COPD的机械通气培训课件1

COPD的机械通气COPD患者的肺泡过度充盈SutherlandER,CherniackRM.ManagementofChronicObstructivePulmonaryDisease.NEnglJMed2004;350:2689-972COPD的机械通气时间常数()=RxC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3COPD的机械通气时间常数()Time/Tau吸气相呼气相Pressure4COPD的机械通气时间常数()PA(t)=(Pplat-PEEP)e-kte=2.718k=1/=1/(RxC)V(t)=Vtxe-kte=2.718k=1/=1/(RxC)5COPD的机械通气时间常数()时间常数成人(正常值)2x0.10=0.20”术后气管插管成人患者5x0.06=0.30”COPD成人患者15x0.06=0.90”ARDS成人患者8x0.03=0.24”ARDS患儿5x0.01=0.05”Tau呼出气容积残余容积00%100%163%37%395%5%599.9%0.1%6COPD的机械通气动态过度充盈:DHIinspexpTimeTidalvolumeTrappedgasLungVolumeFRCObstructedLungsNormalStiffLungs7COPD的机械通气机械通气的适应证: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8COPD的机械通气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9COPD的机械通气机械通气时的PEEPi

Vt10–12ml/kg,f12–15bpm,I:E1:2–3诊断No.PEEPi(范围)发生率COPD452.6–2245/45(100%)CF1111/1(100%)Asthma313.5–203/3(100%)ARDS281.0–8.115/28(58%)CPE101.0–6.08/10(80%)Other101.0–4.15/10(50%)10COPD的机械通气DHI和PEEPi的影响因素内在因素外部因素呼吸力学附加气流阻力气流阻力气管插管管径过细呼气气流受限呼吸机管路和相关装置呼吸系统顺应性呼吸机设置呼吸方式呼吸频率呼吸频率I:ETi/Ttot潮气量潮气量吸气末暂停11COPD的机械通气DHI和PEEPi的影响因素内在因素外部因素呼吸力学附加气流阻力气流阻力气管插管管径过细呼气气流受限呼吸机管路和相关装置呼吸系统顺应性呼吸机设置呼吸方式呼吸频率呼吸频率I:ETi/Ttot潮气量潮气量吸气末暂停12COPD的机械通气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…13COPD的机械通气COPD:不同吸气气流的比较ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210414COPD的机械通气COPD:不同吸气气流的比较波形(均值SD)呼吸机参数恒定气流1正弦波减速气流恒定气流2Vt,ml56267558655665957172RR,bpm18.21.718.61.418.41.918.51.3MV,lpm10.41.610.31.510.61.610.71.8Ti/Ttot0.290.040.280.030.290.040.280.03平均吸气流速,lpm385377397386ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210415COPD的机械通气COPD:不同吸气气流的比较波形(均值SD)呼吸力学参数恒定气流1正弦波减速气流恒定气流2PIP,cmH2O47.111.547.810.839.59.746.611.0Paw,cmH2O7.64.27.24.88.44.58.43.9Pplat,cmH2O20.29.119.610.618.98.821.410.4Vd/Vt,%58.45.254.56.348.65.557.64.9Cst,ml/cmH2O35.38.935.811.236.69.337.29.7ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210416COPD的机械通气COPD:不同吸气气流的比较波形(均值SD)恒定气流1正弦波减速气流恒定气流2pH7.440.047.440.077.430.067.440.04PaO2/FiO2,mmHg23673231652237022767PaCO2,mmHg451045103794612A-aDO2,mmHg133.136.5136.434.2156.333.7134.435.3HR,bpm106.118.1108.320.2105.318.9109.920.5MAP,mmHg9223881888219019ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210417COPD的机械通气COPD:不同吸气气流的比较波形(均值SD)参数恒定气流1正弦波减速气流恒定气流2WOB,J/L0.920.160.880.180.750.150.920.18Raw,cmH2O/L/s12.63.112.43.611.22.412.53.3VO2,ml/min38453389603774938252VCO2,ml/min27452280472735627655症状评分54.513.458.611.942.712.356.112.8ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210418COPD的机械通气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ShiehChingYang,MD,FCCP;andSzePiaoYang.EffectsofInspiratoryFlowWaveformsonLungMechanics,GasExchange,andRespiratoryMetabolisminCOPDPatientsDuringMechanicalVentilation.Chest2002;122:2096–210419COPD的机械通气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20COPD的机械通气呼气流速PalvPEEPFlow =P/Raw =(Palv–PEEP)/RawFlow21COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6Compliance22COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6CompliancePFlow23COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径PEEP24COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP半径流速?P流速25COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-626COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-627COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径28COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径Flow29COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6半径PEEP30COPD的机械通气PEEP与呼气流速SavianC,ChanP,ParatzJ.TheEffectofPositiveEnd-ExpiratoryPressureLevelonPeakExpiratoryFlowDuringManualHyperinflation.AnesthAnalg2005;100:1112-6PEEP半径流速P流速31COPD的机械通气COPD稳定期患者(n=9)年龄(yr) 707.3FEV1(%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

1.1pH 7.40

0.00O’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53932COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53933COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53934COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53935COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53936COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53937COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;57:533-53938COPD的机械通气COPD稳定期:PEEPO’DonoghueFJ,CatchesidePG,JordanAS,BerstenAD,McEvoyRD.EffectofCPAPonintrinsicPEEP,inspiratoryeffort,andlungvolumeinseverestableCOPD.Thorax2002;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39COPD的机械通气COPD急性期患者(n=10)GuérinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2001;18:491-498年龄(yr) 646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

1.540COPD的机械通气COPD急性期:PEEPPEEP(cmH2O)051015PEEPt,cmH2O8.44.810.03.912.32.416.91.8PEEPi,cmH2O7.13.93.73.31.81.80.81.2FRC,L0.540.420.740.481.030.421.500.51Rint,rs,cmH2Os/L9.23.68.12.77.32.77.23.0Rrs,cmH2Os/L7.71.88.51.89.52.79.73.3Rrs,cmH2Os/L173.916.72.716.83.016.93.6Est,rs,cmH2O/L12.73.012.93.312.93.315.54.5GuérinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2001;18:491-49841COPD的机械通气COPD急性期:PEEPGuérinC,FournierG,Milic-EmiliJ.EffectsofPEEPoninspiratoryresistanceinmechanicallyventilatedCOPDpatients.EurRespirJ2001;18:491-49842COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-1528RR6bpmRR9bpm43COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152844COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152845COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152846COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152847COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152848COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;33:1519-152849COPD的机械通气COPD:PEEP与呼气流速CaramezMP,BorgesJB,TucciMR,OkamotoVN,CarvalhoCR,KacmarekRM,MalhotraA,VelascoIT,AmatoMBP.Paradoxicalresponsestopositiveend-expiratorypressureinpatientswithairwayobstructionduringcontrolledventilationCritCareMed2005;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50COPD的机械通气AssessmentofPulmonaryHyperinflationTimeTidalvolumeTrappedgasLungVolumeFRCTidalvol.Tidalhyper-inflationApneaTidalVentilation51COPD的机械通气COPD:缩短吸气时间LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-1370Tinsp

RRTexpPEEPi52COPD的机械通气COPD:缩短吸气时间LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-1370患者基础情况(n=10)基本情况均值SE年龄,yr68.32.9体重,kg82.95.9身高,cm173.52.1FEV1,L1.210.12FEV1,%pred39.74.3FEV1/FVC,%pred40.93.5FRC,L6.50.8TLC,L8.90.7PaO2,mmHg723PaCO2,mmHg38153COPD的机械通气COPD:缩短吸气时间LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137016.11.019.01.420.81.57.01.36.31.16.41.12.10.22.40.22.30.254COPD的机械通气COPD:缩短吸气时间LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137056COPD的机械通气为何需要设置吸气末暂停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduringthePlateauPhase57COPD的机械通气为何需要设置吸气末暂停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNoPENDELLUFTbecauseofconstantflowflow58COPD的机械通气COPD:缩短吸气时间LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137059COPD的机械通气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LaghiF,SegalJ,ChoeWK,TobinMJ.EffectofImposedInflationTimeonRespiratoryFrequencyandHyperinflationinPatientswithChronicObstructivePulmonaryDisease.AmJRespirCritCareMed2001;163:1365-137060COPD的机械通气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 60 4.30 0.50 3.80 0.30 0.5 12 60 5.00 0.50 4.50 1.00提示降低分钟通气量对于减少内源性PEEP的重要作用61COPD的机械通气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613100mL,吸气流速794L/