综合呼衰病人的呼吸治疗2008PPT.ppt

Modes of Ventilation SIMV(VC)+PS (92%) PSV (5%) SIMV(PC) or BiPAP/ bilevel (3%) AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 DECISIONS －－MADE BY CRITICAL CARE NURSES 474 patients －－ 81-day study period 319 (67%) received mechanical ventilation Death occurred in 12.5% (40/319) of patients Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9days A total of 3986 ventilation and weaning decisions DECISIONS MADE BY CRITICAL CARE NURSES －－ adjustment to ventilator settings 决定内容 呼吸模式 支持压力调节 潮气量滴定 PEEP 吸氧浓度 决定比例 护士 2538 (64%) 医生 (17%) 联合 (19%) 在严重的呼吸疾病和MODS护士单独决定少 DECISIONS MADE BY CRITICAL CARE NURSES－－Patients’ Outcomes 269/ 319 (84%) 脱机 再插管率 22 / 319 (7%) 20 /22 可再次顺利脱机 死亡率 40 / 319 (12.5%) 脱机前 13 patients (4%), 脱机过程中 17 patients (5%) 成功拔管48小时后 10 patients (3%) 拔管后NIV(无创通气)28 patients (9%) Only 3 patients (1%) self-extubated 2 required reintubation DECISIONS MADE BY CRITICAL CARE NURSES 高水平的责任 高水平的自主性 缺乏公认的指南和流程 呼吸治疗－－呼吸参数的调节 呼吸频率 10-15次/分 COPD和ARDS者例外 ? 潮气量 ALI/ARDS病人 潮气量Patient without ALI 其他指南 2002 BTS NIV guideline Non-invasive ventilation in acute respiratory failure British Thoracic Society Standards of Care Committee 2001 ATS NIV guideline Am. J. Respir. Crit. Care Med., Volume 163, Number 1, January 2001, 283-291 Strong (multiple controlled trials) COPD exacerbations Acute cardiogenic pulmonary edema* Immunocompromised patients with bilateral infiltrates Facilitation of weaning in COPD patients 有创通气阶段 1 需要气管插管进行辅助通气 2 需要完全支持通气 Siemens 900C PB 760 Benett 7200 PB 840 Drager Evita XL 有创通气阶段 呼吸模式四阶段分析法则 C-A-S循环论 呼吸模式四阶段分析法则 模拟生理 1 吸气触发 2 吸气相 3 吸呼切换 4 呼气相 吸气触发 有或无 压力 流量 容量 智能AUTO-TRIGER 吸气相 容量目标－－定容型 压力目标－－定压型 混合目标－－双重控制型 吸气相特点二元分析法 流速特点 波形是否符合生理，易耐受 起始流速快慢与肺泡复张 压力特点 气道压力是否恒定—安