机械通气的变化.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,*,机械通气的历史与变化,Epidemiology of MV,首都医科大学附属复兴医院,席修明,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,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-,Negative Pressure Ventilation(Iron Lung)that was wildly used during the polio epidemics,Patient no.1,December 21st,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 via facemask and when the SaO2 decreased,with positive pressure ventilation from bag and mask,was started,.,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 ventilation,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 Anaesthesiol 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,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 Respiratory 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,A dramatic,reduction in mortality,from ARF has been achieved when these patients were treated in a unit with,specially trained physicians,nurses,and auxiliary personnel,Availability of,accurate monitoring,inhalation and physical therapy on the unit,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 of 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 Mechanical 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 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 Employed 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,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;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:,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,Vt,的选择通常是,7-10ml/kg,PEEP,的选择多为,5cmH2O,SIMV,和某些新的通气模式很少使用（允许性高碳酸症通气，无创通气）,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 Change,%,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,Mortality,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&ARDS 机械通气的模式（1.3.7天）,COPD ARDS,day 1 day 3 day7 day1 day 3 day 7,(n=522)(n=283)(n=85)(n=231)(n=174)(n=82),MV Modes No(%),A/C 344(65.9)180(63.6)57(67.1)165(67)111(63.8)50(61),SIMV/PS 50(9.6)32(11.3)9(10.6)24(10.4)20(11.5)8(9.8),PS 40(7.6)24(8.5)10(11.8)3(1.4)6(3.4)3(3.7),PCV 20(3.9)11(3.9)2(2.4),24(10.4)23(13.2)13(15.9),SIMV 24(4.6)10(3.5)2(2.4)10(4.2)4(2.3)2(2.4),JAMA，2002；287：345-355,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-,A,28-Day international Study,COPD,ARDS,JAMA，2002；287：345-355,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-,A,28-Day international Study,JAMA，2002；287：345-355,机械通气时间与存活率的关系,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-,A,28-Day international Study,每日机械通气模式的变化,JAMA，2002；287：345-355,The Changing Epidemiology of Mechanical Ventilation:A Population-based Study,Journal of Intensive Care Med 200621(3):173-182,1996-2002 回顾性调查研究,，,北卡罗来那州出院病人资料库，ICD-9修订版的诊断标准,1996年机械通气病人285/10万，2002增加为314/10万，增加11%（p0.05),The Changing Epidemiology of Mechanical Ventilation:A Population-based Study,Journal of Intensive Care Med 200621(3):173-182,机械通气病人合并肾脏病明显增加（96年17%vs 02年 24%）,肾病,The Changing Epidemiology of Mechanical Ventilation:A Population-based Study,Journal of Intensive Care Med 200621(3):173-182,机械通气病人医疗消费指数（,C P I,）增长,12%,The Changing Epidemiology of Mechanical Ventilation:A Population-based Study,Journal of Intensive Care Med 200621(3):173-182,出院病人回家,45.5%,下降到,34.4%,回到,Nursing Home,从,7.3%,增加到,10.7%,，回家的人越来越少,Evolution of Mechanical Ventilation in Response to Clinical Research,多中心、前瞻性、队列研究,23个国家，349个ICU,4968名机械通气的病人入选,对107个ICU中1675名病人与1998年1383名病人临床资料进行比较,2004与1998临床使用机械通的变化,Am J Respir Crit Care Med 2008;177:170-177,Evolution of Mechanical Ventilation in Response to Clinical Research,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 use 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 PS 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,NPPV,的临床应用,2004,明显增加，包括,COPD,和,ARF,NPPV,的时间增加（,2,vs,3 d,p=0.03),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 Med 2008;177:170-177,ARDS,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%),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,PCV,模式，每,1000,个,ARDS,日，,1998,年占,244,天，,2004,年占,202,天,俯卧位通气减少（,2004,，,7%,。,1998,，,13%,）,病死率无变化,Evolution of Mechanical Ventilation in Response to Clinical Research,脱机,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,SBT,成功后拔管的比列明显增加（,62%,vs,77%p0.001),T-piece,是最常用,SBT,（,1998,年,76%,，,2004,年,71%,，,p=0.07),但低水平,PS,用于,SBT,有增加的趋势（,10,vs,14%p=0.06),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 Mechanical Ventilation,hospital resource utilization,and mortality in United States,31340578 出院患者,2.4%on MV,469168(61%)MV96 day,294333(39%)PAMV,Crit Care Med 2008；36：724-730,Prolonged Acute Mechanical Ventilation,hospital resource utilization,and mortality in United States,Crit Care Med 2008；36：724-730,Prolonged Acute Mechanical Ventilation,hospital resource utilization,and mortality in United States,结论,2003年美国有近30万PAMV 患者,每年消耗160亿美金,占全部机械通气的2/3,Crit Care Med 2008；36：724-730,小结,机械通气的变化,1.ARDS Vt 减小、PEEP 增加、HFPV增加,NPPV增加,2.COPD NPPV增加,3.Weaning SBT 增加，SIMV减少,机械通气的模式无变化，最常用的仍为A/C，SIMV，PS,机械通气的改变改善了病人的预后，但PAMV的病人明显增多，消耗大量资源，如何应对？,总结,由于多个RCT研究的不断发表，我们看到机械通气发生悄悄的变化,这些变化也反映了机械通气的发展趋势,这些变化改变了病人的预后，缩短了机械通的时间,机械通气的病人明显增加，长时间依赖MV增多，这些病人如何管理？,