COPD的机械通气

COPD的机械通气:Vt,FiO2,…whatelse?北京协和医院杜斌COPD患者的肺泡过度充盈SutherlandER,CherniackRM.ManagementofChronicObstructivePulmonaryDisease.NEnglJMed2004;350:2689-97时间常数()=RxC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()Time/Tau吸气相呼气相Pressure时间常数()PA(t)=(Pplat-PEEP)e-kte=2.718k=1/=1/(RxC)V(t)=Vtxe-kte=2.718k=1/=1/(RxC)时间常数()时间常数成人(正常值)2x0.10=0.20”术后气管插管成人患者5x0.06=0.30”COPD成人患者15x0.06=0.90”ARDS成人患者8x0.03=0.24”ARDS患儿5x0.01=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:DHIinspexpTimeTidalvolumeTrappedgasLungVolumeFRCObstructedLungsNormalStiffLungs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内源性PEEP过高肺泡过度膨胀胸腔内压过高回心血量减少休克机械通气时的PEEPiVt10–12ml/kg,f12–15bpm,I:E1:2–3诊断No.PEEPi(范围)发生率COPD452.6–2245/45(100%)CF1111/1(100%)Asthma313.5–203/3(100%)ARDS281.0–8.115/28(58%)CPE101.0–6.08/10(80%)Other101.0–4.15/10(50%)DHI和PEEPi的影响因素内在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PEEPi的影响因素内在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COPD机械通气策略降低内源性PEEP的方法外源性PEEP?延长呼气时间增加吸气流速缩短吸气末暂停降低呼吸频率呼气流速PalvPEEPFlow=P/Raw=(Palv–PEEP)/RawFlowPEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6CompliancePEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6CompliancePFlowPEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径PEEPPEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP半径流速?P流速PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP与呼气流速2025303540057.51012.515PEEP(torr)PeakExpiratoryFlow(lpm)C50C20SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径FlowPEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径PEEPPEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP半径流速P流速COPD稳定期患者(n=9)年龄(yr)707.3FEV1(%pred)309.5FVC(%pred)5313.6RV(%pred)18633.1FEV1/VC(%)4411.6TLC(%pred)1038.7TLCO(%pred)4625.4PaO2(kPa)7.40.4PaCO2(kPa)7.11.1pH7.400.00O’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-539总结对于处于稳定期的严重COPD患者,应用高水平的CPAP能够降低PEEPi及肌肉活动指标肺容积显著增加COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-1528RR6bpmRR9bpmCOPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-1528COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponse