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1、COPD的机械通气: Vt, FiO2, what else?,北京协和医院 杜 斌,COPD患者的肺泡过度充盈,Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004; 350: 2689-97,时间常数(), = R x C 测定肺组织充盈或排空的速度 反映肺组织对压力变化的反应速度,时间常数(),Time/Tau,吸气相,呼气相,Pressure,时间常数(),PA(t) = (Pplat - PEEP) e-kt e = 2.718 k = 1
2、/ =1/(R x C) V(t) = Vt x e-kt e = 2.718 k = 1/ =1/(R x C),时间常数(),时间常数 成人(正常值) 2 x 0.10 = 0.20” 术后气管插管成人患者 5 x 0.06 = 0.30” COPD成人患者 15 x 0.06 = 0.90” ARDS成人患者 8 x 0.03 = 0.24” ARDS患儿 5 x 0.01 = 0.05”,动态过度充盈: DHI,insp,exp,Time,Tidal volume,Trapped gas,Lung Volume,FRC,Obstructed Lungs,Normal Stiff Lun
3、gs,机械通气的适应证: COPD,呼吸肌疲劳且濒临呼吸停止 尽管进行充分的保守治疗, PaCO2仍进行性升高 劳累和(或)高碳酸血症导致意识状态恶化 高浓度吸氧治疗无效的低氧血症 痰液清除障碍导致病情恶化 呼吸骤停,COPD患者的病理生理改变,内源性PEEP过高 肺泡过度膨胀 胸腔内压过高 回心血量减少 休克,机械通气时的PEEPi Vt 10 12 ml/kg, f 12 15 bpm, I:E 1:2 3,DHI和PEEPi的影响因素,DHI和PEEPi的影响因素,机械通气参数的设置: COPD,潮气量 吸气流速 吸呼比 / 吸气时间 / 呼气时间 呼吸频率 ,COPD: 不同吸气气流的
4、比较,Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104,COPD: 不同吸气气流的比较,Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Insp
5、iratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104,COPD: 不同吸气气流的比较,Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respi
6、ratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104,COPD: 不同吸气气流的比较,Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation.
7、 Chest 2002; 122: 20962104,COPD: 不同吸气气流的比较,Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104,COPD: 不同吸气气流的比较,结 论 COPD患者机械通气的最佳吸气气流为
8、减速气流 通过选择适宜的吸气气流, 有可能改善上述患者的通气,Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104,COPD机械通气策略,降低内源性PEEP的方法 外源性PEEP ? 延长呼气时间 增加吸气流速 缩短
9、吸气末暂停 降低呼吸频率,呼气流速,Palv,PEEP,Flow = P / Raw = (Palv PEEP) / Raw,Flow,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,Compliance,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Eff
10、ect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,Compliance P ,Flow ,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anes
11、th Analg 2005; 100: 1112-6,半径,PEEP,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,PEEP,半径,流速?,P,流速,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expirat
12、ory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,PEEP与呼气流速,Savian C,
13、Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,半径,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflati
14、on. Anesth Analg 2005; 100: 1112-6,半径,Flow ,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,半径,PEEP,PEEP与呼气流速,Savian C, Chan P, Paratz J. The Effect of Positive End-Expirat
15、ory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6,PEEP,半径,流速,P,流速,COPD稳定期患者(n = 9),年龄(yr) 70 7.3 FEV1 (%pred) 30 9.5 FVC (%pred) 53 13.6 RV (%pred) 186 33.1 FEV1/VC (%) 44 11.6 TLC (%pred) 103 8.7 TLCO (%pred) 46 25.4 PaO2 (kPa) 7.4 0.4 PaCO2 (kP
16、a) 7.1 1.1 pH 7.40 0.00,ODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539,COPD稳定期: PEEP,ODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume
