机械通气临床应用指南XXXX

(2006)Practicalguidelinesformechanicalventilation(2006)SocietyofCriticalCareMedicine,ChineseMedicalAssociationCorrespondingauthors:QINYing2zhi(DepartmentofIntensiveCareUnit,theThirdCentralHospital,Tianjin210009,China.Email:[e-mail])andLIUDa2wei(DepartmentofCriticalCareMedicine,PekingUnionMedicalCollegeHospital,ChineseMedicalScienceAcademy,Beijing100730,China.Email:[e-mail]@pumch.cn)AbstractWiththeexpandingunderstandingofbasicknowledgeconcerningrespiratoryfunctionandtechnologyofrespirator,mechanicalventilationhasbecomeanimportantinterventionalarmamentariumtoimprovegasexchangeanddecreaserespiratorywork.Itisoneoftheimportantmeanstoenhanceoxygendelivery,protectthelung,andrestorehomeostasisinthetreatmentofmultipleorgandysfunctionsyndrome.Theprogressioninmedicalsciencesandincreasingdatapertainingtoevidence-basedmedicinehavealsorendertheuseofmechanicalventilationstandardizedwithmoreappropriateindication.Undertheaforementionedconditions,itseemstobeessentialthattheindicationsandtheoperationandmanipulationofthesophisticatedventilatorshouldbestandardizedinthecareofcriticallyillpatients.Atthesametime,accumulationofclinicalexperiencesinrecentyearswithabundantrelevantdataasaresultofmulti-centerstudieshavefurnishedhighlyvaluableinformationtoaccomplishthiseffort.Basedonevidenced-basedata,theChineseSocietyofCriticalCareMedicine(ChineseMedicalAssociation)heldaconsensusconferencetodraftaguidelinefortherecommendationofmechanicalventilationtocategorizealltheinformationgatheredfromtheliteratureintofivegradesfromAtoE,withAbeingthehighest,accordingtoamodifiedDelphicriteria,whichwereadoptedbytheInternationalSepsisForumheldin2001.Afterfurthernationwideinquiriesandconscientiousdiscussions,thisguidelinehasbeendraftedpendingfurtheradditionandcorrection.Thisguidelinechieflycoversthefollowingaspects:thechoiceofmechanicalventilationforcriticallyillpatients,theaimandindicationofmechanicalventilation,non-invasivepositivepressureventilation,regulationofmodesandsettingsoftheventilator,etc.Withimplementationoftheguideline,itishopedthattheclinicaluseofmechanicalventilationinthecriticallyillpatientswillbemoreorlessstandardized.Theguidelinewillbeupdatedwhennewknowledgeisavailable.,,(DO2),(MODS),,,,,,2001ISFDelphi,5,DelphiAE,A1,,,,,1.11.1.1:,,,,,,:,,;,;,;,;,:,;()1.1.2:,,,,,:,:,;;;,;:,(VAP),,,,1.1.3:,(),,,5620072192ChinCritCareMed,February2007,Vol.19,No12:,,:,();;;;,,,,,1:(D)1.2:,,,,,VAP1989:10d,21d,1021d,,,,,(ICU),VAP,,(RCT),48h,2,7d7d,21d,2:;,;,;,;;,;,:;,;,(PCT),,,,ICU,,2:(C)2,,(Ppeak),(PCV)(VT),,,2.1:2530cmH2O(1cmH2O=01098kPa),,,Granja95,3,Guyton15,,Ppeak3:(C)2.2:,,,,VAP,Kollef343,,VAP,VAP,,4:,(B)2.3:(,,);(),,37,100%,,,VAP,,,,()Kirton,,,VAP,,,,5:(C)2.4:,VAP,Graven24h48h,KollefHess:7d1VAP,7d1dVAP,,VAPVAP,,,,6:,(B)33.1::;;()(PEEP)(EILV)(EELV);,,,3.1.1:(PaCO2)pHPaCO2pH;(COPD);,3.1.2:(FiO2)(PaO2)60mmHg(1mmHg=01133kPa)6620072192ChinCritCareMed,February2007,Vol.19,No12(SaO2)0190(CaO2)PaO2(Hb),DO2CaO2,(CO),,DO23.1.3,:(PEEPi),,,3.1.4:(),3.1.5:,,3.1.6:(),,,,3.2:,,(CO2),,:;;,3540ömin68ömin,,;:PaO250mmHg,50mmHg;PaCO2,pH:,,,,,(,),4(NPPV)NPPV,ö,NPPV,;,,NPPV(VAP),()NPPV,(IMV),,IMV;IMVNPPVIMV,,4.1:,,(),,NPPVNPPV:,,,,NPPV:,,,(),,,,NPPV4.2:Girault2NPPV:6410%,NPPV,1015%,,NPPV,NPPVCOPD(AECOPD)(ACPE),RCT,NPPV,NPPV,,,,(ARDS),,,,,,7:NPPVAECOPDACPE(A)8:NPPV(B)4.3:(BiPAP),(IPAP)2030cmH2O,(100Lömin),;É,FiO2(0150)4.4:NPPV,,24h,NPPV4.5:(CPAP)BiPAP,BiPAP:S,(PSV)+PEEP(T,PCV+PEEP),BiPAPIPAP,(EPAP)(),S;,ST,PCVACPECPAP,BiPAPBiPAP:IPAPöEPAP,,,BiPAP11BiPAPIPAP(VT)1025cmH2O(715mlökg)EPAP35cmH2O(É412cmH2O)(T)1020ömin0.81.2s4.6NPPV:NPPVNPPV,NPPV,:NPPV,NPPV:,NPPV,:Ê(APACHEÊ),,NPPV,X,,,,9:NPPV12h()(D)55.15.1.1:,,7620072192ChinCritCareMed,February2007,Vol.19,No12-IMV(SIMV),(VPV)VPVVT,VPV,,,,,,,51112:,,VTPEEP,PCV(P-ACV)-(PC-SIMV)PSV,(PPV)PPVVT,,(VILI),,,5.1.3(CV)(AV)5111311CV:,VTö,CV,CV,PEEPiCV,;;CVCV,,AV5111312AV:,,()(),VT()IPAP(),AV,,,,5.25.2.1(assist-controlventilation,ACV):ACVAVCV,,VT,CV;,,AVACVP-ACV(V-ACV):AC:VTö;AC::ACICU,VT(),,;CV,,,,5.2.2SIMV:SIMVCV,,,,(SIMV)(SIMV):VTö,SIMV:IMVVT;SIMV,,;IMV,,;;(VT),:VT,VT,:(),,,CV,PSV,,ARDS,PEEPVT,,,ICU5.2.3PSV:PSV,,VTö,(PS),:,(ESENS):,,,;,;,,58cmH2OPSV,PSV,PS;,,,,5.2.4CPAP:CPAP,(),,PEEP:CPAP:,PEEP,,,,,,PEEPiPEEPiCPAP,CPAP,,CPAP,PEEP5.2.5BiPAP:BiPAP,(Phigh)(Plow),(Tinsp)PhighPlow,PhighPlow,,,PSV:PhighPlowPEEPTinsp:BiPAPPhighPlow,,BiPAP(APRV);8620072192ChinCritCareMed,February2007,Vol.19,No12BiPAP,Tinsp,(Pmean),;BiPAPCV,,Phigh;PSV,,,,5.2.65121611(HFOV):HFOV,1517Hz,VT,(,)CO2,HFOV(1ö151ö5),:ARDS:FiO20160(PaO2öFiO2)200mmHg,24h,Pmean20cmH2OPEEP15cmH2O),PaO2öFiO220mmHg(PaO2öFiO2=PmeanFiO2100ö):Pmean:,PaO2,Pmean24cmH2O,,45cmH2OFiO2Pmean,FiO20160($P):PaCO2,5070cmH2O,PaCO2:36Hz,PaCO2(ö)33%50%,öPa2CO2(biasflow):4060Lömin:PaCO2(RM):RM:ARDSRCT,HFOV,(52%37%),,HFOV,5121612(PAV):PAV,,PAV:(FA),(VA),CPAP:PAV,,-,,PAVPmean,,PAV,,PS;,PSFAVA,,,,CPAPPEEPi66.1VT:,VT,512mlökg,,3035cmH2OPCV,VT,6.2:(PaO2),1220öminPaO220ömin,VT(f)6.3:,4060Lömin,,PCV6.4ö:ö,018112s,ö110115210;CVPmean,ö,PEEPi6.5:,-015-115cmH2O,25Lömin,,,,,;,,6.6F