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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-kte = 2.718k = 1/ =1/(
2、R x C)V(t) = Vt x e-kte = 2.718k = 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 Lungs,机械通气的适应证: COPD,呼
3、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PEEPiVt 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: 不同吸气气流的比较,Shieh Ching Yang, MD, FCCP;
4、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 Inspiratory Flow Waveforms on Lung
5、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 Respiratory Metabolism in COPD Patie
6、nts 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. Chest 2002; 122: 20962104,COPD
7、: 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,Shi
8、eh 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吸气末暂停降低呼吸频率,呼气流速,Palv,PEEP,Flow= P / R
9、aw= (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 Effect of Positive End-Expiratory Pressure L
10、evel 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. Anesth Analg 2005; 100: 1112-6,半径,PEEP,PEEP与呼
11、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-Expiratory Pressure Level on Peak Expiratory Flo
12、w 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, Chan P, Paratz J. The Effect of Positive
13、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 Hyperinflation. Anesth Analg 2005; 100: 1112-6,半径,Flo
14、w ,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-Expiratory Pressure Level on Peak Expiratory Flo
15、w 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 7.3FEV1 (%pred)30 9.5FVC (%pred)53 13.6RV (%pred)186 33.1FEV1/VC (%)44 11.6TLC (%pred)103 8.7TLCO (%pred)46 25.4PaO2 (kPa)7.4 0.4PaCO2 (kPa)7.1 1.1pH7.40 0.00,ODonoghue FJ, Catcheside PG, Jordan
16、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 in severe
17、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 in severe stable COPD. Thorax 2002;57:533-539,COPD稳定期: PEEP,ODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvo
18、y 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 in severe stable COPD. Thorax 2
19、002;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 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
20、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 in severe stable COPD. Thorax 2002;57:533-539,总结对于处于
21、稳定期的严重COPD患者, 应用高水平的CPAP能够降低PEEPi及肌肉活动指标肺容积显著增加,COPD急性期患者(n = 10),Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,年龄(yr)64 6身高(cm)167 6体重(kg)72 21体重(%pred)96 27FiO2 (%)48 9Vt (L)0.74 0.09PIF (L/s)0
22、.65 0.12Tinsp (s)1.13 0.15Texp (s)3.42 0.57RR (bpm)13.5 1.5,COPD急性期: PEEP,Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,COPD急性期: PEEP,Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspir
23、atory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498,COPD: PEEP与呼气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstru
24、ction during controlled ventilation Crit Care Med 2005; 33: 1519-1528,RR 6 bpm,RR 9 bpm,COPD: PEEP与呼气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruct
25、ion during controlled ventilation Crit Care Med 2005; 33: 1519-1528,COPD: PEEP与呼气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlle
26、d ventilation Crit Care Med 2005; 33: 1519-1528,COPD: PEEP与呼气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit C
27、are Med 2005; 33: 1519-1528,COPD: PEEP与呼气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 15
28、19-1528,COPD: PEEP与呼气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528,COPD: PEEP与呼
29、气流速,Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528,COPD: PEEP与呼气流速,Caramez MP, Borg
30、es JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528,结论对于部分气道梗阻的患者而言, 应用控制通气过程中, 设置外源性PEEP能够缓解过度充盈基础疾病, 机
31、械力学指标或呼吸机设置均无法预测上述结果逐渐增加PEEP并观察平台压力改变, 是减少副作用的合理方法,Assessment of Pulmonary Hyperinflation,Time,Tidal volume,Trapped gas,Lung Volume,FRC,Tidal vol.,Tidal hyper-inflation,Apnea,Tidal Ventilation,COPD: 缩短吸气时间,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency
32、 and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,Tinsp ,RR ,Texp ,PEEPi ,COPD: 缩短吸气时间,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic O
33、bstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,COPD: 缩短吸气时间,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 136
34、5-1370,16.1 1.0,19.0 1.4,20.8 1.5,7.0 1.3,6.3 1.1,6.4 1.1,2.1 0.2,2.4 0.2,2.3 0.2,COPD: 缩短吸气时间,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163
35、: 1365-1370,COPD: 缩短吸气时间,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,ex
36、piration,Compliance,low,high,PENDELLUFTduring thePlateau Phase,为何需要设置吸气末暂停,Pressure,Flow,Peak,Plateau,PEEP,inspiration,expiration,Compliance,low,high,No PENDELLUFTbecause of constant flow flow,COPD: 缩短吸气时间,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency
37、 and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,COPD: 缩短吸气时间,机械通气患者常常呼吸频数, 肺过度充盈提高吸气流速, 可以缩短吸气时间, 尽管呼吸频率加快, 但能够延长呼气时间, 降低呼吸做功延长吸气暂停能够降低呼吸频率, 却引发肺过度充盈, 呼吸做功增加,Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Ti
38、me on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370,严重气流梗阻患者的处理,增加流量不能显著延长呼气时间(TE)VtRRflowTTOTTITETE0.515 604.000.503.50-0.5151204.000.253.750.250.514 604.300.503.800.300.512 605.000.504.501.00提示降低分钟通气量
39、对于减少内源性PEEP的重要作用,延长呼气时间治疗哮喘持续状态,目的: 评价哮喘持续状态患者降低呼吸频率对动态过度充盈(DHI)的影响气道平台压患者: 12名因严重哮喘接受机械通气患者设置: 定容通气, 潮气量613 100 mL, 吸气流速 79 4 L/min, 分钟通气量约10 L/min干预: 呼吸频率18 12 6 bpm,Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilate
40、d patients with severe asthma. Crit Care Med 2004 Jul;32(7):1542-5.,延长呼气时间治疗哮喘持续状态,Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med 2004 Jul;32(7):1542-5.,病例,NYH, F/82, C82
41、2978, 入院日2004/12/31胸闷, 憋气3天, 神志障碍30分钟PMHx: COPD入院时HR 50, BP 78/43ABG (1617 hrs): 7.034 / 148 / 53.8 / 37.7,病例,处理气管插管, 机械通气镇静肌松安定5 mg/hr + 吗啡2 mg/hrScoline多巴胺5 g/kg/minBP 120/58,病例,呼吸模式: VCV参数设置:Vt 400 mlRR 16 bpmFiO2 0.40ZEEP,PEEPi的测定,Flow (l/s),Pao (cmH2O),occlusion,PEEPi = 10,3.75 sec,病例,呼吸模式: VCV参数设置:Vt 400 mlRR 16 bpm 10 bpmFiO2 0.40ZEEP,MV = 4 lpm能否降低PEEPi能否降低PaCO2,PEEPi的测定,Flow (l/s),Pao (cmH2O),occlusion,PEEPi = 5,6 sec,病例,病例,生命体征HR60BP106/53停用多巴胺SpO296%,COPD患者的机械通气: 总结,内源性PEEP过高是COPD机械通气的主要原因降低内源性PEEP的方法外源性PEEP效果不肯定通过提高吸气流速延长呼气时间效果甚微尽量缩短吸气末暂停降低呼吸频率效果明确,
