mechanicalventilationofcopd杜斌.ppt

COPD的机械通气 Vt, FiO2, what else?,北京协和医院 杜 斌,COPD患者的肺泡过度充盈,Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004; 350: 2689-97,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(),Time/Tau,吸气相,呼气相,Pressure,时间常数(),PA(t) = (Pplat - PEEP) e-kt e = 2.718 k = 1/ =1/(R x C) V(t) = Vt x e-kt e = 2.718 k = 1/ =1/(R x C),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: DHI,insp,exp,Time,Tidal volume,Trapped gas,Lung Volume,FRC,Obstructed Lungs,Normal Stiff Lungs,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,内源性PEEP过高 肺泡过度膨胀 胸腔内压过高 回心血量减少 休克,机械通气时的PEEPi Vt 10 12 ml/kg, f 12 15 bpm, I:E 1:2 3,DHI和PEEPi的影响因素,DHI和PEEPi的影响因素,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,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 2002; 122: 20962104,COPD: 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 2002; 122: 20962104,COPD: 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 2002; 122: 20962104,COPD: 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 2002; 122: 20962104,COPD: 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 2002; 122: 20962104,COPD: 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 Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104,COPD机械通气策略,降低内源性PEEP的方法 外源性PEEP ? 延长呼气时间 增加吸气流速 缩短吸气末暂停 降低呼吸频率,呼气流速,Palv,PEEP,Flow = P / Raw = (Palv PEEP) / Raw,Flow,PEEP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 2005; 100: 1112-6,Compliance,PEEP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 2005; 100: 1112-6,Compliance P ,Flow ,PEEP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 2005; 100: 1112-6,半径,PEEP,PEEP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 2005; 100: 1112-6,PEEP,半径,流速?,P,流速,PEEP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 2005; 100: 1112-6,PEEP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 2005; 100: 1112-6,PEEP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 2005; 100: 1112-6,半径,PEEP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 2005; 100: 1112-6,半径,Flow ,PEEP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 2005; 100: 1112-6,半径,PEEP,PEEP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 2005; 100: 1112-6,PEEP,半径,流速,P,流速,COPD稳定期患者(n = 9),年龄(yr) 70 7.3 FEV1 (%pred) 30 9.5 FVC (%pred) 53 13.6 RV (%pred) 186 33.1 FEV1/VC (%) 44 11.6 TLC (%pred) 103 8.7 TLCO (%pred) 46 25.4 PaO2 (kPa) 7.4 0.4 PaCO2 (kPa) 7.1 1.1 pH 7.40 0.00,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;57:533-539,COPD稳定期: PEEP,ODonoghue 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 2002;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 降低PEEPi及肌肉活动指标 肺容积显著增加,COPD急性期患者(n = 10),Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,年龄(yr) 64 6 身高(cm) 167 6 体重(kg) 72 21 体重(%pred) 96 27 FiO2 (%) 48 9 Vt (L) 0.74 0.09 PIF (L/s) 0.65 0.12 Tinsp (s) 1.13 0.15 Texp (s) 3.42 0.57 RR (bpm) 13.5 1.5,COPD急性期: PEEP,Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,COPD急性期: PEEP,Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,COPD: PEEP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 2005; 33: 1519-1528,RR 6 bpm,RR 9 bpm,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP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 2005; 33: 1519-1528,COPD: PEEP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 2005; 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 Hyperinflation,Time,Tidal volume,Trapped gas,Lung Volume,FRC,Tidal vol.,Tidal hyper-inflation,Apnea,Tidal Ventilation,COPD: 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 2001; 163: 1365-1370,COPD: 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 2001; 163: 1365-1370,COPD: 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 2001; 163: 1365-1370,16.1 1.0,19.0 1.4,20.8 1.5,7.0 1.3,6.3 1.1,6.4 1.1,2.1 0.2,2.4 0.2,2.3 0.2,COPD: 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 2001; 163: 1365-1370,COPD: 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 2001; 163: 1365-1370,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,PENDELLUFT during the Plateau Phase,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,No PENDELLUFT because of constant flow flow,COPD: 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 2001; 163: 1365-1370,COPD: 缩短吸气时间,机械通气患者常常呼吸频数, 肺过度充盈 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 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 Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,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) Vt RR flow TTOT TI TE TE 0.5 15 60 4.00 0.50 3.50 - 0.5 15 120 4.00 0.25 3.75 0.25 0.5 14