呼吸衰竭诊断指标及救治措施高建苑

呼吸衰竭诊断指标及救治措施高建苑第1页/共121页高建苑现任第四军医大学西京医院主任医师、教授，为中华实用医药杂志编委、中华现代影像学杂志常务编辑、中华综合临床杂志编委会副主任委员和美国现代中医学编委，美国theADAProfessionalSection会员，中华内分泌学会陕西分会委员,中华医学会陕西疗养保健分会副主任委员，陕西省老年医学专业委员副会长。

临床特点：老年顽固性心衰、严重肺部感染、高血压危象、糖尿病高渗性昏迷等有比较丰富的经验。糖尿病患者快速强化治疗，高血压、糖尿病、冠心病、高脂血症、痛风等生活方式干预治疗，协助心脏内科（PTCA、RFCA）。临床研究方向：老年和特殊人群糖尿病防治。曾参加过新加坡和墨西哥总统的保健工作。接待外国患者就诊和住院治疗。能进行英语单语教学和担任国际会议专业英语的现场翻译，善于演讲专业知识。第2页/共121页第3页/共121页第4页/共121页第5页/共121页第6页/共121页

第一作发表SCI文章二篇，最高影响因子5.387；核心和源期刊上者论文60多篇。主编临床专著：《临床常见内科疾病的点评》

《ClinicalPracticeinDiabetes》《现代临床糖尿病学》副主编《实用临床急危重症诊断与处理》，《临床呼吸内科学》，《现代内分泌疾病诊疗学》，《实用临床急危重症诊断与处理》，《现代临床内科学》。主持糖尿病的治疗研究省部级基金5项，主编的《ClinicalPracticeinDiabetes》获2009年度中国西部科技图书一等奖。第7页/共121页RespiratoryFailure–2TypesHypoxemicRespiratoryFailureHypercapnicRespiratoryFailure第8页/共121页HypoxemicRespiratory

FailurePaO2<60mmHginanotherwisehealthyindividual第9页/共121页HypercapnicRespiratory

FailurePaCO2>50mmHginanotherwisehealthyindividualAKA“VentilatoryFailure”CausedbyincreasedWOB,↓ventilatorydrive,ormusclefatigue第10页/共121页第11页/共121页orofacialmasks第12页/共121页Nasalmasks第13页/共121页fullfacemasks第14页/共121页Nasal

Pillows第15页/共121页Totalfacemask第16页/共121页Helmetmask.第17页/共121页第18页/共121页第19页/共121页第20页/共121页第21页/共121页第22页/共121页第23页/共121页第24页/共121页第25页/共121页第26页/共121页第27页/共121页第28页/共121页第29页/共121页第30页/共121页第31页/共121页第32页/共121页第33页/共121页第34页/共121页第35页/共121页第36页/共121页第37页/共121页第38页/共121页第39页/共121页第40页/共121页第41页/共121页第42页/共121页第43页/共121页第44页/共121页PrinciplesofMechanicalVentilationDavidM.Lieberman,MDAllenS.Ho,MDSurgeryICUServiceStanfordUniversityMedicalCenterSeptember25,2006TheBasics第45页/共121页OriginsofmechanicalventilationNegative-pressureventilators(“ironlungs”)Non-invasiveventilationfirstusedinBostonChildren’sHospitalin1928Usedextensivelyduringpoliooutbreaksin1940s–1950sPositive-pressureventilatorsInvasiveventilationfirstusedatMassachusettsGeneralHospitalin1955NowthemodernstandardofmechanicalventilationTheeraofintensivecaremedicinebeganwithpositive-pressureventilationTheironlungcreatednegativepressureinabdomenaswellasthechest,decreasingcardiacoutput.IronlungpoliowardatRanchoLosAmigosHospitalin1953.第46页/共121页OutlineTheoryVentilationvs.OxygenationPressureCyclingvs.VolumeCyclingModesVentilatorSettingsIndicationstointubateIndicationstoextubateManagementalgorithimFAQs第47页/共121页Principles(1):VentilationThegoalofventilationistofacilitateCO2releaseandmaintainnormalPaCO2Minuteventilation(VE)Totalamountofgasexhaled/min.VE=(RR)x(TV)VEcomprisedof2factorsVA=alveolarventilationVD=deadspaceventilationVD/VT=0.33VEregulatedbybrainstem,respondingtopHandPaCO2VentilationincontextofICUIncreasedCO2productionfever,sepsis,injury,overfeedingIncreasedVDatelectasis,

lunginjury,ARDS,pulmonaryembolismAdjustments:RRandTVV/QMatching.Zone1demonstratesdead-spaceventilation(ventilationwithoutperfusion).Zone2demonstratesnormalperfusion.Zone3demonstratesshunting(perfusionwithoutventilation).第48页/共121页Principles(2):OxygenationTheprimarygoalofoxygenationistomaximizeO2deliverytoblood(PaO2)Alveolar-arterialO2gradient(PAO2–PaO2)EquilibriumbetweenoxygeninbloodandoxygeninalveoliA-agradientmeasuresefficiencyofoxygenationPaO2partiallydependsonventilationbutmoreonV/QmatchingOxygenationincontextofICUV/QmismatchingPatientposition(supine)Airwaypressure,pulmonaryparenchymaldisease,small-airwaydiseaseAdjustments:FiO2andPEEPV/QMatching.Zone1demonstratesdead-spaceventilation(ventilationwithoutperfusion).Zone2demonstratesnormalperfusion.Zone3demonstratesshunting(perfusionwithoutventilation).第49页/共121页Pressureventilationvs.volumeventilationPressure-cycledmodesdeliverafixedpressureatvariablevolume(neonates)Volume-cycledmodesdeliverafixedvolumeatvariablepressure(adults)Pressure-cycledmodesPressureSupportVentilation(PSV)PressureControlVentilation(PCV)CPAPBiPAPVolume-cycledmodesControlAssistAssist/ControlIntermittentMandatoryVentilation(IMV)SynchronousIntermittentMandatoryVentilation(SIMV)Volume-cycledmodeshavetheinherentriskofvolutrauma.第50页/共121页PressureSupportVentilation(PSV)PatientdeterminesRR,VE,inspiratorytime–apurelyspontaneousmodeParametersTriggeredbypt’sownbreathLimitedbypressureAffectsinspirationonlyUsesComplementvolume-cycledmodes(i.e.,SIMV)DoesnotaugmentTVbutovercomesresistancecreatedbyventilatortubingPSValoneUsedaloneforrecoveringintubatedptswhoarenotquitereadyforextubationAugmentsinflationvolumesduringspontaneousbreathsBiPAP(CPAPplusPS)PSVismostoftenusedtogetherwithothervolume-cycledmodes.PSVprovidessufficientpressuretoovercometheresistanceoftheventilatortubing,andactsduringinspirationonly.第51页/共121页PressureControlVentilation(PCV)Ventilatordeterminesinspiratorytime–nopatientparticipationParametersTriggeredbytimeLimitedbypressureAffectsinspirationonlyDisadvantagesRequiresfrequentadjustmentstomaintainadequateVEPtwithnoncompliantlungsmayrequirealterationsininspiratorytimestoachieveadequateTV第52页/共121页CPAPandBiPAPCPAPisessentiallyconstantPEEP;BiPAPisCPAPplusPSParametersCPAP–PEEPsetat5-10cmH2OBiPAP–CPAPwithPressureSupport(5-20cmH2O)ShowntoreduceneedforintubationandmortalityinCOPDptsIndicationsWhenmedicaltherapyfails(tachypnea,hypoxemia,respiratoryacidosis)Useinconjunctionwithbronchodilators,steroids,oral/parenteralsteroids,antibioticstoprevent/delayintubationWeaningprotocolsObstructiveSleepApnea第53页/共121页Assist/ControlModeControlModePtreceivesasetnumberofbreathsandcannotbreathebetweenventilatorbreathsSimilartoPressureControlAssistModePtinitiatesallbreaths,butventilatorcyclesinatinitiationtogiveapresettidalvolumePtcontrolsratebutalwaysreceivesafullmachinebreathAssist/ControlModeAssistmodeunlesspt’srespiratoryratefallsbelowpresetvalueVentilatorthenswitchestocontrolmodeRapidlybreathingptscanoverventilateandinducesevererespiratoryalkalosisandhyperinflation(auto-PEEP)Ventilatordeliversafixedvolume第54页/共121页IMVandSIMV

Volume-cycledmodestypicallyaugmentedwithPressureSupportIMVPtreceivesasetnumberofventilatorbreathsDifferentfromControl:ptcaninitiateown(spontaneous)breathsDifferentfromAssist:spontaneousbreathsarenotsupportedbymachinewithfixedTVVentilatoralwaysdeliversbreath,evenifptexhalingSIMVMostcommonlyusedmodeSpontaneousbreathsandmandatorybreathsIfpthasrespiratorydrive,themandatorybreathsaresynchronizedwiththept’sinspiratoryeffort第55页/共121页Ventsettingstoimprove<oxygenation>FIO2SimplestmaneuvertoquicklyincreasePaO2Long-termtoxicityat>60%FreeradicaldamageInadequateoxygenationdespite100%FiO2usuallyduetopulmonaryshuntingCollapse–AtelectasisPus-filledalveoli–PneumoniaWater/Protein–ARDSWater–CHFBlood-HemorrhagePEEPandFiO2areadjustedintandem第56页/共121页Ventsettingstoimprove<oxygenation>PEEPIncreasesFRCPreventsprogressiveatelectasisandintrapulmonaryshuntingPreventsrepetitiveopening/closing(injury)RecruitscollapsedalveoliandimprovesV/QmatchingResolvesintrapulmonaryshuntingImprovescomplianceEnablesmaintenanceofadequatePaO2atasafeFiO2levelDisadvantagesIncreasesintrathoracicpressure(mayrequirepulmonarya.catheter)MayleadtoARDSRupture:PTX,pulmonaryedemaPEEPandFiO2areadjustedintandemOxygendelivery(DO2),notPaO2,shouldbeusedtoassessoptimalPEEP.第57页/共121页Ventsettingstoimprove<ventilation>RespiratoryrateMaxRRat35breaths/minEfficiencyofventilationdecreaseswithincreasingRRDecreasedtimeforalveolaremptyingTVGoalof10ml/kgRiskofvolutraumaOthermeanstodecreasePaCO2Reducemuscularactivity/seizuresMinimizingexogenouscarbloadControllinghypermetabolicstatesPermissivehypercapneaPreferabletodangerouslyhighRRandTV,aslongaspH>7.15RRandTVareadjustedtomaintainVEandPaCO2I:Eratio(IRV)IncreasinginspirationtimewillincreaseTV,butmayleadtoauto-PEEPPIPElevatedPIPsuggestsneedforswitchfromvolume-cycledtopressure-cycledmodeMaintainedat<45cmH2OtominimizebarotraumaPlateaupressuresPressuremeasuredattheendofinspiratoryphaseMaintainedat<30-35cmH2Otominimizebarotrauma第58页/共121页AlternativeModesI:Einverseratioventilation(IRV)ARDSandseverehypoxemiaProlongedinspiratorytime(3:1)leadstobettergasdistributionwithlowerPIPElevatedpressureimprovesalveolarrecruitmentNostatisticaladvantageoverPEEP,anddoesnotpreventrepetitivecollapseandreinflationPronepositioningAddressesdependentatelectasisImprovedrecruitmentandFRC,reliefofdiaphragmaticpressurefromabdominalviscera,improveddrainageofsecretionsLogisticallydifficultNomortalitybenefitdemonstratedECHMOAirwayPressureRelease(APR)High-FrequencyOscillatoryVentilation(HFOV)High-frequency,lowamplitudeventilationsuperimposedoverelevatedPawAvoidsrepetitivealveolaropenandclosingthatoccurwithlowairwaypressuresAvoidsoverdistensionthatoccursathighairwaypressuresWelltolerated,consistentimprovementsinoxygenation,butunclearmortalitybenefitsDisadvantagesPotentialhemodynamiccompromisePneumothoraxNeuromuscularblockingagents第59页/共121页TreatmentofrespiratoryfailurePreventionIncentivespirometryMobilizationHumidifiedairPaincontrolTurn,cough,deepbreatheTreatmentMedicationsAlbuterolTheophyllineSteroidsCPAP,BiPAP,IPPBIntubationThecriticalperiodbeforethepatientneedstobeintubated第60页/共121页IndicationsforintubationCriteriaClinicaldeterioration Tachypnea:RR>35 Hypoxia:pO2<60mmHg Hypercarbia:pCO2>55mmHgMinuteventilation<10L/min Tidalvolume<5-10ml/kg Negativeinspiratoryforce<25cmH2O(howstrongtheptcansuckin)InitialventsettingsFiO2=50%PEEP=5cmH2ORR=12–15breaths/minVT=10–12ml/kgCOPD=10ml/kg(preventoverinflation)ARDS=8ml/kg(preventvolutrauma)PermissivehypercapneaPressureSupport=10cmH2OHowthevaluestrendshouldsignificantlyimpactclinicaldecisions第61页/共121页IndicationsforextubationClinicalparametersResolution/StabilizationofdiseaseprocessHemodynamicallystableIntactcough/gagreflexSpontaneousrespirationsAcceptableventsettingsFiO2<50%,PEEP<8,PaO2>75,pH>7.25GeneralapproachesSIMVWeaningPressureSupportVentilation(PSV)WeaningSpontaneousbreathingtrialsDemonstratedtobesuperiorNoweaningparametercompletelyaccuratewhenusedaloneNumericalParametersNormalRangeWeaningThresholdP/F>400>200Tidalvolume5-7ml/kg5ml/kgRespiratoryrate14-18breaths/min<40breaths/minVitalcapacity65-75ml/kg10ml/kgMinutevolume5-7L/min<10L/minGreaterPredictiveValueNormalRangeWeaningThresholdNIF(NegativeInspiratoryForce)>-90cmH2O>-25cmH2ORSBI(RapidShallowBreathingIndex)(RR/TV)<50<100MarinoP,TheICUBook(2/e).1998.第62页/共121页SpontaneousBreathingTrialsSettingsPEEP=5,PS=0–5,FiO2<40%Breatheindependentlyfor30–120minABGobtainedatendofSBTFailedSBTCriteriaRR>35for>5minSaO2<90%for>30secHR>140SystolicBP>180or<90mmHgSustainedincreasedworkofbreathingCardiacdysrhythmiapH<7.32SBTsdonotguaranteethatairwayisstableorptcanself-clearsecretionsCausesofFailedSBTsTreatmentsAnxiety/AgitationBenzodiazepinesorhaldolInfectionDiagnosisandtxElectrolyteabnormalities(K+,PO4-)CorrectionPulmonaryedema,cardiacischemiaDiureticsandnitratesDeconditioning,malnutritionAggressivenutritionNeuromusculardiseaseBronchopulmonaryhygiene,earlyconsiderationoftrachIncreasedintra-abdominalpressureSemirecumbentpositioning,NGTHypothyroidismThyroidreplacementExcessiveauto-PEEP(COPD,asthma)BronchodilatortherapySenaetal,ACSSurgery:PrinciplesandPractice(2005).第63页/共121页ContinuedventilationaftersuccessfulSBTCommonlycitedfactorsAlteredmentalstatusandinabilitytoprotectairwayPotentiallydifficultreintubationUnstableinjurytocervicalspineLikelihoodofreturntripstoORNeedforfrequentsuctioningInherentrisksofintubationbalancedagainstcontinuedneedforintubation第64页/共121页NeedfortracheostomyAdvantagesIssueofairwaystabilitycanbeseparatedfromissueofreadinessforextubationMayquickendecisiontoextubateDecreasedworkofbreathingAvoidcontinuedvocalcordinjuryImprovedbronchopulmonaryhygieneImprovedptcommunicationDisadvantagesLongtermriskoftrachealstenosisProcedure-relatedcomplicationrate(4%-36%)Prolongedintubationmayinjureairwayandcauseairwayedema1-Vocalcords.2-Thyroidcartilage.3-Cricoidcartilage.4-Trachealcartilage.5-Ballooncuff.第65页/共121页VentilatormanagementalgorithimInitialintubationFiO2=50% PEEP=5

RR=12–15VT=8–10ml/kgSaO2<90%SaO2>90%SaO2>90%AdjustRRtomaintainPaCO2=40ReduceFiO2<50%astoleratedReducePEEP<8astoleratedAssesscriteriaforSBTdailySaO2<90%IncreaseFiO2(keepSaO2>90%)IncreasePEEPtomax20IdentifypossibleacutelunginjuryIdentifyrespiratoryfailurecausesAcutelunginjuryNoinjuryFailSBTAcutelunginjuryLowTV(lung-protective)settingsReduceTVto6ml/kgIncreaseRRupto35tokeeppH>7.2,PaCO2<50AdjustPEEPtokeepFiO2<60%SaO2<90%SaO2>90%SaO2<90%Dx/Txassociatedconditions(PTX,hemothorax,hydrothorax)Consideradjunctmeasures(pronepositioning,HFOV,IRV)SaO2>90%Continuelung-protectiveventilationuntil:PaO2/FiO2>300CriteriametforSBTPersistentlyfailSBTConsidertracheostomyResumedailySBTswithCPAPortracheostomycollarPassSBTAirwaystableExtubateIntubated>2wksConsiderPSVwean(gradualreductionofpressuresupport)ConsidergradualincreasesinSBTdurationuntilenduranceimprovesProlongedventilatordependencePassSBTPassSBTAirwaystableModifiedfromSenaetal,ACSSurgery:PrinciplesandPractice(2005).第66页/共121页MechanicalVentilation

forNursingMelissaDearing,BS,RRT-NPS,RCPAssociateProfessorofRespiratoryCareCurtisShelley,BS,RRT-NPS,RCPRespiratoryEducator–HermannChildren’sHospital第67页/共121页

Indicationsfor

MechanicalVentilation

AirwayCompromise–airwaypatencyisindoubtorpatientmaybeatriskoflosingpatency第68页/共121页IndicationsforMechanicalVentilationNeedtoProtecttheAirwayForsomereasonthepatient’sabilitytosneeze,gagorcoughhasbeendulledandaspirationispossible.第69页/共121页ContraindicationsforanArtificialAirwayWhenapt’sdesiretonotberesuscitatedhasbeenexpressedandisdocumentedinthept’schart第70页/共121页EstablishinganArtificialAirway

Adultfemale8.0Adultmale9.0第71页/共121页Millervs.MacIntoshBlades

第72页/共121页IntubationProcedureCheckandAssembleEquipment:OxygenflowmeterandO2tubingSuctionapparatusandtubingSuctioncatheteroryankauerAmbubagandmaskLaryngoscopewithassortedblades3sizesofETtubesStyletStethoscopeTapeSyringeMagillforcepsTowelsforpositioning

第73页/共121页IntubationProcedurePositionyourpatientintothesniffingposition

第74页/共121页IntubationProcedurePreoxygenatewith100%oxygentoprovideapneicordistressedpatientwithreservewhileattemptingtointubate.Donotallowmorethan30secondstoanyintubationattempt.Ifintubationisunsuccessful,ventilatewith100%oxygenfor3-5minutesbeforeareattempt.

第75页/共121页IntubationProcedure

InsertLaryngoscope

第76页/共121页IntubationProcedure

第77页/共121页IntubationProcedure

AfterdisplacingtheepiglottisinserttheETT. Thedepthofthetubeforamale patientonaverageis21-23cmatteethThedepthofthetubeonaverageforafemalepatientis19-21atteeth.第78页/共121页IntubationProcedure

Confirmtubeposition:ByauscultationofthechestBilateralchestriseTubelocationatteethCO2detector–(esophagealdetectiondevice)第79页/共121页IntubationProcedure

StabilizetheETT第80页/共121页IntubationProcedure

VideoonIntubation:/watch?v=eRkleyIJi9U&feature=related第81页/共121页MechanicalVentilatorsDifferentTypesofVentilatorsAvailable:Willdependonyouplaceofemployment第82页/共121页MechanicalVentilators第83页/共121页MechanicalVentilators第84页/共121页MechanicalVentilators第85页/共121页MechanicalVentilators第86页/共121页MechanicalVentilators第87页/共121页HighFrequencyMechanicalVentilator第88页/共121页VentilatorSettingsTerminology

A/C:Assist-ControlIMV:IntermittentMandatoryVentilationSIMV:SynchronizedIntermittentMandatoryVentilationBi-level/Biphasic:Non-inversedPressureVentilationwithPressureSupport(consistsof2levelsofpressure)第89页/共121页VentilatorSettingsTerminology(con’t)

PRVC:PressureRegulatedVolumeControlPEEP:PositiveEndExpiratoryPressureCPAP:ContinuousPositiveAirwayPressurePSV:PressureSupportVentilationNIPPV:Non-InvasivePositivePressureVentilation第90页/共121页VOLUMEvs.PRESSUREVENTILATION

Volumeventilation:Volumeisconstantandpressurewillvarywithpatient’slungcompliance.Pressureventilation:Pressureisconstantandvolumewillvarywithpatient’slungcompliance.第91页/共121页

MODESofVENTILATION第92页/共121页ControlMode

Deliverspre-setvolumesatapre-setrateandapre-setflowrate.ThepatientCANNOTgeneratespontaneousbreaths,volumes,orflowratesinthismode.第93页/共121页ControlMode

第94页/共121页Assist/ControlMode

Deliverspre-setvolumesatapre-setrateandapre-setflowrate.ThepatientCANNOTgeneratespontaneousvolumes,orflowratesinthismode.Eachpatientgeneratedrespiratoryeffortoverandabovethesetratearedeliveredatthesetvolumeandflowrate.第95页/共121页

A/Ccont.Negativedeflection,triggeringassistedbreath第96页/共121页Deliversapre-setnumberofbreathsatasetvolumeandflowrate.Allowsthepatienttogeneratespontaneousbreaths,volumes,andflowratesbetweenthesetbreaths.Detectsapatient’sspontaneousbreathattemptanddoesn’tinitiateaventilatorybreath–preventsbreathstackingSYCHRONIZEDINTERMITTENTMANDATORYVENTILATION(SIMV):第97页/共121页SIMVcont.MachineBreathsSpontaneousBreaths第98页/共121页PRESSUREREGULATEDVOLUMECONTROL(PRVC):Thisisavolumetargeted,pressurelimitedmode.(availableinSIMVorAC)Eachbreathisdeliveredatasetvolumewithavariableflowrateandanabsolutepressurelimit.Theventdeliversthispre-setvolumeattheLOWESTrequiredpeakpressureandadjustwitheachbreath.第99页/共121页PRVC第100页/共121页POSITIVEENDEXPIRATORYPRESSURE(PEEP):ThisisNOTaspecificmode,butisratheranadjuncttoanyoftheventmodes.PEEPistheamountofpressureremaininginthelungattheENDoftheexpiratoryphase.Utilizedtokeepotherwisecollapsinglungunitsopenwhilehopefullyalsoimprovingoxygenation.第101页/共121页

PEEPcont.PEEPistheamountofpressureremaininginthelungattheENDoftheexpiratoryphase.Pressureabovezero第102页/共121页DemonstrationofPEEP/watch?v=oKH7CtsEgHw第103页/共121页ContinuousPositiveAirwayPressure(CPAP):ThisISamodeandsimplymeansthatapre-setpressureispresentinthecircuitandlungsthroughoutboththeinspiratoryandexpiratoryphasesofthebreath.CPAPservestokeepalveolifromcollapsing,resultinginbetteroxygenationandlessWOB.TheCPAPmodeisverycommonlyusedasamodetoevaluatethepatientsreadinessforextubation.第104页/共121页HIGHFREQUENCYVENTILATION第105页/共121页ComparisonofHFOV&ConventionalVentilationDifferences CMV HFOVRates 0-150 180-900TidalVolume 4-20ml/kg 0.1-3ml/kgAlveolarPress 0->50cmH2O 0.1-5cmH2OEndExpVolume Low NormalizedGasFlow Low High第106页/共121页OxygenationOxygenationisprimarilycontrolledbytheMeanAirwayPressure(Paw)andth