COPD的机械通气课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,COPD的机械通气:,Vt, FiO,2, what else?,北京协和医院,杜斌,COPD的机械通气: Vt, FiO2, what els,COPD患者的肺泡过度充盈,Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004; 350: 2689-97,COPD患者的肺泡过度充盈Sutherland ER, Ch,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() = R x C,时间常数(,),Time/Tau,吸气相,呼气相,Pressure,时间常数()Time/Tau吸气相呼气相Pressure,时间常数(,),P,A,(t) = (Pplat - PEEP) e,-kt,e = 2.718,k = 1/ =1/(R x C),V(t) = Vt x e,-kt,e = 2.718,k = 1/ =1/(R x C),时间常数()PA(t) = (Pplat - PEEP),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,0,0%,100%,1,63%,37%,3,95%,5%,5,99.9%,0.1%,时间常数()时间常数Tau呼出气容积残余容积00%100%,动态过度充盈: DHI,insp,exp,Time,Tidal volume,Trapped gas,Lung Volume,FRC,Obstructed Lungs,Normal Stiff Lungs,动态过度充盈: DHIinspexpTimeTidal vo,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, PaCO,2,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,机械通气的适应证: COPD呼吸肌疲劳且濒临呼吸停止,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,COPD患者的病理生理改变内源性PEEP过高,机械通气时的PEEPi,Vt 10 12 ml/kg, f 12 15 bpm, I:E 1:2 3,诊断,No.,PEEPi (范围),发生率,COPD,45,2.6 22,45/45 (100%),CF,1,11,1/1 (100%),Asthma,3,13.5 20,3/3 (100%),ARDS,28,1.0 8.1,15/28 (58%),CPE,10,1.0 6.0,8/10 (80%),Other,10,1.0 4.1,5/10 (50%),机械通气时的PEEPiVt 10 12 ml/kg,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:E,Ti/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,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:E,Ti/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,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,机械通气参数的设置: COPD潮气量,COPD: 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 2002; 122: 20962104,COPD: 不同吸气气流的比较Shieh Ching Yan,COPD: 不同吸气气流的比较,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2,Vt, ml,562,67,558,65,566,59,571,72,RR, bpm,18.2,1.7,18.6,1.4,18.4,1.9,18.5,1.3,MV, lpm,10.4,1.6,10.3,1.5,10.6,1.6,10.7,1.8,Ti/Ttot,0.29,0.04,0.28,0.03,0.29,0.04,0.28,0.03,平均吸气流速, lpm,38,5,37,7,39,7,38,6,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 2002; 122: 20962104,COPD: 不同吸气气流的比较波形(均值 SD)呼吸机参,COPD: 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2,PIP, cmH,2,O,47.1,11.5,47.8,10.8,39.5,9.7,46.6,11.0,Paw, cmH,2,O,7.6,4.2,7.2,4.8,8.4,4.5,8.4,3.9,Pplat, cmH,2,O,20.2,9.1,19.6,10.6,18.9,8.8,21.4,10.4,Vd/Vt, %,58.4,5.2,54.5,6.3,48.6,5.5,57.6,4.9,Cst, ml/cmH,2,O,35.3,8.9,35.8,11.2,36.6,9.3,37.2,9.7,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 2002; 122: 20962104,COPD: 不同吸气气流的比较波形(均值 SD)呼吸力学,COPD: 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2,pH,7.44,0.04,7.44,0.07,7.43,0.06,7.44,0.04,PaO,2,/FiO,2, mmHg,236,73,231,65,223,70,227,67,PaCO,2, mmHg,45,10,45,10,37,9,46,12,A-aDO,2, mmHg,133.1,36.5,136.4,34.2,156.3,33.7,134.4,35.3,HR, bpm,106.1,18.1,108.3,20.2,105.3,18.9,109.9,20.5,MAP, mmHg,92,23,88,18,88,21,90,19,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 2002; 122: 20962104,COPD: 不同吸气气流的比较波形(均值 SD)恒定气流,COPD: 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2,WOB, J/L,0.92, 0.16,0.88, 0.18,0.75, 0.15,0.92, 0.18,Raw, cmH,2,O/L/s,12.6, 3.1,12.4, 3,.6,11.2, 2,.4,12.5, 3,.3,VO,2, ml/min,384, 53,389, 60,377, 49,382, 52,VCO,2, ml/min,274, 52,280, 47,273, 56,276,55,症状评分,54.5, 13.4,58.6, 11.9,42.7, 12.3,56.1, 12.8,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 2002; 122: 20962104,COPD: 不同吸气气流的比较波形(均值 SD)参数恒定,COPD: 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 2002; 122: 20962104,COPD: 不同吸气气流的比较结论Shieh Ching,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,COPD机械通气策略降低内源性PEEP的方法,呼气流速,Palv,PEEP,Flow=,P / Raw,= (Palv PEEP) / Raw,Flow,呼气流速PalvPEEPFlow= P / RawFlo,PEEP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 2005; 100: 1112-6,Compliance,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,Compliance, P ,Flow,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,半径,PEEP,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,PEEP,半径,流速,?,P,流速,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,半径,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,半径,Flow,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,半径,PEEP,PEEP与呼气流速Savian C, Chan P, Par,PEEP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 2005; 100: 1112-6,PEEP,半径,流速,P,流速,PEEP与呼气流速Savian C, Chan P, Par,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,PaO,2,(kPa)7.4, 0.4,PaCO,2,(kPa)7.1, 1.1,pH7.40, 0.00,ODonoghue 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 2002;57:533-539,COPD稳定期患者(n = 9)年龄(yr)70 7,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEPODonoghue FJ, Ca,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEPODonoghue FJ, Ca,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEPODonoghue FJ, Ca,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEPODonoghue FJ, Ca,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEPODonoghue FJ, Ca,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEPODonoghue FJ, Ca,COPD稳定期: PEEP,ODonoghue 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 2002;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稳定期: PEEPODonoghue FJ, Ca,COPD急性期患者(n = 10),Gu,rin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,年龄(yr)64, 6,身高(cm)167, 6,体重(kg)72, 21,体重(%pred)96, 27,FiO,2,(%)48, 9,Vt (L)0.74, 0.09,PIF (L/s)0.65, 0.12,Tinsp (s)1.13, 0.15,Texp (s)3.42, 0.57,RR (bpm)13.5, 1.5,COPD急性期患者(n = 10)Gurin C, Fou,COPD急性期: PEEP,PEEP (cmH,2,O),0,5,10,15,PEEPt, cmH,2,O,8.4,4.8,10.0,3.9,12.3,2.4,16.9,1.8,PEEPi, cmH,2,O,7.1,3.9,3.7,3.3,1.8,1.8,0.8,1.2,FRC, L,0.54,0.42,0.74,0.48,1.03,0.42,1.50,0.51,Rint, rs, cmH,2,O s/L,9.2,3.6,8.1,2.7,7.3,2.7,7.2,3.0,Rrs, cmH,2,O s/L,7.7,1.8,8.5,1.8,9.5,2.7,9.7,3.3,Rrs, cmH,2,O s/L,17,3.9,16.7,2.7,16.8,3.0,16.9,3.6,Est,rs, cmH,2,O/L,12.7,3.0,12.9,3.3,12.9,3.3,15.5,4.5,Gu,rin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,COPD急性期: PEEPPEEP (cmH2O)05101,COPD急性期: PEEP,Gu,rin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,COPD急性期: PEEPGurin C, Fournie,COPD: PEEP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 2005; 33: 1519-1528,RR 6 bpm,RR 9 bpm,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP与呼气流速Caramez MP, Bor,COPD: PEEP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 2005; 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,COPD: PEEP与呼气流速Caramez MP, Bor,Assessment of Pulmonary Hyperinflation,Time,Tidal volume,Trapped gas,Lung Volume,FRC,Tidal vol.,Tidal hyper-inflation,Apnea,Tidal Ventilation,Assessment of Pulmonary Hyperi,COPD: 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 2001; 163: 1365-1370,Tinsp,RR,Texp,PEEPi,COPD: 缩短吸气时间Laghi F, Segal J,COPD: 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 2001; 163: 1365-1370,患者基础情况(n = 10),基本情况,均值, SE,年龄, yr,68.3,2.9,体重, kg,82.9, 5.9,身高, cm,173.5, 2.1,FEV1, L,1.21, 0.12,FEV1, %pred,39.7, 4.3,FEV1/FVC, %pred,40.9, 3.5,FRC, L,6.5, 0.8,TLC, L,8.9, 0.7,PaO,2, mmHg,72, 3,PaCO,2, mmHg,38, 1,COPD: 缩短吸气时间Laghi F, Segal J,COPD: 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 2001; 163: 1365-1370,16.1,1.0,19.0,1.4,20.8,1.5,7.0,1.3,6.3,1.1,6.4,1.1,2.1,0.2,2.4,0.2,2.3,0.2,COPD: 缩短吸气时间Laghi F, Segal J,COPD: 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 2001; 163: 1365-1370,COPD: 缩短吸气时间Laghi F, Segal J,COPD: 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 2001; 163: 1365-1370,COPD: 缩短吸气时间Laghi F, Segal J,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,PENDELLUFT,during the,Plateau Phase,为何需要设置吸气末暂停PressureFlowPeakPla,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,No PENDELLUFT,because of constant,flow flow,为何需要设置吸气末暂停PressureFlowPeakPla,COPD: 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 2001; 163: 1365-1370,COPD: 缩短吸气时间Laghi F, Segal J,COPD: 缩短吸气时间,机械通气患者常常呼吸频数, 肺过度充盈,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,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. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,COPD: 缩短吸气时间机械通气患者常常呼吸频数, 肺过度充,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(T,E,),VtRRflowT,TOT,T,I,T,E,T,E,0.515 604.000.503.50-,0.5151204.000.253.750.25,0.514 604.300.503.800.30,0.512 605.000.504.501.00,提示降低分钟通气量,对于减少内源性PEEP的重要作用,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),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,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 bpm,Leatherman JW, McArthur C, Shapiro RS.,Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma.,Crit Care Med 2004 Jul;32(7):1542-5.,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,延长呼气时间治疗哮喘持续状态,18 bpm,12 bpm,6 bpm,呼气时间(sec),2.9,0.1,4.5,0.1,9.5,0.1,气道峰压(cmH,2,O),66.8,8.7,66.4,9.5,67.8,11.1,气道平台压(cmH,2,O),25.4,2.8,23.3,2.6,21.3,2.9,呼气末流速(mL/sec),61.4,12.6,38.6,4.5,23.1,5.8,内源性PEEP (cmH,2,O),14.8,3.0,12.3,3.0,8.9,3.6,Leatherman JW, McArthur C, Shapiro RS.,Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma.,Crit Care Med 2004 Jul;32(7):1542-5.,延长呼气时间治疗哮喘持续状态18 bpm12 bpm6 bp,病例,NYH, F/82, C822978, 入院日2004/12/31,胸闷, 憋气3天, 神志障碍30分钟,PMHx: COPD,入院时,HR 50, BP 78/43,ABG (1617 hrs): 7.034 /,148,/ 53.8 / 37.7,病例NYH, F/82, C822978, 入院日2004/,病例,处理,气管插管, 机械通气,镇静肌松,安定5 mg/hr + 吗啡2 mg/hr,Scoline,多巴胺5,g/kg/min,BP 120/58,病例处理,病例,呼吸模式: VCV,参数设置:,Vt 400 ml,RR 16 bpm,FiO,2,0.40,ZEEP,病例呼吸模式: VCV,PEEPi的测定,Flow (l/s),Pao (cmH,2,O),occlusion,PEEPi = 10,3.75 sec,PEEPi的测定Flow (l/s)Pao (cmH2O)o,病例,呼吸模式: VCV,参数设置:,Vt 400 ml,RR 16 bpm, 10 bpm,FiO,2,0.40,ZEEP,MV = 4 lpm,能否降低PEEPi,能否降低PaCO,2,病例呼吸模式: VCVMV = 4 lpm,PEEPi的测定,Flow (l/s),Pao (cmH,2,O),occlusion,PEEPi = 5,6 sec,PEEPi的测定Flow (l/s)Pao (cmH2O)o,病例,日期,时间,pH,PaCO,2,PaO,2,HCO,3,2004/12/31,16:17,7.034,148,53.8,37.7,2004/12/31,17:51,7.226,82.1,63.5,32.8,2005/01/01,08:49,7.462,51.2,74.3,36.1,病例日期时间pHPaCO2PaO2HCO32004/12/3,病例,生命体征,HR60,BP106/53,停用多巴胺,SpO,2,96%,病例生命体征,COPD患者的机械通气: 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,外源性PEEP效果不肯定,通过提高吸气流速延长呼气时间效果甚微,尽量缩短吸气末暂停,降低呼吸频率效果明确,COPD患者的机械通气: 总结内源性PEEP过高是COPD机,