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1、SERVO系列呼吸机培训,2022/12/3, MAQUET,3,内容提要,SERVO呼吸机突出的优势,09-03-25, MAQUET,4,MAQUET,全球最大的手术室和ICU设备供应商 MAQUET 公司，总部德国,医疗系统,心血管外科,重症监护,外科工作站,ECMO（体外膜肺），人造血管,SERVO系列呼吸机，麻醉机,手术灯床吊塔,SERVO 900系列80年代产品,SERVO 300系列 90年代中期产品,Servo系列呼吸机 高端呼吸机的典范,瑞典原装进口呼吸机,SERVO-i 系列,SERVO-s 系列,Servo系列呼吸机 高端呼吸机的典范,Frequency: 100,2 m
2、l,This mouse is equivalent to a premature of ca. 300 gram ! 这只老鼠相当于300克的早产儿！,Servo系列呼吸机 高端呼吸机的典范,2022/12/3, MAQUET,9,SERVO系列呼吸机突出优势,2022/12/3, MAQUET,10,简单易用全中文操作界面和中文报警提示关键参数直接控制软件功能与操作简易性最佳结合,SERVO系列呼吸机突出优势,世界上唯一可以进行内外管路彻底消毒的呼吸机,呼出气体模块,SERVO系列呼吸机突出优势,创新的技术 超声流量传感器,超声氧传感器，选配功能，可替代氧电池,SERVO系列呼吸机突出优势
3、,监测更准确，为临床提供精确的信息参考非耗材，节省使用成本,超声流量传感器,特点：采样频率2000次/秒非接触性传感器非耗材，可长期使用好处：测量精确，实时客观；防止因温度、湿度和分泌物 等多因素影响监测数据准确；节省科室成本,SERVO系列呼吸机突出优势,09-03-25, MAQUET,14,Servo呼吸机组成,显示屏 主机空压机,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be
4、 used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe backgroun
5、d must not be changed to any other pictureIt is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. The background mu
6、st not be changed to any other colour,09-03-25, MAQUET,15,外置式空压机：,TEXTSHEET WITH BACKGROUND-IMAGE CC,09-03-25, MAQUET,16,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to
7、 the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureIt is an exception to the standardIt can b
8、e used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. The background must not be changed to any other colour,备用电池工作时间最长维持2小时，最短维持1小时有外接电源时，自动充电只能维持主机工作，不能维
9、持空压机工作,09-03-25, MAQUET,17,呼出盒：是唯一可以拆卸并彻底消毒内管路的呼出盒， 减少交叉感染的机会。,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Present
10、ations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureIt is an exception to the standardIt can be used in the following
11、 caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. The background must not be changed to any other colour,09-03-25, MAQUET,18,呼出盒的拆卸,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides
12、with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use thi
13、s slide layout when placing pictures on the slides slides will look crowdedThe background must not be,09-03-25, MAQUET,19,呼出盒的消毒,将呼出盒浸入消毒剂中（70%酒精、2%戊二醛等）或将消毒液灌入呼出盒内，保留40分钟左右,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt ca
14、n be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe backg
15、round must not be changed to any other pictureIt is an exception to the standardIt can be used in the following c,09-03-25, MAQUET,20,呼出盒的干燥,自然干燥时放置的位置,09-03-25, MAQUET,21,介绍要点12.1英寸彩色触摸屏主旋钮及快键按键全中文操作菜单所有操作在两层菜单内完成,TEXTSHEET WITH BACKGROUND-IMAGE CC,09-03-25, MAQUET,22,Slides with background image s
16、hould be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when pla
17、cing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureIt is an exception to the standardIt can be used in the following caseVery long presentations white background is exhaust,1. 使 用 前 检 查,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background
18、image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout w
19、hen placing pictures on the slides slides will look crowdedThe background must n,09-03-25, MAQUET,23,启动呼吸机,09-03-25, MAQUET,24,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presen
20、tations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureI
21、t is an exception to the standardIt can be used in the following case,开机自检：需要手动操作的三步骤,09-03-25, MAQUET,25,常用呼吸模式,控制模式 容量控制 Volume Control 压力控制 Pressure Control 压力调节容量控制 Pressure Regulated Volume Control 2. 支持模式 压力支持 Pressure Support 3. 自主呼吸 持续气道正压 Continuous Positive Airway Pressure 混合模式 Synchronize
22、d Intermittent Mandatory Ventilation 同步间歇指令通气SIMV(VC)+PS 同步间歇指令通气SIMV(PC)+PS 同步间歇指令通气SIMV(PRVC)+PS,呼吸模式 Ventilation Mode,09-03-25, MAQUET,27,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVe
23、ry long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be changed to any
24、other pictureIt is an exception to the standardIt can be used in the following caseVery long presentations wh,容量控制模式预设潮气量，保证通气效率气道压力可变，在气道阻力增加或肺顺应性降低的情况下容易导致气道压力过高，需要密切观察气道压的变化流速波形为方波，吸气期流速恒定,2022/12/3, MAQUET,29,容量控制 Volume Control,吸气暂停时间占整个呼吸周期的百分比,吸气上升时间：从开始吸气至达到峰流速所花的时间，这里指占整个呼吸周期时间的百分比，,当I：E和暂停
25、时间发生改变时，Ti随之改变,呼气末正压PEEP作用于整个呼吸周期的持续正压可防止肺泡塌陷，增加FRC，改善气体氧合和交换适用于治疗急性肺水肿，ALI、ARDS等,09-03-25, MAQUET,31,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background
26、is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureIt is an exception to the
27、standardIt can be used in the following caseVery long presentations white bac,吸气上升时间意义,指呼吸机提供的吸气流速从基线上升到峰值所需的时间根据患者实际需要调节，理论上吸气驱动越强，吸气上升时间越短；吸气驱动越弱，吸气上升时间越长,报警自动设置功能,11-06-07, MAQUET,32,各项附加设置,2022/12/3, MAQUET,34,容量控制 Volume Control,气道峰压,平台压,平均压,呼气末正压,吸气时间,吸呼比,吸入分钟通气量,呼出分钟通气量,吸入潮气量,呼出潮气量,容量控制波形分析,压
28、力控制通气,控制气道峰压，减少肺损伤流速波形为递减波，比较符合患者的实际需要在气道阻力或肺顺应性改变的情况下不能保证潮气量,对ALI、ARDS等病人适用,2022/12/3, MAQUET,37,压力控制 Pressure Control,吸气上升时间：开始吸气至压力达到峰压所花的时间，此处指占整个呼吸周期时间的百分比,在压控模式下，不需设置吸气暂停时间,吸气时间：当I：E发生改变时，Ti也随之改变,PEEP以上的压力控制水平,2022/12/3, MAQUET,38,压力控制 Pressure Control,1.此时没有平台压，因为压力是恒定的Ppeak=PC above PEEP+PEE
29、P 2.可先用VC，获得平台压作为PC的压力水平,潮气量影响因素：1.PC above PEEP2.顺应性、阻力3.病人自己的吸气努力,呼吸模式PRVC,目前控制通气模式下的问题,容量控制模式 VC气道压力可变，在气道阻力增加或肺顺应性降低的情况下容易导致气道压力过高流速波形为方波或递增波，病人感觉不适,压力控制模式 PC气道峰压固定，在气道阻力或肺顺应性改变的情况下不能保证潮气量为达到目标潮气量，需要经常调整压力水平，增加工作量,2022/12/3, MAQUET,40,PRVC,优势整合,容量控制 VC预设潮气量，保证通气效率,压力控制 PC控制气道峰压，减少肺损伤,PRVC模式集合了两种
30、通气模式的优点,呼吸模式PRVC,PRVC是Servo系列呼吸机首创的通气模式Servo i和Servo s都可以完美展现PRVC的优势,2022/12/3, MAQUET,42,OH 5:008,压力调节容量控制 Pressure Regulated Volume ControlPRVC,刘靖 2005 8 16,2022/12/3, MAQUET,43,刘靖 2005 8 16,压力调节容量控制 (Pressure Regulated Volume Control) PRVC,2022/12/3, MAQUET,44,PRVC原理,第一次呼吸为目标潮气量的容量控制呼吸，暂停时间为10%，以
31、暂停期的压力即平台压为第二次呼吸的压力值每次呼吸间调节压力值以保证以最低的气道压力输送目标潮气量最大压力值为预设压力报警下5cm H2O，并报警“压力调节受限”,2022/12/3, MAQUET,45,PRVC,Servo呼吸机PRVC模式的临床优势,迅速准确的压力调节，最多3次呼吸即可完成目标潮气量的准确输送始终在安全的气道压力范围内进行通气，最大程度的减少肺损伤动态监测气道阻力及顺应性的改变，精准调节压力，保证通气效率吸气流速为递减波，让病人更加舒适，提供更好的人机关系,压力支持模式PS在吸气相提供压力支持所有呼吸必须由患者触发适用于自主呼吸稳定为减轻呼吸功或过渡脱机的患者注意后备通气的
32、设置，以保证安全,2022/12/3, MAQUET,47,压力支持 Pressure Support,后备通气为压控模式，此时压力设置建议高1-2CMH2O,吸气中止：设置5%表示当吸气流速下降到峰流速的5%时，停止吸气，由吸气转为呼气，也称为呼气触发灵敏度,吸气触发灵敏度，分压力触发和流量触发,PEEP以上的压力支持水平,无需设置呼吸频率,按报警设置键，设置“呼吸暂停时间”,呼吸暂停时间的设置,范围: 成人 15 45 s 默认 20s 新生儿 5-45s 默认 10s,压力支持PS,OH 5:015,波形与压力控制模式类似，压力都是恒定的Ppeak=PS above PEEP+PEEP,
33、每次通气都由病人自己触发，用粉红色线表示,无需设置呼吸频率,Trigger,流速触发：同步性好，灵敏度高,压力触发：同步性差，灵敏度低,触发 (Trigger)病人触发呼吸机送气,设置原则：在不引起误触发的前提下，越灵敏越好,BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is e
34、xhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureIt is an exception to the stan
35、dardIt can be used in the following caseVery long presentations white bac,09-03-25, MAQUET,52,压力触发设置,单位：cm H2O绝对值越大，触发灵敏度越低设置为相对值，非绝对值（考虑PEEP）,Servo呼吸机采用持续气流触发方式 Bias flow：成人2L/min小儿0.5L/min 吸入端和呼出端均有传感器，准确感知管路内气流的变化,流量触发,09-03-25, MAQUET,54,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background
36、image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout w
37、hen placing pictures on the slides slides will look crowdedThe background must not be changed to any other pictureIt is an exception to the standardIt can be used in the following caseVery long presentations white bac,概念：基础流速*10 默认值：5 范围：010 在红色的区域，病人仅需吸入 极少的气体就可以触发，有自 触发的危险。,流量触发 Flow Triggering,20
38、22/12/3, MAQUET,55,流量触发 Flow Triggering,概念：持续气流的*10 默认值：5 调节范围：010 持续气流: 成人 2 L/min 儿童 0.5L/min, 2l/min,2l/min,病人吸入0.6l/min（2x30%）,1.4l/min(2x70%),Golden MomentsTM,无效触发,触发灵敏度的设置触发类型内源性PEEP(使用外源性PEEP平衡)压力支持过度,双触发,吸气峰流速过低吸气潮气量过小呼气切换过早,Because Imvery very hungry!,误触发,触发过于灵敏气道内形成痰液管路中积水管路漏气心脏震动,2022/12/
39、3, MAQUET,59,吸气终止 Inspiratory Cycle Off呼气触发灵敏度,Inspiratory Cycle off 吸气终止：指在自主呼吸和支持通气模式下，由吸气转为呼气的转折点。以峰流速的表示范围： 1- 70% 可调 默认 ： 30%,Golden MomentsTM,呼吸机上的吸呼气切换,在控制模式下采用时间切换 支持模式中，一般采用流速切换 方式，当气道流速下降到峰流速 的一定百分比后切换为呼气,提早切换:引起吸气末流速紊乱及双触发延迟切换:引起呼气肌活动及吸气末压力超射漏气：可致吸气流速下降缓慢，达不到预设切换标准,如何判断设置是否合理,自主模式CPAP,完全由
40、患者完成自主呼吸，呼吸机提供持续正压适用于自主呼吸稳定过渡脱机的患者,持续气道正压通气 CPAP,将压力支持水平设为0，则由PS变成了CPAP,同样需要设置后备通气,2022/12/3, MAQUET,64,气道中维持一个连续的正压。恰当地设置 PEEP可防止气道异常塌陷。在病人尝试时开始吸气。开始呼气的情况 与压力支持模式相同。如果达到呼吸暂停的报警极限，呼吸机将自动切换至后备模式。成人少用，婴儿， nasal CPAP,自主呼吸模式-CPAP,呼吸模式和功能,-混合模式 同步间歇指令通气SIMV(VC) + PS 同步间歇指令通气SIMV(PC) + PS 同步间歇指令通气SIMV(PRV
41、C)+ PS,Servo,混合模式SIMV保证患者最低通气要求的同时允许患者自主呼吸合理使用可以锻炼患者呼吸能力，促进脱机自主呼吸易与呼吸机协调，减少对镇静剂的需要适用于有一定自主呼吸能力或准备过渡脱机的患者,呼吸模式探讨,OH 5:023,SIMV（VC）+PS模式参数设置,控制通气相关参数,支持通气相关参数,SIMV频率，每个SIMV周期含控制通气和支持通气,呼吸周期时间：指一次控制通气所花的时间,SIMV模式详解,OH 5:030,SIMV模式详解,触发窗：呼吸周期的前90%时间这个90%为机器默认值，不需要设置,第1个SIMV周期,第2个SIMV周期,09-03-25, MAQUET,
42、70,肺功能监测,09-03-25, MAQUET,71,Servo s可以通过选配升级支持肺功能监测,Servo i标配全套肺功能监测,09-03-25, MAQUET,72,总PEEP,09-03-25, MAQUET,73,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations whit
43、e background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must,总PEEP,内源性PEEP（PEEPi) = 总PEEP- 外源性PEEP注意点：尽可能抑制患者
44、自主呼吸 建议将外源性PEEP设定为零,内源性PEEP,概念 intrinsic positive end-expiratory pressure,PEEPi 是指在没有用呼吸机预设PEEP的情况下,肺泡压力在呼气末从而也在整 个呼气 过程保持正压。临床上产生内源性PEEP的原因 1 气流阻力增加（和呼气流速受限） 2 呼气时间缩短，如反比通气和浅快自主呼吸 3 吸气后呼气肌的兴奋性增高,09-03-25, MAQUET,75,评价内源性PEEP,09-03-25, MAQUET,76,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with backgro
45、und image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include pure text slides only white background is exhausting to the human eye. Do not use this slide layo
46、ut when placing pictures on the slides slides will look crowdedThe background must not be,SBI 浅快呼吸指数,定义：SBI指数f(呼吸频率)/VTe（呼出潮气量）判断患者呼吸形态，评估脱机可能性临界值105，大于临界值脱机可能性下降SBI在预测病人维持通气的能力方面是相当准确的,77,口腔闭口压 P 0.1,吸气开始100ms时的口腔闭合负压反映了患者中枢呼吸驱动的强弱作为指导脱机的参考指标正常人2cm H2O临界值46cm H2O,P0.1增高表示病人呼吸窘迫和意味着呼吸中枢对肺功能受损的反应临床应用
47、：对阻塞性肺疾病和急性呼吸衰竭是有用的脱机指标,09-03-25, MAQUET,78,TEXTSHEET WITH BACKGROUND-IMAGE CC,Slides with background image should be used rarely. It is an exception to the standardIt can be used in the following caseVery long presentations white background is exhausting to the human eye. Presentations that include
48、 pure text slides only white background is exhausting to the human eye. Do not use this slide layout when placing pictures on the slides slides will look crowdedThe background must not be,静态顺应性（Cstat）=V/PplatPEEPtotal动态顺应性（Cdyn）= V/PpeakPEEP Cstat正常值60-100ml/cmH2O，Cdyn由于将克服气道阻力的压力也计算在内，因此数值上低于Cstat，
49、约50-80ml/cmH2O，监测值受潮气量大小影响。弹性（E）与顺应性互为倒数关系,顺应性测定,顺应性（compliance,C）临床意义高顺应性提示吸气时低的弹性阻力，同时呼气时低的回缩力低顺应性提示病人“硬”肺，（如肺纤维化、肺水肿、肺塌陷以及肺挫伤），或胸廓占位性病变如气胸、血胸或伴随腹内压高的肠梗阻,High compliance (low pressure) Low compliance (high pressure),静态顺应性static compliance,Cstatic测量方法：在没有自主呼吸的情况下产生已知容量( V=VT)所需要的压力(P) 肺顺应性Cpulm的计算
50、通过肺外压力和肺内压力的差值计算计算公式 潮气量/肺内压胸膜内压,胸膜腔,静态顺应性 static compliance,Cstatic 胸廓顺应性Cthx计算 胸膜腔和外部气压（大气压 之间的压力差计算公式潮气量/胸腔内压大气压,静态顺应性 static compliance,Cstatic 总顺应性Ctot计算 相对于大气压的肺内压改变。计算公式1/Ctot=1/Cpulm + 1/Cthx1/Ctot=（肺内压-胸腔内压） /潮气量 + （胸腔内压-大气压）/潮气量=肺内压-大气压/潮气量Ctot=潮气量/肺内压-大气压,静态顺应性 static compliance,Cstatic正常
