机械通气的变化课件

1、机械通气的变化机械通气的变化 讨论的问题 ?历史回顾 ?机械通气的流行病学调查 ?循证医学与机械通气的变化 ?总结 人工呼吸器的历史人工呼吸器的历史 ?Artificial Respiration in Pre-Physiology ?最古老的人工呼吸器的描述来自古埃及神话，Isis 用呼吸拯救Osiris 的生命 ?圣经-创世纪(Genesis) 和国王(Kings) 中的描写; 历史回顾历史回顾-Negative Pressure Ventilation (Iron Lung) that was wildly used during the polio epidemics 历史回顾-The

2、 first ICU in the world Kommunehospitalet in Copenhagen. The hospital was inaugurated in 1863. The student nurses Turned into the worlds first ICU was on the first floor Acta Anaesthesiol Scand 2003;47:1190-1195 历史回顾-The first ICU in the world Bjorn Ibsen (1915-). Initiator Of the first multidiscipl

3、inary ICU In 1951 he receivede his specialist diploma In anesthesiology. The turning Point in his career came when He became involved in the treatment Of the most severely ill victims Of the 1952 poliomyelitis outbreak In Denmark Acta Anaesthesiol Scand 2003;47:1190-1195 ?Patient no. 1 December 21st

4、,1953 6.00 p.m: A 43 year-old-man was admitted from the medical ward to the Observation Room, three days after he had attempted to hang himself. He was agitated, confused and cyanotic with laboured respiration. T 38.6C, pulse 136. An X-ray showed bilateral infiltrated and oedema of the lung. Oxygen

5、via facemask and when the SaO2 decreased, with positive pressure ventilation from bag and mask, was started. 历史回顾历史回顾 Acta Anaesthesiol Scand 2003;47:1190-1195 ?December 22 nd 7.15 a.m: The condition of the patient had deteriorated. A tube with cuff was passed into his trachea and manual positive ve

6、ntilation with 60% oxygen in N2O was started. 00.45 p.m: SaO2 80%, Increases to 86% when 100% oxygen was used instead of the O2/N2O mixture 3.00 p.m: ABG pH 7.51, pCO2 31mmHg, SaO2100%. Clinically the patient was much improved. The respiration was sufficient and he was extubated. 历史回顾 Acta Anaesthes

7、iol Scand 2003;47:1190-1195 历史回顾 ?Bjorn Ibsen第一次使用正压通气治疗呼吸衰 竭的医生 （In the first ICU in the world ） ?这项新技术的应用使脊髓灰质炎的病死率从 1952.7 的87% 下降到1953.3 的15% ?因此1953 年3月是机械通气的生日 Acta Anaesthesiol Scand 2003;47:1190-1195 历史回顾 机械通的流行病学机械通的流行病学 第一个机械通气流行病学的报告是Rogers 1972 发表的 Chest 1972 ；62：94-97 Impact of the Resp

8、iratory Intensive Care Unit on Survival of Patients with Acute Respiratory Failure 持续机械通气患者病死率的比较（1965-1968 普通病房 vs 1969 on RICU) Chest 1972 ；62：94-97 Conclusion 1.A dramatic reduction in mortality from ARF has been achieved when these patients were treated in a unit with specially trained physician

9、s, nurses and auxiliary personnel 2.Availability of accurate monitoring, inhalation and physical therapy on the unit 3.Interaction of the physicians, nurses and technicians from the unit with other members of hospital staff has raised the level of respiratory care for the entire institution Impact o

10、f the Respiratory Intensive Care Unit on Survival of Patients with Acute Respiratory Failure Chest 1972；62：94-97 Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital ?1992.1 Esdeban 对西班牙47个ICU 机械通气模式和脱机方法 进行了调查，290 名病人机械通气时间大于24小时 Chest 1994;106:1188-1193 Modes of Mech

11、anical Ventilation and Weaning - A National Survey of Spanish Hospital Chest 1994;106:1188-1193 呼吸机可提供的模式 病人应用的模式 Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital 病人机械通气的天数 Chest 1994;106:1188-1193 Modes of Mechanical Ventilation and Weaning - A National Survey of

12、Spanish Hospital 脱机模式与成功率 T-piece 最好 SIMV PS SIMV+PS Chest 1994;106:1188-1193 How is the Mechanical Ventilation Employed in ICU ？ ?1996.11-1997.1 Esteban 主持8个国家412 个ICU 参加的机 械通气流行病学调查 ?共有4153 住ICU 病人，其中1638 名机械通气（39% ） Am J Respir Crit Care Med 2000;106:1450-1458 How is the Mechanical Ventilation Em

13、ployed in ICU ？ 人工气道的选择（8个国家） Am J Respir Crit Care Med 2000;106:1450-1458 How is the Mechanical Ventilation Employed in ICU ？ 机械通气选择的模式 脱机选择的模式脱机选择的模式 Am J Respir Crit Care Med 2000;106:1450-1458 How is the Mechanical Ventilation Employed in ICU ？ A/C 和 PSV 时呼吸机参数的设定 Am J Respir Crit Care Med 2000;

14、106:1450-1458 How is the Mechanical Ventilation Employed in ICU ？ PEEP 的设定 Am J Respir Crit Care Med 2000;106:1450-1458 How is the Mechanical Ventilation Employed in ICU ？ ?In summary: 1.机械通气模式多种多样，90% 机械通气病人使用 A/C or PS or PS+SIMV 2.Vt 的选择通常是7-10ml/kg 3.PEEP 的选择多为5cmH2O 4.SIMV 和某些新的通气模式很少使用（ 允许性高碳

15、酸症通气，无创通气） 5.脱机的方式多种多样，使用SBT 的不多 Am J Respir Crit Care Med 2000;106:1450-1458 Mechanical Ventilation in Ontaroio; 1992-2000 ?回顾性，队列调查研究 ?1992-2000 Ontario 州住院病人资料库 ?150755 名非心脏手术病人，接受机械通气 Crit Care Med 2004；32 ：1504-1509 Mechanical Ventilation in Ontaroio; 1992-2000 92 93 94 95 96 97 98 99 2000 Chan

16、ge % MV Patient 15989 16108 16964 17303 17686 18017 18785 19609 19388 20 MV per 10,0000 population 200 199 207 208 210 211 217 223 217 12 Inpatient Bed day 8394 7975 7452 7138 6713 6239 6209 6158 6199 -26 MV days Per 10,0000 Population 86827 81701 90392 96434 95518 101724 107394 111573 109030 26 Mor

17、tality 30 day 27 28 29 30 31 31 33 33 32 p12 小 时，观察28天 ?平均机械通气时间5.9天 ?平均ICU 住院11.2 天 JAMA ，2002 ；287 ：345-355 Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study COPD 177:170-177 Evolution of Mechanical Ventilation in Response to Clinical Rese

18、arch 2004 vs 1998 推测发生的变化 ？ Noninvasive positive-pressure ventilation ? Increased use of NPPV for COPD ? Increased use of NPPV for Acute hypoxemic respiratory failure ARDS ?Decreased tidal volumes ?Minimal increase in levels of PEEP ?No change in the use of pressure-control modes ?No change in the u

19、se of prone position Weaning from mechanical ventilation ?Increased use of PS versus T-piece in spontaneous breathing trials ?Increased use of spontaneous breathing trials to assess extubation readiness ?Decreased use of SIMV as a method for gradually reducing ventilation support ?Increased use of P

20、S as a method for gradually reducing ventilation support ?No significant change in tracheostomy uuse or timing Evolution of Mechanical Ventilation in Response to Clinical Research NPPV 病人 2004 与1998 的比较 Am J Respir Crit Care Med 2008;177:170-177 ?NPPV 1.NPPV 的临床应用 2004 明显增加，包括COPD 和 ARF 2.NPPV 的时间增加

21、（2 vs 3 d, p=0.03) 3.气管插管率和无明显变化。但NPPV 成功的病人病 死率有下降（20% vs 10%，p=0.08) Evolution of Mechanical Ventilation in Response to Clinical Research Am J Respir Crit Care Med 2008;177:170-177 Evolution of Mechanical Ventilation in Response to Clinical Research ARDS 病人的特点 2004 与1998 的比较 Am J Respir Crit Care

22、Med 2008;177:170-177 ?ARDS 1.Vt的临床使用明显减少（2004 年Vt超过10ml/kg 7.5 vs29.6%.p0.001, 小于6ml/kg 增加 19.6 vs4.4%， p10cmH2O 40% vs 20%) 4.Volume assist-control 仍是ARDS 患者最常用机械通气模 式，每1000 个ARDS 日，1998 年A/C 占548 天，2004 年 占504 天 5.PCV 模式，每1000 个ARDS 日，1998 年占244 天，2004 年 占202 天 6.俯卧位通气减少（2004 ，7% 。1998 ，13% ） 7.病死

23、率无变化 Evolution of Mechanical Ventilation in Response to Clinical Research ?脱机 1.共有1649 名计划性脱机的患者，拔管前做SBT 1998 年 58% ，2004 年62% p=0.09，SBT 有增加的趋势 2.SBT 成功后拔管的比列明显增加（62% vs 77% p0.001) 3.T-piece 是最常用SBT （1998 年76% ，2004 年71% ， p=0.07) 4.但低水平PS用于SBT 有增加的趋势（10 vs 14% p=0.06) 5.第一次SBT 后未能拔管的病人中使用SIMV 和SIMV+PS 明显 减少(11 vs 1.6% p0.001)和(26% vs 15%,p0.001) ， 使用PSV 明显增加（19 vs 55%,p96 小时为长期急性机械通气（ Prolonged Acute MV,PAMV), 按ICD-9 96.70-96.72 Crit Care Med 2008；36：724-730 Prolonged Acute M