机械通气波形分析

机械通气波形分析VentilatorGraphicsVentilatorGraphicsMechanicalVentilationGraphicsSCALARSLOOPSVentilatorGraphicsSCALARSFlow/TimePressure/TimeVolume/TimeVentilatorGraphicsLOOPSPressure-Volume800-5.0102030401000700600500400300200InspirationExpiration-70-50050Flow-Volume70InspirationPIFRExpirationPEFRVentilatorGraphics波形分析的意义：（一）、增加人机同步性、合理的参数设置（二）、呼吸力学的分析VentilatorGraphics（一）人机同步性–发生率Patient-ventilatorasynchronyduringassistedmechanicalventilationThilleAW,etal,ICM2006Oct:32(10)1515-22VentilatorGraphicsdeWitM,MillerKB,GreenDA,OstmanHE,GenningsC,EpsteinSK(2009)Ineffectivetriggeringpredictsincreaseddurationofmechanicalventilation.CritCareMed37:2740–2745NavaS,BruschiC,FracchiaC,BraschiA,RubiniF(1997)Patient-ventilatorinteractionandinspiratoryeffortduringpressuresupportventilationinpatientswithdifferentpathologies.EurRespirJ10:177–183PurroA,AppendiniL,DeGaetanoA,GudjonsdottirM,DonnerCF,RossiA(2000)Physiologicdeterminantsofventilatordependenceinlong-termmechanicallyventilatedpatients.AmJRespirCritCareMed161:1115–1123（一）人机同步性–发生率值得注意的是，阻塞性肺疾病的患者更容易产生auto-PEEP或者无效触发，因为这些病人需要更长的呼气时间才能呼气完全VentilatorGraphicsThilleAW,RodriguezP,CabelloB,LelloucheF,BrochardL(2006)Patientventilatorasynchronyduringassistedmechanicalventilation.IntensiveCareMed32:1515–1522DeWitM,MillerKB,GreenDA,OstmanHE,GenningsC,EpsteinSK(2009)Ineffectivetriggeringpredictsincreaseddurationofmechanicalventilation.CritCareMed37:2740–2745BosmaK,FerreyraG,AmbrogioC,PaseroD,MirabellaL,BraghiroliA,AppendiniL,MasciaL,RanieriVM(2007)Patient-ventilatorinteractionandsleepinmechanicallyventilatedpatients:pressuresupportversusproportionalassistventilation.CritCareMed35:1048–1054ChaoDC,ScheinhornDJ,Stearn-HassenpflugM(1997)Patientventilatortriggerasynchronyinprolongedmechanicalventilation.Chest112:1592–1599VignauxL,VargasF,RoeselerJ,TassauxD,ThilleAW,KossowskyMP,BrochardL,JollietP(2009)Patientventilatorasynchronyduringnoninvasiveventilationforacuterespiratoryfailure:amulticenterstudy.IntensiveCareMed35:840–846DimitrisGeorgopoulos;Editorial:Ineffectiveeffortsduringmechanicalventilation:thebrainwants,themachinedeclines;IntensiveCareMed(2012)38:738–740DOI10.1007/s00134-012-2497-0KondiliE,PrinianakisG,GeorgopoulosD(2003)Patient-ventilatorinteraction.BrJAnaesth91:106–119（一）人机同步性–影响VentilatorGraphics（一）人机同步性–四个过程触发吸气吸呼气切换呼气VentilatorGraphics（一）人机同步性–触发困难流量触发：Trigger设置3L/min11VentilatorGraphicsImagefromdeWitM,MillerKB,GreenDA,OstmanHE,GenningsC,EpsteinSK:Ineffectivetriggeringpredictsincreaseddurationofmechanicalventilation.CritCareMed.2009;37(10):2740-2745.（一）人机同步性–无效触发VentilatorGraphics人机同步性如何？（一）人机同步性–触发延迟VentilatorGraphicsVentilatorGraphics（一）人机同步性–误触发心脏振荡、管路积水、管路漏气、不适当的设定VentilatorGraphicsFlow(L/min)Time(sec)NormalAbnormal患者吸气努力（一）人机同步性–流量限制PVTVentilatorGraphicsVolumePressureFlowcmH2O01234756403530252015105.0流速凹陷（一）人机同步性–流速饥渴VentilatorGraphics（一）人机同步性–提供流量FernandezAJRCCM 1999:159:710VentilatorGraphics（一）人机同步性–压力上升时间压力上升过快压力上升过慢VentilatorGraphicsFlowInteractivityandSynchronyUS0910避免流速波形的“Ringing”(减小斜率/增加上升时间)（一）人机同步性–压力上升时间VentilatorGraphics-800PCVW/OActiveValveSpontaneousEfforts246PCVwithActiveValve12sPCIRCcmH2O40302010010-20SpontaneousEfforts8 10INSP806040200204060.V

LminEXP（一）人机同步性–吸呼气切换GoodVentilatorGraphicsFlow呼气灵敏度相同呼气灵敏度Time（一）人机同步性–吸呼气切换VentilatorGraphicsTargetPressurePEEPTime(s)在典型的25-30%呼气灵敏度设置下出现的切换延迟切换延迟AirwayPressureFlow（一）人机同步性–吸呼气切换VentilatorGraphicsAirwayPressureFlow漏触发漏触发是撤机延迟的常见原因TargetPressurePEEP漏触发23|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人机同步性–吸呼气切换VentilatorGraphicsFlowTime（一）人机同步性–吸呼气切换合适的呼气灵敏度合适的呼气灵敏度VentilatorGraphics低的上升斜率=低的峰流速25%峰流速TimeFlow25|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人机同步性–吸呼气切换VentilatorGraphics123456SEC-120.VL/min增加流速使得吸气时间缩短120（一）人机同步性–吸呼气切换VentilatorGraphicsAirwayPressureTargetPressurePEEPTime(s)Flow27|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人机同步性–吸呼气切换VentilatorGraphicsFlow/TimeFlow-1400123Auto-PEEP4 5 6 7InspirationFlow(L/m)/mVolume(ml)NormalAbnormalExpiration（一）人机同步性–呼气时间VentilatorGraphicsS29|CovidienRespiratoryandMonitoringSolutions|7/7浙/234561VTmL（一）人机同步性–呼气时间Auto-PEEP:呼气支没有回到基线下一次吸气开始于呼气支可能回到基线之前800VentilatorGraphicsS漏气:呼气支没有回到基线下一次吸气在可能回到基线的呼气支之后开始800230|CovidienRespiratoryandMonitoringSolutions|7/7浙/34561VTmL（一）人机同步性–呼气时间VentilatorGraphicsFlow/TimeFlow0.001234 5 6 77cmH2O－内源性PEEP-2cmH2O设定的灵敏度-9cmH2O实际触发值（一）人机同步性–PEEP的指导VentilatorGraphicsFlow呼气（一）人机同步性–PEEP的指导=32|CovidienRespiratoryandMonitoringSolutions|7/7浙/VentilatorGraphicsFlowAuto-PEEP有时患者的自主努力不足以触发呼吸机时，自主努力就成了无效做功.33|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人机同步性–PEEP的指导VentilatorGraphics（一）波形分析--增加人机同步VentilatorGraphicsElastance顺应性volumetransthoracicpressuretransairwaypressuretransrespiratorypressureResistance阻力（二）呼吸力学–力学模型flowCO2O2VentilatorGraphicsFlowxresistance(Volume/compliance)+PEEPA(PAW)（二）呼吸力学–力学方程VentilatorGraphicsPaw (cmH2O)NormalPPlatIncreasedPIP}PIPNormalPPlatFlow/timeFlo.0w01 2 3 4 5 6 7Pre/PostBDincreasingsetVIlooksthesameObstructiveLungDisease/阻塞性肺疾病前PEFR