高頻振蕩通氣的臨床應(yīng)用北京協(xié)和醫(yī)院杜 斌高頻振蕩通氣的臨床應(yīng)用北京協(xié)和醫(yī)院內(nèi) 容高頻振蕩通氣的操作原理1高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2高頻振蕩通氣的臨床應(yīng)用3內(nèi) 容高頻振蕩通氣的操作原理1高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2內(nèi) 容高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2高頻振蕩通氣的臨床應(yīng)用3高頻振蕩通氣的操作原理1內(nèi) 容高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2高頻振蕩通氣的臨床應(yīng)用3SensorMedicsModel3100B:面板設(shè)置平均氣道壓(mPaw)監(jiān)測(cè)平均氣道壓高限及低限報(bào)警靜音45sec重新設(shè)置(reset)平均氣道壓開始/停止呼吸頻率(Hertz)平均氣道壓設(shè)置(mPaw)偏流設(shè)置(biasflow)Power吸氣時(shí)間設(shè)置(%)

SensorMedicsModel3100B:面板設(shè)置影響氧合與通氣的參數(shù)氧合平均氣道壓(mPaw)吸入氧濃度(FiO2)肺泡復(fù)張操作通氣振蕩幅度(Power)呼吸頻率(Hertz)吸氣時(shí)間(%Itime)氣管插管套囊放氣影響氧合與通氣的參數(shù)氧合通氣平均氣道壓(mPaw)平均氣道壓(mPaw)HFOV參數(shù)對(duì)氧合的影響mPaw5cmH2OmPaw25cmH2O健康家兔Vr以上肺容積(mL)48–50PaO2(mmHg)變化不顯著PaCO2(mmHg)變化不顯著鹽水灌洗后Vr以上肺容積(mL)48–50PaO2(mmHg)42.87.8137.318.3PaCO2(mmHg)變化不顯著BoyntonBR,VillanuevaD,HammondMD,etal.Effectofmeanairwaypressureongasexchangeduringhigh-frequencyoscillatoryventilation.JApplPhysiol1991;70:701-707HFOV參數(shù)對(duì)氧合的影響mPaw5cmH2OmPaw2HFOV參數(shù)對(duì)通氣的影響MinVent=fxVtHFOV參數(shù)對(duì)通氣的影響MinVent=fxVtHFOV參數(shù)對(duì)通氣的影響MinVent=fxVt2HFOV參數(shù)對(duì)通氣的影響MinVent=fxVt2P(Power):影響PaCO2的重要參數(shù)P(Power):影響PaCO2的重要參數(shù)吸氣時(shí)間%(%InspiratoryTime)也能夠控制活塞運(yùn)動(dòng)的時(shí)間,從而影響CO2的清除增加吸氣時(shí)間%還可以通過增加Paw影響肺泡復(fù)張吸氣時(shí)間%吸氣時(shí)間%(%Inspiratory吸氣時(shí)間%吸氣時(shí)間%(I/E比)通過吸氣時(shí)間%調(diào)整吸呼比吸氣時(shí)間=活塞向前運(yùn)動(dòng)呼氣時(shí)間=活塞向后運(yùn)動(dòng)=主動(dòng)呼氣!推薦吸氣時(shí)間=33%+

33%67%吸氣時(shí)間%(I/E比)通過吸氣時(shí)間%調(diào)整吸呼比+33%6呼吸頻率:影響PaCO2的重要參數(shù)呼吸頻率:影響PaCO2的重要參數(shù)不同HFOV呼吸機(jī)的比較PillowJJ,WilkinsonMH,NeilHL,etal.Invitroperformancecharacteristicsofhigh-frequencyoscillatoryventilators.AmJRespirCritCareMed2001;164:1019-1024不同HFOV呼吸機(jī)的比較PillowJJ,Wilkins不同HFOV呼吸機(jī)的比較PillowJJ,WilkinsonMH,NeilHL,etal.Invitroperformancecharacteristicsofhigh-frequencyoscillatoryventilators.AmJRespirCritCareMed2001;164:1019-1024不同HFOV呼吸機(jī)的比較PillowJJ,Wilkins不同HFOV呼吸機(jī)的比較PillowJJ,WilkinsonMH,NeilHL,etal.Invitroperformancecharacteristicsofhigh-frequencyoscillatoryventilators.AmJRespirCritCareMed2001;164:1019-1024不同HFOV呼吸機(jī)的比較PillowJJ,WilkinsHFOV參數(shù)設(shè)置對(duì)潮氣量的影響參數(shù)范圍呼吸頻率,Hz4,6,8,10,12壓力幅度,cmH2O50,60,70,80,90氣管插管直徑,mm6,7,8順應(yīng)性,mL/cmH2O10,30,50平均氣道壓,cmH2O20,30,40偏流,L/min20,30,40吸呼比1:2,1:1HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響參數(shù)范圍呼吸頻率,Hz4,HFOV參數(shù)設(shè)置對(duì)潮氣量的影響參數(shù)增加平均變化,%SD,%模擬肺呼吸頻率+2Hz-21.34.1壓力幅度+10cmH2O+21.43.4氣管插管直徑8–7mm-15.31.7氣管插管直徑7–6mm-18.92.1順應(yīng)性+20mL/cmH2O-3.83.6平均氣道壓+10cmH2O+1.13.6偏流20–30L/min+11.23.9偏流30–40L/min+2.63.1患者呼吸頻率+2Hz-23.16.3壓力幅度+10cmH2O+5.64.5HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響參數(shù)增加平均變化,%SD,HFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslHFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslHFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslHFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響HagerDN,FesslHFOV參數(shù)設(shè)置對(duì)潮氣量的影響HFOV時(shí)潮氣量不一定很低影響潮氣量的主要因素呼吸頻率壓力幅度氣管插管內(nèi)徑HagerDN,FesslerHE,KaczkaDW,etal.Tidalvolumedeliveryduringhigh-frequencyoscillatoryventilationinadultswithacuterespiratorydistresssyndrome.CritCareMed2007;35:1522-1529HFOV參數(shù)設(shè)置對(duì)潮氣量的影響HFOV時(shí)潮氣量不一定很低Ha內(nèi) 容高頻振蕩通氣的臨床應(yīng)用3高頻振蕩通氣的操作原理1高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2內(nèi) 容高頻振蕩通氣的臨床應(yīng)用3高頻振蕩通氣的操作原理1高頻振HFOV的適應(yīng)癥氧合功能衰竭:FiO2

0.7及PEEP>14cmH2O通氣功能障礙:Vt>6ml/kgPBW及平臺(tái)壓30cmH2O時(shí)pH<7.25FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV的適應(yīng)癥氧合功能衰竭:FesslerHE,DerHFOV的適應(yīng)癥ARDS彌漫性雙側(cè)肺浸潤(rùn)影無左心衰的臨床證據(jù)PaO2/FiO2<200mmHg以及傳統(tǒng)機(jī)械通氣48小時(shí)后FiO2>0.6無法維持PaO2>65mmHg(PEEP

15cmH2O)FromIntensiveCare,PrinceofWalesHospitalHFOV的適應(yīng)癥ARDSFromIntensiveCarHFOV的適應(yīng)癥早期應(yīng)用FiO2

0.60,PEEP

10,PaO2/FiO2<200平臺(tái)壓>30cmH2O氧合指數(shù)(OI)>24OI=(FiO2x100)xMAP/PaO2ARDSnet機(jī)械通氣方案失敗HFOV的適應(yīng)癥早期應(yīng)用HFOV的禁忌癥已知嚴(yán)重氣流梗阻顱內(nèi)高壓FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV的禁忌癥已知嚴(yán)重氣流梗阻FesslerHE,DeHFOV的基本原則常規(guī)機(jī)械通氣失敗的ARDS患者可嘗試HFOV.由于尚無研究證實(shí)HFOV能夠改善病死率,因此作為ARDS的常規(guī)治療仍處于研究階段HFOV的通氣目標(biāo)是維持pH7.25–7.35主要通過調(diào)整呼吸頻率而非振蕩壓力幅度盡量使用最高呼吸頻率FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV的基本原則常規(guī)機(jī)械通氣失敗的ARDS患者可嘗試HFOHFOV的基本原則HFOV的氧合目標(biāo)是維持PaO255–80mmHg或SpO288–95%以避免氧中毒或氣道高壓的不良影響迅速進(jìn)行初始設(shè)置及隨后調(diào)整(每5分鐘)達(dá)到穩(wěn)態(tài)后參數(shù)調(diào)整間隔不短于2小時(shí)FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV的基本原則HFOV的氧合目標(biāo)是維持PaO255–實(shí)施HFOV前的準(zhǔn)備工作充分吸痰,保證氣道通暢纖維支氣管鏡檢查應(yīng)在HFOV前進(jìn)行充分鎮(zhèn)靜,鎮(zhèn)痛和(或)肌松評(píng)估患者循環(huán)功能實(shí)施HFOV前的準(zhǔn)備工作充分吸痰,保證氣道通暢HFOV的鎮(zhèn)靜與肌松原則開始HFOV時(shí)應(yīng)充分鎮(zhèn)靜建議聯(lián)合使用苯二氮卓與麻醉藥可加用異丙酚以減少苯二氮卓與麻醉藥劑量調(diào)整鎮(zhèn)靜藥物過程中可間斷應(yīng)用肌松藥物持續(xù)使用肌松藥物時(shí),應(yīng)每日終止一次,以評(píng)估繼續(xù)使用的必要性患者輕微的呼吸動(dòng)作使mPaw改變<5cmH2O無需處理除非氧合或通氣受到影響FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV的鎮(zhèn)靜與肌松原則開始HFOV時(shí)應(yīng)充分鎮(zhèn)靜FessleHFOV的目標(biāo)通氣:維持pH7.20–7.35呼吸性酸中毒失代償(pH<7.20)時(shí)給予NaHCO3.例如:PaCO2>70mmHg,BE正常氧合:PaO255–80mmHg或SpO288–95%FromIntensiveCare,PrinceofWalesHospitalHFOV的目標(biāo)通氣:維持pH7.20–7.35FroHFOV參數(shù)的最初設(shè)置偏流(biasflow)40L/min吸氣時(shí)間33%平均氣道壓34cmH2OFiO21.0

P90cmH2OpHFrequency(Hz)<7.1047.10–7.1957.20–7.356>7.357FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV參數(shù)的最初設(shè)置偏流(biasflow)pHFreqHFOV參數(shù)的初始設(shè)置HFOV前進(jìn)行肺復(fù)張mPaw40cmH2Ox30–40sec若循環(huán)不穩(wěn)定,需隨時(shí)終止操作設(shè)置平均氣道壓血流動(dòng)力學(xué)穩(wěn)定: mPaw@CMV+5cmH2O血流動(dòng)力學(xué)不穩(wěn)定: mPaw@CMV+0–3cmH2O設(shè)置偏流30–40L/min設(shè)置壓力幅度使胸廓振蕩達(dá)到大腿中部設(shè)置呼吸頻率為5Hz設(shè)置吸氣時(shí)間為33%(嚴(yán)重氧合障礙時(shí)50%)FromRespiratoryCare,StanfordHospital&ClinicsHFOV參數(shù)的初始設(shè)置HFOV前進(jìn)行肺復(fù)張F(tuán)romRespHFOV參數(shù)的初始設(shè)置通氣:最高呼吸頻率及最低P若PaCO2>60mmHg

P=60cmH2OFrequency=6Hz若PaCO2>60mmHgP=70cmH2OFrequency=5Hz氧合:mPaw30cmH2O,FiO2

0.60mPaw=mPaw@CMV+5cmH2OmPaw35cmH2OFiO2=1.0FromIntensiveCare,PrinceofWalesHospitalHFOV參數(shù)的初始設(shè)置通氣:最高呼吸頻率及最低P氧合:HFOV參數(shù)的初始設(shè)置胸廓振蕩幅度(chestwigglefactor,CWF)理想狀況應(yīng)達(dá)到大腿中部通氣是否充分的表現(xiàn)振蕩幅度不足肺順應(yīng)性和(或)氣道阻力改變不對(duì)稱時(shí)提示氣胸改變體位后應(yīng)重新評(píng)估HFOV參數(shù)的初始設(shè)置胸廓振蕩幅度(chestwiggleHFOV療效的監(jiān)測(cè)HFOV開始15–20分鐘后檢查ABG以確定PaCO2的改變趨勢(shì)改變參數(shù)30–60分鐘后復(fù)查AGBPaCO2的改善較常規(guī)機(jī)械通氣緩慢HFOV療效的監(jiān)測(cè)HFOV開始15–20分鐘后檢查ABGHFOV參數(shù)的調(diào)整:氧合與通氣氧合惡化每30分鐘增加mPaw2–3cmH2O通氣惡化pH>7.2:每30分鐘增加P10cmH2OP達(dá)到最大值后,逐步降低呼吸頻率至3HzpH<7.2:設(shè)置最大P及呼吸頻率3Hz,套囊放氣除外氣管插管梗阻FromRespiratoryCare,StanfordHospital&ClinicsHFOV參數(shù)的調(diào)整:氧合與通氣氧合惡化FromRespiHFOV參數(shù)的調(diào)整:氧合氧合改善逐步降低FiO2至0.40每4–6小時(shí)降低mPaw2–3cmH2O直至mPaw達(dá)到22–24cmH2OFromRespiratoryCare,StanfordHospital&ClinicsHFOV參數(shù)的調(diào)整:氧合氧合改善FromRespiratHFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzFrequency>12HzSTOPYpH7.25–7.35FesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzHFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzFrequency>12HzSTOPYpH7.25–7.35每2小時(shí)增加f1HzpH>7.35Frequency>15Hz每1–2小時(shí)降低P5–10cmH2OYFesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzHFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzFrequency>12HzSTOPYpH7.25–7.35每1–2小時(shí)增加P5–10cmH2O每2小時(shí)增加f1HzpH>7.35pH<7.25Frequency>15Hz每1–2小時(shí)降低P5–10cmH2OP=90cmH2OYY每2小時(shí)降低f1HzFrequency=3HzYSTOPFesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfromaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzHFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzFrequency>12HzSTOPYpH7.20–7.35增加P5cmH2O增加呼吸頻率1–2HzpH>7.35pH<7.20Frequency>12Hz降低P5cmH2OP20cmH2OSTOPYP=90cmH2OYY套囊放氣降低呼吸頻率1HzFrequency=3HzYSTOPFromIntensiveCare,PrinceofWalesHospitalHFOV參數(shù)的調(diào)整:通氣pH?增加呼吸頻率1–2HzHFOV參數(shù)的調(diào)整:通氣套囊放氣降低套囊壓力至mPaw降低5cmH2O提高偏流使mPaw恢復(fù)到原來水平FromIntensiveCare,PrinceofWalesHospitalHFOV參數(shù)的調(diào)整:通氣套囊放氣FromIntensivHFOV參數(shù)的調(diào)整:氧合FromIntensiveCare,PrinceofWalesHospitalPaO2?SpO2?降低FiO20.1增加mPaw5cmH2OPaO2<55mmHgSpO2<88%mPaw45cmH2O進(jìn)行肺復(fù)張F(tuán)iO2

<0.60YY降低mPaw5cmH2OmPaw20cmH2OYSTOPPaO2>80mmHgSpO2>95%HFOV參數(shù)的調(diào)整:氧合FromIntensiveCaHFOV期間的一般治療HFOV一旦開始,應(yīng)至少持續(xù)12小時(shí)如無禁忌癥,床頭應(yīng)抬高30

使用加熱濕化器而非HME使用密閉吸痰裝置,以免吸痰時(shí)管路脫開如需脫開管路,應(yīng)確定套囊充氣,并鉗夾氣管插管以防肺泡塌陷短暫終止振蕩后,進(jìn)行心臟及腹部聽診如需肺部聽診,可進(jìn)行手法通氣每小時(shí)檢查呼吸機(jī)設(shè)置,直至氧合與通氣達(dá)到目標(biāo)范圍記錄f,biasflow,mPaw,FiO2,P,powersettingFesslerHE,DerdakS,FergusonND,etal.Aprotocolforhigh-frequencyoscillatoryventilationinadults:resultsfomaroundtablediscussion.CritCareMed2007;35:1649-1654HFOV期間的一般治療HFOV一旦開始,應(yīng)至少持續(xù)12小時(shí)吸痰可能因肺泡塌陷導(dǎo)致嚴(yán)重低氧血癥如有可能,最初12小時(shí)內(nèi)不要吸痰以下表現(xiàn)提示需要吸痰近端振蕩幅度突然增加伴胸廓振蕩減弱無法解釋的高碳酸血癥氧需求增加使用密閉吸痰裝置不使用直角接頭吸痰可能因肺泡塌陷導(dǎo)致嚴(yán)重低氧血癥HFOV的并發(fā)癥低血壓低血容量:輸液升壓藥物氣胸進(jìn)行性低血壓及氧合下降mPaw及P無變化聽診無差異,受累側(cè)胸廓振蕩消失氣管插管梗阻頑固性高碳酸血癥胸廓振蕩消失HFOV的并發(fā)癥低血壓HFOV突然終止或管路脫開無后備通氣模式氣道壓力降低時(shí)工作終止床旁準(zhǔn)備復(fù)蘇球囊并連接氧源HFOV突然終止或管路脫開無后備通氣模式內(nèi) 容高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2高頻振蕩通氣的操作原則1高頻振蕩通氣的臨床應(yīng)用3內(nèi) 容高頻振蕩通氣的參數(shù)設(shè)置及調(diào)整2高頻振蕩通氣的操作原則1病例1SRF,M,89yo,119382重癥社區(qū)獲得性肺炎急性呼吸功能衰竭感染性休克PMHx:陳舊性肺結(jié)核,BPH,HTN病例1SRF,M,89yo,119382病例1:HFOV對(duì)氧合及通氣的影響時(shí)間0126101214FiO20.600.600.600.600.500.500.40PC/P20375651515345PEEP/mPaw17302930293030RR/f24555555Biasflow303030303030Ti%335040454550pH7.3877.1727.2787.2217.3497.2487.327PaO286.585.688.885.0162.065149PaCO236.459.542.851.933.451.938.7HCO322.2181918.717.92019.7BE-2.8-6.3-6.2-6.0-6.9-4.3-5.3病例1:HFOV對(duì)氧合及通氣的影響時(shí)間0126101214病例1:HFOV對(duì)氧合及通氣的影響時(shí)間1415.5202430FiO20.400.400.400.400.50PC/P4545484716PEEP/mPaw3030302914RR/f555524Biasflow30303030Ti%50505050pH7.3277.3457.2947.2567.329PaO214910894.8104143PaCO238.738.544.545.739.6HCO319.720.520.918.820.3BE-5.3-4.3-5.0-6.3-4.8病例1:HFOV對(duì)氧合及通氣的影響時(shí)間1415.52024病例1:降低呼吸頻率對(duì)PaCO2的影響時(shí)間059FiO20.400.400.40PC/P565656PEEP/mPaw232323RR/f4.54.54.0Biasflow303030Ti%505050pH7.4767.3887.503PaO211290.282.8PaCO246.157.638.9HCO333.63430.4BE9.27.87.0時(shí)間05