慢性阻塞性肺疾病急性加重患者的机械通气指南1.doc

20072007-05-08 17:58:47 : chronic obstructive pulmonary disease, COPD2002WHOCOPD52020COPD3COPDAECOPDCOPDAECOPDAECOPDAECOPDAECOPD2001ISFDelphi(1)5DelphiAEA1 DelphiA 2IB 1IC IID 1IIIE IVVIII/IIIIVV COPDCOPD12-4mm2mm,COPDdynamic pulmonary hyperinflation, DPH123DPH-DPHintrinsic positive end-expiratory pressure, PEEPi34PEEPiPEEPi526COPDCO2COPD-1,7DPH238AECOPD,7,9,noninvasive positive pressure ventilationNPPVinvasive positive pressure ventilationIPPVNPPV-,IPPV,NPPV-10-13,AECOPD NPPV(full face mask)14NPPVAECOPD15 1. RCT 16-241525-27NPPVAECOPD80-85%NPPV1-6pHPaCO2NPPVAECOPDNPPV93%NPPV67%19NPPVNPPV9NPPVAECOPDNPPVIPPVNPPVNPPV1281 NPPVAECOPD28RCT17-21(7.25pH7.35)25/AECOPDNPPVNPPV/ICU/ICUBardi291NPPV1pH7.35AECOPDPaCO2pHNPPVAECOPDRCTpH7.3522.8% vs 11.3%,p=0.047NPPV7NPPVDPH30,31AECOPDNPPV32,33IPPV32RCT49AECOPDpH 7.200.05, PaCO2 8516 mmHgNPPVIPPVICUICU3464AECOPDpH 7.180.05, PaCO2 10414 mmHgNPPV,IPPV64AECOPDNPPV40IPPVICU3536NPPVICUNPPV25%-63%34-36GCS11APACHE II2930/pH7.25NPPV50%37,NPPV1-2IPPV37153COPD5Kelly-Matthay350%NPPV38IPPV/NPPVAECOPD50%-60%39-41NPPV1NPPVAECOPDA2AECOPDNPPV E3pH7.35PaCO245mmHgAECOPDNPPVC47.25pH7.35 25/AECOPDNPPVA5pH7.25AECOPD1-2hNPPVC6AECOPDNPPVD2. NPPVRCT16-24NPPVNPPV:NPPV NPPV1 NPPVcritical care ventilatorNPPV, 42,NPPV/AECOPDPEEP2443AECOPD14CPAPAECOPD2NPPV44NPPV14/45/(),AECOPDNPPV147NPPVA3CO2AECOPDNPPVplateau valve(port)(whisper swivel)CO246,47CO24648 NPPVSpO2NPPVNPPVNPPVNPPVNPPVPlant218NPPVNPPV14,1549NPPVRCTICU17-2022,23RCT16,21NPPVpH7.3ICU21pH7.3NPPVICUNPPVIPPV148816NPPVNPPV28,29,37NPPV8AECOPDNPPVNPPVE 1 IPPVNPPV,NPPVNPPV()542 434,3,50(4cmH2OCPAP)3 NPPVCPAP/PCV/VCVPAV+PSV+PEEP16-24EPAP24cmH2OIPAP48cmH2O494 ,NPPV 214,49,50 2 NPPVAECOPD SpO2pHPaCO2PaO2 ()SpO2NPPVNPPV1-214SpO2NPPVAECOPDNPPVSpO2/SpO290%14NPPV1-2NPPV28,29,374-6NPPVIPPV14NPPVNPPV,11NPPVNPPVNPPVNPPVNPPVIPPV/NPPV5 1) (25cmH2O)5125cmH2ONPPV2) 3) ,(),;4) 52p(),50,535) NPPV()NPPV6) ():,NPPVNPPV,7) 9AECOPDNPPV2-4D AECOPDNPPVIPPV16-24NPPVNPPVIPPV33 AECOPDPaO250mmHgPaO2/FiO2200 mmHg)? PaCO2pH7.20? 40/8/? NPPV? AECOPDIPPV54-5854AECOPDIPPVICU59-61COPDpercutaneous dilational tracheostomy626310AECOPDD 1. 6465A/CSIMVPSVPAVSIMV+ PSVPSVPSVSIMVPAV662. DPHPEEPiPEEPe1) VTPaw68ml/kg30cmH2O/35-4