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1、The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机的使用及撤机呼吸机的使用及撤机 路伟娜路伟娜 The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机系统简图呼吸机系统简图成立时间：2009年科室人员配置：主任：傅水桥 护士长：徐珏华 目前医生10人，护士28
2、人，其中副主任医师2人，主 治医师4人，住院医师4人。The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸模式呼吸模式辅助/控制型(A/C:Assist/Control; CMV)半自主型: 同步间歇指令呼吸SIMV自主型(Spontaneous)The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come
3、 FirstCome First辅助辅助/ /控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸 临床应用：病人基本没有自主呼吸临床应用：病人基本没有自主呼吸呼吸机根据临床医生的设定参数供气：呼吸机根据临床医生的设定参数供气：潮气量或压力潮气量或压力流速和流速波形，或吸气时间流速和流速波形，或吸气时间呼吸频率呼吸频率由机器启动，也可由病人同步触发通气由机器启动，也可由病人同步触发通气TimePressureThe Needs of The Patients and The Customers The Needs of The Patients and The Customers Come
4、 FirstCome First辅助辅助/ /控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸一.控制通气（controlled mechanical ventilation,CMV） 呼吸机完全替代自主呼吸的通气方式 1.容量控制通气（volume controlled mechanical,VCV） 特点：能保证潮气量的供给，完全替代自主呼吸，有利于呼吸机休息；易发生人机对抗、通气不足或同期过度，不利于呼吸机锻炼 2.压力控制通气（pressure controlled mechanical,PCV） 特点：通气功能差、气道压力高的患者；用于ARDS有利于改善换气；新生儿、婴幼儿补
5、偿漏气The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First辅助辅助/ /控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸二、辅助通气（Assisted ventilation,AV） 关键是预设触发灵敏度和潮气量或吸气压力要恰当三、辅助控制通气（A/C） 病人有自主呼吸时，机器随呼吸启动，一旦自发呼吸在一段时间内不发生时，机械通气自动由辅助转为控制性通气。它属于间歇正压通气。The Needs of The Patients
6、 and The Customers The Needs of The Patients and The Customers Come FirstCome First 半自主型半自主型: :同步间隙指令通气同步间隙指令通气 (SIMV)(SIMV)临床应用：病人有一定频率的自主呼吸由呼吸机强制通气和自主呼吸组合而成强制通气是由机器启动(IMV)或病人触发(SIMV)在自主呼吸时，病人决定潮气量和呼吸频率机器启动机器启动的强制通气的强制通气病人触发的强制通气病人触发的强制通气自主呼吸自主呼吸病人触发病人触发TimePressureThe Needs of The Patients and The
7、 Customers The Needs of The Patients and The Customers Come FirstCome First半自主型半自主型: :同步间隙指令通气同步间隙指令通气 (SIMV)(SIMV)属于辅助通气方式，呼吸机于一定的间歇时间自主呼吸导致气道内负压信号，同步送出气流，间歇进行辅助通气。即（可自主呼吸）若干次自主呼吸后给一次正压通气，保证每分钟通气量，IMV的呼吸频率承认一般小于10次/分。The Needs of The Patients and The Customers The Needs of The Patients and The Cust
8、omers Come FirstCome First自主型自主型(Spontaneous)(Spontaneous)临床应用：病人有足够的自主呼吸频率临床应用：病人有足够的自主呼吸频率定义定义要求有主动的自主呼吸驱动力要求有主动的自主呼吸驱动力持续气道内正压通气持续气道内正压通气(CPAP)(CPAP)：在自主呼吸的前：在自主呼吸的前提下，在整个呼吸周期内人为地施以一定程度提下，在整个呼吸周期内人为地施以一定程度的气道内正压。可防止气道内萎陷的气道内正压。可防止气道内萎陷。可提供或不提供吸气支持可提供或不提供吸气支持(PSV)(PSV)呼吸机的工作都有病人自主呼吸来控制。呼吸机的工作都有病人自
9、主呼吸来控制。The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机参数呼吸机参数时间参数时间参数压力参数压力参数容量参数容量参数The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机参数设置呼吸机参数设置时间参数：呼吸频率（f）、吸呼比（I/E）容量参数：分钟通
10、气量 (Minute Volume，MV ) 潮气量(Tidal Volume，VT)，VTI，VTE 流量触发灵敏度 (Trigger ，L/min)压力参数: 吸气压力水平 (Pi) 吸气末正压（Pplateau ) 呼气末正压 (PEEP) 平均气道压( Pmean ) 气道峰压( Ppeak )The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机参数设置呼吸机参数设置潮气量 VT 正常肺功能患者：8-12ml/kg C
11、OPD或者ARDS患者小潮气量通气：6-8ml/kg 平台压30cmH2O呼吸频率（RR）：1218次/分每分通气量呼吸频率潮气量 正常成人约为69L 吸入气氧浓度（FiO2）：能维持理想PaO2的最低FiO2The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机参数设置呼吸机参数设置吸呼比（I/E）：通常设定在1： 阻塞性肺疾病：延长呼气时间，有利于CO2排出，如 COPD和哮喘的患者，I：E常小于1：2 限制性疾病：延长吸起
12、时间，有利于改善氧合，如ARDS可适当增加I：E，甚至采用反比通The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First呼吸机参数设置呼吸机参数设置吸气压力水平控制压力水平：在PCV 模式下，需设定吸气压力水平。吸气压力水平的高低取决于病人需要潮气量的大小。压力支持水平：在应用PSV模式时，压力支持水平可通过病人自主呼吸频率和病人所需潮气量来设定。参照依据：如病人自主呼吸频率和潮气量可维持在1525次min、612ml/kg，那么认为设
13、定的压力水平是恰当的。The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome FirstThe Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome FirstThe Needs of The Patients and The Customers The Needs of The Patients and
14、 The Customers Come FirstCome FirstThe Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome FirstThe Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome FirstThe Needs of The Patients and The Customers The N
15、eeds of The Patients and The Customers Come FirstCome First撤机难易程度分级撤机难易程度分级简单或容易撤机（60%-70%）困难撤机（20%-25%） 直到3次撤机或第一次撤机后7天内才撤机的患者呼吸机依赖（5%-15%） 需要3次以上撤机或第一次撤机后超过7天以上才撤机的患者The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First规范化撤机规范化撤机机械通气患者的每日筛查自主呼
16、吸实验（SBT）气道自洁能力和气道通畅能力的评估The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First每日筛查每日筛查The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome FirstSBTSBT的实施的实施The Needs of The Patients and The Custom
17、ers The Needs of The Patients and The Customers Come FirstCome FirstSBTSBTThe Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome FirstSBTSBT步骤步骤 The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First气道通畅和气道自洁能力的评估气道通畅和气道自洁能力的评估套囊漏气实验呛咳、咳嗽情况The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First标准撤机步骤标准撤机步骤The Needs of The Patients and The Customers The Needs of The Patients and The Customers Come FirstCome First 谢谢！谢谢！
