机械通气的变化.ppt

机械通气的历史与变化EpidemiologyofMV,首都医科大学附属复兴医院席修明,讨论的问题,历史回顾机械通气的流行病学调查循证医学与机械通气的变化总结,人工呼吸器的历史,ArtificialRespirationinPre-Physiology最古老的人工呼吸器的描述来自古埃及神话，Isis用呼吸拯救Osiris的生命圣经-创世纪(Genesis)和国王(Kings)中的描写;,历史回顾-NegativePressureVentilation(IronLung)thatwaswildlyusedduringthepolioepidemics,历史回顾-ThefirstICUintheworld,KommunehospitaletinCopenhagen.Thehospitalwasinauguratedin1863.ThestudentnursesTurnedintotheworldsfirstICUwasonthefirstfloor,ActaAnaesthesiolScand2019;47:1190-1195,历史回顾-ThefirstICUintheworld,BjornIbsen(1915-).InitiatorOfthefirstmultidisciplinaryICUIn1951hereceivedehisspecialistdiplomaInanesthesiology.TheturningPointinhiscareercamewhenHebecameinvolvedinthetreatmentOfthemostseverelyillvictimsOfthe1952poliomyelitisoutbreakInDenmark,ActaAnaesthesiolScand2019;47:1190-1195,Patientno.1December21st,19536.00p.m:A43year-old-manwasadmittedfromthemedicalwardtotheObservationRoom,threedaysafterhehadattemptedtohanghimself.Hewasagitated,confusedandcyanoticwithlabouredrespiration.T38.6C,pulse136.AnX-rayshowedbilateralinfiltratedandoedemaofthelung.OxygenviafacemaskandwhentheSaO2decreased,withpositivepressureventilationfrombagandmask,wasstarted.,历史回顾,ActaAnaesthesiolScand2019;47:1190-1195,December22nd7.15a.m:Theconditionofthepatienthaddeteriorated.Atubewithcuffwaspassedintohistracheaandmanualpositiveventilationwith60%oxygeninN2Owasstarted.00.45p.m:SaO280%,Increasesto86%when100%oxygenwasusedinsteadoftheO2/N2Omixture3.00p.m:ABGpH7.51,pCO231mmHg,SaO2100%.Clinicallythepatientwasmuchimproved.Therespirationwassufficientandhewasextubated.,历史回顾,ActaAnaesthesiolScand2019;47:1190-1195,历史回顾,BjornIbsen第一次使用正压通气治疗呼吸衰竭的医生（InthefirstICUintheworld）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月是机械通气的生日,ActaAnaesthesiolScand2019;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Rogers1972发表的,Chest1972；62：94-97,ImpactoftheRespiratoryIntensiveCareUnitonSurvivalofPatientswithAcuteRespiratoryFailure,持续机械通气患者病死率的比较（1965-1968普通病房vs1969onRICU),Chest1972；62：94-97,ConclusionAdramaticreductioninmortalityfromARFhasbeenachievedwhenthesepatientsweretreatedinaunitwithspeciallytrainedphysicians,nursesandauxiliarypersonnelAvailabilityofaccuratemonitoring,inhalationandphysicaltherapyontheunitInteractionofthephysicians,nursesandtechniciansfromtheunitwithothermembersofhospitalstaffhasraisedthelevelofrespiratorycarefortheentireinstitution,ImpactoftheRespiratoryIntensiveCareUnitonSurvivalofPatientswithAcuteRespiratoryFailure,Chest1972；62：94-97,ModesofMechanicalVentilationandWeaning-ANationalSurveyofSpanishHospital,1992.1Esdeban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,Chest1994;106:1188-1193,ModesofMechanicalVentilationandWeaning-ANationalSurveyofSpanishHospital,Chest1994;106:1188-1193,呼吸机可提供的模式,病人应用的模式,ModesofMechanicalVentilationandWeaning-ANationalSurveyofSpanishHospital,病人机械通气的天数,Chest1994;106:1188-1193,ModesofMechanicalVentilationandWeaning-ANationalSurveyofSpanishHospital,脱机模式与成功率T-piece最好SIMVPSSIMV+PS,Chest1994;106:1188-1193,HowistheMechanicalVentilationEmployedinICU？,2019.11-2019.1Esteban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%）,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？,人工气道的选择（8个国家）,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？,机械通气选择的模式,脱机选择的模式,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？,A/C和PSV时呼吸机参数的设定,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？,PEEP的设定,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？,Insummary:机械通气模式多种多样，90%机械通气病人使用A/CorPSorPS+SIMVVt的选择通常是7-10ml/kgPEEP的选择多为5cmH2OSIMV和某些新的通气模式很少使用（允许性高碳酸症通气，无创通气）脱机的方式多种多样，使用SBT的不多,AmJRespirCritCareMed2000;106:1450-1458,MechanicalVentilationinOntaroio;1992-2000,回顾性，队列调查研究1992-2000Ontario州住院病人资料库150755名非心脏手术病人，接受机械通气CritCareMed2019；32：1504-1509,MechanicalVentilationinOntaroio;1992-2000,92939495969798992000Change%MVPatient15989161081696417303176861801718785196091938820MVper10,0000population20019920720821021121722321712InpatientBedday839479757452713867136239620961586199-26MVdaysPer10,0000Population868278170190392964349551810172410739411157310903026Mortality30day272829303131333332p12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，2019；287：345-355,CharacteristicsandOutcomesinAdultPatientsReceivingMechanicalVentilation-A28-DayinternationalStudy,COPD177:170-177,EvolutionofMechanicalVentilationinResponsetoClinicalResearch,2019vs2019推测发生的变化？,Noninvasivepositive-pressureventilationIncreaseduseofNPPVforCOPDIncreaseduseofNPPVforAcutehypoxemicrespiratoryfailureARDSDecreasedtidalvolumesMinimalincreaseinlevelsofPEEPNochangeintheuseofpressure-controlmodesNochangeintheuseofpronepositionWeaningfrommechanicalventilationIncreaseduseofPSversusT-pieceinspontaneousbreathingtrialsIncreaseduseofspontaneousbreathingtrialstoassessextubationreadinessDecreaseduseofSIMVasamethodforgraduallyreducingventilationsupportIncreaseduseofPSasamethodforgraduallyreducingventilationsupportNosignificantchangeintracheostomyuuseortiming,EvolutionofMechanicalVentilationinResponsetoClinicalResearch,NPPV病人2019与2019的比较,AmJRespirCritCareMed2019;177:170-177,NPPVNPPV的临床应用2019明显增加，包括COPD和ARFNPPV的时间增加（2vs3d,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%vs10%，p=0.08),EvolutionofMechanicalVentilationinResponsetoClinicalResearch,AmJRespirCritCareMed2019;177:170-177,EvolutionofMechanicalVentilationinResponsetoClinicalResearch,ARDS病人的特点2019与2019的比较,AmJRespirCritCareMed2019;177:170-177,ARDSVt的临床使用明显减少（2019年Vt超过10ml/kg7.5vs29.6%.p10cmH2O40%vs20%)Volumeassist-control仍是ARDS患者最常用机械通气模式，每1000个ARDS日，2019年A/C占548天，2019年占504天PCV模式，每1000个ARDS日，2019年占244天，2019年占202天俯卧位通气减少（2019，7%。2019，13%）病死率无变化,EvolutionofMechanicalVentilationinResponsetoClinicalResearch,脱机共有1649名计划性脱机的患者，拔管前做SBT2019年58%，2019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%vs77%p0.001)T-piece是最常用SBT（2019年76%，2019年71%，p=0.07)但低水平PS用于SBT有增加的趋势（10vs14%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(11vs1.6%p0.001)和(26%vs15%,p0.001)，使用PSV明显增加（19vs55%,p96小时为长期急性机械通气（ProlongedAcuteMV,PAMV),按ICD-996.70-96.72CritCareMed2019；36：724-730,ProlongedAcuteMechanicalVentilation,hospitalresourceutilization,andmortalityinUnitedSta