機(jī)械通氣波形

機(jī)械通氣波形FA-PMR倪杰睿生理呼吸壓力流量容量壓力呼吸機(jī)應(yīng)用過(guò)程中，所有壓力均是針對(duì)呼吸道（氣道）的壓力而言影響因素：呼吸機(jī)工作壓力壓力控制或支持水平潮氣量氣道阻力自主呼吸用力幅度流速流速：流動(dòng)物體單位時(shí)間內(nèi)所經(jīng)過(guò)的距離（m/s）流量：?jiǎn)挝粫r(shí)間內(nèi)流經(jīng)某一橫截面積的流體體積（L/min）呼吸力學(xué)中，流速和流量?；煊糜绊懸蛩兀ê粑l率、吸氣時(shí)間及自主用力）容量呼吸機(jī)使用過(guò)程中，容量是治療的目標(biāo)，各種呼吸功能的改善和完善，均是通過(guò)先保證容量，再逐步完成影響因素：壓力控制或支持水平阻力和順應(yīng)性吸氣時(shí)間價(jià)值？無(wú)效觸發(fā)MISSED

TRIGGER7Presentation

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Only誤觸發(fā)AUTO-TRIGGERING8Presentation

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Only雙觸發(fā)DOUBLE-TRIGGERING9Presentation

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Only人機(jī)不同步的發(fā)生和影響Thille

AW,

Rodriguez

P,

Cabello

B,

Lellouche

F,

Brochard

L.

Patient-ventilator

asynchrony

during

assisted

mechanical

ventilation.

IntensiveCareMed.

2006;32(10):1515-22.de

Wit

M,

Miller

KB,

Green

DA,

Ostman

HE,

GenningsC,

Epstein

SK.

Ineffective

triggering

predicts

increased

duration

of

mechanicalventilation.

Crit

Care

Med.

2009;37(10):2740-5.Colombo

D.

Efficacy

of

ventilator

waveforms

observation

in

detecting

patient–ventilator

asynchrony.

Crit

Care

Med.

2011;39(11):2452-7.在觀察的機(jī)械通氣病人中，24-27%

的病人在超過(guò)10%的呼吸中出現(xiàn)了人機(jī)不同步1,2無(wú)效觸發(fā)占了人機(jī)不同步的80%2不同步指數(shù)

≥

10%的病人的平均通氣時(shí)間多4天，更長(zhǎng)的ICU及總住院時(shí)間2ICU醫(yī)生可以發(fā)現(xiàn)1/3不到的人機(jī)不同步，一般的住院醫(yī)生可以發(fā)現(xiàn)16%的人機(jī)不同步。310Presentation

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Only識(shí)別？機(jī)械通氣要素壓 力（pressure）容 積（volume）流 量（flow）時(shí) 間（Time）12Presentation

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Only波形構(gòu)成13Presentation

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Only壓力（pressure）

＋

時(shí)間（time）流量（flow） ＋

時(shí)間（time）容量（volume）

＋

時(shí)間（time）壓力（pressure）

＋

容積（volume）流量（flow） ＋

容積（volume）機(jī)械通氣波形類型14Presentation

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Only壓力－時(shí)間曲線容量－時(shí)間曲線流量－時(shí)間曲線流量－容積環(huán)壓力－容積環(huán)壓力（PRESSURE）＋時(shí)間（TIME）壓力－時(shí)間波形：15Presentation

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Only壓力-時(shí)間波形ABCDEF吸氣時(shí)間呼氣時(shí)間阻力壓力壓力時(shí)間時(shí)間定容定壓BACD壓力

VS

時(shí)間20151050-5-10-15-20024681012sPEEP10cm

H20Covidien

Respiratoryand

Monitoring

Solutions

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|PEEP壓力

VS

時(shí)間20151050-5-10-15-20024681012s觸發(fā)靈敏度觸發(fā)做功Covidien

Respiratoryand

Monitoring

Solutions

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January

10,

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Confidential18

|壓力

VS

時(shí)間20151050-5-10-15-20024681012s壓力升高Covidien

Respiratoryand

Monitoring

Solutions

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January

10,

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Confidential19

|壓力

VS

時(shí)間20151050-5-10-15-20024681012s暫停Covidien

Respiratoryand

Monitoring

Solutions

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January

10,

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Confidential20

|吸氣壓力

VS

時(shí)間20151050-5-10-15-20024681012s呼氣開(kāi)始Covidien

Respiratoryand

Monitoring

Solutions

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|22Presentation

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Only壓力時(shí)間曲線VCV下的P－T曲線不同通氣方式下的壓力時(shí)間曲線機(jī)器啟動(dòng)的呼吸(VIMB)患者啟動(dòng)的呼吸(PIMB)Spontaneous

breaths（CPAP）Spontaneous

breaths（pressure

suppor不同通氣方式下的壓力時(shí)間曲線壓力控制壓力控制伴有主動(dòng)呼氣閥BiLevel

ventilationAirwaypressure

releaseventilation(

APRV)流量（FLOW）＋時(shí)間（TIME）流量-時(shí)間曲線是反映呼吸機(jī)送氣氣流的流速隨時(shí)間而變化的圖形所有曲線基線上代表吸氣，基線下代表呼氣流量-時(shí)間波形流速LPM流速LPM吸氣相呼氣相吸氣相TIME方波遞減波遞增波正弦波TIME 呼氣相定容通氣時(shí)的流速-時(shí)間波形流量（FLOW）＋時(shí)間（TIME）流量—時(shí)間曲線反映了吸氣相和呼氣相各自的流量變化，流量的單位為升/分（縱軸），而時(shí)間單位為秒（橫軸），橫軸上的曲線為吸氣流量，橫軸下的曲線為呼氣流量，呼吸機(jī)輸送的容量是流量在時(shí)間上積分計(jì)算而得且等于流量曲線下面積。時(shí)間14532圖1 流量曲線（方波）--機(jī)械呼吸吸氣相呼氣相流量

LPM27Presentation

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Only容量（VOLUME）＋時(shí)間（TIME）容量－時(shí)間曲線28Presentation

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Only壓力（PRESSURE）＋容積（VOLUME）壓力－容積環(huán)：29Presentation

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Only流量（FLOW）＋容積（VOLUME）流量－容積環(huán)：30Presentation

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Only主要內(nèi)容31Presentation

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Only機(jī)械通氣波形類型各波形的臨床應(yīng)用各波形的臨床應(yīng)用32Presentation

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Only壓力－時(shí)間曲線：判斷呼吸頻率、節(jié)律及類型判斷呼吸評(píng)估吸氣做功判斷壓力的維持評(píng)估壓力上升速度判斷漏氣判斷呼吸系統(tǒng)物理機(jī)制PEEPi的估計(jì)壓力-時(shí)間波形壓力時(shí)間壓力-時(shí)間波形管路積水或氣道分泌物壓力-時(shí)間波形壓力時(shí)間壓力時(shí)間壓力-時(shí)間波形自主觸發(fā)及觸發(fā)做功各波形的臨床應(yīng)用壓力－時(shí)間曲線吸氣流量不足/漏氣36Presentation

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Only各波形的臨床應(yīng)用壓力－時(shí)間曲線壓力上升速度37Presentation

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Only各波形的臨床應(yīng)用壓力－時(shí)間曲線Decreased

Compliance

——

順應(yīng)性降低表現(xiàn)：峰壓和平臺(tái)壓均升高原因：順應(yīng)性降低（ARDS）38Presentation

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Only運(yùn)動(dòng)方程呼吸動(dòng)力呼吸阻力呼吸肌肉呼吸機(jī)氣道阻力彈性阻力+PEEPi運(yùn)動(dòng)方程P總=flow*Resistance+Vt/C+PEEPtot當(dāng)flow=0時(shí)（吸氣暫停），Pplat=VT/C+PEEPtotC=VT/(Pplat-PEEPtot)40Presentation

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Only順應(yīng)性順應(yīng)性：?jiǎn)挝粔毫σ鸬娜莘e變化C=ΔV/ΔP單位：ml/cmH2O機(jī)械通氣患者正常值：60-100

ml/cmH2O彈性阻力E=1/C41Presentation

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Only各波形的臨床應(yīng)用壓力－時(shí)間曲線Increased

Resistance

——

阻力增加表現(xiàn)：峰壓升高、平臺(tái)壓不變?cè)颍簹夤懿骞茏枞蚍置谖锞奂?2Presentation

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Only運(yùn)動(dòng)方程P總=flow*Resistance+Vt/C+PEEPtotPplat=VT/C+PEEPtotPpeak=flow*Resistance+PplatResistance=(Ppeak-Pplat)/flow43Presentation

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Only氣道阻力（粘滯阻力）44Presentation

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Only氣體分子間和氣體分子與氣道壁之間的摩擦力氣道：人工氣道+自身氣道主要影響因素：Raw=8ηl/πr4L指氣道長(zhǎng)度，r氣道半徑，η粘滯系數(shù)機(jī)械通氣患者的正常值：5-10

cmH2O/L/S各波形的臨床應(yīng)用45Presentation

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Only流量－時(shí)間曲線：呼吸節(jié)律和頻率識(shí)別內(nèi)源性PEEP的存在識(shí)別支氣管擴(kuò)張劑的效果識(shí)別漏氣及漏氣量的評(píng)估流速-時(shí)間波形流速

流速-時(shí)間波形時(shí)間管路積水或氣道分泌物判斷有無(wú)PEEPI的存在呼氣流速在下一次吸氣開(kāi)始前突然回到0, 這是由于小氣道在呼氣時(shí)過(guò)早地關(guān)閉,

使部分氣體阻滯在肺泡內(nèi)而導(dǎo)致存在PEEPi。注意圖中的A,B和C,

其降至0時(shí)呼氣流速高低不一50Presentation

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Only各波形的臨床應(yīng)用流量－時(shí)間曲線：無(wú)效吸氣做功流速-時(shí)間波形流速時(shí)間低峰流速長(zhǎng)TE短TE高峰流速前后流速-時(shí)間波形評(píng)估支氣管擴(kuò)張劑療效52Presentation

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Only各波形的臨床應(yīng)用流量－時(shí)間曲線：評(píng)估漏氣流速-時(shí)間波形ABTIMETIMEC定壓通氣（PCV）時(shí)的吸氣時(shí)間哪一個(gè)吸氣時(shí)間是合適的？流速時(shí)間流速-時(shí)間波形流速-時(shí)間波形速

時(shí)間A流監(jiān)測(cè)PSV時(shí)回路有無(wú)漏氣A點(diǎn)是正常的嗎？流速-時(shí)間波形各波形的臨床應(yīng)用容量－時(shí)間曲線：氣體陷閉漏氣55Presentation

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Only各波形的臨床應(yīng)用58Presentation

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Only壓力-容量曲線吸氣做功的判斷呼吸類型的識(shí)別呼吸系統(tǒng)阻力和/或順應(yīng)性的改變肺過(guò)度擴(kuò)張最佳PEEP的選擇吸氣流量的選擇吸氣觸發(fā)靈敏度的選擇壓力-容積環(huán)容積壓力吸氣呼氣容積壓力吸氣呼氣容積吸氣呼氣壓力輔助通氣生理呼吸控制通氣各波形的臨床應(yīng)用壓力-容量曲線PEEPandPV

loop.PV環(huán)：可發(fā)現(xiàn)和測(cè)量PEEP，自壓力軸向右變化。PEEP水平為決定y

軸和x軸在吸氣開(kāi)始的距離60Presentation

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Only各波形的臨床應(yīng)用壓力-容量曲線High

Resistance

阻力升高容量控制通氣時(shí)，容量恒定，壓力依據(jù)阻力和順應(yīng)性而變化當(dāng)阻力增加時(shí)，

PIP

上升（A-B），

PV

loops

變寬。61Presentation

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Only壓力-容積環(huán)容量吸氣壓力呼氣斜率2、判斷肺順應(yīng)性變化順應(yīng)性（Compliance）：?jiǎn)挝粔毫λ鸬娜萘孔兓疌=VT/

Pa