医学专题一呼吸机的使用及撤机.ppt

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1、The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸机的使用呼吸机的使用(shyng)(shyng)及撤机及撤机 路伟娜路伟娜 第一页，共二十九页。The Needs of The Patients and The

2、Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸机系统呼吸机系统(xtng)(xtng)简图简图成立时间：2009年科室人员配置：主任(zhrn)：傅水桥 护士长：徐珏华 目前医生10人，护士28人，其中副主任医师2人，主 治医师4人，住院医师4人。第二页，共二十九页。The N

3、eeds of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸呼吸(hx)(hx)模式模式辅助/控制型(A/C:Assist/Control;CMV)半自主型:同步间歇(jin xi)指令呼吸SIMV自主型(Spontaneous)第三

4、页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First辅助辅助/控制控制(kngzh)(kngzh)模式模式(A/C):(A/C):机控呼吸机控呼吸 临床应用：病人基本没有自主呼吸临床应用：病人基本没有自主

5、呼吸呼吸机根据临床医生的设定呼吸机根据临床医生的设定(sh dn)(sh dn)参数供气：参数供气：潮气量或压力潮气量或压力流速和流速波形，或吸气时间流速和流速波形，或吸气时间呼吸频率呼吸频率由机器启动，也可由病人同步触发通气由机器启动，也可由病人同步触发通气TimePressure第四页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Custom

6、ers Come FirstThe Needs of The Patients and The Customers Come First辅助辅助(fzh)(fzh)/控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸一.控制通气（controlled mechanical ventilation,CMV）呼吸机完全替代自主呼吸的通气方式(fngsh)1.容量控制通气（volume controlled mechanical,VCV）特点：能保证潮气量的供给，完全替代自主呼吸，有利于呼吸机休息；易发生人机对抗、通气不足或同期过度，不利于呼吸机锻炼 2.压力控制通气（pressure con

7、trolled mechanical,PCV）特点：通气功能差、气道压力高的患者；用于ARDS有利于改善换气；新生儿、婴幼儿补偿漏气第五页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First辅助辅助/控制模

8、式控制模式(msh)(msh)(A/C):(A/C):机控呼吸机控呼吸二、辅助通气（Assisted ventilation,AV）关键是预设触发灵敏度和潮气量或吸气压力要恰当三、辅助控制通气（A/C）病人有自主呼吸时，机器随呼吸启动，一旦自发呼吸在一段时间内不发生(fshng)时，机械通气自动由辅助转为控制性通气。它属于间歇正压通气。第六页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of

9、The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 半自主半自主(zzh)(zzh)型型:同步间隙指令通气同步间隙指令通气 (SIMV)(SIMV)临床应用：病人有一定(ydng)频率的自主呼吸由呼吸机强制通气和自主呼吸组合而成强制通气是由机器启动(IMV)或病人触发(SIMV)在自主呼吸时，病人决定潮气量和呼吸频率机器启动的强制(qingzh)通气病人触发的强制通气自主呼吸病人触发TimePressure第七页，共二十九页。The Needs of Th

10、e Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First半自主半自主(zzh)(zzh)型型:同步间隙指令通气同步间隙指令通气 (SIMV)(SIMV)属于辅助通气方式，呼吸机于一定的间歇时间自主呼吸导致气道内负压信号，同步送出气流，间歇进行(jnxng

11、)辅助通气。即（可自主呼吸）若干次自主呼吸后给一次正压通气，保证每分钟通气量，IMV的呼吸频率承认一般小于10次/分。第八页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First自主自主(zzh)型型(Spo

12、ntaneous)临床应用：病人有足够的自主呼吸频率临床应用：病人有足够的自主呼吸频率定义定义要求有主动的自主呼吸驱动力要求有主动的自主呼吸驱动力持续气道内正压通气持续气道内正压通气(CPAP)(CPAP)：在自主呼吸的前提下，：在自主呼吸的前提下，在整个呼吸周期内人为地施以一定程度的气道内正压。在整个呼吸周期内人为地施以一定程度的气道内正压。可防止气道内萎陷可防止气道内萎陷。可提供或不提供吸气支持可提供或不提供吸气支持(PSV)(PSV)呼吸机的工作呼吸机的工作(gngzu)(gngzu)都有病人自主呼吸来控制。都有病人自主呼吸来控制。第九页，共二十九页。The Needs of The P

13、atients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸机参数呼吸机参数(cnsh)(cnsh)时间时间(shjin)(shjin)参数参数压力参数压力参数容量参数容量参数第十页，共二十九页。The Needs of The Patients and Th

14、e Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸机参数设置呼吸机参数设置时间参数：呼吸频率（f）、吸呼比（I/E）容量参数：分钟通气量(Minute Volume，MV)潮气量(Tidal Volume，VT)，VTI，VTE 流量触发灵敏度(Trigger，L/min)压力

15、参数:吸气压力水平(Pi)吸气末正压（Pplateau)呼气(h q)末正压(PEEP)平均气道压(Pmean)气道峰压(Ppeak)第十一页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸机参数设

16、置呼吸机参数设置潮气量 VT 正常肺功能患者：8-12ml/kg COPD或者ARDS患者小潮气量通气：6-8ml/kg 平台压30cmH2O呼吸频率(pnl)（RR）：1218次/分每分通气量呼吸频率潮气量 正常成人约为69L 吸入气氧浓度（FiO2）：能维持理想PaO2的最低FiO2第十二页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Cus

17、tomers Come FirstThe Needs of The Patients and The Customers Come First呼吸机参数设置呼吸机参数设置吸呼比（I/E）：通常设定在1：阻塞性肺疾病：延长呼气时间，有利于CO2排出，如 COPD和哮喘的患者，I：E常小于1：2 限制性疾病：延长吸起时间，有利于改善氧合，如ARDS可适当增加I：E，甚至(shnzh)采用反比通第十三页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Custo

18、mers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First呼吸机参数设置呼吸机参数设置吸气压力水平控制压力水平：在PCV 模式下，需设定吸气压力水平。吸气压力水平的高低取决于病人需要潮气量的大小。压力支持水平：在应用PSV模式时，压力支持水平可通过病人自主呼吸频率和病人所需潮气量来设定。参照依据：如病人自主呼吸频率和潮气量可维持(wich)在1525次min、612ml/kg，那么认为设定的压力水平是恰当的。

19、第十四页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First第十五页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Need

20、s of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First第十六页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients a

21、nd The Customers Come FirstThe Needs of The Patients and The Customers Come First第十七页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Co

22、me First第十八页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First第十九页，共二十九页。The Needs of The Patients and The Customers Come First

23、The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First撤机难易撤机难易(nn y)(nn y)程度分级程度分级简单或容易撤机（60%-70%）困难撤机（20%-25%）直到3次撤机或第一次撤机后7天内才撤机的患者(hunzh)呼吸机依赖（5%-15%）需要3次以上撤机或第一次撤机后超过7天以上才撤机的患者第二十页，共二十九页。T

24、he Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First规范化撤机规范化撤机机械通气患者(hunzh)的每日筛查自主呼吸实验（SBT）气道自洁能力和气道通畅能力的评估第二十一页，共二十九页。The Needs of The P

25、atients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First每日筛查每日筛查第二十二页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients an

26、d The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstSBTSBT的实施的实施(shsh)(shsh)第二十三页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patie

27、nts and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstSBTSBT第二十四页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The

28、Customers Come FirstSBTSBT步骤步骤(bzhu)(bzhu)第二十五页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First气道通畅和气道自洁能力气道通畅和气道自洁能力(nngl)(n

29、ngl)的评的评估估套囊漏气(lu q)实验呛咳、咳嗽情况第二十六页，共二十九页。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First标准标准(biozhn)(biozhn)撤机步骤撤机步骤第二十七页，共二十九页。The

30、 Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 谢谢(xi xie)！第二十八页，共二十九页。内容(nirng)总结呼吸机的使用及撤机。治医师4人，住院医师4人。由机器启动，也可由病人同步触发通气。1.容量控制通气（volume controlled mechanical,VCV）。时间参数：呼吸频率（f）、吸呼比（I/E）。吸呼比（I/E）：通常设定在1：1.5-2.5。参照依据：如病人自主呼吸频率和潮气量可维持(wich)在1525次min、612ml/kg，那么认为设定的压力水平是恰当的。谢谢第二十九页，共二十九页。