医学呼气末二氧化碳在急诊的临床应用课件

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,2021/2/5,#,第六生命体征,第六生命体征,1,概述,呼气末二氧化碳（,end-tidal carbon dioxide,，,ETCO,2,),是指呼气终末期呼出的,混合肺泡气含有的二氧化碳分压,（,P,ET,CO,2,),或浓度（,C,ET,CO,2,),值,无创、连续、实时、简便、重要,概述呼气末二氧化碳（ end-tidal carbon di,2,医学呼气末二氧化碳在急诊的临床应用课件,3,体内,CO,2,产量,(VCO,2,),和肺通气量,(VA),决定,P,A,CO,2,P,A,CO,2,= VCO,2,0.863/VA,0.863,为气体容量转换为压力的系数,正常人,P,ET,CO,2, P,A,CO,2, PaCO,2,（正常通气血流比例），,P,ET,CO,2,略低于,PaCO2,，差值小于,5mmHg,P,ET,CO,2,和,Pa CO,2,受到,CO,2,产量,、,肺泡通气量,和,肺血流灌注量,影响,体内CO2产量(VCO2)和肺通气量(VA)决定PACO2,4,P,ET,CO,2,监测的方法,质谱仪法,：,反应快，能连续监测，但仪器价格昂贵，难以在临床广泛应用,比色法,：,简便有用，但精确性欠佳,红外线监测法：,CO,2,仅对波长,4.26,微米的红外线,才有强烈的吸收作用。流经的,CO,2,吸收掉一部分红外线能量，吸收的多少与,CO,2,浓度成比例关系。经过微电脑处理获得,P,ET,CO,2,。,主流型,旁流型,PETCO2监测的方法质谱仪法：反应快，能连续监测，但仪器价,5,主流和旁流区别,主流和旁流区别,6,医学呼气末二氧化碳在急诊的临床应用课件,7,P,ET,CO,2,与,PaCO,2,的一致性,Ebrahim Razi, et.,Arch Trauma Res. 2012;1(2):58-62,.,PETCO2与PaCO2的一致性Ebrahim Razi,8,McSwain SD,et al. Respir Care. 2010 ; 55(3): 288293.,McSwain SD,et al. Respir Care,9,旁流,Nonintubated patients with dyspnea ( 18 years) in an ED,38% had a difference of 10 mm Hg or more.,The mean difference between the PaCO2 and ETCO,2,levels was 8 mm Hg,Delerme S, et al.Am J Emerg Med.2010,;28(6):711-4.,旁流Nonintubated patients with d,10,正常,ETCO,2,波形,正常人的,ETCO,2,值范围,32-43,相,：,吸气基线，处于零点，是呼气的开始部分,相,：,呼气上升支，为肺泡和无效腔的混合气,相,：,呼气平台，呈水平形，是混合,肺泡气,相,：,呼气下降支，迅速而陡直下降至基线，新鲜气体进入气道,正常ETCO2波形正常人的ETCO2 值范围 32-43相,11,ETCO,2,观察指标,基线：,代表吸入,CO,2,浓度,高度：,代表呼出,CO,2,的浓度,形态：,正常,CO,2,波形与不正常波形,频率：,反映呼吸频率,节律：,反映呼吸中枢或呼吸机的设置,ETCO2观察指标基线：代表吸入CO2浓度,12,影响,ETCO,2,因素,机体因素,：,影响,CO,2,产生：体温、代谢、药物等,影响,CO,2,运输：心输出、肺灌注,影响通气：阻塞性及限制性肺疾病，呼吸频率,通气血流比例变化,设备因素,：,呼吸机设置、故障，管道脱落、阻塞及漏气,取样管堵塞，取样部位及速率,影响ETCO2因素机体因素：,13,ETCO,2,常见异常波形,ETCO2常见异常波形,14,ETCO,2,急诊应用,常见异常波形,代谢,：体温降低,循环,：全身或肺灌注降低（,PE,、,shock,，严重时会突然降低）,通气,：分钟通气量增大，过度通气,仪器,：漏气、取样管故障等,ETCO2急诊应用常见异常波形代谢：体温降低,15,代谢,：体温升高，寒颤，抽搐,循环,：心输出量增加，输入碳酸氢钠，缺血肢体血供恢复,通气,：分钟通气量降低，通气不足,仪器,：呼吸机活瓣故障,代谢：体温升高，寒颤，抽搐,16,LossofWaveform,呼吸骤停,窒息,人工气道脱落或阻塞,CO2,仪器故障,采样管堵塞扭曲,LossofWaveform呼吸骤停,17,Howe TA, et al. J Emerg Me,d,.2011;41(6):581-9.,LossofAlveolarPlateau,支气管痉挛,哮喘,AECOPD,气道阻塞,痰液,呼吸回路的呼气段阻塞,气管插管或螺纹管部分阻塞或打折,shark finning,Howe TA, et al. J Emerg Med.2,18,ElevatedBaseline,不完全吸气或呼气,回路内部分重吸入,哮喘或者,COPD,的病人气体受阻,呼气时间不足,球囊通气呼气期或呼吸机出现故障,校准有误,延长呼气时间,ElevatedBaseline不完全吸气或呼气,19,EtCO,2,decreases as exhalation continues, CO,2,is not reaching the detector.,气囊漏气,tube that is too small,EtCO2 decreases as exhalation,20,自主呼吸恢复,肌松作用消失,自主呼吸恢复,21,肺泡死腔增大,吸气流速降低,肺泡死腔增大吸气流速降低,22,ETCO,2,急诊临床应用,ETCO2急诊临床应用,23,ETCO,2,急诊应用,心肺复苏,提示心跳骤停,指导复苏,按压质量,提示,ROSC,预后意义,ETCO2急诊应用心肺复苏提示心跳骤停,24,按压深度与,ETCO,2,S,heak KR,.et al. Resuscitatio,n,.2015;89:149-54.,按压深度与ETCO2Sheak KR.et al. Resu,25,P,ET,CO,2,突然大于,40mmHg,提示,ROSC,PETCO2突然大于40mmHg提示ROSC,26,ETCO,2,与,ROSC,2010,指南,：,P,ET,CO,2,10mmHg,设法改进,CPR,质量,复苏成功者,P,ET,CO,2,明显高于复苏失败者,P,ET,CO,2,持续, 16 mmHg were signicantly associated with survival from emergency department resuscitation.,No patient survived with a level 16 mm Hg,ETCO2与ROSC2010指南： PETCO210mmH,27,Hartmann SM, et al. J Intensive Care M,ed.,2014 Apr 22. Epub ahead of print,Hartmann SM, et al. J Intensiv,28,医学呼气末二氧化碳在急诊的临床应用课件,29,ETCO,2,与预后,Retrospective observational study,16542 cardiac arrest patients admitted to 125 Australia and New Zealand ICUs between 2000 and 2011,PaCO,2, 97% on 2 - 4 L/min of oxygen.,More sensitive than pulse oximetry in,predicting a trend toward respiratory failure,Abramo TJ. Crit Care Med 1997;25:12426.,ETCO2急诊应用围插管期监测插管前及时识别呼吸功能异常,32,提前预警缺氧,132 adults underwent sedation with propofol in the ED.,All patients received supplemental oxygen at 3 L/min. Capnography gave advanced warning for all hypoxic events (SpO 2 97% on 2 - 4 L/min of oxygen.,More sensitive than pulse oximetry in,predicting a trend toward respiratory failure,Abramo TJ. Crit Care Med 1997;25:12426.,ETCO2急诊应用围插管期监测插管前及时识别呼吸功能异常,55,AVDSf (mm Hg ) = (PaCO,2,- PETCO,2,)/PaCO,2,AVDSf (mm Hg ) = (PaCO2 - PETC,56,小结,ETCO,2,的作用：,监测通气功能,维持正常通气量,确定气管插管的位置,及时发现呼吸机的故障,指导呼吸机调节和撤机,监测体内,CO2,产量变化,了解肺泡无效腔及肺血流量的变化,监测循环功能,心肺复苏,急诊病人的预后信息,小结ETCO2的作用：,57,