新生儿常见肺部疾病辅助通气策略-.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,*,*,新生儿常见肺部疾病辅助通气策略,1,常频通气的基本模式,新生儿常见肺部疾病,(TDS,MAS,PPHN,BPD,APNEA),常频通气新策略,内 容,2,常频通气的基本模式,A,SIMV,PSV,PRVC,CPAP,biPAP,C,3,常频通气呼吸机,4,常频通气的基本模式,定压,定容,定容限压,SIMV+VG,PRVC,-FiO2,-Rate,-PIP,-PEEP,-It,-FiO2,-Rate,-TV,-PEEP,-It,恒流,病人触发,5,A/,触发（,Trigger,）,:,E-I,Patient(assisted),Time(controlled),B/,限制（,Limit,）,:,I,Volume,Pressure,C/,切换（,Cycle,）,:,I-E,Volume,Time,A,B,C,常频通气的基本模式,6,常频通气标准,Neonatal Ventilation,2003,7,新生儿常见肺部疾病辅助通气新策略,8,新生儿呼吸窘迫综合征,9,Hack M.Am J Obstet Gynecol 1995;172(2pt1):457-64,发生率,10,里程碑,产前应用激素,肺表面活性物质,死亡率,40%,气胸,30-65%,11,预防性应用,PS,及,nCPAP,Meta-analysis of eight randomized trials comparing prophylactic and rescue,treatment with surfactant.Numbers in parentheses following the outcomes are the,numbers of trials in which that outcome was reported.(From Soil RF,Morley CJ:,Prophylactic versus selective use of surfactant for preventing morbidity and,mortality in preterm infants.In:TheCochrane Library,Issue 2,2001.Oxford),12,Figure 20-7.Meta-analysis of four randomized trials comparing early and delayed administration,of surfactant.(From Yost CC,Soil RF:Early versus delayed selective surfactant treatment for,neonatal respiratory distress syndrome.In:The Cochrane Library,Issue 2,2001.Oxford),预防性应用,PS,及,nCPAP,13,RDS,常频通气新策略,肺保护,低氧浓度,小潮气量,低,PIP,允许性,高碳酸血症,封闭式,吸痰,俯卧位,14,RDS,常频通气新策略,轻度允许性,高碳酸血症,PCO2:45-55,PCO255,危害,且维持,PH7.20-7.25,高,CO2,脑血流量,IVH,低,PH PS,形成,肺血管阻力,心肌收缩,膈肌运动,BPD,PVL,15,允许性高碳酸血症,Woodgate PG.Cochrane Library.2001(2).,与常规通气策略相比，,未发现足够的证据证明,允许性高碳酸血症策略有足够 的优势,建议：,慎用,PaCO255mmHg,16,RDS,常频通气新策略,Gentle,Ventilation,最适,PIP,10-20,高频率,60bpm,PEEP,4-5,吸气时间,0.3-0.4,小潮气量,4-6ml/kg,保证足够的,分钟通气量,减少,容量损伤,开放肺,保障,FRC,减少气漏,PS,后降至,0.3,减少,压力损伤,17,CO,2,CO,2,CO,2,CO,2,CO,2,HFOV,HFJV,高频通气,高频通气与早产儿,RDS,18,结果差别较大,高频通气与早产儿,RDS,高频通气优势,高频率,(600-800,次,/,分,),小潮气量,(dead space),动物试验,人类试验,减少肺损伤,19,对象：,RDS,早产儿（,GA:24-29w,）,例数：,273,结果：,需要,2,剂以上的,PS,的患儿减少（,30%vs 62%,）,严重颅内出血率明显增加,（,24%vs 14%,）,存活者,28,天用氧率无差别,气漏发生率无差别,高频通气与早产儿,RDS,Moriette G.,Pediatrics.,2001;107:363372-1,20,高频通气与早产儿,RDS,RDS,早产儿,（,wt:601-1200g,）,500,严重,IVH,和,PVL,发生率无差别,校正胎龄,36,周时需要用氧的比例,(44%vs.53%,p=0.046,）,Courtney HE.N Engl J Med,2002;347:643-52.,797,RDS,早产儿,（,GA:23-28w,）,肺部疾病发生率无差别,死亡率均为,10%,，无差别,对,严重脑损伤,和气漏无差别,Johnson AH.N Engl J Med,2002;347:633-642,对象,例数,结果,出处,21,高频通气与早产儿,RDS,Henderson-Smart DJ,Elective high frequency oscillatory ventilation,versus conventional ventilation for acute pulmonary dysfunction in,preterm infants.Cochrane Database Syst Rev.2007 Jul 18;(3):CD000104.,对象,：早产儿,例数,：,3,585,结果,：,There is,no,clear evidence that elective HFOV,offers important advantages over CV when used as,the initial ventilation strategy to treat preterm infants,with acute pulmonary dysfunction.There may be a,small reduction in the rate of CLD with HFOV use,but the evidence is weakened,22,激素在拔管中的应用,Davis PG.Cochrane Library.2004,（,4,）,减少气管内再插管的可能，,在喉头水肿发生率不高时作用不明显,高血糖和尿糖阳性,仅限有高度发生气道水肿和阻塞 危险者,建议,23,胎粪吸入综合征,24,治疗进展,25,并未显著降低死亡率,延长了氧疗时间,机械通气时间无降低,气漏发生率无降低,长期预后结果未见报道,激 素,Ward M.Cochrane Database Syst Rev.2003;(4):CD003485,2003,年系统综述（,1966-2003,）,26,方式：常用,HFOV,和,HF,目的：减少气压伤,证据：前瞻性,RCT,目前仍较少,高频通气,27,2002,年美国,9,家医院所作的,RCT,制剂：稀释的肺表面活性物质（,surfaxin,）,对象：中度,MAS,（,15OI 15-20mmHg,sPO210%,高氧试验,Pre-,ductal,Post-,ductal,吸入,100%,氧气,5,10 min,缺氧无改善或导管后,PaO260-80,高氧,+,过度通气,2,天,iNO,HFO,高频通气可能减轻气压伤,Henderson-Smart et al,2004,34,起始量,10ppm,，如果病情严重，可以,5ppm,的速度增至,20ppm,临床显效时，可考虑减量,吸入,NO,的浓度尽可能的低，在,5ppm,左右，减量到低于该浓度时，一定要微降,PPHN,与,NO,35,维持恒定血压,早产儿平均动脉压应,35mmHg,足月儿,40-45mmHg,扩容,补充新鲜冰冻血浆,/,血小板,红细胞压积应在,50-60,正性肌力药物,-,多巴酚丁胺,+/-,多巴胺,Central South Coast Neonatal Network,2006,England,PPHN,36,支气管肺发育不良,37,BPD,常频通气新策略,New BPD,38,BPD,常频通气新策略,39,BPD,的分级,40,预防早产,产前应用激素,早期应用,CPAP,表面活性物质,积极处理,PDA,Vit A,可容许的高碳酸血症,生后激素,抗氧化剂,支气管扩张剂,利尿剂,BPD,的防治,41,早产儿反复呼吸暂停,42,CPAP,与,Apnea,早产儿呼吸暂停分类：中枢性（,central,）,阻塞性（,obstructive,）,混合性（,mixed,）,除外：贫血,感染,低氧,代谢因素,中枢神经系统异常,治疗：茶碱或咖啡因和,/,或,CPAP,机理：减轻呼吸道梗阻,43,主机 正压发生器,CPAPThe Infant Flow System,44,The Infant Flow System,45,The Infant Flow System,46,High-flow nasal cannulae(flows 1 to 2.5 L/min),also generate positive distending pressure and,may be as effective as CPAP for apnea.,Sreenan C,High-flow nasal cannulae in the management of apnea of,prematurity:A comparison with conventional nasal continuous positive,airway pressure.Pediatrics 107:1081-1083,2001.,其他通气方法与,Apnea,47,Davis PG,Nasal intermittent positive pressure ventilation(NIPPV)versus nasal continuous positive airway pressure(NCPAP)for preterm neonates after extubation(Cochrane Review).Cochrane Database Syst Rev 3:CD003212,2001.,Infants with persistent apnea on CPAP can be,given a trial of nasal intermittent positive-pressure,ventilation(CPAP+IMV or NIPPV),although more,studies are required to evaluate the benefits and risks,of this technique in infants with refractory apnea,其他通气方法与,Apnea,48,常频通气策略,10-15/min,7-15 cm H2O,PEEP 3 cm H2O,FiO20.25,pH 7.25-7.30,Pao2 50-70 mm Hg,Paco2 55+mm Hg,49,体外膜肺,ECMO,其他通气模式,50,Perfluorocarbon liquid,其他通气模式,51,呼吸管理不是全部,循环,镇静,镇痛,安静,避免寒冷,液体营养,控制感染,电解质,52,谢谢！,53,