高频振荡通气的临床应用课件.ppt

高频振荡通气的临床应用,北京协和医院杜斌,内容,高频振荡通气的操作原理,1,高频振荡通气的参数设置及调整,2,高频振荡通气的临床应用,3,内容,高频振荡通气的参数设置及调整,2,高频振荡通气的临床应用,3,高频振荡通气的操作原理,1,SensorMedics Model 3100B:面板设置,平均气道压(mPaw)监测平均气道压高限及低限报警静音45 sec重新设置(reset)平均气道压开始/停止,呼吸频率(Hertz)平均气道压设置(mPaw)偏流设置(bias flow)Power吸气时间设置(%),影响氧合与通气的参数,氧 合平均气道压(mPaw)吸入氧浓度(FiO2)肺泡复张操作,通 气振荡幅度(Power)呼吸频率(Hertz)吸气时间(%I time)气管插管套囊放气,平均气道压(mPaw),HFOV参数对氧合的影响,Boynton BR,Villanueva D,Hammond MD,et al.Effect of mean airway pressure on gas exchange during high-frequency oscillatory ventilation.J Appl Physiol 1991;70:701-707,HFOV参数对通气的影响,MinVent=f x Vt,HFOV参数对通气的影响,MinVent=f x Vt2,P(Power):影响PaCO2的重要参数,吸气时间%(%InspiratoryTime)也能够控制活塞运动的时间,从而影响CO2的清除增加吸气时间%还可以通过增加Paw影响肺泡复张,吸气时间%,吸气时间%(I/E比),通过吸气时间%调整吸呼比吸气时间=活塞向前运动呼气时间=活塞向后运动=主动呼气!推荐吸气时间=33%,+,33%,67%,呼吸频率:影响PaCO2的重要参数,不同HFOV呼吸机的比较,Pillow JJ,Wilkinson MH,Neil HL,et al.In vitro performance characteristics of high-frequency oscillatory ventilators.Am J Respir Crit Care Med 2001;164:1019-1024,不同HFOV呼吸机的比较,Pillow JJ,Wilkinson MH,Neil HL,et al.In vitro performance characteristics of high-frequency oscillatory ventilators.Am J Respir Crit Care Med 2001;164:1019-1024,不同HFOV呼吸机的比较,Pillow JJ,Wilkinson MH,Neil HL,et al.In vitro performance characteristics of high-frequency oscillatory ventilators.Am J Respir Crit Care Med 2001;164:1019-1024,HFOV参数设置对潮气量的影响,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,HFOV参数设置对潮气量的影响,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,HFOV参数设置对潮气量的影响,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,HFOV参数设置对潮气量的影响,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,HFOV参数设置对潮气量的影响,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,HFOV参数设置对潮气量的影响,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,HFOV参数设置对潮气量的影响,HFOV时潮气量不一定很低影响潮气量的主要因素呼吸频率压力幅度气管插管内径,Hager DN,Fessler HE,Kaczka DW,et al.Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.Crit Care Med 2007;35:1522-1529,内容,高频振荡通气的临床应用,3,高频振荡通气的操作原理,1,高频振荡通气的参数设置及调整,2,HFOV的适应症,氧合功能衰竭:FiO2 0.7及PEEP 14 cmH2O通气功能障碍:Vt 6 ml/kg PBW及平台压 30 cmH2O时pH 7.25,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV的适应症,ARDS弥漫性双侧肺浸润影无左心衰的临床证据PaO2/FiO2 0.6无法维持PaO2 65mmHg(PEEP 15 cmH2O),From Intensive Care,Prince of Wales Hospital,HFOV的适应症,早期应用FiO2 0.60,PEEP 10,PaO2/FiO2 30 cmH2O氧合指数(OI)24OI=(FiO2 x 100)x MAP/PaO2ARDSnet机械通气方案失败,HFOV的禁忌症,已知严重气流梗阻颅内高压,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV的基本原则,常规机械通气失败的ARDS患者可尝试HFOV.由于尚无研究证实HFOV能够改善病死率,因此作为ARDS的常规治疗仍处于研究阶段HFOV的通气目标是维持pH 7.25 7.35主要通过调整呼吸频率而非振荡压力幅度尽量使用最高呼吸频率,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV的基本原则,HFOV的氧合目标是维持PaO2 55 80 mmHg或SpO2 88 95%以避免氧中毒或气道高压的不良影响迅速进行初始设置及随后调整(每5分钟)达到稳态后参数调整间隔不短于2小时,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,实施HFOV前的准备工作,充分吸痰,保证气道通畅纤维支气管镜检查应在HFOV前进行充分镇静,镇痛和(或)肌松评估患者循环功能,HFOV的镇静与肌松原则,开始HFOV时应充分镇静建议联合使用苯二氮卓与麻醉药可加用异丙酚以减少苯二氮卓与麻醉药剂量调整镇静药物过程中可间断应用肌松药物持续使用肌松药物时,应每日终止一次,以评估继续使用的必要性患者轻微的呼吸动作使mPaw改变 5 cmH2O无需处理除非氧合或通气受到影响,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV的目标,通气:维持pH 7.20 7.35呼吸性酸中毒失代偿(pH 70 mmHg,BE正常氧合:PaO2 55 80 mmHg或SpO2 88 95%,From Intensive Care,Prince of Wales Hospital,HFOV参数的最初设置,偏流(bias flow)40 L/min吸气时间33%平均气道压34 cmH2OFiO21.0P90 cmH2O,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV参数的初始设置,HFOV前进行肺复张mPaw 40 cmH2O x 30 40 sec若循环不稳定,需随时终止操作设置平均气道压血流动力学稳定:mPaw CMV+5 cmH2O血流动力学不稳定:mPaw CMV+0 3 cmH2O设置偏流30 40 L/min设置压力幅度使胸廓振荡达到大腿中部设置呼吸频率为5 Hz设置吸气时间为33%(严重氧合障碍时50%),From Respiratory Care,Stanford Hospital&Clinics,HFOV参数的初始设置,通气:最高呼吸频率及最低P若PaCO2 60 mmHg P=60 cmH2OFrequency=6 Hz若PaCO2 60 mmHgP=70 cmH2OFrequency=5 Hz,氧合:mPaw 30 cmH2O,FiO2 0.60mPaw=mPaw CMV+5 cmH2OmPaw 35 cmH2OFiO2=1.0,From Intensive Care,Prince of Wales Hospital,HFOV参数的初始设置,胸廓振荡幅度(chest wiggle factor,CWF)理想状况应达到大腿中部通气是否充分的表现振荡幅度不足肺顺应性和(或)气道阻力改变不对称时提示气胸改变体位后应重新评估,HFOV疗效的监测,HFOV开始15 20分钟后检查ABG以确定PaCO2的改变趋势改变参数30 60分钟后复查AGBPaCO2的改善较常规机械通气缓慢,HFOV参数的调整:氧合与通气,氧合恶化每30分钟增加mPaw 2 3 cmH2O通气恶化pH 7.2:每30分钟增加P 10 cmH2OP达到最大值后,逐步降低呼吸频率至3 HzpH 7.2:设置最大P及呼吸频率3 Hz,套囊放气除外气管插管梗阻,From Respiratory Care,Stanford Hospital&Clinics,HFOV参数的调整:氧合,氧合改善逐步降低FiO2至0.40每4 6小时降低mPaw 2 3 cmH2O直至mPaw达到22 24 cmH2O,From Respiratory Care,Stanford Hospital&Clinics,HFOV参数的调整:通气,pH?,增加呼吸频率1 2 Hz,Frequency 12 Hz,STOP,Y,pH 7.25 7.35,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV参数的调整:通气,pH?,增加呼吸频率1 2 Hz,Frequency 12 Hz,STOP,Y,pH 7.25 7.35,每2小时增加f 1 Hz,pH 7.35,Frequency 15 Hz,每1 2小时降低P 5 10 cmH2O,Y,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV参数的调整:通气,pH?,增加呼吸频率1 2 Hz,Frequency 12 Hz,STOP,Y,pH 7.25 7.35,每1 2小时增加P 5 10 cmH2O,每2小时增加f 1 Hz,pH 7.35,pH 7.25,Frequency 15 Hz,每1 2小时降低P 5 10 cmH2O,P=90 cmH2O,Y,Y,每2小时降低f 1 Hz,Frequency=3 Hz,Y,STOP,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results from a roundtable discussion.Crit Care Med 2007;35:1649-1654,HFOV参数的调整:通气,pH?,增加呼吸频率1 2 Hz,Frequency 12 Hz,STOP,Y,pH 7.20 7.35,增加P 5 cmH2O,增加呼吸频率1 2 Hz,pH 7.35,pH 7.20,Frequency 12 Hz,降低P 5 cmH2O,P 20 cmH2O,STOP,Y,P=90 cmH2O,Y,Y,套囊放气降低呼吸频率1 Hz,Frequency=3 Hz,Y,STOP,From Intensive Care,Prince of Wales Hospital,HFOV参数的调整:通气,套囊放气降低套囊压力至mPaw降低5 cmH2O提高偏流使mPaw恢复到原来水平,From Intensive Care,Prince of Wales Hospital,HFOV参数的调整:氧合,From Intensive Care,Prince of Wales Hospital,PaO2?SpO2?,降低FiO2 0.1,增加mPaw 5 cmH2O,PaO2 55 mmHgSpO2 88%,mPaw 45 cmH2O,进行肺复张,FiO2 0.60,Y,Y,降低mPaw 5 cmH2O,mPaw 20 cmH2O,Y,STOP,PaO2 80 mmHgSpO2 95%,HFOV期间的一般治疗,HFOV一旦开始,应至少持续12小时如无禁忌症,床头应抬高30使用加热湿化器而非HME使用密闭吸痰装置,以免吸痰时管路脱开如需脱开管路,应确定套囊充气,并钳夹气管插管以防肺泡塌陷短暂终止振荡后,进行心脏及腹部听诊如需肺部听诊,可进行手法通气每小时检查呼吸机设置,直至氧合与通气达到目标范围记录f,bias flow,mPaw,FiO2,P,power setting,Fessler HE,Derdak S,Ferguson ND,et al.A protocol for high-frequency oscillatory ventilation in adults:results fom a roundtable discussion.Crit Care Med 2007;35:1649-1654,吸痰,可能因肺泡塌陷导致严重低氧血症如有可能,最初12小时内不要吸痰以下表现提示需要吸痰近端振荡幅度突然增加伴胸廓振荡减弱无法解释的高碳酸血症氧需求增加使用密闭吸痰装置不使用直角接头,HFOV的并发症,低血压低血容量:输液 升压药物气胸进行性低血压及氧合下降mPaw及P无变化听诊无差异,受累侧胸廓振荡消失气管插管梗阻顽固性高碳酸血症胸廓振荡消失,HFOV突然终止或管路脱开,无后备通气模式气道压力降低时工作终止床旁准备复苏球囊并连接氧源,内容,高频振荡通气的参数设置及调整,2,高频振荡通气的操作原则,1,高频振荡通气的临床应用,3,病例1,SRF,M,89yo,119382重症社区获得性肺炎急性呼吸功能衰竭感染性休克PMHx:陈旧性肺结核,BPH,HTN,病例1:HFOV对氧合及通气的影响,病例1:HFOV对氧合及通气的影响,病例1:降低呼吸频率对PaCO2的影响,病例1:HFOV对血流动力学的影响,病例1:HFOV对血流动力学的影响,病例2,YBF,M,86 yo,C805588胃穿孔,急性腹膜炎,剖腹探查术后,肺部感染,感染性休克PMHx:HTN,病例2:HFOV对氧合及通气的影响,总结,HFOV安全有效的机械通气方式常规机械通气的辅助手段需要积累更多的临床经验,