無創(chuàng)呼吸的臨床應(yīng)用-課件

1、無創(chuàng)正壓通氣的臨床應(yīng)用Noninvasive ventilation in acute respiratory failure武漢協(xié)和醫(yī)院急診科張勁農(nóng)Pickwickian syndrome and Sleep apnea1980s以前，以氣管切開治療高血壓1980s經(jīng)鼻CPAP用于治療OSAHSColin Sulliven，2002.11.1980s, Australia按人-機(jī)連接方式分類侵入性(有創(chuàng))機(jī)械通氣(IMV)經(jīng)口或鼻氣管插管氣管切開氣管插管非侵入性(無創(chuàng))通氣(NIV)正壓 (Noninvasive Positive Pressure Ventilation, NIPPV)負(fù)壓

2、 (Negative Pressure ventilation, NPV)侵入性(有創(chuàng))通氣經(jīng)氣管插管NIPPV的連接方式Normal, OSA and OSA treated with CPAPCPAP treatmentPrevalence of SDB in the general population: the HypnoLaus studyThe CoLaus/PsyCoLaus database included a sample of 6733 people aged 3575 yrs selected at random between 2003 to 2006 in Swit

3、zerland2121 people were included between Sept 1, 2009 to June 30, 2013, 48% M, 52% F, median age 57 years and mean BMI 256 kg/m2The median AHI was 69 /h in women and 149 / h in men The AHI 15 /h was 234% in women and 497% in menAHI 206/h was associated independently with presenceHypertension, odds r

4、atio 160, p=00292Diabetes, 200, p=00467), metabolic syndrome 280, p00001)Depression, 192, p=00292).Heinzer R, et al. The Lancet Respiratory medicine 2015: 3(4): 310-318.OSAHS: CPAP or Tracheotomy?1999年 武漢OSAHS 與睡眠剝奪2001年武漢肢端肥大癥男，50歲，EDS ，睡眠不均勻打鼾多年甲狀腺功能減退合并OSApHPaO2mmHgPaCO2mmHgHCO3mmol/LBEmmol/LK+mm

5、ol/LNa+mmol/LClmmol/L7.455450.713486女,29歲.呼吸困難、乏力、嗜睡半年。體檢: 呼吸困難，極度困乏，口唇和指(趾)明顯紫紺，心率108次/分，律齊，無雜音，雙肺無明顯干濕啰音，下肢凹陷性浮腫。動(dòng)脈血?dú)夥治龊碗娊赓|(zhì)測(cè)定結(jié)果如下: 10年追蹤觀察SDB相關(guān)病死率264 healthy men, 377 simple snorers, 403 with untreated mild-moderate obstructive sleep apnoea-hypopnoea, 235 with untreated severe disease,

6、and 372 with the disease and treated with CPAP Marin JM, et al. Lancet 2005;365:1046-53 澳大利亞Busselton Health Study 14年隊(duì)列研究: 中重度OSA是全因死亡的獨(dú)立危險(xiǎn)因素Survival Distribution FunctionSurvive timeRDI15 RDI 514 (紅) RDI 5 (黑) P 45 mm HgObese, BMI 30 kg/m2 Exclude other causes that could account for awake hypovent

7、ilation, such as lung or neuromuscular diseaseSleep hypoventilation alone does not define OHSPiper AJ and Grunstein R. Am J Respir Crit Care Med, 2011, 183: 292298Some of the interactions between factors believed to be contributing to hypercapnia in pts with severe obesityPiper AJ, Grunstein RR. J A

8、ppl Physiol 2010;108:199205HCVR=hypercapnic ventilatory responseMechanisms of heart failure in obesityEbong IM, et al. Obesity Research & Clinical Practice, 2014: 8, e540e548Kaplan-Meier outcome curves for OHS and OSAHSPLOS ONE | DOI:10.1371/journal.pone.0117808 February 11, 2015Survival of Obesity

9、hypoventilationPriou P,et al. Chest , 2010 138: 8490With / Without O2With / Without NIVA prospective RCT:NIV vs. standard treatment in immunosuppressed pts with pulmonary infiltrates, fever, and ARFHilbert G, et al. N Engl J Med 2001;344:481-7NIV vs. standard treatment in immunosuppressed pts with p

10、ulmonary infiltrates, fever, and ARFHilbert G, et al. N Engl J Med 2001;344:481-7.)Serious complications and death in ICUHilbert G, et al. N Engl J Med 2001;344:481-7.)NIV用于免疫低下ARF：當(dāng)前的證據(jù)Study reference (No. O2 / NIV)NIV is betterO2 is betterLemiale V, et al. 2015NIV用于免疫低下ARF：當(dāng)前的認(rèn)識(shí)NIV may be useful a

11、s a prophylactic treatment to obviate the need for IMVIn contrast, the use of NIV as an alternative to IMV in patients with severe ARF seems to adversely impact survivalDiscontinuation of ventilatory support: newsolutions to old dilemmasAm J Respir Crit Care Med Vol 184. pp 672679, 2011AT A GLANCE C

12、OMMENTARYThe use of noninvasive ventilation (NIV) as an early weaning/extubation technique from invasive mechanicalventilation remains controversial.What This Study Adds to the FieldNIV used as an early weaning/extubation technique in difficult-to-wean patients with chronic respiratory failure did n

13、ot reduce the reintubation rate within 7 days as compared with conventional weaning and early extubation with standard oxygen therapy. Nevertheless, NIV may improve the weaning results in these patients by shortening the intubation duration and reducing the risk of postextubation acute respiratory f

14、ailure. The potential benefit of rescue postextubation NIV in these patients needs further study.應(yīng)用NIPPV前應(yīng)該思考的問題人機(jī)接口能否牢靠？鼻罩還是口鼻面罩？如何進(jìn)行給氧？治療壓需要多大？口腔閉合壓有多大？食道能承受多大壓？鼓膜能承受多大壓？有無腦脊液漏？痰從哪里排除？有無吞咽障礙？患者為什么會(huì)張口？CO2重吸收如何控制？如何防治窒息？有無插管必要？呼吸機(jī)的模式應(yīng)用什么樣的無創(chuàng)呼吸模式？帶有目標(biāo)潮氣量功能有效的漏氣補(bǔ)償能力高達(dá)170L/min，堅(jiān)固耐用且靜音極佳 26dbTrigger loc

15、kout, 解決了提高觸發(fā)靈敏度和誤觸發(fā)之間的矛盾獨(dú)有ATC技術(shù)，有效治療肺泡塌陷，糾正血?dú)馕蓙y流速-時(shí)間曲線，容量-時(shí)間曲線，吸氣同步率/呼氣同步率監(jiān)測(cè)通氣管路外設(shè)連接接口數(shù)據(jù)下載接口一體化濕化器接口 顯示屏數(shù)字顯示/圖形顯示操作快捷鍵IPAPEPAP呼吸頻率吸呼比導(dǎo)航旋鈕Pts with COPD and hypercapnic encephalopathyBiPAP S/T with AVAPS vs. BiPAP S/T aloneGlasgow Coma ScaleBrain injury is classified as:Severe, with GCS 89Moderate, G

16、CS 8 or 912 (controversial)Minor, GCS 13123456EyeDoes not open eyesOpens eyes in response to painful stimuliOpens eyes in response to voiceOpens eyes spontaneouslyN/AN/AVerbalMakes no soundsIncomprehensible soundsUtters inappropriate wordsConfused, disorientedOriented, converses normallyN/AMotorMake

17、s no movementsExtension to painful stimuli (decerebrate response)Abnormal flexion to painful stimuli (decorticate response)Flexion / Withdrawal to painful stimuliLocalizes painful stimuliObeys commands Pts with COPD and hypercapnic encephalopathyBriones Claudett et al. BMC Pulmonary Medicine 2013, 1

18、3:12BiPAP S/T with AVAPS vs. BiPAP S/T aloneContraindications of NIVAbsoluteRelativeRespiratory arrestMedically unstable (hypotensive shock, uncontrolled cardiac ischemia, or arrhythmia)Unable to fit maskAgitated, uncooperativeUncontrolled vomiting or copious upper gastrointestinal bleedingUnable to protect airwayTotal upper airway obstructionSwallowing impairmentFacial traumaExcessive secretions not managed by secretion clearance