1、新生儿新生儿机械通气机械通气指征指征1、严重呼吸困难、呼吸暂停，治疗（、严重呼吸困难、呼吸暂停，治疗（CPAP）无效）无效2、严重胎粪吸入综合征、气漏等，吸氧不能缓解、严重胎粪吸入综合征、气漏等，吸氧不能缓解3、FiO2 60%时，时，SpO2仍仍 60-70 mmHg,pH 7.20 5、肺出血、心跳呼吸骤停、循环衰竭、肺出血、心跳呼吸骤停、循环衰竭 呼气呼气吸气吸气稳定的稳定的机械通气机械通气不稳定的不稳定的机械通气机械通气非机械通气状态非机械通气状态“Baby Lung”“肺不张损伤肺不张损伤”Recruitment/de-recruitment injuryRDS患者非均匀性的肺泡患者
2、非均匀性的肺泡PIP,PEEP压力不够压力不够CCPCOPIEFRCPV通气不足通气不足,肺不张损伤肺不张损伤,低氧血症低氧血症PVTPIP适当适当,PEEP不够不够CCPCOPIEFRCPV PRECOREX,high delta P,increased surfactant turnoverVT适当的适当的 PIP,适当的适当的 PEEPCOPCCPFRCPVVTP氧合良好氧合良好,FiO2较低较低,肺损伤减少肺损伤减少Normal FRC with optimal lung expansion,good lung complianceLow FRC due to atelectasis
3、Poor lung compliance,hypoxemiaABC容量容量压力压力TLCDANGER!PIP太高太高,PEEP适当适当!PVTFRCEICOPCCP压力压力FRC 2PVVTDelta PFRC 1FRC 2PVVT PFRC 1Volutrauma zone!颅内压升高颅内压升高 静脉回流受阻静脉回流受阻 胸腔内压升高胸腔内压升高 PEEP和和 Paw 太高太高心输出量减少心输出量减少静水压增高静水压增高=水肿水肿,无明显影响；无明显影响；-：无影响：无影响波型波型 流速流速-时间曲线时间曲线 压力压力-时间曲线时间曲线 容量容量-时间曲线时间曲线 图形图形 压力压力-容量环
4、容量环 流速流速-容量环容量环 流速流速-容量环容量环 监测机械通气的参数是否合适监测机械通气的参数是否合适 动态了解患儿肺功能的状态动态了解患儿肺功能的状态 观察患儿自主呼吸动的程度观察患儿自主呼吸动的程度 评价某些药物的治疗效果评价某些药物的治疗效果ExpirationInspiratory Tidal Volume123456SEC1.2-0.4VTLitersAA=exhalation that does not return to zeroInspirationExpirationPaw (cm H2O)时间时间(sec)TIPIPTE12345630SecPawcmH2O-1012
5、345620SecPawcmH2O压力通气压力通气Expiration容量通气容量通气123456SEC120120呼气呼气吸气吸气V.LPMInspirationExpirationFlow(L/min)Time(sec)NormalAbnormalPatients effort适宜的吸气时间适宜的吸气时间500 cc450 ccLost VT123456SEC123456VT600 cc 120120SEC.VLPM0Flow-Volume CurvePressure-Volume Curvecomplianceinversetime constantmenue:measurement1、
6、压力、压力-容量环容量环 Expiration02040602040-600.2LITERS0.40.6PawcmH2OInspirationVT CounterclockwisePreset PIPVT levels肺顺应性肺顺应性IncreasedNormalDecreasedPressure Targeted Ventilation肺过度膨胀肺过度膨胀BA0204060-20-40-600.20.40.6LITERSPawcmH2OCA=inspiratory pressureB=upper inflection pointC=lower inflection pointVTVolume
7、(ml)VT变化很小变化很小Paw risesNormalAbnormalVolume(ml)Air LeakA:Resistive Work B:Elastic WorkPressure(cm H2O)Volume(ml)Higher PTAPEFRFRCInspirationExpirationPIFRVTInspirationExpirationVolume(ml)Air Leak in mLNormalAbnormalFlow-Volume CurvePressure-Volume Curvecomplianceinversetime constantmenue:measurement
8、Flow-Volume Curvecompliancemenue:measurementInspirationExpirationFlow(L/min)NormalAbnormalInspirationExpirationFlow(L/min)Decreased PEFRAbnormal“Scooped out”patternmlHumler,et al,1996*p0.01*Lung VolumePatientsPleural PressureMachineGeneratedPressureLung VolumeSIMV vs.A/C or PSV:呼吸功和潮气量比较呼吸功和潮气量比较CPA
9、P/SIMV (unsupported)A/C or PSVMachineGeneratedPressurePatientsPleural PressureLung Volume SIMV(supported)PatientsPleural PressureMachineGeneratedPressurePEEPpeak flow15%of peak flowExpirationInspirationPIPNo Termination!termination criteria(15%of peak flow)leakage flowOnset of inspirationTermination
10、 criteriaautomatically adaptedto leak flowleakage flowOnset of inspirationOnset ofexpirationTrigger thresholdautomaticallyadapted to leak flowMrozek,et al,Pediatr Pulm,2000*p0.05*mlHumler,et al,1996*p0.01*Hummler,et al,1996mm Hg*p0.05*p0.05Velarde,et al,Crit Care Med,1997Mantzur,et al,Crit Care Med
11、2000Mantzur,et al,Crit Care Med 2000PawP tracheaP musP mus P tubewithout ATCwith ATC8 mbar-8 mbar+8 mbarPawP trachea P tube8 mbarP mus additionalWithout compensationWith compensationPEEPpeak flow15%of peak flowExpirationInspirationPIPNo Termination!termination criteria(15%of peak flow)leakage flowOn
12、set of inspirationTermination criteriaautomatically adaptedto leak flowleakage flowOnset of inspirationOnset ofexpirationTrigger thresholdautomaticallyadapted to leak flow P TubeFlow1020304050607080510152025PS pressurePressure difference betweentube connector and distal tube end of a 7,5 mm tube PS over compensationPS under compensationllow flows-overcompensationhigh flows-undercompensationVTLung mLCRS mL/mbar
