1、COPD機械通氣-PPT課件COPD機械通氣-PPT課件COPD患者的肺泡過度充盈Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2019; 350: 2689-97COPD患者的肺泡過度充盈Sutherland ER, Ch時間常數(shù)() = R x C測定肺組織充盈或排空的速度反映肺組織對壓力變化的反應(yīng)速度時間常數(shù)() = R x C時間常數(shù)()Time/Tau吸氣相呼氣相Pressure時間常數(shù)()Time/Tau吸氣相呼氣相Pressure時間常數(shù)

2、()PA(t) = (Pplat - PEEP) e-kte = 2.718k = 1/ =1/(R x C)V(t) = Vt x e-kte = 2.718k = 1/ =1/(R x C)時間常數(shù)()PA(t) = (Pplat - PEEP) 時間常數(shù)()時間常數(shù)成人(正常值)2 x 0.10 = 0.20”術(shù)后氣管插管成人患者5 x 0.06 = 0.30”COPD成人患者15 x 0.06 = 0.90”ARDS成人患者8 x 0.03 = 0.24”ARDS患兒5 x 0.01 = 0.05”時間常數(shù)()時間常數(shù)動態(tài)過度充盈: DHIinspexpTimeTidal volume

3、Trapped gasLung VolumeFRCObstructed LungsNormal Stiff Lungs動態(tài)過度充盈: DHIinspexpTimeTidal vo機械通氣的適應(yīng)證: COPD呼吸肌疲勞且瀕臨呼吸停止盡管進行充分的保守治療, PaCO2仍進行性升高勞累和(或)高碳酸血癥導(dǎo)致意識狀態(tài)惡化高濃度吸氧治療無效的低氧血癥痰液清除障礙導(dǎo)致病情惡化呼吸驟停機械通氣的適應(yīng)證: COPD呼吸肌疲勞且瀕臨呼吸停止COPD患者的病理生理改變內(nèi)源性PEEP過高肺泡過度膨脹胸腔內(nèi)壓過高 回心血量減少 休克COPD患者的病理生理改變內(nèi)源性PEEP過高機械通氣時的PEEPiVt 10 12

4、ml/kg, f 12 15 bpm, I:E 1:2 3機械通氣時的PEEPiVt 10 12 ml/kg, DHI和PEEPi的影響因素DHI和PEEPi的影響因素DHI和PEEPi的影響因素DHI和PEEPi的影響因素機械通氣參數(shù)的設(shè)置: COPD潮氣量吸氣流速吸呼比 / 吸氣時間 / 呼氣時間呼吸頻率機械通氣參數(shù)的設(shè)置: COPD潮氣量COPD: 不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exch

5、ange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2019; 122: 20962104COPD: 不同吸氣氣流的比較Shieh Ching YanCOPD: 不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in C

6、OPD Patients During Mechanical Ventilation. Chest 2019; 122: 20962104COPD: 不同吸氣氣流的比較Shieh Ching YanCOPD: 不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventil

7、ation. Chest 2019; 122: 20962104COPD: 不同吸氣氣流的比較Shieh Ching YanCOPD: 不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2019; 122: 20962104COPD:

8、 不同吸氣氣流的比較Shieh Ching YanCOPD: 不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2019; 122: 20962104COPD: 不同吸氣氣流的比較Shieh Ching YanCOPD: 不同吸氣氣流

9、的比較結(jié)論COPD患者機械通氣的最佳吸氣氣流為減速氣流通過選擇適宜的吸氣氣流, 有可能改善上述患者的通氣Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2019; 122: 20962104COPD: 不同吸氣氣流的比較結(jié)論Shieh Ching C

10、OPD機械通氣策略降低內(nèi)源性PEEP的方法外源性PEEP ?延長呼氣時間增加吸氣流速縮短吸氣末暫停降低呼吸頻率COPD機械通氣策略降低內(nèi)源性PEEP的方法呼氣流速PalvPEEPFlow= P / Raw= (Palv PEEP) / RawFlow呼氣流速PalvPEEPFlow= P / RawFloPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Ane

11、sth Analg 2019; 100: 1112-6CompliancePEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6Compliance P Flow PEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Sa

12、vian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6半徑PEEPPEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Exp

13、iratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6PEEP半徑流速?P流速PEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6PEEP與呼氣流速Sa

14、vian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6PEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pr

15、essure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6半徑PEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 111

16、2-6半徑Flow PEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6半徑PEEPPEEP與呼氣流速Savian C, Chan P, ParPEEP與呼氣流速Savian C, Chan P, Paratz J. The Effect of

17、 Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6PEEP半徑流速P流速PEEP與呼氣流速Savian C, Chan P, ParCOPD穩(wěn)定期患者(n = 9)年齡(yr)70 7.3FEV1 (%pred)30 9.5FVC (%pred)53 13.6RV (%pred)186 33.1FEV1/VC (%)44 11.6TLC (%pred)103 8.7TLCO (%pred)46 25

18、.4PaO2 (kPa)7.4 0.4PaCO2 (kPa)7.1 1.1pH7.40 0.00ODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期患者(n = 9)年齡(yr)70 7COPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan

19、 AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期: PEEPODonoghue FJ, CaCOPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort

20、, and lung volume in severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期: PEEPODonoghue FJ, CaCOPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期: PEEPODon

21、oghue FJ, CaCOPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期: PEEPODonoghue FJ, CaCOPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McE

22、voy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期: PEEPODonoghue FJ, CaCOPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in

23、 severe stable COPD. Thorax 2019;57:533-539COPD穩(wěn)定期: PEEPODonoghue FJ, CaCOPD穩(wěn)定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539總結(jié)對于處于穩(wěn)定期的嚴(yán)重COPD患者, 應(yīng)用高水平的CPAP能夠降低PEE

24、Pi及肌肉活動指標(biāo)肺容積顯著增加COPD穩(wěn)定期: PEEPODonoghue FJ, CaCOPD急性期患者(n = 10)Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2019; 18: 491-498年齡(yr)64 6身高(cm)167 6體重(kg)72 21體重(%pred)96 27FiO2 (%)48 9Vt (L)0.74 0.09PIF (L/s)0.65 0

25、.12Tinsp (s)1.13 0.15Texp (s)3.42 0.57RR (bpm)13.5 1.5COPD急性期患者(n = 10)Gurin C, FouCOPD急性期: PEEPGurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2019; 18: 491-498COPD急性期: PEEPGurin C, FournieCOPD急性期: PEEPGurin C, Fou

26、rnier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2019; 18: 491-498COPD急性期: PEEPGurin C, FournieCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical

27、responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528RR 6 bpmRR 9 bpmCOPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT,

28、 Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528COPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Vel

29、asco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528COPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotr

30、a A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528COPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM,

31、 Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528COPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacm

32、arek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528COPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho

33、CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528COPD: PEEP與呼氣流速Caramez MP, BorCOPD: PEEP與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, C

34、arvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2019; 33: 1519-1528結(jié)論對于部分氣道梗阻的患者而言, 應(yīng)用控制通氣過程中, 設(shè)置外源性PEEP能夠緩解過度充盈基礎(chǔ)疾病, 機械力學(xué)指標(biāo)或呼吸機設(shè)置均無法預(yù)測上述結(jié)果逐漸增加PEEP并觀察

35、平臺壓力改變, 是減少副作用的合理方法COPD: PEEP與呼氣流速Caramez MP, BorAssessment of Pulmonary HyperinflationTimeTidal volumeTrapped gasLung VolumeFRCTidal vol.Tidal hyper-inflationApneaTidal VentilationAssessment of Pulmonary HyperiCOPD: 縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Resp

36、iratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 163: 1365-1370Tinsp RR Texp PEEPi COPD: 縮短吸氣時間Laghi F, Segal J, COPD: 縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and

37、Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 163: 1365-1370COPD: 縮短吸氣時間Laghi F, Segal J, COPD: 縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Ob

38、structive Pulmonary Disease. Am J Respir Crit Care Med 2019; 163: 1365-137016.1 1.019.0 1.420.8 1.57.0 1.36.3 1.16.4 1.12.1 0.22.4 0.22.3 0.2COPD: 縮短吸氣時間Laghi F, Segal J, COPD: 縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in

39、Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 163: 1365-1370COPD: 縮短吸氣時間Laghi F, Segal J, COPD: 縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonar

40、y Disease. Am J Respir Crit Care Med 2019; 163: 1365-1370COPD: 縮短吸氣時間Laghi F, Segal J, 為何需要設(shè)置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFTduring thePlateau Phase為何需要設(shè)置吸氣末暫停PressureFlowPeakPla為何需要設(shè)置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhi

41、ghNo PENDELLUFTbecause of constant flow flow為何需要設(shè)置吸氣末暫停PressureFlowPeakPlaCOPD: 縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 163: 1365-13

42、70COPD: 縮短吸氣時間Laghi F, Segal J, COPD: 縮短吸氣時間機械通氣患者常常呼吸頻數(shù), 肺過度充盈提高吸氣流速, 可以縮短吸氣時間, 盡管呼吸頻率加快, 但能夠延長呼氣時間, 降低呼吸做功延長吸氣暫停能夠降低呼吸頻率, 卻引發(fā)肺過度充盈, 呼吸做功增加Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2019; 163: 1365-1370COPD: 縮短吸氣時間機械通氣患者常常呼吸頻數(shù), 肺過度充嚴(yán)重氣流梗阻患者的處理增加流量不能顯著延長呼氣時間(TE)VtRRflowTTOTTITETE0.515 604.000.503.50-0.5151204.000.253.750.250.514 604.300.503.800.300.512 605.00