无创正压通气在急性呼吸衰竭中的应用.PPT

经有创通气行气管镜检查 病例 女，61岁,干燥综合征，系统红斑狼疮，间质性肺炎 因“发热、咳嗽咯痰4天”于2006-8-11入住风湿免疫科 长期口服激素（美卓乐25mg/d）及免疫抑制剂（骁悉 0.5 tid） 8月18日呼吸困难加重，发热，体温39 ℃ ABG（FiO2 50％）: pH 7.56 PO2 35.8 PCO2 30.3 2006-8-18 2006-8-21 2006-8-22 2006-8-24 2006-8-21 拔管前情况 　 HR RR 模式 ΔPS PEEP PaO2 PaO2/FiO2 2006-8-24- 2PM(拔管前) 91 39 PSV 18 12 65.8 110 2006-8-24- 4PM(拔管后) 104 45 CPAP 0 9 74.4 100 2006-8-25 90 38 CPAP 0 10 71.6 110 2006-8-26 88 32 CPAP 0 10 69.8 116 2006-8-28 100 29 CPAP 0 10 91.8 153 2006-9-1 105 31 CPAP 0 7 71 158 2006-9-6 104 28 CPAP 0 6 83.5 186 2006-9-9 100 26 CPAP 0 5 78 200 拔管前后变化 　 HR RR 模式 ΔPS PEEP PaO2 PaO2/FiO2 2006-8-24- 2PM(拔管前) 91 39 PSV 18 12 65.8 110 2006-8-24- 4PM(拔管后) 104 45 CPAP 0 9 74.4 100 2006-8-25 90 38 CPAP 0 10 71.6 110 2006-8-26 88 32 CPAP 0 10 69.8 116 2006-8-28 100 29 CPAP 0 10 91.8 153 2006-9-1 105 31 CPAP 0 7 71 158 2006-9-6 104 28 CPAP 0 6 83.5 186 2006-9-9 100 26 CPAP 0 5 78 200 9.15转至综合科病房，9.29日出院 免疫抑制合并呼吸衰竭的呼吸支持策略 灵活选择NPPV与IPPV NPPV：避免气管插管的一线治疗，辅助早期拔管 IPPV：NPPV的补救手段，保障气管镜检查的安全 Rocker GM,et al.Chest 1999;115:173–177 Success rate ：66% Survival (ICU and hospital) for the 10 patients was 70% NPPV for ALI/ARDS Observational cohort study,2 ICU 54/79 ALI/ARDS initially treated with NPPV 70.3% failed NPPV NPPV failure predicted by: Shock: all 19 pats with shock failed to NPPV Metabolic acidosis:7.37 (7.26–7.43) vs 7.39 (7.32–7.45) Severe hypoxemia:112 (70–157) vs 147 (118–209) critical care,2006;10:R79 Design: Prospective, multiple-center cohort study Setting: 3 European ICU having expertise with NPPV Patients: Between March 2002 and April 2004 479 patients with ARDS were admitted to the ICU 332 ARDS patients were already intubated 147 were eligible for the study Crit Care Med 2007; 35:18–25 Avoided intubation in 79 patients (54%) Less VAP: 2% vs 20%, p 0.001 Lower ICU mortality rate: 6% vs 53%, p0.001 NPPV failure predictor: SAPS II 34 PaO2/FIO2 175 after 1 hr of NPPV ALI/ARDS登记研究流程 所有ALI/ARDS 符合入选标准 获取知情同意 随机分组 观察，填写表格 观察结束后7 天内邮寄表格 Y N 排除