機(jī)械通氣波形分析VentilatorGraphicsVentilatorGraphicsMechanicalVentilationGraphicsSCALARSLOOPSVentilatorGraphicsSCALARSFlow/TimePressure/TimeVolume/TimeVentilatorGraphicsLOOPSPressure-Volume800-5.0102030401000700600500400300200InspirationExpiration-70-50050Flow-Volume70InspirationPIFRExpirationPEFRVentilatorGraphics波形分析的意義：（一）、增加人機(jī)同步性、合理的參數(shù)設(shè)置（二）、呼吸力學(xué)的分析VentilatorGraphics（一）人機(jī)同步性–發(fā)生率Patient-ventilatorasynchronyduringassistedmechanicalventilationThilleAW,etal,ICM2006Oct:32(10)1515-22VentilatorGraphicsdeWitM,MillerKB,GreenDA,OstmanHE,GenningsC,EpsteinSK(2009)Ineffectivetriggeringpredictsincreaseddurationofmechanicalventilation.CritCareMed37:2740–2745NavaS,BruschiC,FracchiaC,BraschiA,RubiniF(1997)Patient-ventilatorinteractionandinspiratoryeffortduringpressuresupportventilationinpatientswithdifferentpathologies.EurRespirJ10:177–183PurroA,AppendiniL,DeGaetanoA,GudjonsdottirM,DonnerCF,RossiA(2000)Physiologicdeterminantsofventilatordependenceinlong-termmechanicallyventilatedpatients.AmJRespirCritCareMed161:1115–1123（一）人機(jī)同步性–發(fā)生率值得注意的是，阻塞性肺疾病的患者更容易產(chǎn)生auto-PEEP或者無效觸發(fā)，因為這些病人需要更長的呼氣時間才能呼氣完全VentilatorGraphicsThilleAW,RodriguezP,CabelloB,LelloucheF,BrochardL(2006)Patientventilatorasynchronyduringassistedmechanicalventilation.IntensiveCareMed32:1515–1522DeWitM,MillerKB,GreenDA,OstmanHE,GenningsC,EpsteinSK(2009)Ineffectivetriggeringpredictsincreaseddurationofmechanicalventilation.CritCareMed37:2740–2745BosmaK,FerreyraG,AmbrogioC,PaseroD,MirabellaL,BraghiroliA,AppendiniL,MasciaL,RanieriVM(2007)Patient-ventilatorinteractionandsleepinmechanicallyventilatedpatients:pressuresupportversusproportionalassistventilation.CritCareMed35:1048–1054ChaoDC,ScheinhornDJ,Stearn-HassenpflugM(1997)Patientventilatortriggerasynchronyinprolongedmechanicalventilation.Chest112:1592–1599VignauxL,VargasF,RoeselerJ,TassauxD,ThilleAW,KossowskyMP,BrochardL,JollietP(2009)Patientventilatorasynchronyduringnoninvasiveventilationforacuterespiratoryfailure:amulticenterstudy.IntensiveCareMed35:840–846DimitrisGeorgopoulos;Editorial:Ineffectiveeffortsduringmechanicalventilation:thebrainwants,themachinedeclines;IntensiveCareMed(2012)38:738–740DOI10.1007/s00134-012-2497-0KondiliE,PrinianakisG,GeorgopoulosD(2003)Patient-ventilatorinteraction.BrJAnaesth91:106–119（一）人機(jī)同步性–影響VentilatorGraphics（一）人機(jī)同步性–四個過程觸發(fā)吸氣吸呼氣切換呼氣VentilatorGraphics（一）人機(jī)同步性–觸發(fā)困難流量觸發(fā)：Trigger設(shè)置3L/min11VentilatorGraphicsImagefromdeWitM,MillerKB,GreenDA,OstmanHE,GenningsC,EpsteinSK:Ineffectivetriggeringpredictsincreaseddurationofmechanicalventilation.CritCareMed.2009;37(10):2740-2745.（一）人機(jī)同步性–無效觸發(fā)VentilatorGraphics人機(jī)同步性如何？（一）人機(jī)同步性–觸發(fā)延遲VentilatorGraphicsVentilatorGraphics（一）人機(jī)同步性–誤觸發(fā)心臟振蕩、管路積水、管路漏氣、不適當(dāng)?shù)脑O(shè)定VentilatorGraphicsFlow(L/min)Time(sec)NormalAbnormal患者吸氣努力（一）人機(jī)同步性–流量限制PVTVentilatorGraphicsVolumePressureFlowcmH2O01234756403530252015105.0流速凹陷（一）人機(jī)同步性–流速饑渴VentilatorGraphics（一）人機(jī)同步性–提供流量FernandezAJRCCM 1999:159:710VentilatorGraphics（一）人機(jī)同步性–壓力上升時間壓力上升過快壓力上升過慢VentilatorGraphicsFlowInteractivityandSynchronyUS0910避免流速波形的“Ringing”(減小斜率/增加上升時間)（一）人機(jī)同步性–壓力上升時間VentilatorGraphics-800PCVW/OActiveValveSpontaneousEfforts246PCVwithActiveValve12sPCIRCcmH2O40302010010-20SpontaneousEfforts8 10INSP806040200204060.V

LminEXP（一）人機(jī)同步性–吸呼氣切換GoodVentilatorGraphicsFlow呼氣靈敏度相同呼氣靈敏度Time（一）人機(jī)同步性–吸呼氣切換VentilatorGraphicsTargetPressurePEEPTime(s)在典型的25-30%呼氣靈敏度設(shè)置下出現(xiàn)的切換延遲切換延遲AirwayPressureFlow（一）人機(jī)同步性–吸呼氣切換VentilatorGraphicsAirwayPressureFlow漏觸發(fā)漏觸發(fā)是撤機(jī)延遲的常見原因TargetPressurePEEP漏觸發(fā)23|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人機(jī)同步性–吸呼氣切換VentilatorGraphicsFlowTime（一）人機(jī)同步性–吸呼氣切換合適的呼氣靈敏度合適的呼氣靈敏度VentilatorGraphics低的上升斜率=低的峰流速25%峰流速TimeFlow25|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人機(jī)同步性–吸呼氣切換VentilatorGraphics123456SEC-120.VL/min增加流速使得吸氣時間縮短120（一）人機(jī)同步性–吸呼氣切換VentilatorGraphicsAirwayPressureTargetPressurePEEPTime(s)Flow27|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人機(jī)同步性–吸呼氣切換VentilatorGraphicsFlow/TimeFlow-1400123Auto-PEEP4 5 6 7InspirationFlow(L/m)/mVolume(ml)NormalAbnormalExpiration（一）人機(jī)同步性–呼氣時間VentilatorGraphicsS29|CovidienRespiratoryandMonitoringSolutions|7/7浙/234561VTmL（一）人機(jī)同步性–呼氣時間Auto-PEEP:呼氣支沒有回到基線下一次吸氣開始于呼氣支可能回到基線之前800VentilatorGraphicsS漏氣:呼氣支沒有回到基線下一次吸氣在可能回到基線的呼氣支之后開始800230|CovidienRespiratoryandMonitoringSolutions|7/7浙/34561VTmL（一）人機(jī)同步性–呼氣時間VentilatorGraphicsFlow/TimeFlow0.001234 5 6 77cmH2O－內(nèi)源性PEEP-2cmH2O設(shè)定的靈敏度-9cmH2O實際觸發(fā)值（一）人機(jī)同步性–PEEP的指導(dǎo)VentilatorGraphicsFlow呼氣（一）人機(jī)同步性–PEEP的指導(dǎo)=32|CovidienRespiratoryandMonitoringSolutions|7/7浙/VentilatorGraphicsFlowAuto-PEEP有時患者的自主努力不足以觸發(fā)呼吸機(jī)時，自主努力就成了無效做功.33|CovidienRespiratoryandMonitoringSolutions|7/7浙/（一）人機(jī)同步性–PEEP的指導(dǎo)VentilatorGraphics（一）波形分析--增加人機(jī)同步VentilatorGraphicsElastance順應(yīng)性volumetransthoracicpressuretransairwaypressuretransrespiratorypressureResistance阻力（二）呼吸力學(xué)–力學(xué)模型flowCO2O2VentilatorGraphicsFlowxresistance(Volume/compliance)+PEEPA(PAW)（二）呼吸力學(xué)–力學(xué)方程VentilatorGraphicsPaw (cmH2O)NormalPPlatIncreasedPIP}PIPNormalPPlatFlow/timeFlo.0w01 2 3 4 5 6 7Pre/PostBDincreasingsetVIlooksthesameObstructiveLungDisease/阻塞性肺疾病前PEFR