机械通气与RM

AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide1机械通气与RM东莞市中医院ICUAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide2人呼吸的重要性：呼吸的维持=生命的维持生命之吻！AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide3机械通气的目的建立人工气道促进肺泡复张促进二氧化碳排出纠正呼吸衰竭保持有效氧合目前广泛应用于临床一线呼吸医学、重症监护、急诊医学、外科术后、睡眠呼吸障碍等诸多领域，机械通气应用适当与否，直接关系到患者的生死存亡应用得当会起到立竿见影的效果AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide4机械通气种类AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide5机械通气种类--无创AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide6呼吸机的种类--有创AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide7无创？有创？AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide8有创机械通气的模式定压通气定容通气完全控制压力控制通气(PCV)容量控制通气(VCV)间歇指令通气(SIMV+PSV)完全支持压力支持通气(PSV)AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide9机械通气模式指令通气同步指令通气有支持的自主呼吸完全自主呼吸患者的呼吸功呼吸机的呼吸功AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide10机械通气模式完全休息大量体力消耗模式的选择=仅仅是医生的选择AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide11机械通气临床应用指南2006------中华重症医学会AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide12机械通气适应症通气功能障碍：呼吸肌功能障碍中枢驱动力减弱气道阻力增加或阻塞难治性低氧血症确保镇静和神经肌肉阻滞时通气安全降低全身和心肌氧耗降低颅内压采取姑息性过度通气AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide13机械通气的相对禁忌症张力性气胸或气胸需进行闭式引流者大咯血或严重误吸引起的窒息性呼吸衰竭伴有肺大泡的呼吸衰竭严重心衰并发的呼吸衰竭AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide14病理生理目标（1）支持肺泡通气（2）改善或维持肺泡氧合（3）减少呼吸功耗（4）维持或增加肺容积；AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide15容积控制通气（volumecontrolledventilation,VCV）呼吸机按预设的频率和潮气量送气需设置基本参数：吸氧浓度(FiO2),VT,RR,I/E不同呼吸机设置不同AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide16A.PIP,B.Pplat,C.End-expiratorypressurePawPResistanceP=ResistanceP=ComplianceAB0Time(sec)C吸气开始呼气开始吸气暂停PIP-PplatPplat-PEEPAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide17VCV时PEEPi的波形AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide18VCV时去除PEEPi方法减少RR——最有效吸气流速不变情况下降低VT-缩短吸气时间、延长呼气时间VT不变情况下增加吸气流速-缩短吸气时间、延长呼气时间AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide19VCV的局限性气道压不恒定峰值流速不足可导致空气饥饿和呼吸功增加固定VT、Ti、RR导致人机协调性不佳设置不当可产生PEEPiAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide20压力控制通气（pressurecontrolledventilation,PCV）预置压力控制水平和吸气时间需设置基本参数：FiO2,压力控制水平，RR,吸气时间减速气流吸气向呼气切换方式？时间AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide21PCV的局限性固定PC、Ti、RR导致人机协调性不佳潮气量不确定潮气量确定的因素：患者因素气道阻力呼吸系统顺应性自主吸气力量机械因素设置的送气压力附加装置阻力顺应性AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide22压力支持通气（pressuresupportventilation,PSV）患者自主吸气达到触发灵敏度（压力或流量），呼吸机按预设的压力送气需设置基本参数：触发灵敏度、送气压力水平减速气流吸气向呼气转换？流速AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide23AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide24AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide25PSV的特点和不足适应症：自主呼吸能力，中枢稳定主要监测参数：VTVT决定因素：患者因素：气道阻力呼吸系统顺应性自主吸气力量辅助因素：设置的送气压力水平附加装置阻力顺应性优点：人机协调性好局限性：潮气量不稳定、窒息AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide26简单认识ARDSAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide27ARDSAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide28重力依赖区域的肺不张AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide29重力依赖区域的肺不张AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide30重力依赖区域的肺不张AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide31AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide32A.HypoxamiaB.ShearforcesC.SurfactantsinactivateD.BiotraumaandMODSPathophysiologyConsolidationandalvcollapseAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide33A.低氧血症肺泡塌陷：ARDS重力依赖区炎症或不张区生理性低氧缩血管反应：障碍AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide34HowDoesExcessiveMechanicalStressInflametheLung?“Shear”AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide35Verbruggeetal.CritCareMed1999;27：779Ventilator-associatedlunginjury012345Control7/045/1045/0PurineProtein•Purine:amarkerofATPbreakdownandVILI•42SDrats•PCV6min•PCVPre/PEEP•BALFpurineandproteinAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide36SurfactantmoveawayWhenlungregionscollapseatend–expiration,surfactantmoleculesmoveawayfromthealvsurfacetowardterminalbronchiolesandcannotbereusedduringnextinflationRoubyJJ.AmJRespirCritCareMed,2001,165:1182AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide37D.预防Biotrauma和MODSMariniJJ,GattinoniL.Ventilatorymanagementofacuterespiratorydistresssyndrome:aconsensusoftwoCritCareMed.2004Jan;32(1):250-5.“Stretch”“Shear”AirwayTraumaAFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide38AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide39AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide40AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide41AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide42AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide43AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide44AFreesamplebackgroundfromwww.powerpointbackgrounds.comSlide45肺开放后的PEEP选择----PaO2/FiO21.RM后PEEP:20cmH2O2.PEEP递减:2cmH2O/5min3.PEEP阈值:PaO2/FiO2400的PEEP或PaO2/FiO2降低5