《COPD機(jī)械通氣》

1、COPD的機(jī)械通氣的機(jī)械通氣COPD患者的肺泡過(guò)度充盈患者的肺泡過(guò)度充盈Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004; 350: 2689-97時(shí)間常數(shù)時(shí)間常數(shù)( ) = R x C測(cè)定肺組織充盈或排空的速度反映肺組織對(duì)壓力變化的反應(yīng)速度時(shí)間常數(shù)時(shí)間常數(shù)( )Time/Tau吸氣相吸氣相呼氣相呼氣相Pressure時(shí)間常數(shù)時(shí)間常數(shù)( )PA(t) = (Pplat - PEEP) e-ktk = 1/ =1/(R x C)V(t) = Vt

2、x e-ktk = 1/ =1/(R x C)時(shí)間常數(shù)時(shí)間常數(shù)( )時(shí)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”動(dòng)態(tài)過(guò)度充盈動(dòng)態(tài)過(guò)度充盈: DHIinspexpTimeTidal volumeTrapped gasLung VolumeFRCObstructed LungsNormal Stiff Lungs機(jī)械通氣的適應(yīng)證機(jī)械通氣的適應(yīng)證: COPD呼吸肌疲勞且瀕臨呼吸停止盡管進(jìn)行充分的保守

3、治療, PaCO2仍進(jìn)行性升高勞累和(或)高碳酸血癥導(dǎo)致意識(shí)狀態(tài)惡化高濃度吸氧治療無(wú)效的低氧血癥痰液清除障礙導(dǎo)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(guò)高n肺泡過(guò)度膨脹n胸腔內(nèi)壓過(guò)高 回心血量減少 休克機(jī)械通氣時(shí)的機(jī)械通氣時(shí)的PEEPiVt 10 12 ml/kg, f 12 15 bpm, I:E 1:2 3DHI和和PEEPi的影響因素的影響因素DHI和和PEEPi的影響因素的影響因素機(jī)械通氣參數(shù)的設(shè)置機(jī)械通氣參數(shù)的設(shè)置: COPD潮氣量吸氣流速吸呼比 / 吸氣時(shí)間 / 呼氣時(shí)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 Chin

4、g 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Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspirator

5、y 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Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Resp

6、iratory 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 Vent

7、ilation. Chest 2002; 122: 20962104COPD: 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. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較

8、結(jié)論COPD患者機(jī)械通氣的最佳吸氣氣流為減速氣流通過(guò)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 on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD機(jī)械通氣策略機(jī)械通氣策略降低內(nèi)源性PEEP的方法n外源性P

9、EEP ?n延長(zhǎng)呼氣時(shí)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 Effect 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,

10、Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 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 M

11、anual 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 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

12、. 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 Flow During Manual Hyperinflation. Anesth Analg

13、 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 Flow 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 P

14、eak 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 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

15、, 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

16、PaCO2 ODonoghue 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 RD. Effect of CPAP on intrinsic PEEP, ins

17、piratory 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 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ

18、, 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 RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, a

19、nd 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 2002;57:533-539COPD穩(wěn)定期穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, J

20、ordan 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 RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in

21、severe stable COPD. Thorax 2002;57:533-539總結(jié)對(duì)于處于穩(wěn)定期的嚴(yán)重COPD患者, 應(yīng)用高水平的CPAP能夠n降低PEEPi及肌肉活動(dòng)指標(biāo)n肺容積顯著增加COPD急性期患者急性期患者(n = 10)Gurin C, Fournier 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 2

22、1體重(%pred)96 27FiO2 (%)48 9 COPD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急性期急性期: PEEPGurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanica

23、lly 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, 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 ve

24、ntilation 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, 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 ven

25、tilation 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 positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Car

26、e 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 positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1

27、519-1528COPD: 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 positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEE

28、P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 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Carame

29、z MP, Borges JB, Tucci MR, 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,

30、Tucci MR, 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: 1519-1528結(jié)論對(duì)于部分氣道梗阻的患者而言, 應(yīng)用控制通氣過(guò)程中, 設(shè)置外源性PEEP能夠緩解過(guò)度充盈基礎(chǔ)疾病, 機(jī)械力學(xué)指標(biāo)或呼吸

31、機(jī)設(shè)置均無(wú)法預(yù)測(cè)上述結(jié)果逐漸增加PEEP并觀察平臺(tái)壓力改變, 是減少副作用的合理方法Assessment of Pulmonary HyperinflationTimeTidal volumeTrapped gasLung VolumeFRCTidal vol.Tidal hyper-inflationApneaTidal VentilationCOPD: 縮短吸氣時(shí)間縮短吸氣時(shí)間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinfl

32、ation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370Tinsp RR Texp PEEPi COPD: 縮短吸氣時(shí)間縮短吸氣時(shí)間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pul

33、monary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時(shí)間縮短吸氣時(shí)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: 1365-137016.1

34、 19.0 20.8 7.0 6.3 6.4 2.1 2.4 2.3 COPD: 縮短吸氣時(shí)間縮短吸氣時(shí)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: 1365-1370COPD: 縮短吸氣時(shí)間縮短吸氣時(shí)間Laghi F, Sega

35、l 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PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFT

36、during 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(shí)間縮短吸氣時(shí)間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with

37、 Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時(shí)間縮短吸氣時(shí)間機(jī)械通氣患者常常呼吸頻數(shù), 肺過(guò)度充盈n提高吸氣流速, 可以縮短吸氣時(shí)間, 盡管呼吸頻率加快, 但能夠延長(zhǎng)呼氣時(shí)間, 降低呼吸做功n延長(zhǎng)吸氣暫停能夠降低呼吸頻率, 卻引發(fā)肺過(guò)度充盈, 呼吸做功增加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嚴(yán)重氣流梗阻患者的處理嚴(yán)重氣流梗阻患者的處理增加流量不能顯著延長(zhǎng)