严重呼吸衰竭高频应用.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,严重呼吸衰竭时高频通气临床应用,1,高频通气为,20,余年来新通气方法,以小于正常生理潮气量、高于正常呼吸频率数倍的通气频率维持气体交换。,气体交换机制不同于常规呼吸机。,目前最常用的为高频振荡通气（,HFOV,）及高频气流阻断通气（,HFFI,）,2,3,HFOV,应用作用,减轻潜在容量,/,气压伤危险性,降低吸入氧浓度、减少氧中毒,使已存在的肺部损伤愈合（如气漏）,减少慢性肺部疾病,4,HFOV,适应症,肺气漏（气胸，,PIE,）,重症均匀性肺部疾病（,RDS,）,重症非均匀性肺部疾病（,MAS,）,肺发育不良（膈疝）,腹胀，胸廓活动受限,5,HFOV,基本设置,MAP,（,CPAP or PEEP,）,P,（振幅）,频率（,Hz,）,FiO,2,高容量策略：较,CV,压力高,2-5cmH,2,O,低容量策略：较,CV,压力低,2cmH,2,O,6,7,HFOV,与,CMV,的气道和肺泡内压力比较示意图,HFO,：高频振荡通气；,CMV,：常规通气；,MAP,：平均气道压,8,9,Eleven eligible studies on 3,275 preterms,Randomized controlled trials comparing HFOV and CV,no evidence of effect on mortality at 28-30 days of age,small reduction in the rate of CLD,increased rates of Grade 3 or 4 IVH and of periventricular leukomalacia on low volume strategy,Adverse effect of HFOV on longer term neurodevelopment was found in one large trial,Cochrane Database Syst Rev.2003;(4):CD000104.,10,Neonatal data,less chronic lung disease,increased intracranial hemorrhage and periventricular leukomalasia,Crit Care.2002;6(3):183185,11,应用注意点,气管插管漏气,需更改大一号插管,持续监护,SPO,2,，或经皮,PO,2,，,CO,2,，间隙测血压,HFOV,应用前摄胸片，用后,1-2h,重复胸片,HFOV,应用时应维持血压及灌注正常,（必要时补充容量及用正性肌力药）,用低顺应性呼吸机管路,可用镇静剂，但不推荐用肌松剂,胸壁振荡运动减弱时，疑,ETT,阻塞，应吸痰，吸痰后短时提高,MAP 3-5cmH,2,O,12,HOFV,的调节,改变,CO,2,：调振幅及频率,开始可设振幅于,50%,。逐步递增见胸壁明显振荡,（维持,CO,2,40-50mmHg,）,频率：胎龄小 频率快，调低频率可降低,CO,2,13,改善氧合 调节,MAP,及,FiO,2,除气漏外原则采用高容量及低,FiO,2,策略,气漏 低容量高,FiO,2,策略,14,抢救性,HFOV,：,MAP,高于,CMV,时,2-5cmH,2,O,预防性,HFOV,：根据肺部疾病 一般,MAP,自,8cmH,2,O,开始，顺应性差时自,10cmH,2,O,开始,递增,MAP,：每次,1cmH,2,O,间隔,5,分钟递增一次，直至,FiO,2,0.4,上机,1-2h,摄胸片，维持右肺底于,8-9,肋水平。病情不稳定,6h,后重复胸片,右肺底于,10,肋时，下调,MAP,。,RDS,时要求肺透亮度改善,FiO,2,0.3,氧合稳定，可递减,MAP,。（需,FiO,2,0.3,示,MAP,下降太快）,15,HFOV,时某些问题处理,低,PO,2,时考虑,气管插管漏气，管内及接口处积水,注意胸廓振动度（气道阻塞？）,气漏可疑（双肺振动对称否？透光试验，立即摄胸片）,肺未复张 提高,MAP,，重复摄片,肺扩张过度 血压测定，下调,MAP,16,高,PCO,2,时考虑,气管插管漏气，并发气胸,低通气，肺复张不充分，胸廓震荡小，增加振幅,MAP,疑肺过度充气，胸部,X,光检查,无上述问题 下调频率（因肺、气道阻力下降，,V,T,、,CO,2,排除 ）,17,持续酸中毒,/,低血压,考虑容量，心肌收缩力,肺过度扩张（下调,MAP,，观察氧合改善与否，复胸片）,18,撤机,下降,FiO,2,至,9,肋）,递减,MAP,，每次,1-2cmH,2,O,至,8cmH,2,O,气漏应先降,MAP,，再降,FiO,2,一般不降频率,FiO,2,0.3,，,MAP 8cmH,2,O,，可直接撤机或增加,IMV,数,后转成常频通气，再撤,机,19,Success rate of HFV,Homogenous lung diseases 70-80%,Inhomogeneous lung diseases 50-79%,Air leaks 63-80%,PPHN 39-69%,CDH 22-27%,20,Key Points,HFOV has been likened to CPAP with wobbles.The CPAP oxygenates and the wobbles ventilate.,Babies with diffuse lung disease produce the best immediate response to HFOV.,The high volume low oxygen strategy seems to give the best outcome,Great care must be taken to avoid over expansion of the lungs.,Routine HFOV is associated with a lower incidence of chronic lung disease than conventional ventilation in very preterm babies.,There remain concerns that HFOV may be associated with a higher rate of neurological injury.,21,22,23,24,25,Stephanie,呼吸机,HFOV,治疗膈疝病例报告,26,例,1.,汤,XX,，出生,2,小时，体重,3.05Kg,，胎儿,B,超宫内诊断为膈疝。行剖宫产，,APGAR,评分,5/7/9,FiO,2,0.6,PIP 23,PEEP 4,MAP 9.5,PH 7.2,PO,2,40mmHg,PCO,2,56mmHg.,生后即气促，胸部,X,片显示：左肺未见肺纹理，腹中部见充气肠管影，心脏纵膈右移，诊为左膈疝。入院后即予,SIMV,通气支持。,2,天后行左膈修补术，见部分空肠、回肠、脾脏疝入左胸腔，左肺发育不全，仅大拇指大小，回纳脏器修补疝囊后回,NICU,用,HFOV,。,6,天后撤离,HFOV,，继续常频,2,天，住院,24,天痊愈出院。,27,MODE,HOUR,IMV IMV+HFO HFO HFO HFO HFO,8pm 10pm 12MN 2AM 4AM 8AM,HFO,8AM,HFO,8AM,IMV-Freq,35 3 2 2 2 2,2,2,IMV-Peak,22 20 20 20 20 20,18,18,PEEP,4 12 12 12 12 11,10,9,MAP,9.0 12 12.2 12.2 12 11.2,10.2,9.2,FiO,2,0.5 0.55 0.5 0.45 0.4 0.4,0.35,0.3,HFO-Freq(Hz),9 8 8 8 8,8,8,HFO-Amp,5 5 5 3.5 3.5,3,2.5,PO,2,64 70 62 70 78 80,84,86,PCO,2,51 42 40 38 36 35,36,38,pH,7.21 7.3 7.36 7.38 7.4 7.42,7.4,7.38,Pulse,150 145 143 141 138 130,126,124,Bp,55/34 56/38 58/36 60/34 61/40 62/42,64/40,60/40,28,29,30,31,例,2,江,XX,，,19h,，因生后呼吸困难,19,小时入院。基层医院胸部,CT,示膈疝。入院当时在气管插管纯氧正压人工通气情况下,PH 7.001 PO,2,75mmhg,PCO,2,74mmHg,HCO,3,-,17.5mmol/L,听诊左肺闻肠鸣音，诊为膈疝。立即机械通气，用,SIMV/PEEP,模式：,FIO,2,0.6,，,PIP/PEEP 20/3,，,MAP 7.8,，持续机械通气,12,小时后手术治疗。术中见小肠结肠均移位至胸腔，左肺发育甚差。术后,HFOV,支持。持续应用,4,天后直接撤机。住院,11,天痊愈出院。,32,MODE,HOUR,IMV IMV+HFV HFO HFO HFO HFO HFO,2pm 4pm 8MN 10PM 2AM 6AM 2PM,HFO,6AM,HFO,6AM,IMV-Freq,30 3 2 2 2 2 2,2,2,IMV-Peak,22 20 20 20 20 20 20,20,20,PEEP,4 11 11 11 11 11 10,10,9,MAP,7.8 11.2 11.2 11.2 11.2 11.2 10.2,10.2,9.1,FiO,2,0.5 0.5 0.5 0.45 0.4 0.35 0.35,0.35,0.3,HFO-Freq(Hz),8 8 8 8 7 7,7,6,HFO-Amp,5 5 4 3 3 3,3,2.5,PO,2,50 60 68 70 75 74 80,78,86,PCO,2,61 49 43 40 42 40 38,39,35,pH,7.25 7.3 7.34 7.36 7.38 7.41 7.44,7.4,7.45,Pulse,156 141 138 132 130 126 128,124,120,Bp,51/31 54/32 58/30 56/32 61/38 64/38 63/30,61/36,64/35,33,34,35,36,谢谢！,37,Stephanie,呼吸机应用模式,应用模式齐全,1.,常频通气模式,-Contr SIMV ass./contr.CPAP,容控 压控 流量触发 压力触发 近端流量传感器 依据压差触发敏感度高,反应快 同步好,2.,高频振荡通气（,HFOV,）,纯高频振荡，可叠加于所有常频通气模式上，吸、呼振荡，,Piston,正弦振荡气流，噪音低,先湿化，后振荡可避免更多能量衰减,38,比例辅助通气（,PAV,）以流量和容量辅助，减少呼吸功，与,PSV,相比，更低的,MAP,，达相同的,Vt,，减少呼吸机依赖，,脱机容易。,4.,通气监测完整：值、曲线、环,具三种力学环,V-P V-P V-V,39,