医学呼吸治疗最佳湿化.ppt

Click to edit Master title style,Click to edit Master text styles,Click to edit Master title style,Click to edit Master text styles,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master text styles,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master text styles,Second level,Third levelFourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Click to edit Master title style,Click to edit Master text styles,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Click to edit Master title style,Click to edit Master text styles,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Click to edit Master text styles,Page Title,Click to edit Master text styles,Second level,Third level,Fourth levelFifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Click to edit Master text styles,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Page Title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,呼吸治疗最佳湿化,总述,什么是湿化,人工通气过程中为什么需要湿化,有,创通气湿化,无,创通气湿化,氧疗,什么是湿化？,为什么机械通气需要湿化？,正常气道,吸气时，气体被加温加湿至核心体温饱和湿度状态,-37,，,44mg/L,粘液纤毛转运系统是一个高度平衡的系统，极度受到湿度水平的影响,95%,加温加湿在鼻咽、口咽及气管完成,呼气,-,湿，热回收,25%,的热量和水分在呼气时回,收,1,2,大部分是在鼻咽和口咽回收,1.,Ingelstedt,1996.2.Cole,1993,33,C,30mg/L,85%RH,气体调节,湿，热回收,水分,热量,水分,水分,热量,水分,呼吸干预,-,干冷医用气体,呼吸干预,-,气管插管,绕过上气道和肺部的防御机制,输送相对湿度较低的气体至下气道,呼吸干预,-,气管切开,呼吸干预,-,无创通气,呼吸窘迫,呼吸困难,张口呼吸,NIV,干冷气体,高流量,气道湿化调节功能障碍,气道防护机制,生理状态的粘液纤毛转运系统,(,电镜下,),粘液纤毛转运系统,粘液纤毛转运系统,Courtesy of,Spinger,Verlag,1992,37,44mgH,2,0/L,Humidification of,Inspired Gas is,particularly important in asthmatic patients to prevent thickening of secretions and drying of airway mucosa,a stimulus for bronchospasm in itself.,Thorax,2003 58:81-88,为什么呼吸治疗病人需要湿化,?,最佳湿化，最佳气道防御和通气,最佳湿化,37,，,44mg/L,，,100%,相对湿度,粘液纤毛转运系统,有创通气湿化,呼吸气体湿化,-AARC,临床操作指南,2012,为有创通气病人提供主动湿化时，建议湿化器能够提供湿度水平在,33mg/L,至,44mg/L,，,Y,型件处气体温度在,34,-41,，相对湿度,100%,。,Humidification During Invasive and Noninvasive Mechanical Ventilation:2012 Ruben D Restrepo MD;Resp Care May 2012 Vol 57 No 5,湿化的应用,-,有创通气,维持分泌物清理,减少感染的发生,最佳的气体交换,最佳气道防御,最佳通气,最佳湿度,37C,44mg/L,有创模式,37C,44mg/L,+3C,-,3C,40C,44mg/L,37C,44mg/L,15C,无创通气湿化,基本湿度可以尽可能让,NIV,治疗成功,湿化的应用,-,无创通气,防止气道干燥,1,防止支气管痉挛,2,尽量维持鼻气道完整性和减少鼻部症状,3,清理滞留分泌物,4,改善,Pa0,2,5,增加痰液清理,6,对口干症的患者缓解症状,7,增加舒适度和病人依从性,8,Dodd,1998;Shupak,1997;Richards,1996;Edwards,1999;Burioka,1997;Conway,1992;Hay 2004;Neill,2003,面罩模式,31C,34C,31C,+3C,干燥 湿化,PaO,2,72.8,16.8,87.2,27.2,p 0.05,PaCO,2,49.0,9.4,46.1,9.2,p 0.05,Wilkinson,M.,Eur Respir J,30,A2576(2000).,PaO,2,58.9,10.0,61.6,11.0,p=0.06,PaCO,2,54.4,10.0,50.8,9.0,p 0.01,Nammour,H.,Am J Respir Crit Care Med,160,A49(1999).,临床摘要,(0,2,),这种改善主要是因为减少上气道阻力,减少痰液栓塞,改善痰液清理,建议每例使用有创机械通气的病人都推荐使用湿化,湿化对于防气道上皮损伤，支气管痉挛和气道堵塞至关重要,建议,NIV,使用主动湿化,可以改善依从性和舒适度,不推荐,NIV,时使用被动湿化,(HME),，,因为可以,WOB,和,PaCO,2,Restrepo and Walsh 2012;American Association of Respiratory Care,主动湿化,-,常用湿化器,MR810,普及型加温湿化器,两种模式选择,主动湿化,-,常用湿化器,MR850,无创模式,有创模式,最佳湿化的气体,(37,C,44mg/L),湿化系统,干燥气体,(15,C,1mg/L),高流量氧气治疗的温湿化,Oxyflo,流量,-,多少？,4,15,+,鼻塞,/,鼻导管,吸氧面罩,储氧面罩,LPM,100%O,2,室内空气,21%O,2,低温,/,湿度,？,处方氧浓度,空氧混合,最佳湿化,正常流速,峰值流速，吸气最大风速,NIV,OPTIFLOW,WOB,FRC,RR,HR,PEP,ETT,氧疗的流量和浓度,流量,高流量供氧,低流量供氧,浓度,高浓度供氧,低浓度供氧,低流量系统,是指所供给的气流不能完全满足吸入气量的需要，因而必须提供室内空气以补充部分吸入气体,.,方法,:,1,鼻导管法：为常用的给氧法，缺点为易被分泌物所阻塞。吸氧浓度（,%,）,=21+4,氧流量（,L/min,）。,2,面罩法,:,吸入氧浓度可达,50%,60%,，但面罩密闭，患者不舒服。,3,贮氧气囊面罩法,:,可提供高浓度氧，吸入氧浓度可达,70%,甚至更高。,4,T,管法,:,高流量系统,则能完全满足所有吸入气量的需要。,高流量系统有以下优点：,只要该系统调节适当，可供给持久和正确的吸氧浓度，并不受患者通气量的变化；能控制吸入气体的温度和湿度；可监测吸入氧浓度。但需注意高流量供氧系统必 须满足患者吸气高峰流速，一般 至少应为每分通气量的,4,倍，才能 保证吸氧浓度恒定。,氧疗的温湿化,氧疗与气道湿化,经鼻高流量氧疗,通过经鼻高流量氧疗您可以为有轻、中度呼吸窘迫的低血氧患者提供舒适、,有效的输氧。,Williams et.al.,1996;Ryan et.al.,2002;Lomholt,1968;Chanques et.al.,2009;Sim et.al.,2008;Ritchie et.al.,2006;Dysart et.al.,2009;Groves et.al.,2007;Parke et.al.,2008;Hasani et.al.,2008,NHF,在全方位呼吸治疗方案中用于哪个阶段？,最佳湿度,呼吸湿化治疗仪进行经鼻高流量氧疗输送被调节到最佳湿度的空氧混合气体。,最佳湿度为,37 C,，,44 mg/L,这种调节使经鼻高流量氧疗成为可能,Williams et.al.,1996;Ryan et.al.,2002;Lomholt,1968;Dysart et.al.,2009,最佳湿度与鼻塞导管相结合确保舒适地输送高流量氧气,通过鼻塞导管舒适地输送高流量氧气,Lomholt,1968;Chanques et.al.,2009;Groves et.al.,2007,通过鼻塞导管舒适地输送高流量氧气,最佳湿度与鼻塞导管相结合确保舒适地输送高流量氧气,患者可继续：,进食,饮水,交谈,/,沟通,睡眠,Lomholt,1968;Chanques et.al.,2009;Dysart et.al.,2009,通过鼻塞导管舒适地输送高流量氧气,最佳湿度与鼻塞导管相结合确保舒适地输送高流量氧气,经鼻高流量氧疗的四大好处：,精确输送浓度高达,100%,的氧气,消除解剖学死腔,保持气道正压,使粘液纤毛清理功能处于最佳状态,精确输送浓度高达,100%,的氧气,最佳湿度确保舒适地输送高流量氧气，而使得：,可精确输送浓度高达,100%,的氧气,可以做到满足患者的呼吸需要,室内空气的混入最少，减少处方氧浓度和湿度的稀释,Lomholt,1968;Sim et.al.,2008;Ritchie et.al.,2006,30 L/min,混合氧气,吸气需要：,30 L/min,20-25 L/min,室内空气,5-10 L/min,100%,氧气,吸气需要：,30 L/min,最佳湿度确保舒适地输送高流量氧气，而使得：,减少呼出二氧化碳（,CO,2,）的再吸入，提高呼吸效率,通过富氧气体持续“冲刷”上气道（解剖学死腔）,在上气道为每次呼吸建立了一个新鲜气体储存室,消除解剖学死腔,Lomholt,1968;Dysart et.al.,2009,在整个呼吸周期中保持气道正压,吸气支持,呼气支持,流量和压力成正比，气道压力也会随着,流量的增加而增加,气道正压,Ritchie et.al.,2006;Groves et.al.,2007;Parke et.al.,2008,显示流量和压力关系的回归模型图,一例在,35 L/min,的流量下使用面罩氧疗和,NHF,的压力波形比较,最佳湿度确保舒适地输送高流量氧气，,而使得：,使粘液纤毛清理功能处于最佳状态,最佳湿度确保舒适地输送高流量氧气，而使得：,使粘液纤毛清理功能处于最佳状态,保持痰液流动,使痰液向上转运并排出气道,降低呼吸系统感染的风险,Williams et.al.,1996;Ryan et.al.,2002;Hasani et.al.,2008,哪些患者可以通过,NHF,受益,疾病种类,实例,导致低氧血症的特征,阻塞性肺疾病（气道疾病）,慢性支气管炎,肺气肿,哮喘,阻塞的气道限制了气流和通气。痰液的量和性状会造成痰痂形成和阻塞,限制性肺疾病（弥散性肺疾病）,肺纤维化,尘肺,肺顺应性和肺容积降低：功能残气量减少,感染性肺疾病,肺炎,分泌物导致痰痂形成和肺实变,肺膨胀紊乱,肺不张,肺泡塌陷减少了进行气体交换的肺表面积,通过经鼻高流量氧疗您可以为有轻、中度呼吸窘迫的低血氧患者提供舒适、有效的输氧。,哪些患者可以通过,NHF,受益,有创通气,呼吸治疗,经鼻低流量氧疗,(O,2,)4 L/min,高浓度面罩氧疗,高浓度面罩氧疗,经鼻低流量氧疗,(O,2,)4 L/min,NIV,NIV,严重程度,急性期,撤机阶段,哪些患者可以通过,NHF,受益,高浓度面罩氧疗,高浓度面罩氧疗,NIV,NIV,严重程度,急性期,撤机阶段,呼吸治疗,经鼻低流量氧疗,(O,2,)4 L/min,经鼻低流量氧疗,(O,2,)4 L/min,有创通气,