COPD机械通气.ppt

COPD的机械通气,COPD患者的肺泡过度充盈,SutherlandER,CherniackRM.ManagementofChronicObstructivePulmonaryDisease.NEnglJMed2019;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”,动态过度充盈:DHI,insp,exp,Time,Tidalvolume,Trappedgas,LungVolume,FRC,ObstructedLungs,NormalStiffLungs,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PEEPiVt1012ml/kg,f1215bpm,I:E1:23,DHI和PEEPi的影响因素,DHI和PEEPi的影响因素,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,COPD:不同吸气气流的比较,ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2019;122:20962104,COPD:不同吸气气流的比较,ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2019;122:20962104,COPD:不同吸气气流的比较,ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2019;122:20962104,COPD:不同吸气气流的比较,ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2019;122:20962104,COPD:不同吸气气流的比较,ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2019;122:20962104,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,ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2019;122:20962104,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,Palv,PEEP,Flow=P/Raw=(PalvPEEP)/Raw,Flow,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,Compliance,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,ComplianceP,Flow,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,半径,PEEP,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,PEEP,半径,流速?,P,流速,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,半径,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,半径,Flow,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,半径,PEEP,PEEP与呼气流速,SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2019;100:1112-6,PEEP,半径,流速,P,流速,COPD稳定期患者(n=9),年龄(yr)707.3FEV1(%pred)309.5FVC(%pred)5313.6RV(%pred)18633.1FEV1/VC(%)4411.6TLC(%pred)1038.7TLCO(%pred)4625.4PaO2(kPa)7.40.4PaCO2(kPa)7.11.1pH7.400.00,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;57:533-539,COPD稳定期:PEEP,ODonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2019;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急性期患者(n=10),GurinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2019;18:491-498,年龄(yr)646身高(cm)1676体重(kg)7221体重(%pred)9627FiO2(%)489Vt(L)0.740.09PIF(L/s)0.650.12Tinsp(s)1.130.15Texp(s)3.420.57RR(bpm)13.51.5,COPD急性期:PEEP,GurinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2019;18:491-498,COPD急性期:PEEP,GurinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2019;18:491-498,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,RR6bpm,RR9bpm,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;33:1519-1528,COPD:PEEP与呼气流速,CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2019;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,AssessmentofPulmonaryHyperinflation,Time,Tidalvolume,Trappedgas,LungVolume,FRC,Tidalvol.,Tidalhyper-inflation,Apnea,TidalVentilation,COPD:缩短吸气时间,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;163:1365-1370,COPD:缩短吸气时间,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;163:1365-1370,COPD:缩短吸气时间,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;163:1365-1370,16.11.0,19.01.4,20.81.5,7.01.3,6.31.1,6.41.1,2.10.2,2.40.2,2.30.2,COPD:缩短吸气时间,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;163:1365-1370,COPD:缩短吸气时间,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;163:1365-1370,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,PENDELLUFTduringthePlateauPhase,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,NoPENDELLUFTbecauseofconstantflowflow,COPD:缩短吸气时间,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;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,LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2019;163:1365-1370,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)VtRRflowTTOTTITETE0.515604.000.503.50-0.5151204.000.253.750.250.514604.3