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2019.11.20广州,历史回顾-NegativePressureVentilation(IronLung)thatwaswildlyusedduringthepolioepidemicsin50th,“OnAugust25,1952,IwascalledinasanasthetistforconsultationintheEpidemiologicalHospitalofCopenhagenWithintheprecedingthreeweekstherehadbeen31patientsbulbarpoliomylitistreatedinrespirators-tankaswellascuirass.27haddied.”Fourpatientswereseenintheautopsyroomthatday.Oneofthema12-year-boy-haddiedinarespiratorwithabloodpressureof160andbiocarbonatelevelintheserumfarabovethenormallevel.ThelungdidnotappeartobesufficientlyatelecttictomakeadequateventilationimpossibleShewasa12-year-oldgirlwhoparalysisofallfourextremities.Shehadatelectasisofthelungandwasgaspingforair.Hertemperaturewas40.2C.Shewascyanoticandsweating.Atracheotomywasdone,acuffedendotrachealtubeputin,goodsuction,and100mgPentothal,herownrespirationstoppedandIfoundthatIcouldnowinflateherlung.,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月是正压机械通气的生日,ActaAnaesthesiolScand2019;47:1190-1195,历史回顾-ThefirstICUintheworld,KommunehospitaletinCopenhagen.Thehospitalwasinauguratedin1863.ThestudentnursesTurnedintotheworldsfirstICUwasonthefirstfloor,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,机械通气12小时病人的病死率，ICU建立前（U-PenGeneralHospitalMedicalandSurgicalCareAreas1965.6-1968.8,Chest1972；62：94-97,1969建立RICU后的机械通气病人病死率,Chest1972；62：94-97,成人急性呼吸衰竭机械通气的存活率-1979-1989,JLStaufferChest1993；104：1222-1229,1992.1Esdeban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,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？常用的机械通气模式,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？常用的脱机模式,AmJRespirCritCareMed2000;106:1450-1458,HowistheMechanicalVentilationEmployedinICU？,AmJRespirCritCareMed2000;106:1450-1458,医生最喜欢的模式,HowistheMechanicalVentilationEmployedinICU？常用的脱机模式,AmJRespirCritCareMed2000;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,AmJRespirCritCareMed2000;106:1450-1458,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,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,AmJRespirCritCareMed2019;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)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),31340578出院患者,2.4%onMV,469168(61%)MV96h,294333(39%)PAMV,CritCareMed2019；36：724-730,ProlongedAcuteMechanicalVentilation,hospitalresourceutilization,andmortalityinUnitedStates,CritCareMed2019；36：724-730,ProlongedAcuteMechanicalVentilation,hospitalresourceutilization,andmortalityinUnitedStates,CritCareMed2019；36：724-730,ProlongedAcuteMechanicalVentilation,hospitalresourceutilization