(yīng)用廣泛新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMnNagata 研究的結(jié)論:nHFNC 明顯改善生活質(zhì)量，降低 COPD 伴慢性高碳酸血癥呼吸衰竭患者的高碳酸血癥 nHFNC 非常容易耐受，治療期間沒有相關(guān)嚴(yán)重不良事件發(fā)生 （2018 年日本神戶多中心隨機(jī)交叉研究2018年發(fā)表于美國(guó)胸科協(xié)會(huì)雜志）二型呼衰：明確適應(yīng)證，前景看好二型呼衰：明確適應(yīng)證，前景看好新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSP

20、ITAL OF TCMStorgaard 研究的結(jié)論研究的結(jié)論nHFNC 降低 COPD 伴慢性低血氧性呼衰患者的 AECOPD 發(fā)作率和入院率 n能夠穩(wěn)定晚期 COPD 患者的臨床情況 nNFNC 應(yīng)被考慮作為 COPD 伴慢性低血氧性呼衰患者的基本治療方法 (完成于丹麥 奧爾堡2018 年發(fā)表于國(guó)際 COPD 雜志) 新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM急診科急診科AECOPD使用使用HFNC的回顧性研究的回顧性研究n出現(xiàn)高碳酸血癥的病人13例（33.3%），平均PaCO2 64.6mmHn其中6例進(jìn)行了治

21、療前后對(duì)比，PaCO2從70mmHg降到55mmHg (P=0.041)n無高碳酸血癥組，治療前后PaCO2分別為32.7mmHg和32.4mmHg (P=0.919)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn應(yīng)用高流量氧療后，COP2水平下降新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMnCOPD患者使用了高流量氧療后潮氣量增加，呼吸頻率下降，分鐘通氣量保持不變。n提示通氣效率提高?？赡芘c死腔沖刷及呼末正壓打開氣道有關(guān)新昌縣中醫(yī)院新昌縣中醫(yī)

22、院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM氣管插管前預(yù)充氧：無縫連接，爭(zhēng)議中前行氣管插管前預(yù)充氧：無縫連接，爭(zhēng)議中前行新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM撤機(jī)拔管流程撤機(jī)拔管流程n原發(fā)病好轉(zhuǎn)n低水平氧合下（FiO20.40.5，PEEP5）氧合指數(shù)可接受n血流動(dòng)力學(xué)穩(wěn)定n神志狀態(tài)可（無需強(qiáng)求清醒，自主呼吸穩(wěn)定即可）n行SBT（T管法、PSV法、CPAP法）30min2hn撤機(jī)n評(píng)估氣道保護(hù)能力（氣囊漏氣試驗(yàn)）n拔管nHFNC氣管插管拔管后：有效降低失敗率氣

23、管插管拔管后：有效降低失敗率新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM急性左心衰：壓力比氧氣更重要，所以流速更重要急性左心衰：壓力比氧氣更重要，所以流速更重要新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM姑息性治療：不改變結(jié)局，但生活質(zhì)量更好姑息性治療：不改變結(jié)局，但生活質(zhì)量更好新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM纖支鏡操作：關(guān)注流纖支鏡操作：關(guān)注流程安全程安全

24、新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn總共灌洗30例，成功25例nHFNC中位流量50L/min，F(xiàn)iO2 1.0n僅2例出現(xiàn)SpO2瞬間降到88%以下，并迅速恢復(fù)新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCMn問題：加溫加濕和高流速會(huì)促進(jìn)氣溶膠在管路的沉積霧化吸入治療：老問題，新方法霧化吸入治療：老問題，新方法新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM高流量氧

25、療時(shí)霧化吸入建議：高流量氧療時(shí)霧化吸入建議：n霧化器位置放在濕化器前n使用較低的流速n鼓勵(lì)病人加強(qiáng)自主呼吸n叮囑病人維持閉口狀態(tài)以減少漏氣損耗新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM整理ppt2014-2016 HFNC 相關(guān)重要研究相關(guān)重要研究 HFNC能降低急性低氧性呼吸衰竭患者的90天病死率N Engl J Med 2015;372:2185-96. HFNC能預(yù)防胸腹術(shù)后患者呼吸衰竭的發(fā)生，效果不亞于BiPAP治療JAMA 2015;313(23):2331-2339. HFNC能降低氣管插管操作時(shí)低氧血癥

26、的發(fā)生Crit Care Med 2015;43: 574-583 HFNC能降低急性呼吸衰竭患者拔管后的再插管率，顯著改善氧合和增加患者舒適性nAm J Respir Crit Care Med 2014; 190:282288 與傳統(tǒng)氧療相比HFNC能降低低風(fēng)險(xiǎn)拔管病人的再插管風(fēng)險(xiǎn)JAMA 2016; 2016, 315(13):1354-61. 新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL OF TCM我們常常會(huì)用n一型呼衰n二型呼衰n氣管插管拔管后n急性左心衰新昌縣中醫(yī)院新昌縣中醫(yī)院XINCHANG HOSPITAL OF TCMXINCHANG HOSPITAL