人工气道之气囊管理

1、人工气道之人工气道之气囊管理气囊管理EICU TitleTitleReferenceReferenceConclusionConclusionManage Manage of of BalloonBalloonPrefacePreface人工气道是保证气道通畅的有效手段，在抢人工气道是保证气道通畅的有效手段，在抢救中发挥极为重要的作用救中发挥极为重要的作用. .建立人工气道，特别是气管插管后，患建立人工气道，特别是气管插管后，患者的吞咽受限，口腔分泌物及胃食道反者的吞咽受限，口腔分泌物及胃食道反流物受气囊阻隔滞留于气囊上方，会形流物受气囊阻隔滞留于气囊上方，会形成气囊上滞留物。成气囊上滞留物。

2、PrefacePreface国内外研究结果显示，气囊上滞留物是呼吸机相关性肺炎（国内外研究结果显示，气囊上滞留物是呼吸机相关性肺炎（ventilator ventilator associated pnemnonia,VAPassociated pnemnonia,VAP）病原的重要来源）病原的重要来源11PrefaceThe management of balloon is The management of balloon is an important part of an important part of artificial airway managementartificial

3、airway management气囊管理是人工气道管理中的一个重要环节你还在用这种方你还在用这种方法管理气囊吗？法管理气囊吗？PrefaceManage of BalloonTypeTypePressurePressureNursingNursing3 31 12 2Manage of BalloonType2淘汰淘汰 顺应性较好顺应性较好椭圆形椭圆形与气管粘膜接与气管粘膜接触面积较大触面积较大囊内压力等于大气压囊内压力等于大气压自动调节气囊的充盈度自动调节气囊的充盈度损伤较小损伤较小High volume low-High volume low-pressure balloonpressu

4、re balloon 高容低压气囊高容低压气囊Low volume high-Low volume high-pressure balloonpressure balloon 低容高压气囊低容高压气囊Constant pressure Constant pressure balloonballoon等压气囊等压气囊Pressure研究结果显示：患者在接受气管插管研究结果显示：患者在接受气管插管前前8d内，气囊压力低于内，气囊压力低于20cmH2O导导致误吸率明显上升，成为发生致误吸率明显上升，成为发生VAP的的独立危险因素独立危险因素【4】Manage of Balloon压力压力理想压力理想

5、压力3保持有效封闭气囊与气管间隙的最小压力保持有效封闭气囊与气管间隙的最小压力, ,又又可防止气囊对粘膜的压迫性损伤。可防止气囊对粘膜的压迫性损伤。Manage of BalloonAir pressure should be keep inAir pressure should be keep in2530cmh2o将人工气道气囊内压力保持在2530cmh2o Chinese Society of Critical Care Chinese Society of Critical Care Medicine(CSCCM)adviseMedicine(CSCCM)advise: :压力压力影响

6、因素影响因素Patients with clinical airbags pressure Patients with clinical airbags pressure fluctuations may be related to intervention fluctuations may be related to intervention 临床患者气囊压力波动可能与干预有关 Sputum suctionSputum suction 吸痰 Swallowing reflex Swallowing reflex 吞咽反射 Position etc. Position etc. 体位等Mana

7、ge of Balloon压力压力影响因素影响因素 有吞咽反射的患者压力明显有吞咽反射的患者压力明显低于无吞咽反射的患者低于无吞咽反射的患者 压力由低到高依次压力由低到高依次为半卧位、平卧位、为半卧位、平卧位、左侧卧位、右侧卧位左侧卧位、右侧卧位Adjust the air Adjust the air pressure pressure a after the fter the sputum suction sputum suction 吸痰后应及时调整囊内压力For the existence of For the existence of swallowing reflex patien

8、ts swallowing reflex patients should be gas injection should be gas injection correction after 4 hours correction after 4 hours 对于存在吞咽反射的患者4小时后应注气校正semireclinisemireclining positionng position半卧位Manage of Balloon吸痰时气囊内吸痰时气囊内的压力升高的压力升高压力压力监测监测Timing 刘亚芳等刘亚芳等44研究表明人工气囊压力研究表明人工气囊压力4 4小时内衰减不明显小时内衰减不明显。赵

9、静。赵静月月55等也认为气囊压力等也认为气囊压力每每隔隔4 4小时应注气校正小时应注气校正1 1次次，以保证在安全范围内。以保证在安全范围内。Manage of BalloonManage of Balloontouch judge method （TJM） 触摸判断法Quantitative aeration method（MOV MLT）定量充气法cuff pressure measurement（CPM）气囊压力表测量压力压力监测监测不能采用根据经验判定充不能采用根据经验判定充气的指触法给予气囊充气气的指触法给予气囊充气(推荐级别推荐级别:C级级)不宜常规采用不宜常规采用MOV给予气给予

10、气囊充气，在无法测量气囊囊充气，在无法测量气囊压的情况下，可临时采用压的情况下，可临时采用(推荐级别推荐级别:E级级)推荐级推荐级别别A级级NursingNursingdeflate the balloondeflate the balloon气囊的放气techknowledge of techknowledge of subglottic secretion clean subglottic secretion clean upup囊上滞留物的清除inflate the ballooninflate the balloon气囊的充气judge the air-leak of the judg

11、e the air-leak of the balloonballoon气囊漏气的判断Manage of Balloon气囊的护理气囊的护理-充气充气 最小闭合容量最小闭合容量 (MOV) 最小漏气技术（最小漏气技术（MLT) 气囊充气后吸气时无气体无气体漏出 气囊充气后吸气时有少量气体有少量气体漏出 1.将听诊器放于气管处,向气囊 内注气直到听不到漏气声 2.抽出0.5ml气体，可闻及少量 2.抽出气体，从0.1ml开始，直到 漏气声 吸气时听到少量漏气声 缓慢注气，直到吸气时听不 到漏气声 Manage of Balloon不推荐不推荐17气囊的放气气囊的放气1 1气囊放气后1h内气囊压力

12、压迫过的黏膜毛细血管血流难以恢复 2 2气囊放气时易导致上方积液流入下呼吸道造成肺部感染或窒息, 且影响有效的机械通气3 3常规定时放、充气使医务人员忽视充气容积或压力的调整, 反而会充气过多压力过高Manage of Balloon181324气囊漏气的判断气囊漏气的判断Air pressure Air pressure is too lowis too low 气囊压力过低The patient cheeks The patient cheeks are muscle tremorare muscle tremor 病人两腮肌肉颤动The neck is heard in The neck

13、 is heard in the throatthe throat颈部听到喉鸣音Ventilator with low Ventilator with low gas flow alarmgas flow alarm 呼吸机低通气量报警Manage of Balloonthreat to life囊上滞留物清除囊上滞留物清除Manage of Balloon使用简易呼吸器清除囊上滞留物使用简易呼吸器清除囊上滞留物头低足高位头低足高位病人吸气末呼气初病人吸气末呼气初给予较大潮气量给予较大潮气量同时放气同时放气再充气再充气气囊周围形成较大的冲力气囊周围形成较大的冲力将其上方的分泌物将其上方的分泌物

14、冲到口咽部，有利冲到口咽部，有利于充分吸净于充分吸净陶兆武等认为陶兆武等认为6对气囊上间断冲洗或持续引流能有效清除滞留物对气囊上间断冲洗或持续引流能有效清除滞留物可冲洗气管导管持续声门下分泌物吸引技术可冲洗气管导管持续声门下分泌物吸引技术Manage of Balloon预防预防VAP发生，应定期清除气囊上滞留物，尤其是气囊放气前（推荐级别：发生，应定期清除气囊上滞留物，尤其是气囊放气前（推荐级别：A级）级）清除气囊上滞留物可采用带声门下吸引的人工气道（推荐级别：清除气囊上滞留物可采用带声门下吸引的人工气道（推荐级别：A级）级）宜进行间断吸引（推荐级别：宜进行间断吸引（推荐级别：D级）级）Cl

15、uster balloon management strategies to prevent VAPCluster balloon management strategies to prevent VAP 集束化气囊管理策略预防vap1 1、Air pressure table monitoring pressureAir pressure table monitoring pressure 专用气囊测压表监测气囊压力2 2、Before the nasogastric monitoring pressureBefore the nasogastric monitoring pressure

16、鼻饲前监测气囊压力3 3、After Sputum aspiration monitoring pressureAfter Sputum aspiration monitoring pressure 吸痰后监测气囊压力4 4、Every 4h monitoring air pressureEvery 4h monitoring air pressure 每4h监测气囊压力5 5、Does not perform balloon deflated regularlyDoes not perform balloon deflated regularly 不执行气囊定时放气EICU annual c

17、ontinuous quality improvement project in 2016EICU annual continuous quality improvement project in 2016 2016年EICU的年度持续质量改进项目Scientific use of Scientific use of air bag pressure air bag pressure gaugegauge科学利用气囊测压表Artificial airway Artificial airway care is a key care is a key factor in the factor in

18、 the success or failure success or failure of the rescueof the rescue人工气道护理的好坏是抢救成功与否的关键因素之一Strengthen theory Strengthen theory and technology and technology training to ensure training to ensure effective effective implementation of implementation of mechanical mechanical ventilationventilation加强理论与技术培训以确保机械通气的有效实施ConclusionConclusion1Frosr SA,Azeem A,Alexandrou E,e