机械通气的演变.ppt

机械通气的演变,首都医科大学附属复兴医院 席修明 2008.11.20 广州,历史回顾-Negative Pressure Ventilation (Iron Lung) that was wildly used during the polio epidemics in 50th,“On August 25,1952, I was called in as anasthetist for consultation in the Epidemiological Hospital of Copenhagen Within the preceding three weeks there had been 31 patients bulbar poliomylitis treated in respirators-tank as well as cuirass. 27 had died .” Four patients were seen in the autopsy room that day. One of them a 12-year-boy-had died in a respirator with a blood pressure of 160 and biocarbonate level in the serum far above the normal level. The lung did not appear to be sufficiently atelecttic to make adequate ventilation impossible She was a 12-year-old girl who paralysis of all four extremities. She had atelectasis of the lung and was gasping for air. Her temperature was 40.2C. She was cyanotic and sweating. A tracheotomy was done , a cuffed endotracheal tube put in, good suction, and 100mg Pentothal, her own respiration stopped and I found that I could now inflate her lung,历史回顾,Bjorn Ibsen第一次使用正压通气治疗呼吸衰竭的医生 （In the first ICU in the world） 这项新技术的应用使脊髓灰质炎的病死率从1952.7的87%下降到1953.3的15% 因此1953年3月是正压机械通气的生日,Acta Anaesthesiol Scand 2003;47:1190-1195,历史回顾-The first ICU in the world,Kommunehospitalet in Copenhagen. The hospital was inaugurated in 1863. The student nurses Turned into the worlds first ICU was on the first floor,Acta Anaesthesiol Scand 2003;47:1190-1195,历史回顾,机械通的流行病学,第一个机械通气流行病学的报告是Rogers 1972 发表的,Chest 1972；62：94-97,机械通气12小时病人的病死率，ICU建立前（U-Pen General Hospital Medical and Surgical Care Areas 1965.6-1968.8,Chest 1972；62：94-97,1969 建立RICU后的机械通气病人病死率,Chest 1972；62：94-97,成人急性呼吸衰竭机械通气的存活率-1979-1989,JL Stauffer Chest 1993；104 ：1222-1229,1992.1 Esdeban 对西班牙47个ICU机械通气模式和脱机方法进行了调查，290名病人机械通气时间大于24小时,Chest 1994;106:1188-1193,Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital,病人机械通气的天数,Chest 1994;106:1188-1193,Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital,脱机模式与成功率 T-piece 最好 SIMV PS SIMV+PS,Chest 1994;106:1188-1193,How is the Mechanical Ventilation Employed in ICU ？,1996.11-1997.1 Esteban 主持8个国家412个ICU参加的机械通气流行病学调查 共有4153住ICU病人，其中1638名机械通气（39%）,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？,人工气道的选择（8个国家）,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？ 常用的机械通气模式,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？ 常用的脱机模式,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？,Am J Respir Crit Care Med 2000;106:1450-1458,医生最喜欢的模式,How is the Mechanical Ventilation Employed in ICU ？ 常用的脱机模式,Am J Respir Crit Care Med 2000;106:1450-1458,医生最喜欢的脱机模式,A/C 和 PSV 时呼吸机参数的设定,Am J Respir Crit Care Med 2000;106:1450-1458,Mechanical Ventilation in Ontaroio; 1992-2000,92 93 94 95 96 97 98 99 2000 Change % MV Patient 15989 16108 16964 17303 17686 18017 18785 19609 19388 20 MV per 10,0000 population 200 199 207 208 210 211 217 223 217 12 Inpatient Bed day 8394 7975 7452 7138 6713 6239 6209 6158 6199 -26 MV days Per 10,0000 Population 86827 81701 90392 96434 95518 101724 107394 111573 109030 26 Mortality 30 day 27 28 29 30 31 31 33 33 32 p0.001,Crit Care Med 2004；32：1504-1509,回顾性，队列调查研究 1992-2000 Ontario 州住院病人资料库 150755名非心脏手术病人，接受机械通气,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,多中心、前瞻性的队列研究 20个国家，361个ICU，98.3.1-98.3.31 共15757病人收入ICU，5183病人机械通气12小时，观察28天 平均机械通气时间5.9天 平均ICU住院11.2天 JAMA，2002；287：345-355,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,COPD & ARDS 机械通气的模式（1.3.7天） COPD ARDS day 1 day 3 day7 day1 day 3 day 7 (n=522) (n=283) (n=85) (n=231) (n=174) (n=82) MV Modes No(%) A/C 344(65.9) 180(63.6) 57(67.1) 165(67) 111(63.8) 50(61) SIMV/PS 50(9.6) 32(11.3) 9(10.6) 24(10.4) 20(11.5) 8(9.8) PS 40(7.6) 24(8.5) 10(11.8) 3(1.4) 6(3.4) 3(3.7) PCV 20(3.9) 11(3.9) 2(2.4) 24(10.4) 23(13.2) 13(15.9) SIMV 24(4.6) 10(3.5) 2(2.4) 10(4.2) 4(2.3) 2(2.4),JAMA，2002；287：345-355,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,COPD 1.3.7,ARDS 1.3.7,JAMA，2002；287：345-355,COPD & ARDS 机械通气的参数,The Changing Epidemiology of Mechanical Ventilation: A Population-based Study Journal of Intensive Care Med 200621(3):173-182,1996-2002 回顾性调查研究，北卡罗来那州出院病人资料库，ICD-9修订版的诊断标准 1996年机械通气病人285/10万，2002增加为314/10万，增加11%（p0.05),The Changing Epidemiology of Mechanical Ventilation: A Population-based Study Journal of Intensive Care Med 200621(3):173-182,机械通气病人医疗消费指数（C P I）增长12%,The Changing Epidemiology of Mechanical Ventilation: A Population-based Study Journal of Intensive Care Med 200621(3):173-182,出院病人回家45.5%下降到34.4%, 回到Nursing Home 从7.3% 增加到 10.7%,Evolution of Mechanical Ventilation in Response to Clinical Research,多中心、前瞻性、队列研究 23个国家，349个ICU 4968名机械通气的病人入选 对107个ICU中1675名病人与1998年1383名病人临床资料进行比较 2004与1998临床使用机械通的变化 Am J Respir Crit Care Med 2008;177:170-177,NPPV NPPV的临床应用 2004明显增加，包括COPD和ARF NPPV的时间增加（2 vs 3 d, p=0.03) 气管插管率和无明显变化。但NPPV成功的病人病死率有下降（20% vs 10%，p=0.08),Evolution of Mechanical Ventilation in Response to Clinical Research,Am J Respir Crit Care Med 2008;177:170-177,Am J Respir Crit Care Med 2008;177:170-177,ARDS机械通气的变化,脱机 共有1649名计划性脱机的患者，拔管前做SBT 1998年58%，2004年62% p=0.09，SBT有增加的趋势 SBT成功后拔管的比列明显增加（62% vs 77% p0.001) T-piece 是最常用SBT（1998年76%，2004年71%，p=0.07) 低水平PS用于SBT有增加的趋势（10 vs 14% p=0.06) 第一次SBT后未能拔管的病人中使用SIMV和SIMV+PS明显减少(11 vs 1.6% p0.001)和(26% vs 15%,p0.001)，使用PSV明显增加（19 vs 55%,p0.001),Evolution of Mechanical Ventilation in Response to Clinical Research,多中心、横断面调查,2003年美国出院的成年患者。机械通气96小时为长期急性机械通气（Prolonged Acute MV,PAMV),31