机械通气2015.4学会.pptVIP

* * * * * * * * * 机械通气的护理管理 4．清醒病人给予解释，说明目的，并交待上机后注意事项，争取配合。对昏迷、躁动病人予适当镇静和必要的约束，以防意外拔管。 镇静剂：咪唑安定1mg/ml,3-5ml/h泵入，丙泊酚2-5ml/h泵入，Rmsay评分3－4分，病人安静配合 机械通气的护理管理 5．设置通气模式、参数。使用呼吸机前后30min和改变呼吸参数30min,及时查血气分析，根据其结果调整通气量和吸氧浓度。 6、正确设置报警范围，发现报警分析查找原因及时处理，不可单纯消音。 7、保持呼吸机管道通畅，管道衔接紧密,无脱落扭曲, 细听呼吸机声音,发现故障及时解决。 机械通气的护理管理 8.密切观察病人的神志、心率、血压、呼吸、SO2、胸廓起伏、呼吸音是否对称及眼睑、双下肢水肿情况等，发现人机对抗，应及时查找原因，调整通气模式及参数，必要时给予镇静剂，应用镇静评分，确保人机同步。 9.加强气道温湿化，做好气道吸引和气囊管理，气囊不放气，每班测压一次，25－30cmH2O，气体6－8ml，不漏气的最小压力 10.预防VAP，床头抬高30-45度,严格手卫生 呼吸环路的管理 呼吸机管路每周更换一次,若有污染应及时更换，尤其Y型管延长管。管路中冷凝水应及时清除。 呼出回路集水杯应垂直向下，位于管路最低处，防止冷凝水倒流至气管插管或呼吸机内，呼吸回路低于气管插管口，冷凝水细菌浓度高达2*105cFu/ml。  呼吸管路清洗消毒 呼吸管路自动清洗消毒架 先清洗、再消毒、晾干或烘干装入清洁袋内干燥保存备用 呼吸机及附件的消毒 呼出阀（外置) 一定终末高压消毒,呼末端安装细菌过滤器则不需消毒。 压缩机和主机的外露空气过滤网24～72h清洗除尘。封闭的一月清洗一次（Savina） 压缩机每5000-10000h清洁保养。 机身与台面软布每日去除污物与尘埃。 * * * * * * * * * * * * * * * * * * * In the case of Acute Respiratory Distress Syndrome patients or patient with Acute Lung Injury, one can observe on a “Lower Inflexion Point”. The main reason for this can be explained as follow: - on the above picture, when the insufflation starts,only the alveoli “V1” are inflated. There total volume is V1. The alveoli “V2” are not recruited because of the collapsed airway; - but after a given level of pressure, this airway is opened and the alveoli “V2” can be inflated. Above this opening pressure, the total volume is “V1+V2”, and so, it is easy to understand that the compliance is greater. The PEEP level should be adjusted just above this LIP to recruit the maximum number of alveoli. * The above ARDS grey curve, plot in ZEEP, will give the physician an indication of how to set the external PEEP: it is said that a good value should be: Pressure at the LIP + 2 hPa. After having applied the PEEP to the patient for a certain amount of time, one can observe that: 1. The volume in the lungs at PEEP pressure (red curve) is higher than the volume in the chest at the same pressure level on the ARDS grey curve; 2. The slope of the curve during PEEP is