压力支持通气课件.ppt

1、压力支持通气压力支持通气2023-1-42 Pulmonary and critical care medicine -a peculiarly American hybrid？Tobin,MJ.Thorax 1999;54:2862872023-1-49国内的情况国内的情况q 国内目前主要有两种情况：国内目前主要有两种情况：综合综合ICU：代表医院有广州医：代表医院有广州医学院第一附属医院等学院第一附属医院等1/4/202310控制模式控制模式 Controlled ventilation2.支持模式支持模式 Supported ventilation3.自主呼吸自主呼吸 Spontaneo

2、us breathing4.混合模式混合模式 Combined control and supported or spontaneous and supported ventilation1/4/2023111/4/202312VA,volume assistBest Practice&Research Clinical Anaesthesiology 23(2009)81931/4/202313压力支持通气是每次由病人触发，并在吸气相给予预压力支持通气是每次由病人触发，并在吸气相给予预设的恒定的压力水平设的恒定的压力水平-压力目标的机械通气模式压力目标的机械通气模式1/4/202314特性特

3、性带压力支持的自主呼吸带压力支持的自主呼吸吸气检测吸气检测压力或流速触发压力或流速触发吸气期间吸气期间压力和流压力和流速速压力上升依据设置的流量加速度和理想体重，目标是压力支压力上升依据设置的流量加速度和理想体重，目标是压力支持水平与持水平与PEEP的和，吸气流速的形状是一个减速波，随着流的和，吸气流速的形状是一个减速波，随着流量加速度从最小到最大的变化，达到压力目标的时间也随之量加速度从最小到最大的变化，达到压力目标的时间也随之减少，对于体重小于减少，对于体重小于24公斤的小儿，可获得的最大流速为公斤的小儿，可获得的最大流速为80L/min,对于体重大于对于体重大于24kg的成人，流速最大可

4、到的成人，流速最大可到200L/min.吸气期间吸气期间呼气阀状呼气阀状态态调整到超过目标压力一个最小值，并维持在这个目标水平调整到超过目标压力一个最小值，并维持在这个目标水平-压力目标的机械通气模式压力目标的机械通气模式1/4/2023151/4/2023161/4/202317提早切换：引起双触发提早切换：引起双触发1/4/202318延迟切换：呼气肌活动延迟切换：呼气肌活动1/4/202319怎么办怎么办1/4/2023201/4/2023211/4/2023221/4/2023231/4/202324在吸气末气道压力升高在吸气末气道压力升高1/4/202325VAPS:问题问题如何设定

5、最大峰流速将很困难如何设定最大峰流速将很困难PSV设定过高设定过高 则全部为则全部为PSV 呼吸方式呼吸方式PSV设定过低设定过低 吸气末气道压力过高吸气末气道压力过高1/4/2023261/4/202327自动调节压力水平以便达到设定的潮气自动调节压力水平以便达到设定的潮气量量1/4/202328VSV与与VAPSV的区别的区别1/4/2023291/4/2023301/4/2023311/4/2023321/4/2023331/4/2023341/4/2023351/4/202336Best Practice&Research Clinical Anaesthesiology 23(200

6、9)81931/4/202337健康人的呼吸由健康人的呼吸由PaCO2控制控制为保持为保持 PaCO2 恒定恒定,病人升高或降低病人升高或降低 MVMV 是潮气量和呼吸频率的乘积是潮气量和呼吸频率的乘积(MV=Vt*f)病人在疲劳时倾向于降低病人在疲劳时倾向于降低 Vt,增加频率增加频率 支持过多支持过多(Vt 过大过大)情况下情况下,病人倾向于降病人倾向于降低呼吸频率低呼吸频率1/4/202338VTfspontetCO2呼吸稳定:PS PS 撤机:PS Closed loop ventilationPatientVentilator1/4/202339基本原理基本原理f_spnVTetCO

7、2通气分类通气分类PS值调节值调节病人病人:血流动力学稳定血流动力学稳定,自主呼吸活跃自主呼吸活跃只限于压力支持模式只限于压力支持模式自动调节的参数是自动调节的参数是PS值值主要监测的参数主要监测的参数:f_spn,VT,etCO21/4/2023401/4/2023411/4/202342呼吸舒适区呼吸舒适区f_spnVTetCO2f_spn=15 30 (神经功能紊乱神经功能紊乱15-34)etCO2 55 mmHg(COPD 300 ml (体重体重250ml)1/4/2023431/4/202344具有具有24h管理的优势，依据患者呼吸能力变化及时调整管理的优势，依据患者呼吸能力变化及

8、时调整PS(每每2min评评价一次）价一次）节省了人力，减轻了医生和护士的日常工作量，且更安全节省了人力，减轻了医生和护士的日常工作量，且更安全自动行自主呼吸试验（自动行自主呼吸试验（1h）较常规较常规CPAP/ASB缩短了带机时间缩短了带机时间 再插管率低再插管率低较常规较常规CPAP/ASB能及时发现自主呼吸能力的变化，提高病人的舒适能及时发现自主呼吸能力的变化，提高病人的舒适度和对通气的适应度度和对通气的适应度减少化验血气的次数减少了穿刺，为医院节约了成本减少化验血气的次数减少了穿刺，为医院节约了成本夜间不会因为医生休息而中断脱机进程夜间不会因为医生休息而中断脱机进程1/4/202345

9、Am J Respir Crit Care Med.2006;174:894900CDW:computer-driven weaning1/4/202346Am J Respir Crit Care Med.2006;174:894900Weaning protocol:computer-driven vs.Physician controlled 1/4/202347Kaplan-Meier analysis of weaning time until successful extubation or death after inclusion for all included patien

10、ts in each study groupWeaning protocol:computer-driven vs.Physician controlled Am J Respir Crit Care Med.2006;174:8949001/4/202348Am J Respir Crit Care Med.2006;174:894900Conclusions:The specific computer-driven system used in this study can reduce mechanical ventilation duration and ICU length of s

11、tay,as compared with a physician-controlled weaning processWeaning protoccol:computer-driven vs.Physician controlled 1/4/202349Best Practice&Research Clinical Anaesthesiology 23(2009)8193Weaning is an art or a science?Science is gaining ground as knowledge accumulates from physiologic studies and ra

12、ndomized trials Incorporation of this knowledge into a computer-driven weaning system is a step forward in a scientific approach to weaning Am J Respir Crit Care Med.2006;174:8949002023-1-450Current Status of Respiratory Critical Care RICU:Respiratory Intensive Care UnitRICU:Respiratory Intermediate

13、 Care UnitRMU:Respiratory Monitoring UnitArch Bronconeumol.2008;44(1):1-22023-1-451Definition of“RICUs”Respiratory Intermediate Care units(RICUs)is an area for monitoring and treating patients with acute or exacerbated chronic respiratory failure caused primarily by a respiratory disease Cardiorespi

14、ratory monitoring or treatment of respiratory failure with NIV Continuous monitoring of patients following thoracic surgery and of tracheostomized patients Treatment of critical patients whose weaning from invasive ventilation is difficultArch Bronconeumol.2008;44(1):1-22023-1-452The Respiratory Med

15、icine Status in ICUCriteria adopted by the components of Task Force in order to define a respiratory intermediate care unitCriteria for admissionType of intervention and equipmentStaffingSingle organ failure(respiratory failure)Noninvasive mechanical ventilationA minimum of one nurse to four patient

16、s(throughout 24 h)Acute respiratory failure requiring monitoring(but not necessarily mechanical ventilation)Availability of life support ventilators Conventional mechanical ventilation by an artificial airway should be provided when necessary and the patient should be transferred to the ICUDoctor im

17、mediately available 24 hday1 with the same profile as the senior doctorTracheostomy ventilated patients coming from ICU(post-acute or weaning)Minimum monitoring required(Oximetry,ECG,noninvasive blood pressure,respiratory rate)for each bedUnit under supervision of at least one senior doctor(with tra

18、ining in pneumology and in noninvasive and invasive mechanical ventilation)Availability of respiratory physiotherapistEur Respir J 2002;20:1343-13502023-1-453The Respiratory Medicine Status in ICUDefinition of the three levels of care Eur Respir J 2002;20:1343-1350Respiratory ICURICURMUMajor Criteri

19、a Nurse:patient ratio per shift1:31:3 or 1:41:4 Bed equipmentPolyfunctional monitors#Polyfunctional monitors#Polyfunctional monitors#Life support ventilatorsMechanical ventilators(for NIV,with availability of life support ventilators)Mechanical ventilators(for NIV)TreatmentLung or more than one orga

20、n failureLung failure(one organ failure)Lung failure(one organ failure)Attending physician24 hImmediately available 24 h On call(within the hospital)Mechanical ventilationInvasive and noninvasive when neededNoninvasive and invasive when neededNoninvasive when neededMinor criteria BronchoscopyInside

21、unitInside unitInside or outside unit ABGAInside unitInside unitInside or outside unit2023-1-454RICU未来的发展方向未来的发展方向 q RICU应向应向MICU（Medical Intensive Care Unit）发展，收）发展，收 治治对象应涵盖内科各种合并感染的危重症患者（不包括急性心肌对象应涵盖内科各种合并感染的危重症患者（不包括急性心肌梗塞患者，但是如果合并感染亦应收治）梗塞患者，但是如果合并感染亦应收治）q 但是人才梯队的建设也是当务之急但是人才梯队的建设也是当务之急Our Aim:Provide principal care for all patients in(medical)ICUs.-ATS Statement1/4/202355解放军总医院呼吸科是国家重点学科，目前拥有解放军总医院呼吸科是国家重点学科，目前拥有4个病区共个病区共120张床位，其中张床位，其中RICU20张；明年张；明年8月新内科大楼竣工，届时我们科室将拥有月新内科大楼竣工，届时我们科室将拥有5个病区，个病区，160张床位，张床位，RICU的的硬件配备将达到更高的水平（智能化硬件配备将达到更高的水平（智能化ICU），为今后的工作开展建立了良好的条件，为今后的工作开展建立了良好的条件