无创呼吸机临床应用操作要点

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Any medical information is provided as a general information service only and is not intended as a substitute for advice from a registered physician or other health care professional.”,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2021/1/12,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,2021/1/12,*,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,*,*,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,*,*,无创呼吸机临床应用操作要点,无创呼吸机临床应用操作要点无创呼吸机临床应用操作要点充分理解和熟悉机器理解机器原理、熟悉机器操作,熟悉配件的构造和使用方法,工作人员必须亲自试戴呼吸机：,体会不同压力的感受；,体验FLEX技术；,体验不同呼吸频率下，呼吸机同步性能；,鼻罩漏气时噪声特点及主管感受；,22021/1/12,充分理解和熟悉机器,理解机器原理、熟悉机器操作,熟悉配件的构造和使用方法,工作人员必须亲自试戴呼吸机：,体会不同压力的感受；,体验FLEX技术；,体验不同呼吸频率下，呼吸机同步性能；,鼻罩漏气时噪声特点及主管感受；,2021/1/12,2,正确选择病人,早期发现患者辅助通气的潜在需求,呼吸频率过快,呼吸困难,掌握无创通气的早期上机指征,神志清楚，可以配合的患者,痰量不多，可自主有效咯痰患者,血流动力学稳定,2021/1/12,3,上机指征,中等程度的呼吸困难,动用辅助呼吸肌,胸腹矛盾运动,PH,45mmHg,SpO290%,呼吸频率25/,min,成功应用无创通气的重要因素,正确的介入时机早期使用,2021/1/12,4,呼吸机使用的初始培训,30分钟！,2021/1/12,5,帮助患者选择适宜鼻罩款式、大小,详细介绍鼻罩构造排气口、氧气接口、佩戴方法，让患者亲自动手佩戴。,帮助患者尽快习惯鼻面罩通气,消除不良心理因素,恐惧、观念、其他心理因素,解释排气阀的作用,解释氧气接入和氧流量调节方法,介绍鼻罩、头带清洗保养方法,管道安装、拔除技巧,管道清洗方法,成功应用无创呼吸机的重要因素,耐心的病人辅导30分钟鼻罩、管道,2021/1/12,6,详细介绍机器根本构造,面板控制按钮的功能,主机拆卸,过滤片的作用及安装方法,两种过滤片的清洗、更换频率,湿化器温度调节,湿化盒拆装,湿化盒清洗方法,提醒湿化器水倒灌危险,细菌过滤器的意义、使用方法、更换标准,耐心的病人辅导30分钟机器使用,2021/1/12,7,无创通气上机后的监测,患者主诉,心率、呼吸频率,动态监测SPO224小时慢性呼衰患者,2小时后动脉血气检查急性呼衰患者,睡眠监测：评价夜间通气效果及睡眠质量,睡眠期间的压力滴定,2021/1/12,8,最常用通气形式：S/T,IPAP：5cmH2O 10cmH2O,EPAP：4cmH2O 临床需要,BPM：较自主呼吸慢2-4次/分,吸呼比：1:1.52,吸入氧流量：15L/min,或根据临床需要,治疗过程中，各种参数应随病情变化及时调整，稳定期治疗压力相对恒定,通气形式、压力及给氧量的调定COPD,2021/1/12,9,无创通气的几个细节问题,2021/1/12,10,鼻罩的选择与佩戴,2021/1/12,11,鼻罩佩戴的重要性,“Success is optimized when a skilled team applies a well-fitted, comfortable interface,Liesching T, Kwok H, Hill NSChest 2003; 124:699-713,2021/1/12,12,鼻罩、面罩的选择与佩戴,2021/1/12,13,测量面罩、鼻罩及鼻枕大小,2021/1/12,14,鼻罩测量点与量鼻器的使用,2021/1/12,15,2021/1/12,16,2021/1/12,17,湿化与湿化技术进展,2021/1/12,18,Among the most frequently reported side-effects of CPAP is dryness of the nose, mouth and throat, which experienced by 30-66% of patients on NCPAP,Wiest, et al. Respiratory Medicine 1999,使用CPAP最常报告的副作用是鼻腔枯燥、口干和喉咙枯燥。,2021/1/12,19,Our results demonstrate that heated humidification significantly improves the nCPAP daily rate of use and that its need may be predicted.,Rakotonanahary Det al. Heated Humidification significantly improves,CPAP daily rate of use.,Chest,2001: 460-465.,2021/1/12,20,2021/1/12,21,管道冷凝水对,CPAP,压力的影响,Bacon et al., 2000,2021/1/12,22,无创通气过程中常见问题与解决,2021/1/12,23,无创通气中常见问题,呼吸困难病症加重,缺氧不缓解,CO2潴留加重,患者疲惫,睡眠质量不改善,部分皮肤损伤,2021/1/12,24,呼吸困难加重,精神紧张，主动用力呼吸,起始压力过高，患者屏气,支持压力缺乏,可能存在未发现的禁忌症，如气胸,其它非医学因素,病情改变,耐心解释、示范使用方法，使病人能放松自然的方式呼吸,起始压力从6/4cmH2O开场,仔细查体,理解其回绝使用的真正心理因素：费用？或其他,找出病情变化所在，进展相应处理。,原 因,解决方法,2021/1/12,25,低氧血症改善不明显,氧源？供氧管路漏气,氧流量？,EPAP,？,分泌物？,治疗时间？,其它措施？,调整氧源设备及供氧管路,适当进步吸入氧流量,适当进步EPAP，同时进步相应进步IPAP,去除气道分泌物,延长治疗时间,调整其它治疗措施,原因,解决方法,2021/1/12,26,IPAP/EPAP,潮气量,2,lpmO2,4,lpmO2,10,lpmO2,10/5,15/5,300,600,300,600,36.3,37.4,35.2,34.1,51.7,51.7,47.3,50.6,47.8,81.4,47.8,80.3,吸入氧流量与病人吸入氧浓度的关系,注：给氧位置在鼻罩处,2021/1/12,27,CO2,潴留改善不明显,支持压力不够,漏气量不够,EPAP,过低,合并,OSA,分泌物？,其它治疗？,治疗时间？,增大压差,适当增大漏气量,IPAP低于15cmH2O时采用PEV排气阀,适当调节EPAP，抵消PEEPi,夜间进展压力滴定,调整其它治疗,给予足够的治疗时间,原因,解决方法,2021/1/12,28,150,80,60,40,20,PaCO2 mm Hg,5,4,VAL,高碳酸血症程度与肺泡通气量的关系,2021/1/12,29,无创通气的感染时机,鼻 罩,鼻 孔,清洁良好,(n=13),清洁不良,(n=27),1 (7.7%),5 (12.5%),1 (7.7%),9 (22.5%),不同清洁程度致病微生物别离情况,Arch Bronconeumol 2004;40(9):392-6,2021/1/12,30,防止无创通气穿插感染,及时清洁鼻罩、管道及湿化器,及时清洗和更换空气过滤棉,使用低阻力细菌过滤器,2021/1/12,31,小 结,适应征广泛,平安有效，操作非常简单,可使急性插管率下降70%左右,对急、慢性呼衰、心衰及OSA，疗效显著,肺、心康复的有效手段,无创通气具有以下优势：,2021/1/12,32,人有了知识，就会具备各种分析才能，,明辨是非的才能。,所以我们要勤恳读书，广泛阅读，,古人说“书中自有黄金屋。,通过阅读科技书籍，我们能丰富知识，,培养逻辑思维才能；,通过阅读文学作品，我们能进步文学鉴赏程度，,培养文学情趣；,通过阅读报刊，我们能增长见识，扩大自己的知识面。,有许多书籍还能培养我们的道德情操，,给我们宏大的精神力量，,鼓舞我们前进。,