COPD机械通气课件.ppt

1、COPD的机械通气的机械通气COPD患者的肺泡过度充盈患者的肺泡过度充盈Sutherland ER,Cherniack RM.Management of Chronic Obstructive Pulmonary Disease.N Engl J Med 2019;350:2689-97时间常数时间常数()=R x C测定肺组织充盈或排空的速度反映肺组织对压力变化的反应速度时间常数时间常数()Time/Tau吸气相吸气相呼气相呼气相Pressure时间常数时间常数()PA(t)=(Pplat-PEEP)e-kte=2.718k=1/=1/(R x C)V(t)=Vt x e-kte=2.718

2、k=1/=1/(R x C)时间常数时间常数()时间常数成人(正常值)2 x 0.10=0.20”术后气管插管成人患者5 x 0.06=0.30”COPD成人患者15 x 0.06=0.90”ARDS成人患者8 x 0.03=0.24”ARDS患儿5 x 0.01=0.05”动态过度充盈动态过度充盈:DHIinspexpTimeTidal volumeTrapped gasLung VolumeFRCObstructed LungsNormal Stiff Lungs机械通气的适应证机械通气的适应证:COPD呼吸肌疲劳且濒临呼吸停止尽管进行充分的保守治疗,PaCO2仍进行性升高劳累和(或)高碳

3、酸血症导致意识状态恶化高浓度吸氧治疗无效的低氧血症痰液清除障碍导致病情恶化呼吸骤停COPD患者的病理生理改变患者的病理生理改变内源性PEEP过高n肺泡过度膨胀n胸腔内压过高 回心血量减少 休克机械通气时的机械通气时的PEEPiVt 10 12 ml/kg,f 12 15 bpm,I:E 1:2 3DHI和和PEEPi的影响因素的影响因素DHI和和PEEPi的影响因素的影响因素机械通气参数的设置机械通气参数的设置:COPD潮气量吸气流速吸呼比/吸气时间/呼气时间呼吸频率COPD:不同吸气气流的比较不同吸气气流的比较Shieh Ching Yang,MD,FCCP;and Sze Piao Yan

4、g.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较Shieh Ching Yang,MD,FCCP;and Sze Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchan

5、ge,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较Shieh Ching Yang,MD,FCCP;and Sze Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ven

6、tilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较Shieh Ching Yang,MD,FCCP;and Sze Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较Shieh Ching Y

7、ang,MD,FCCP;and Sze Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD:不同吸气气流的比较不同吸气气流的比较结论COPD患者机械通气的最佳吸气气流为减速气流通过选择适宜的吸气气流,有可能改善上述患者的通气Shieh Ching Yang,MD,FCCP;and Sze

8、Piao Yang.Effects of Inspiratory Flow Waveforms on Lung Mechanics,Gas Exchange,and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.Chest 2019;122:20962104COPD机械通气策略机械通气策略降低内源性PEEP的方法n外源性PEEP?n延长呼气时间u增加吸气流速u缩短吸气末暂停u降低呼吸频率呼气流速呼气流速PalvPEEPFlow=P/Raw=(Palv PEEP)/RawFlowPEEP与呼气流速与呼气

9、流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6CompliancePEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual

10、 Hyperinflation.Anesth Analg 2019;100:1112-6Compliance P Flow PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径PEEPPEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Posi

11、tive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6PEEP半径半径流速流速?P 流速流速 PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;1

12、00:1112-6PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow Du

13、ring Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径 Flow PEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Posit

14、ive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6半径半径 PEEPPEEP与呼气流速与呼气流速Savian C,Chan P,Paratz J.The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation.Anesth Analg 2019;100:1112-6PEE

15、P半径半径 流速流速 P 流速流速 COPD稳定期患者稳定期患者(n=9)年龄(yr)70 7.3FEV1(%pred)30 9.5FVC(%pred)53 13.6RV(%pred)186 33.1FEV1/VC(%)44 11.6TLC(%pred)103 8.7TLCO(%pred)46 25.4PaO2(kPa)7.4 0.4PaCO2(kPa)7.1 1.1pH7.40 0.00ODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory e

16、ffort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan

17、AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.T

18、horax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on int

19、rinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539COPD稳定期稳定期:PEEPODonoghue

20、 FJ,Catcheside PG,Jordan AS,Bersten AD,McEvoy RD.Effect of CPAP on intrinsic PEEP,inspiratory effort,and lung volume in severe stable COPD.Thorax 2019;57:533-539总结对于处于稳定期的严重COPD患者,应用高水平的CPAP能够n降低PEEPi及肌肉活动指标n肺容积显著增加COPD急性期患者急性期患者(n=10)Gurin C,Fournier G,Milic-Emili J.Effects of PEEP on inspiratory r

21、esistance in mechanically ventilated COPD patients.Eur Respir J 2019;18:491-498年龄(yr)64 6身高(cm)167 6体重(kg)72 21体重(%pred)96 27FiO2(%)48 9Vt(L)0.74 0.09PIF(L/s)0.65 0.12Tinsp(s)1.13 0.15Texp(s)3.42 0.57RR(bpm)13.5 1.5COPD急性期急性期:PEEPGurin C,Fournier G,Milic-Emili J.Effects of PEEP on inspiratory resist

22、ance in mechanically ventilated COPD patients.Eur Respir J 2019;18:491-498COPD急性期急性期:PEEPGurin C,Fournier G,Milic-Emili J.Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients.Eur Respir J 2019;18:491-498COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalh

23、o CR,Kacmarek RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528RR 6 bpmRR 9 bpmCOPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek

24、 RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco IT,Ama

25、to MBP.Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses

26、to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses to positive end-expiratory pr

27、essure in patients with airway obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses to positive end-expiratory pressure in patients with airwa

28、y obstruction during controlled ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controll

29、ed ventilation Crit Care Med 2019;33:1519-1528COPD:PEEP与呼气流速与呼气流速Caramez MP,Borges JB,Tucci MR,Okamoto VN,Carvalho CR,Kacmarek RM,Malhotra A,Velasco IT,Amato MBP.Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med

30、2019;33:1519-1528结论对于部分气道梗阻的患者而言,应用控制通气过程中,设置外源性PEEP能够缓解过度充盈基础疾病,机械力学指标或呼吸机设置均无法预测上述结果逐渐增加PEEP并观察平台压力改变,是减少副作用的合理方法Assessment of Pulmonary HyperinflationTimeTidal volumeTrapped gasLung VolumeFRCTidal vol.Tidal hyper-inflationApneaTidal VentilationCOPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Eff

31、ect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370Tinsp RR Texp PEEPi COPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Respiratory Frequency

32、 and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370COPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease

33、.Am J Respir Crit Care Med 2019;163:1365-137016.1 1.019.0 1.420.8 1.57.0 1.36.3 1.16.4 1.12.1 0.22.4 0.22.3 0.2COPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Re

34、spir Crit Care Med 2019;163:1365-1370COPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370为何需要设置吸气末暂停为何需要设置吸气末暂停PressureFlowPea

35、kPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduring thePlateau Phase为何需要设置吸气末暂停为何需要设置吸气末暂停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNo PENDELLUFTbecause of constant flow flowCOPD:缩短吸气时间缩短吸气时间Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inflation Time on Re

36、spiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370COPD:缩短吸气时间缩短吸气时间机械通气患者常常呼吸频数,肺过度充盈n提高吸气流速,可以缩短吸气时间,尽管呼吸频率加快,但能够延长呼气时间,降低呼吸做功n延长吸气暂停能够降低呼吸频率,却引发肺过度充盈,呼吸做功增加Laghi F,Segal J,Choe WK,Tobin MJ.Effect of Imposed Inf

37、lation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med 2019;163:1365-1370严重气流梗阻患者的处理严重气流梗阻患者的处理增加流量不能显著延长呼气时间(TE)VtRRflowTTOTTITETE0.515 604.000.503.50-0.5151204.000.253.750.250.514 604.300.503.800.300.512 605.000.504.

38、501.00提示降低分钟通气量对于减少内源性PEEP的重要作用延长呼气时间治疗哮喘持续状态延长呼气时间治疗哮喘持续状态目的:评价哮喘持续状态患者降低呼吸频率对动态过度充盈(DHI)的影响n气道平台压患者:12名因严重哮喘接受机械通气患者设置:定容通气,潮气量613 100 mL,吸气流速 79 4 L/min,分钟通气量约10 L/min干预:呼吸频率18 12 6 bpmLeatherman JW,McArthur C,Shapiro RS.Effect of prolongation of expiratory time on dynamic hyperinflation in mecha

39、nically ventilated patients with severe asthma.Crit Care Med 2019 Jul;32(7):1542-5.延长呼气时间治疗哮喘持续状态延长呼气时间治疗哮喘持续状态Leatherman JW,McArthur C,Shapiro RS.Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma.Crit Care Med 2019 Jul;32(7):1

40、542-5.病例病例NYH,F/82,C822978,入院日2019/12/31胸闷,憋气3天,神志障碍30分钟PMHx:COPD入院时nHR 50,BP 78/43nABG(1617 hrs):7.034/148/53.8/37.7病例病例处理n气管插管,机械通气n镇静肌松u安定5 mg/hr+吗啡2 mg/hruScolinen多巴胺5 g/kg/minuBP 120/58病例病例呼吸模式:VCV参数设置:nVt 400 mlnRR 16 bpmnFiO2 0.40nZEEPPEEPi的测定的测定Flow(l/s)Pao(cmH2O)occlusionPEEPi=103.75 sec病例病例3呼吸模式:VCV参数设置:nVt 400 mlnRR 16 bpm 10 bpmnFiO2 0.40nZEEPMV=4 lpm能否降低PEEPi能否降低PaCO2PEEPi的测定的测定Flow(l/s)Pao(cmH2O)occlusionPEEPi=56 sec病例病例病例病例生命体征HR60BP106/53n停用多巴胺SpO296%COPD患者的机械通气患者的机械通气:总结总结内源性PEEP过高是COPD机械通气的主要原因降低内源性PEEP的方法n外源性PEEP效果不肯定n通过提高吸气流速延长呼气时间效果甚微n尽量缩短吸气末暂停n降低呼吸频率效果明确谢谢谢谢