mechanicalventilationofcopd-ppt课件-PPT精选文档.ppt

1、COPD的机械通气的机械通气Vt,FiO2,what else?北京协和医院杜斌COPD患者的肺泡过度充盈患者的肺泡过度充盈Sutherland ER,Cherniack RM.Management of Chronic Obstructive Pulmonary Disease.N Engl J Med 2019;350:2689-97时间常数时间常数()=R x C测定肺组织充盈或排空的速度反映肺组织对压力变化的反应速度时间常数时间常数()Time/Tau吸气相吸气相呼气相呼气相Pressure时间常数时间常数()PA(t)=(Pplat-PEEP)e-kte=2.718k=1/=1/(R

2、 x C)V(t)=Vt x e-kte=2.718k=1/=1/(R x C)时间常数时间常数()时间常数成人(正常值)2 x 0.10=0.20”术后气管插管成人患者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患儿5 x 0.01=0.05”Tau呼出气容积残余容积00%100%163%37%395%5%599.9%0.1%动态过度充盈动态过度充盈:DHIinspexpTimeTidal volumeTrapped gasLung VolumeFRCObstructed LungsNormal Stiff L

3、ungs机械通气的适应证机械通气的适应证:COPD呼吸肌疲劳且濒临呼吸停止尽管进行充分的保守治疗,PaCO2仍进行性升高劳累和(或)高碳酸血症导致意识状态恶化高浓度吸氧治疗无效的低氧血症痰液清除障碍导致病情恶化呼吸骤停COPD患者的病理生理改变患者的病理生理改变内源性PEEP过高n肺泡过度膨胀n胸腔内压过高 回心血量减少 休克机械通气时的机械通气时的PEEPiVt 10 12 ml/kg,f 12 15 bpm,I:E 1:2 3诊断No.PEEPi(范围)发生率COPD452.6 2245/45(100%)CF1111/1(100%)Asthma313.5 203/3(100%)ARDS28

4、1.0 8.115/28(58%)CPE101.0 6.08/10(80%)Other101.0 4.15/10(50%)DHI和和PEEPi的影响因素的影响因素内在因素内在因素外部因素外部因素呼吸力学附加气流阻力气流阻力气管插管管径过细呼气气流受限呼吸机管路和相关装置呼吸系统顺应性呼吸机设置呼吸方式呼吸频率呼吸频率I:ETi/Ttot潮气量潮气量吸气末暂停DHI和和PEEPi的影响因素的影响因素内在因素内在因素外部因素外部因素呼吸力学附加气流阻力气流阻力气管插管管径过细呼气气流受限呼吸机管路和相关装置呼吸系统顺应性呼吸机设置呼吸方式呼吸频率呼吸频率I:ETi/Ttot潮气量潮气量吸气末暂停机

5、械通气参数的设置机械通气参数的设置:COPD潮气量吸气流速吸呼比/吸气时间/呼气时间呼吸频率COPD:不同吸气气流的比较不同吸气气流的比较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 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比

6、较波形(均值 SD)呼吸机参数恒定气流1正弦波减速气流恒定气流2Vt,ml562 67558 65566 59571 72RR,bpm18.2 1.718.6 1.418.4 1.918.5 1.3MV,lpm10.4 1.610.3 1.510.6 1.610.7 1.8Ti/Ttot0.29 0.040.28 0.030.29 0.040.28 0.03平均吸气流速,lpm38 537 739 738 6Shieh Ching Yang,MD,FCCP;and Sze Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mecha

7、nics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较波形(均值 SD)呼吸力学参数恒定气流1正弦波减速气流恒定气流2PIP,cmH2O47.1 11.547.8 10.839.5 9.746.6 11.0Paw,cmH2O7.6 4.27.2 4.88.4 4.58.4 3.9Pplat,cmH2O20.2 9.119.6 10.618.9 8.821.4 10.4Vd/V

8、t,%58.4 5.254.5 6.348.6 5.557.6 4.9Cst,ml/cmH2O35.3 8.935.8 11.236.6 9.337.2 9.7Shieh 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 2019;122:20962104COPD:不同吸气气流

9、的比较不同吸气气流的比较波形(均值 SD)恒定气流1正弦波减速气流恒定气流2pH7.44 0.047.44 0.077.43 0.067.44 0.04PaO2/FiO2,mmHg236 73231 65223 70227 67PaCO2,mmHg45 1045 1037 946 12A-aDO2,mmHg133.1 36.5136.4 34.2156.3 33.7134.4 35.3HR,bpm106.1 18.1108.3 20.2105.3 18.9109.9 20.5MAP,mmHg92 2388 1888 2190 19Shieh Ching Yang,MD,FCCP;and Sze

10、 Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较波形(均值 SD)参数恒定气流1正弦波减速气流恒定气流2WOB,J/L0.92 0.160.88 0.180.75 0.150.92 0.18Raw,cmH2O/L/s12.6 3.112.4 3.6

11、11.2 2.412.5 3.3VO2,ml/min384 53389 60377 49382 52VCO2,ml/min274 52280 47273 56276 55症状评分54.5 13.458.6 11.942.7 12.356.1 12.8Shieh 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 V

12、entilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较结论COPD患者机械通气的最佳吸气气流为减速气流通过选择适宜的吸气气流,有可能改善上述患者的通气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 201

13、9;122:20962104COPD机械通气策略机械通气策略降低内源性PEEP的方法n外源性PEEP?n延长呼气时间u增加吸气流速u缩短吸气末暂停u降低呼吸频率呼气流速呼气流速PalvPEEPFlow=P/Raw=(Palv PEEP)/RawFlowPEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6C

14、ompliancePEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6Compliance P Flow PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak

15、Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径PEEPPEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6PEEP半径半径流速流速?P 流速流速 PEEP与呼气流速与呼气流速Savian C,Cha

16、n P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth A

17、nalg 2019;100:1112-6PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Exp

18、iratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径 Flow PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径 PEEPPEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J

19、.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6PEEP半径半径 流速流速 P 流速流速 COPD稳定期患者稳定期患者(n=9)年龄(yr)70 7.3FEV1(%pred)30 9.5FVC(%pred)53 13.6RV(%pred)186 33.1FEV1/VC(%)44 11.6TLC(%pred)103 8.7TLCO(%pred)46 25.4PaO2(kPa)7

20、.4 0.4PaCO2(kPa)7.1 1.1pH7.40 0.00ODonoghue 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 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intri

21、nsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期: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 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue F

22、J,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume

23、in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期: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 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy R

24、D.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期: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 2019;57:533-539总

25、结对于处于稳定期的严重COPD患者,应用高水平的CPAP能够n降低PEEPi及肌肉活动指标n肺容积显著增加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 2019;18:491-498年龄(yr)64 6身高(cm)167 6体重(kg)72 21体重(%pred)96 27FiO2(%)48 9Vt(L)0.74 0.09PIF(L/s)0.65

26、 0.12Tinsp(s)1.13 0.15Texp(s)3.42 0.57RR(bpm)13.5 1.5COPD急性期急性期:PEEPPEEP(cmH2O)051015PEEPt,cmH2O8.4 4.810.0 3.912.3 2.416.9 1.8PEEPi,cmH2O7.1 3.93.7 3.31.8 1.80.8 1.2FRC,L0.54 0.420.74 0.481.03 0.421.50 0.51Rint,rs,cmH2O s/L9.2 3.68.1 2.77.3 2.77.2 3.0Rrs,cmH2O s/L7.7 1.88.5 1.89.5 2.79.7 3.3Rrs,cmH

27、2O s/L17 3.916.7 2.716.8 3.016.9 3.6Est,rs,cmH2O/L12.7 3.012.9 3.312.9 3.315.5 4.5Gurin C,Fournier G,Milic-Emili J.Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients.Eur Respir J 2019;18:491-498COPD急性期急性期:PEEPGurin C,Fournier G,Milic-Emili J.Effects of PEEP on inspira

28、tory resistance in mechanically ventilated COPD patients.Eur Respir J 2019;18:491-498COPD:PEEP与呼气流速与呼气流速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 durin

29、g controlled ventilation Crit Care Med 2019;33:1519-1528RR 6 bpmRR 9 bpmCOPD:PEEP与呼气流速与呼气流速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

30、ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速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 201

31、9;33:1519-1528COPD:PEEP与呼气流速与呼气流速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 2019;33:1519-1528COPD:PEEP与呼气流速与

32、呼气流速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 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucc

33、i 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 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,K

34、acmarek 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 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco

35、 IT,Amato MBP.Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528结论对于部分气道梗阻的患者而言,应用控制通气过程中,设置外源性PEEP能够缓解过度充盈基础疾病,机械力学指标或呼吸机设置均无法预测上述结果逐渐增加PEEP并观察平台压力改变,是减少副作用的合理方法Assessment of Pulmonary Hyperinfl

36、ationTimeTidal volumeTrapped gasLung VolumeFRCTidal vol.Tidal hyper-inflationApneaTidal VentilationCOPD:缩短吸气时间缩短吸气时间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 Ca

37、re Med 2019;163:1365-1370Tinsp RR Texp PEEPi COPD:缩短吸气时间缩短吸气时间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 2019;163:1365-1370患者基础情况(n=10)基本情况均值 SE年龄,yr68.

38、3 2.9体重,kg82.9 5.9身高,cm173.5 2.1FEV1,L1.21 0.12FEV1,%pred39.7 4.3FEV1/FVC,%pred40.9 3.5FRC,L6.5 0.8TLC,L8.9 0.7PaO2,mmHg72 3PaCO2,mmHg38 1COPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructiv

39、e Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-137016.1 1.019.0 1.420.8 1.57.0 1.36.3 1.16.4 1.12.1 0.22.4 0.22.3 0.2COPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmon

40、ary Disease.Am J Respir Crit Care Med 2019;163:1365-1370COPD:缩短吸气时间缩短吸气时间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 2019;163:1365-1370为何需要设置吸气末暂停为何需要设置吸

41、气末暂停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduring thePlateau Phase为何需要设置吸气末暂停为何需要设置吸气末暂停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNo PENDELLUFTbecause of constant flow flowCOPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed I

42、nflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370COPD:缩短吸气时间缩短吸气时间机械通气患者常常呼吸频数,肺过度充盈n提高吸气流速,可以缩短吸气时间,尽管呼吸频率加快,但能够延长呼气时间,降低呼吸做功n延长吸气暂停能够降低呼吸频率,却引发肺过度充盈,呼吸做功增加Laghi F,Segal J,Choe WK,Tobin MJ.Ef

43、fect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370严重气流梗阻患者的处理严重气流梗阻患者的处理增加流量不能显著延长呼气时间(TE)VtRRflowTTOTTITETE0.515 604.000.503.50-0.5151204.000.253.750.250.514 604.300.503.800.3

44、00.512 605.000.504.501.00提示降低分钟通气量对于减少内源性PEEP的重要作用延长呼气时间治疗哮喘持续状态延长呼气时间治疗哮喘持续状态目的:评价哮喘持续状态患者降低呼吸频率对动态过度充盈(DHI)的影响n气道平台压患者:12名因严重哮喘接受机械通气患者设置:定容通气,潮气量613 100 mL,吸气流速 79 4 L/min,分钟通气量约10 L/min干预:呼吸频率18 12 6 bpmLeatherman JW,McArthur C,Shapiro RS.Effect of prolongation of expiratory time on dynamic hype

45、rinflation in mechanically ventilated patients with severe asthma.Crit Care Med 2019 Jul;32(7):1542-5.延长呼气时间治疗哮喘持续状态延长呼气时间治疗哮喘持续状态18 bpm12 bpm6 bpm呼气时间(sec)2.9 0.14.5 0.19.5 0.1气道峰压(cmH2O)66.8 8.766.4 9.567.8 11.1气道平台压(cmH2O)25.4 2.823.3 2.621.3 2.9呼气末流速(mL/sec)61.4 12.638.6 4.523.1 5.8内源性PEEP(cmH2O

46、)14.8 3.012.3 3.08.9 3.6Leatherman JW,McArthur C,Shapiro RS.Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma.Crit Care Med 2019 Jul;32(7):1542-5.病例病例NYH,F/82,C822978,入院日2019/12/31胸闷,憋气3天,神志障碍30分钟PMHx:COPD入院时nHR 50,BP 78/43nABG

47、(1617 hrs):7.034/148/53.8/37.7病例病例处理n气管插管,机械通气n镇静肌松u安定5 mg/hr+吗啡2 mg/hruScolinen多巴胺5 g/kg/minuBP 120/58病例病例呼吸模式:VCV参数设置:nVt 400 mlnRR 16 bpmnFiO2 0.40nZEEPPEEPi的测定的测定Flow(l/s)Pao(cmH2O)occlusionPEEPi=103.75 sec病例病例3呼吸模式:VCV参数设置:nVt 400 mlnRR 16 bpm 10 bpmnFiO2 0.40nZEEPMV=4 lpm能否降低PEEPi能否降低PaCO2PEEP

48、i的测定的测定Flow(l/s)Pao(cmH2O)occlusionPEEPi=56 sec病例病例日期时间pHPaCO2PaO2HCO32019/12/3116:177.03414853.837.72019/12/3117:517.22682.163.532.82019/01/0108:497.46251.274.336.1病例病例生命体征HR60BP106/53n停用多巴胺SpO296%COPD患者的机械通气患者的机械通气:总结总结内源性PEEP过高是COPD机械通气的主要原因降低内源性PEEP的方法n外源性PEEP效果不肯定n通过提高吸气流速延长呼气时间效果甚微n尽量缩短吸气末暂停n降低呼吸频率效果明确