无创正压通气在急性呼吸衰竭中的应用孙兵.pptVIP

* Initial 90-120 minutes * ZXP,45yr,renal transplantation,PCP，first case of RICU * 那么，什么是呼吸机相关肺炎？事实上，把他叫人工气道相关肺炎更合适，因为从发生机制上讲，人工气道与VAP的关系非常密切，换句话讲，如果能拿掉人工气道，VAP就可以避免。 * CASE：康玉芳 * CASE：康玉芳 8-18全用NPPV * CASE：康玉芳 8-21-24使用IPPV * CASE：康玉芳 9.15病情稳定，转至综合科病房 9.29日出院 * CASE：康玉芳 9.15病情稳定，转至综合科病房 9.29日出院 * 10例病人，回顾性研究 Success rate (avoidance of intubation and no further assisted ventilation for 72 h) was achieved on six of nine occasions (66%) when NPPV was used as the initial mode of assisted ventilation. It failed after three episodes of planned (1) or self (2) extubation. Duration of successful NPPV was 64.5 h (23.5 to 80.5 h) with ICU discharge in the next 24 to 48 h for three of six patients. Unsuccessful episodes lasted 7.3 h (0.1 to 116 h) with need for conventional ventilation for an additional 5 days (2.7 to 14 days). Survival (ICU and hospital) for the 10 patients was 70%. * * * Tidal volume of 10 to 15 mg/kg can allow lungs to reach a total lung capacity of healthy lungs. In patients with Sepsis/ARDS, this can cause disruption of alveolar walls: ventilator-induced liquid lung and alveolar rupture (VILLAR) 22% REDUCTION in death * * Tidal volume of 10 to 15 mg/kg can allow lungs to reach a total lung capacity of healthy lungs. In patients with Sepsis/ARDS, this can cause disruption of alveolar walls: ventilator-induced liquid lung and alveolar rupture (VILLAR) 22% REDUCTION in death NPPV干预ARDS入选标准 符合ARDS诊断标准 有明确的ARDS诱因 急性起病，具有相应的临床表现 120mmHg＜PaO2/FiO2≤200mmHg 胸片或胸部CT示肺水肿浸润影 没有左房高压的临床证据 呼吸频率（RR）≥35次/分 有明显的辅助呼吸肌收缩或胸腹矛盾运动 排除标准 超过70岁或小于18岁 PaCO2＞50mmHg Glasgow评分＜11 上气道或颌面部损伤 无力排痰 严重腹胀 拒绝接受NPPV 不能很好配合或面罩不适 气胸或纵隔气肿 严重心律失常或急性心肌缺血 严重的脏器功能不全 Marshall评分≥3或SOFA评分≥3 预计生存时间小于6个月 心肺复苏后 严重慢性肺疾病 ALI/ARDS流行病学基本情况 ? ALI (n＝57) ARDS (n=166) 年龄,岁 49.3±18.0 53.2±19.7 性别,n/n（M/F） 32/21 100/52 ALI/ARDS诱因 ? ? 肺内原因, n(%) 31(58.5) 68(44.7) 肺外原因, n(%) 22(41.5) 84(55.3) PaO2/FiO2,mmHg 235.2±27.1 129.3±37.8 Glasgow评分 13.7±3 12.7±4.0 APACHE II评分 17.3±10.8 18.3±9.9 吸烟指数,年.支 483