人工气道之气囊管理幻灯片.ppt

Diazepam,作品,欢迎交流,Dizepam,作品,1102065947,Page,过渡页,Transition Page,Title,Reference,Conclusion,Manage of Balloon,Preface,人工气道是保证气道通畅的有效手段，在抢救中发挥极为重要的作用,.,建立人工气道，特别是气管插管后，患者的吞咽受限，口腔分泌物及胃食道反流物受气囊阻隔滞留于气囊上方，会形成气囊上滞留物。,Preface,Preface,国内外研究结果显示，气囊上滞留物是呼吸机相关性肺炎（,ventilator associated pnemnonia,VAP,）病原的重要来源,1,Preface,The management of balloon is an important part of artificial airway management,气囊管理是人工气道管理中的一个重要环节,你还在用这种方法管理气囊吗？,Preface,Manage of Balloon,Type,Pressure,Nursing,Manage of Balloon,3,1,2,理想压力？,影响因素？,压力监测？,Pressure,研究结果显示：患者在接受气管插管前,8d,内，气囊压力低于,20cmH,2,O,导致误吸率明显上升，成为发生,VAP,的独立危险因素,【4】,Manage of Balloon,压力理想压力,3,保持有效封闭气囊与气管间隙的最小压力,又可防止气囊对粘膜的压迫性损伤。,Manage of Balloon,Air pressure should be keep in,25,30cmh2o,将人工气道气囊内压力保持在,2530cmh2o,Chinese Society of Critical Care Medicine(CSCCM)advise,:,压力影响因素,Patients with clinical airbags pressure fluctuations may be related to intervention,临床患者气囊压力波动可能与干预有关,Sputum suction,吸痰,Swallowing reflex,吞咽反射,Position etc.,体位等,Manage of Balloon,压力影响因素,有吞咽反射的患者压力明显低于无吞咽反射的患者,压力,由低到高,依次为半卧位、平卧位、左侧卧位、右侧卧位,Adjust the air pressure,a,fter the sputum suction,吸痰后应及时调整囊内压力,For the existence of swallowing reflex patients should be gas injection correction after 4 hours对于存在吞咽反射的患者,4,小时后应注气校正,semireclining position,半卧位,Manage of Balloon,吸痰时气囊内的压力升高,压力监测,Timing,刘亚芳等,4,研究表明人工气囊压力,4小时内衰减不明显,。赵静月,5,等也认为气囊压力,每隔4小时应注气校正1次,，以保证在安全范围内。,Manage of Balloon,Manage of Balloon,touch judge method（TJM）,触摸判断法,Quantitative aeration method（MOV MLT）,定量充气法,cuff pressure measurement（CPM）,气囊压力表测量,压力监测,不能采用根据经验判定充气的指触法给予气囊充气(推荐级别:,C,级),不宜常规采用MOV给予气囊充气，在无法测量气囊压的情况下，可临时采用(推荐级别:,E,级),推荐级别,A,级,Nursing,deflate the balloon,气囊的放气,techknowledge of subglottic secretion clean up,囊上滞留物的清除,inflate the balloon,气囊的充气,judge the air-leak of the balloon,气囊漏气的判断,Manage of Balloon,气囊的护理-充气,最小闭合容量(MOV),最小漏气技术（MLT),气囊充气后吸气时,无气体,漏出,气囊充气后吸气时,有少量气体,漏出,1.将听诊器放于气管处,向气囊,1.同MOV,内注气直到听不到漏气声,2.抽出0.5ml气体，可闻及少量,2.抽出气体，从0.1ml开始，直到,漏气声,吸气时听到少量漏气声,3.再,缓慢注气，直到吸气时听不,到漏气声,Manage of Balloon,定义,方法,不推荐,推荐使用专业气囊测压表充气,16,气囊的放气,1,气囊放气后1h内气囊压力压迫过的黏膜毛细血管血流难以恢复,2,气囊放气时易导致上方积液流入下呼吸道造成肺部感染或窒息,且影响有效的机械通气,3,常规定时放、充气使医务人员忽视充气容积或压力的调整,反而会充气过多压力过高,Manage of Balloon,17,1,3,2,4,气囊漏气的判断,Air pressure is too low,气囊压力过低,The patient cheeks are muscle tremor,病人两腮肌肉颤动,The neck is heard in the throat,颈部听到喉鸣音,Ventilator with low gas flow alarm,呼吸机低通气量报警,Manage of Balloon,threat to life,囊上滞留物清除,Manage of Balloon,使用简易呼吸器清除囊上滞留物,头低足高位,病人吸气末呼气初,给予较大潮气量,同时放气,再充气,气囊周围形成较大的冲力,将其上方的分泌物冲到口咽部，有利于充分吸净,陶兆武等认为,6,对气囊上间断冲洗或持续引流能有效清除滞留物,可冲洗气管导管持续声门下分泌物吸引技术,Manage of Balloon,预防,VAP,发生，应定期清除气囊上滞留物，尤其是气囊放气前（推荐级别：,A,级）,清除气囊上滞留物可采用带声门下吸引的人工气道（推荐级别：,A,级）,宜进行间断吸引（推荐级别：,D,级）,Cluster balloon management strategies to prevent VAP,集束化气囊管理策略预防vap,1,、Air pressure table monitoring pressure,专用气囊测压表监测气囊压力,2,、Before the nasogastric monitoring pressure,鼻饲前监测气囊压力,3,、After Sputum aspiration monitoring pressure,吸痰后监测气囊压力,4,、Every 4h monitoring air pressure,每4h监测气囊压力,5,、Does not perform balloon deflated regularly,不执行气囊定时放气,EICU annual continuous quality improvement project in 2016,2016,年,EICU,的年度持续质量改进项目,Scientific use of air bag pressure gauge,科学利用气囊测压表,Artificial airway care is a key factor in the success or failure of the rescue,人工气道护理的好坏是抢救成功与否的关键因素之一,Strengthen theory and technology training to ensure effective implementation of mechanical ventilation,加强理论与技术培训以确保机械通气的有效实施,Conclusion,Conclusion,1Frosr SA,Azeem A,Alexandrou E,et al.Subglottic secretion drainage for preventing ventilator associated pneumonia:a meta-analysisJ.Aust Crit Care.2013,26:180-188,2宋志芳主编.现代呼吸机治疗学.北京:人民军医出版社,2005:235.高数海.双囊单腔气管导管对气管粘膜的保护作用.潍坊医学院学报,2005,27(1):34-35.,3中华医学会.临床诊疗指南.北京:人民卫生出版社，2009,129-160.,4刘亚芳,贺丽君,任璐璐,等.人工气道套囊压力调整频率的临床研究.护士进修志,2011,26(7):584-586.,5赵静月,赵向琴,蒋芳琴,等.重症监护病房人工气道气囊压力连续监测的方法探究.护士进修杂志,2007,22(5);397-39,6陶兆武,赵苏.清除气管导管气囊上滞留物预防呼吸机相关性肺炎临床观察.山东医药,2010,50(21):37-38.,reference,