呼吸力學監(jiān)測的臨床應(yīng)用課件

呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測監(jiān)測指標氣道壓力(Pressure)吸氣峰壓(PIP)平臺壓(Pplat)呼氣末正壓(PEEP)氣流流速(Flow)吸氣流速呼氣流速氣體容積(Volume)…反映指標順應(yīng)性(Compliance)呼吸系統(tǒng)順應(yīng)性肺順應(yīng)性胸廓順應(yīng)性氣道阻力(Resistance)吸氣阻力呼氣阻力呼吸功(WOB)…呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測的意義沒有自主呼吸的患者應(yīng)用定容通氣模式time Vt Ti PEEP Ppeak Pplat1 0.5 0.5 0 25 202 0.5 0.5 0 45 40究竟出了什么問題?呼吸力學監(jiān)測的臨床應(yīng)用順應(yīng)性呼吸力學監(jiān)測的臨床應(yīng)用順應(yīng)性C=V/PPVttVtPplat–PEEPPIP–PEEP呼吸力學監(jiān)測的臨床應(yīng)用呼吸系統(tǒng)順應(yīng)性動態(tài)順應(yīng)性

Crs,dyn=靜態(tài)順應(yīng)性

Crs,st=呼吸力學監(jiān)測的臨床應(yīng)用呼吸系統(tǒng)順應(yīng)性新生兒 3-5ml/mmHg/kgBWt嬰兒 10-20ml/mmHg/kgBWt兒童 20-40ml/mmHg/kgBWt成人 70-100ml/mmHg/kgBWt呼吸力學監(jiān)測的臨床應(yīng)用呼吸系統(tǒng)順應(yīng)性靜態(tài)順應(yīng)性無肺部疾患的氣管插管患者

50-70ml/mmHg動態(tài)順應(yīng)性極少應(yīng)用呼吸力學監(jiān)測的臨床應(yīng)用呼吸系統(tǒng)順應(yīng)性導致順應(yīng)性下降的原因肺實質(zhì)改變ARDS,(支氣管)肺炎,肺水腫,纖維化表面活性物質(zhì)功能障礙ARDS,肺泡肺水腫,肺不張,誤吸肺容量減少氣胸,膈肌抬高呼吸力學監(jiān)測的臨床應(yīng)用氣道阻力呼吸力學監(jiān)測的臨床應(yīng)用阻力R=P/flowPinPoutflowR呼吸力學監(jiān)測的臨床應(yīng)用吸氣阻力PIPPplat呼吸力學監(jiān)測的臨床應(yīng)用吸氣阻力Raw=呼吸力學監(jiān)測的臨床應(yīng)用吸氣阻力Hagen-Poiseuille定律

P=flowx8

l/

r4

層流Venturi定律

P=flow2xK

l/

r2湍流層流R=

P/flow=8

l/

r4呼吸力學監(jiān)測的臨床應(yīng)用氣道阻力新生兒 30-50mmHg/L/sec嬰兒 20-30mmHg/L/sec兒童 20mmHg/L/sec成人 2-4mmHg/L/sec呼吸力學監(jiān)測的臨床應(yīng)用吸氣阻力導致氣道阻力增加的原因分泌物過多—

分泌物潴留粘膜水腫(哮喘,氣管炎,肺水腫)肺氣腫(氣道壓迫)異物腫瘤所致狹窄呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測的意義沒有自主呼吸的患者應(yīng)用定容通氣time Vt Ti PEEP Ppeak Pplat1 0.5 0.5 0 25 202 0.5 0.5 0 45 40Raw

(Ppeak-Pplat)Crs,st

1/(Pplat-PEEP)呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測的意義沒有自主呼吸的患者應(yīng)用定容通氣time Vt Ti PEEP Ppeak Pplat1 0.5 0.5 0 25 202 0.5 0.5 0 45 25Crs,st

1/(Pplat-PEEP)Raw

(Ppeak-Pplat)呼吸力學監(jiān)測的臨床應(yīng)用呼吸力學監(jiān)測:病例分析北京協(xié)和醫(yī)院杜 斌呼吸力學監(jiān)測的臨床應(yīng)用病例1ZBQ,F/52歲,C761332,入院日2004/07/21既往史:高血壓x3年,130/110mmHgAML-M5x1+年,13程化療主訴:發(fā)熱腹痛x3天2004-07-17:WCC1.3,Hb83,plt372004-07-18:BT40

C,右下腹疼痛,頭孢哌酮治療無效呼吸力學監(jiān)測的臨床應(yīng)用病例12004-07-20:ER惡心,嘔吐,腹瀉BT39.3

C,HR140,RR30,BP67/27,SpO282%氣管插管機械通氣x7小時SpO296–100%(鼻導管O27lpm)CBC:wcc0.1,Hb56,plt13Tx:GCSF 300gihqd亞胺培南 0.5gmivq8hIVIG 10givdripqd呼吸力學監(jiān)測的臨床應(yīng)用病例12004-07-22定向力障礙,發(fā)熱CT:右額葉小面積高密度影超聲:腹水2004-07-25ABG:7.265/73.9/71.4 氣管插管及機械通氣DA6g/kg/min2004-07-26昏迷抽搐ABG:7.379/60.6/169HR140,BP110/70(NE6–10g/min,DA3–16g/kg/min)呼吸力學監(jiān)測的臨床應(yīng)用病例12004-07-30Vt400,PIP55–59,ABG7.228/74.4/70.8吸痰,氨茶堿0.25均無效PIP57–58更換ETT后仍無明顯改變ABG7.26–7.29/71.1–63.2/60.9–82.7CBC:wcc0.35,Hb126,plt31初步印象腹腔感染引起膈肌升高導致胸廓順應(yīng)性降低肺部感染導致肺順應(yīng)性降低呼吸力學監(jiān)測的臨床應(yīng)用病例12004-07-31:收入ICUVt250,inspiratoryflow30,FiO21.0,PEEP5RR40,PIP63,Pplat20PEEPionZEEP9ABG7.138/89.7/69.2/29.1E1VTM2BP80/40(DA10g/kg/min)O/E:雙肺輕度喘鳴音,呼氣相延長呼吸力學監(jiān)測的臨床應(yīng)用病例1初步診斷Raw明顯升高,順應(yīng)性降低Raw70–90,Crs15Tx鎮(zhèn)靜肌松甲強龍40mg+氨茶堿40mg/hr+支氣管擴張劑(霧化)Vt400,Flow25(減速氣流),FiO20.8,PEEP7,f15NE0.08g/kg/min結(jié)果RR15(沒有自主觸發(fā))BP100–110/60–70,UO70–80ml/hrABG7.086/108/65.1/31.0支氣管痙攣?無顯著效果呼吸力學監(jiān)測的臨床應(yīng)用病例1嚴重呼吸功能衰竭的可能原因除外支氣管痙攣腹腔內(nèi)感染?腹水:細胞數(shù)668,wcc146,單核44%肺部感染?痰涂片(07/26)GNB 大量真菌菌絲 可見痰培養(yǎng)(07/26)Stenotrophomonas 對替卡西林/克拉維酸,頭孢他啶或環(huán)丙沙星敏感呼吸力學監(jiān)測的臨床應(yīng)用病例1抗生素:頭孢他啶+環(huán)丙沙星是否有其他致病菌?支氣管鏡檢查隆突及所有支氣管開口均可見白斑組織活檢涂片:大量有隔菌絲真菌培養(yǎng):Aspergillusflavus呼吸力學監(jiān)測的臨床應(yīng)用病例1的教訓更換氣管插管的錯誤決定使患者不必要地承擔缺氧的風險排除不可能的感染灶原發(fā)感染灶沒有明顯的器官功能障礙,而遠隔器官即出現(xiàn)嚴重功能衰竭的情況非常罕見重視微生物學檢查鑒別可能的致病菌以及污染菌(定植菌)及時采樣以便正確診斷呼吸力學監(jiān)測的臨床應(yīng)用病例2YJC,M/58歲,C812258,入院日2004/07/272003/12 食道癌2004/02/19 擇期手術(shù)術(shù)后并發(fā)反復吸入性肺炎既往史慢性支氣管炎x20+年1976年因胃穿孔行胃大部切除手術(shù)呼吸力學監(jiān)測的臨床應(yīng)用病例207/12 呼吸困難及發(fā)熱ABG:7.47/48/186(FiO20.45)07/15 CT:氣管狹窄,縱隔多發(fā)淋巴結(jié)07/23 呼吸困難加重ABG:7.20/112/68氣管插管(ETT6.5)及機械通氣07/27 T管(3lpm)x24小時ABG:7.327/69.9/110呼吸力學監(jiān)測的臨床應(yīng)用病例2PIP34Pplat10PEEP5Time(sec)Pressure(cmH2O)Raw=(PIP–Plat)/Flow =(34–10)/0.75 =32cmH2Osec/LCrs =Vt/(Pplat–PEEP) =300/(10–5) =60mL/cmH2O呼吸力學監(jiān)測的臨床應(yīng)用病例2吸氣阻力明顯增加,原因包括氣管狹窄?氣管插管口徑過小?呼吸力學監(jiān)測的臨床應(yīng)用病例2氣管狹窄CT可見病變氣管插管前高碳酸血癥COPD不能解釋CO2潴留氣管插管口徑過細氣管僅有一半狹窄6.5號氣管插管阻力很高疾病進展迅速呼吸力學監(jiān)測的臨床應(yīng)用氣管插管導致的壓力差Flowrate=0.75L/secDeltaP= 272.36xe-0.5396*

ETTIDFor6.5#ETTDeltaP=8.17cmH2O呼吸力學監(jiān)測的臨床應(yīng)用氣管插管導致的附加阻力Flowrate=0.75L/secResistance= 363.42xe-0.5396*

ETTIDFor6.5#ETTResistance=10.9cmH2Osec/L呼吸力學監(jiān)測的臨床應(yīng)用壓力差及阻力的鑒別ETT氣道總計壓力差8.215.824阻力10.921.132呼吸力學監(jiān)測的臨床應(yīng)用治療的結(jié)果因患者不能耐受及配合,不能進行呼吸力學監(jiān)測ABG07/28 7.466/43.2/96 (FiO20.37)07/29 7.512/40.9/87.9 (FiO20.37)07/30 7.458/46.3/109 (FiO20.37)呼吸力學監(jiān)測的臨床應(yīng)用病例2的經(jīng)驗導致氣道峰壓過高的原因很多,包括醫(yī)源性因素了解呼吸力學有助于推理分析及正確的治療呼吸力學監(jiān)測的臨床應(yīng)用時間常數(shù)呼吸力學監(jiān)測的臨床應(yīng)用時間常數(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(yīng)速度呼吸力學監(jiān)測的臨床應(yīng)用時間常數(shù)()Time/Tau吸氣相呼氣相Pressure呼吸力學監(jiān)測的臨床應(yīng)用時間常數(shù)()PA(t)=(Pplat-PEEP)e-kte=2.718k=1/=1/(RxC)V(t)=Vtxe-kte=2.718k=1/=1/(RxC)呼吸力學監(jiān)測的臨床應(yīng)用時間常數(shù)()時間常數(shù)成人(正常值)2x0.10=0.20”術(shù)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%呼吸力學監(jiān)測的臨床應(yīng)用時間常數(shù)()肺泡的呼吸力學分類快反應(yīng)肺泡時間常數(shù)較小慢反應(yīng)肺泡時間常數(shù)較大CcRr呼吸力學監(jiān)測的臨床應(yīng)用為何需要設(shè)置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduringthePlateauPhase呼吸力學監(jiān)測的臨床應(yīng)用為何需要設(shè)置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNoPENDELLUFTbecauseofconstantflowflow呼吸力學監(jiān)測的臨床應(yīng)用時間常數(shù)與呼吸模式AdaptiveSupportVentilationAutomaticclosed-loopcontrolsystemonexpiratorytriggersensitivity呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoASV所獨特的呼吸機設(shè)置最低(目標)分鐘通氣量患者的理想體重(IBW)男性 50.0+2.3[身高(inch)–60]女性 45.5+2.3[身高(inch)–60]分鐘通氣量%(范圍25–350%)IBW>15kg %MinVolxIBW/1000IBW<15kg %MinVolxIBW/500 呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileo分鐘通氣量相同時的不同呼吸形式RRVT呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoASV的安全范圍參數(shù)最低限最高限吸氣壓力PEEP+5cmH2OPHIGH

–10cmH2O潮氣量4.4ml/kgBWt(2xVD)22ml/kgBWt(10xVD)指令通氣頻率固定界限5bpm60bpm可調(diào)界限IBW>15kg22x%MinVol/100IBW<15kg45x%MinVol/100吸氣時間RCexpor0.5sec2xRCexpor3sec呼氣時間2xRCexp12secI:E比1:41:1呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoRRVT固定MV目標RR目標VT安全范圍安全范圍呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoRRVT氣壓傷/容積傷淺快呼吸窒息內(nèi)源性PEEP目標VT目標RR固定MV安全范圍呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileo概 念最適呼吸形式=分鐘通氣量固定時‘呼吸功最低’RRVTWOB最低呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoOtisAB,FennWO,RahnH.Mechanicsofbreathinginman.JApplPhysiol1950;2:592-607WOBf彈性阻力總計最適呼吸頻率呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileo最適呼吸形式的計算(Otis公式)2

2RCeMV–fxVDVD1+4

2RCe–1f=RCe expiratorytimeconstantMV minuteventilationf totalrespiratoryrateVD deadspaceOtisAB,FennWO,RahnH.Mechanicsofbreathinginman.JApplPhysiol1950;2:592-607呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileo最低WOB的確定(Otis公式)RRVT固定MV目標RR目標VT死腔:1mL/poundBWt(Radfordnomogram)呼氣時間常數(shù):測定參數(shù)分鐘通氣量:預先設(shè)置呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileo預先設(shè)置監(jiān)測參數(shù)ASV輸出%MinVolTI(sec)MandatoryRate(bpm)PHIGH

–Alarm(cmH2O)TE(sec)TI(sec)BodyWeight(kg)TotalRate(bpm)PControl,PSupport(cmH2O)VTinsp(ml)RCexp(sec)V/P(ml/cmH2O)呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoRRVT設(shè)定MV目標RR

指令通氣頻率

指令通氣頻率最適呼吸形式的實現(xiàn)呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoRRVT設(shè)定MV目標VT

吸氣壓力

吸氣壓力最適呼吸形式的實現(xiàn)呼吸力學監(jiān)測的臨床應(yīng)用AdaptiveSupportVentilation(ASV)–HamiltonGalileoRRVT設(shè)定MV目標RR目標VT

吸氣壓力指令通氣頻率

吸氣壓力指令通氣頻率

吸氣壓力指令通氣頻率

吸氣壓力指令通氣頻率最適呼吸形式的實現(xiàn)呼吸力學監(jiān)測的臨床應(yīng)用呼氣觸發(fā)靈敏度VentilatorETSFixedETSSiemens3005%Bird840025%Star25%or4lpmEvita425%(Adult)6%(Paediatric)Bear100025%AdjustableETSGalileo10–40%NPB8401–45%Servoi1–40%CardiopulmonaryVenturi5–80%呼吸力學監(jiān)測的臨床應(yīng)用呼氣觸發(fā)靈敏度吸氣峰流量25%15%45%Tinsp呼吸力學監(jiān)測的臨床應(yīng)用呼氣觸發(fā)靈敏度的影響ETS40%ETS5%潮氣量(L)0.51

0.170.61

0.25吸氣時間(sec)1.04

0.291.66

0.62呼吸頻率(bpm)25.0

12.121.5

12.6ChiumelloD,PelosiP,TacconeP,etal.Effectofdifferentinspiratoryrisetimeandcyclingoffcriteriaduringpressuresupportventilationinpatientsrecoveringfromacutelunginjury.CritCareMed2003;31:2604-10.呼吸力學監(jiān)測的臨床應(yīng)用呼氣觸發(fā)靈敏度與時間常數(shù)YamadaY,DuH.Analysisofthemechanismsofexpiratoryasynchronyinpressuresupportventilation:amathematicalapproach.JApplPhysiol2000;88:2143-50呼吸力學監(jiān)測的臨床應(yīng)用壓力支持通氣中呼氣觸發(fā)靈敏度的閉環(huán)控制系統(tǒng)時間常數(shù)ETS范圍平臺上壓力壓力支持通氣呼吸力學監(jiān)測的臨床應(yīng)用呼氣觸發(fā)靈敏度與吸氣終止延遲YamadaY,DuHL.Effectsofdifferentpressuresupportterminationonpatient-ventilatorsynchrony.RespiratoryCare1998;43:1048-1057PIF60lpm呼吸力學監(jiān)測的臨床應(yīng)用呼氣觸發(fā)靈敏度與吸氣終止延遲YamadaY,DuHL.Effectsofdifferentpressuresupportterminationonpatient-ventilatorsynchrony.RespiratoryCare1998;43:1048-1057PIF30lpm呼吸力學監(jiān)測的臨床應(yīng)用嚴重氣流梗阻內(nèi)源性PEEP過高肺泡過度膨脹胸腔內(nèi)壓過高回心血量減少休克降低內(nèi)源性PEEP的方法延長呼氣時間增加吸氣流量降低呼吸頻率外源性PEEP?呼吸力學監(jiān)測的臨床應(yīng)用嚴重氣流梗阻患者的處