力学机械通气的呼吸力学基础教程幻灯片课件.ppt

auto PEEP的处理 改变呼吸机参数 增加呼气时间， 减少通气频率， 减少潮气量 降低病人的通气需要 减少碳水化合物的摄取，减少死腔通气，治疗焦虑、寒战、疼痛、发热 减低呼吸道阻力（用大口径的气管插管，经常吸痰避免分泌物潴留，应用支气管扩张剂） 加用适当的外源性PEEP，一般为PEEPi的75%左右 外源性PEEP改善触发的机理 重症哮喘患者外源性PEEP的影响 死腔通气问题 解剖死腔 正常人100-150ml 机械通气时可明显增大（延长管、湿化器） 肺泡死腔 肺栓塞时VD/VT可显著增大（0.6） COPD、Asthma时V/Q比例失衡， VD/VT增大 VD/VT增大将导致分钟通气量显著增大 呼吸力学测定的质量控制 No significant leaks Compliance should subtract out circuit compliance, especially in pediatrics Manual calculations often contribute to errors Respiratory Mechanics Requirements For Accuracy The patient must be at rest during peak and plateau pressure measurements Adding plateau should not restrict exhalation and create auto-PEEP Plateau time must not be too short or too long  Patient Effort During Inspiratory Plateau P T Diaphragm Efforts Plateau Pressure = ?? Plateau Time Too Short 500 20-5 = 33 ml / cmH20 500 15 - 5 = 50 ml / cmH20 Results in falsely low compliance values ! Displayed Plateau Pressure 20 cm PEEP 5 cm Actual Plateau Pressure 15 cm VTE 500 cc P T Static Compliance Leaks and/or Too Long a Plateau 500 15-5 = 50 ml / cmH20 500 10 - 5 = 100 ml / cmH20 Results in falsely high compliance values ! Displayed Plateau Pressure 10 cm PEEP 5 cm Actual Plateau Pressure 15 cm VTE 500 cc P T Air Leak Volume (ml) Time (sec) Air Leak Volume Change = Pressure Difference x Compliance of the Balloon Volume Pressure D V D P C = D V D P 顺应性 静态顺应性与动态顺应性 顺应性—肺的“硬度”或弹性变性能力 Static —No flow dynamic —flow and resistance 肺顺应性监测的意义 静态顺应性（Cs）反映肺和胸壁的弹性（弹性阻力）特征,排除了气道阻力成分 动态顺应性（Cd）反映气道的阻力（非弹性阻力）和呼吸系统弹性（弹性阻力）特征，气道阻力可明显影响Cd的水平 顺应性的动态变化趋势更有意义 顺应性测定要求 The gold standard for measuring compliance and resistance utilizes a volume breath delivered with a square wave flow and adequate plateau 40 PCIRCcmH2O INSP L min EXP PLOT SETUP 30 20 10 0 10 -20 80 60 40 20 0 20 -80 40 60 V . 0 4 8 12s 2 6 10 UNFREEZE Compliance Calculations 500 15-5 = 50 ml/cmH20 Compliance = Vte Plateau - PEEP Plateau P