新生儿常见肺部疾病辅助通气策略 .ppt

新生儿常见肺部疾病辅助通气策略,1,.,常频通气的基本模式新生儿常见肺部疾病(TDS,MAS,PPHN,BPD,APNEA)常频通气新策略,内容,2,.,常频通气的基本模式,ASIMVPSVPRVC,CPAPbiPAP,C,3,.,常频通气呼吸机,4,.,常频通气的基本模式,定压,定容,定容限压,SIMV+VG,PRVC,-FiO2-Rate-PIP-PEEP-It,-FiO2-Rate-TV-PEEP-It,恒流病人触发,5,.,A/触发（Trigger）:E-IPatient(assisted)Time(controlled)B/限制（Limit）:IVolumePressureC/切换（Cycle）:I-EVolumeTime,A,B,C,常频通气的基本模式,6,.,常频通气标准,NeonatalVentilation,2003,7,.,新生儿常见肺部疾病辅助通气新策略,8,.,新生儿呼吸窘迫综合征,9,.,HackM.AmJObstetGynecol1995;172(2pt1):457-64,发生率,10,.,里程碑,产前应用激素,肺表面活性物质,死亡率40%气胸30-65%,11,.,预防性应用PS及nCPAP,Meta-analysisofeightrandomizedtrialscomparingprophylacticandrescuetreatmentwithsurfactant.Numbersinparenthesesfollowingtheoutcomesarethenumbersoftrialsinwhichthatoutcomewasreported.(FromSoilRF,MorleyCJ:Prophylacticversusselectiveuseofsurfactantforpreventingmorbidityandmortalityinpreterminfants.In:TheCochraneLibrary,Issue2,2001.Oxford),12,.,Figure20-7.Meta-analysisoffourrandomizedtrialscomparingearlyanddelayedadministrationofsurfactant.(FromYostCC,SoilRF:Earlyversusdelayedselectivesurfactanttreatmentforneonatalrespiratorydistresssyndrome.In:TheCochraneLibrary,Issue2,2001.Oxford),预防性应用PS及nCPAP,13,.,RDS常频通气新策略,肺保护,低氧浓度,小潮气量,低PIP,允许性高碳酸血症,封闭式吸痰,俯卧位,14,.,RDS常频通气新策略,轻度允许性高碳酸血症PCO2:45-55,PCO255危害,且维持PH7.20-7.25,高CO2脑血流量IVH低PHPS形成肺血管阻力心肌收缩膈肌运动,BPDPVL,15,.,允许性高碳酸血症,WoodgatePG.CochraneLibrary.2001(2).,与常规通气策略相比，未发现足够的证据证明允许性高碳酸血症策略有足够的优势,建议：慎用PaCO255mmHg,16,.,RDS常频通气新策略,GentleVentilation,最适PIP10-20,高频率60bpm,PEEP4-5,吸气时间0.3-0.4,小潮气量4-6ml/kg,保证足够的分钟通气量,减少容量损伤,开放肺保障FRC,减少气漏PS后降至0.3,减少压力损伤,17,.,CO2,CO2,CO2,CO2,CO2,HFOV,HFJV,高频通气,高频通气与早产儿RDS,18,.,结果差别较大,高频通气与早产儿RDS,高频通气优势,高频率(600-800次/分)小潮气量(deadspace),动物试验,人类试验,减少肺损伤,19,.,对象：RDS早产儿（GA:24-29w）例数：273结果：需要2剂以上的PS的患儿减少（30%vs62%）严重颅内出血率明显增加（24%vs14%）存活者28天用氧率无差别气漏发生率无差别,高频通气与早产儿RDS,MorietteG.Pediatrics.2001;107:363372-1,20,.,高频通气与早产儿RDS,RDS早产儿（wt:601-1200g）,500,严重IVH和PVL发生率无差别校正胎龄36周时需要用氧的比例(44%vs.53%,p=0.046）,CourtneyHE.NEnglJMed2002;347:643-52.,797,RDS早产儿（GA:23-28w）,肺部疾病发生率无差别死亡率均为10%，无差别对严重脑损伤和气漏无差别,JohnsonAH.NEnglJMed2002;347:633-642,对象,例数,结果,出处,21,.,高频通气与早产儿RDS,Henderson-SmartDJ,Electivehighfrequencyoscillatoryventilationversusconventionalventilationforacutepulmonarydysfunctioninpreterminfants.CochraneDatabaseSystRev.2007Jul18;(3):CD000104.,对象：早产儿例数：3,585结果：ThereisnoclearevidencethatelectiveHFOVoffersimportantadvantagesoverCVwhenusedastheinitialventilationstrategytotreatpreterminfantswithacutepulmonarydysfunction.TheremaybeasmallreductionintherateofCLDwithHFOVuse,buttheevidenceisweakened,22,.,激素在拔管中的应用,DavisPG.CochraneLibrary.2004（4）,减少气管内再插管的可能，在喉头水肿发生率不高时作用不明显,高血糖和尿糖阳性,仅限有高度发生气道水肿和阻塞危险者,建议,23,.,胎粪吸入综合征,24,.,治疗进展,25,.,并未显著降低死亡率延长了氧疗时间机械通气时间无降低气漏发生率无降低长期预后结果未见报道,激素,WardM.CochraneDatabaseSystRev.2003;(4):CD003485,2003年系统综述（1966-2003）,26,.,方式：常用HFOV和HF目的：减少气压伤证据：前瞻性RCT目前仍较少,高频通气,27,.,2002年美国9家医院所作的RCT制剂：稀释的肺表面活性物质（surfaxin）对象：中度MAS（15OI2天,iNO,HFO,高频通气可能减轻气压伤Henderson-Smartetal,2004,34,.,起始量10ppm，如果病情严重，可以5ppm的速度增至20ppm临床显效时，可考虑减量吸入NO的浓度尽可能的低，在5ppm左右，减量到低于该浓度时，一定要微降,PPHN与NO,35,.,维持恒定血压早产儿平均动脉压应35mmHg,足月儿40-45mmHg扩容补充新鲜冰冻血浆/血小板红细胞压积应在50-60正性肌力药物-多巴酚丁胺+/-多巴胺,CentralSouthCoastNeonatalNetwork,2006,England,PPHN,36,.,支气管肺发育不良,37,.,BPD常频通气新策略,NewBPD,38,.,BPD常频通气新策略,39,.,BPD的分级,40,.,预防早产产前应用激素早期应用CPAP表面活性物质积极处理PDAVitA可容许的高碳酸血症生后激素抗氧化剂支气管扩张剂利尿剂,BPD的防治,41,.,早产儿反复呼吸暂停,42,.,CPAP与Apnea,早产儿呼吸暂停分类：中枢性（central）阻塞性（obstructive）混合性（mixed）除外：贫血,感染,低氧,代谢因素,中枢神经系统异常治疗：茶碱或咖啡因和/或CPAP机理：减轻呼吸道梗阻,43,.,主机正压发生器,CPAPTheInfantFlowSystem,44,.,TheInfantFlowSystem,45,.,TheInfantFlowSystem,46,.,High-flownasalcannulae(flows1to2.5L/min)alsogeneratepositivedistendingpressureandmaybeaseffectiveasCPAPforapnea.,SreenanC,High-flownasalcannulaeinthemanagementofapneaofprematurity:Acomparisonwithconventionalnasalcontinuouspositiveairwaypressure.Pediatrics107:1081-1083,2001.,其他通气方法与Apnea,47,.,DavisPG,Nasalintermittentpositivepressureventilation(NIPPV)versusnasalcontinuouspositiveairwaypressure(NCPAP)forpretermneonatesafterextubation(CochraneReview).CochraneDatabaseSystRev3:CD003212,2001.,InfantswithpersistentapneaonCPAPcanbegivenatrialofnasalintermittentpositive-pressureventilation(CPAP+IMVorNIPPV),althoughmorestudiesarerequiredtoevaluatethebenefitsandrisksofthistechniqueininfantswithrefrac