icu病人困难脱机的原因及处理对策

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1、ICU病人困难脱机的原因及处理对策撤机撤机（weaning）是一个缓慢、逐渐地降低呼吸支持的过程，20%-30%的患者出现撤机困难，有的患者甚至出现严重的呼吸机依赖，总的来说用来撤机的时间约占整个机械通气时间的40%，而在某些特殊的疾病状态下（如COPD）撤机时间可占总通气时间的60%左右。撤机快速撤机：几个小时内成功撤机缓慢撤机：需要几天、几周的撤机技术COPD，高龄或虚弱，ARDS困难撤机：呼吸机依赖或脑损伤或神经肌肉病变困难撤机标准（WeaningFailureCriteria）MAPch

2、ange>20mmHgPulseratechang>20bpmPaCO2increae>10-20mmHgPaCO2decreae>10-20mmHgorSpO2<90%despiteincreasingFiO2to45%PH<7.30Frequency>30-40bpm困难撤机的表现呼衰的病理生理学困难脱机的常见原因FAILURETOWEANOFFVENTILATOR:CAUSES-1Respiratory:-Usewiderboreartificialairway–ETtube/tracheo

3、stomy-Treatbronchospasmadequately-Improvelungcompliancebyremovingexcessfluid(“wetlungs”)byusingdiureticsifvolumeoverloaded/congestivecardiacfailureisthecause.-Cardiovascular:leftventriculardysfunction-pulmonaryoedema(backwardfailure)-inabilityofthecar

4、diovascularsystemtoprovidetheincreaseindeliveryofoxygenneededbytherespiratorymusclesduringweaning(forwardfailure)Appropriatetherapy(diuretics/vasodilators/inotropes)Weantheinotropesonlyaftersuccessfulweaningfrommechanicalventilatorysupport.Haemoglobin

5、mustalsobeoptimized>8g%>10g%withmyocardialischemia/cerebralischemiaFAILURETOWEANOFFVENTILATOR:CAUSES-2Neurological:-brainstemdysfunctionduetotrauma,hypoxiaorinfection,criticalillnesspolyneuropathy-intermediatesyndromeduetoorganophosphorusinsecticidesF

6、luidBalance:Positivecumulativefluidbalanceisassociatedwithfailuretoweanandanegativefluidbalancewaspredictiveofasuccessfulweaninginarecentstudy.Infection:anysepsisand/orrespiratoryinfectionshouldhaveresolvedFAILURETOWEANOFFVENTILATOR:CAUSES-3Drugs-sto

7、psedativesanddrugslikelytoimpairneuromuscularfunction.-giveantidotes(flumazenil,nalorphine,neostigmine)asindicatedElectrolytes-maintainnormalserumpotassiumandphosphorousAlkalosis-respiratory–don’tchasethePaCO2-metabolic–reducebaseexcess(?acetazolamide

8、)PaO2Endocrine-hypothyroidism呼吸负荷与呼吸肌做功能力失衡呼吸肌做功能力下降呼吸肌负荷增加心血管功能状态精神心理因素呼吸负荷与呼吸肌做功能力失衡大量的实验和临床研究认为呼吸肌功能不全的主要原因是呼吸负荷和呼吸肌做功能力的失衡。主要包括：呼吸中枢的兴奋性冲动降低、呼吸肌本身做功能力的下降及呼吸负荷过高等因素。呼吸肌做功能力下降呼吸中枢的兴奋性下降：主要见于颅脑损伤引起的延髓呼吸中枢损害，高位脊髓损伤，膈神经损伤，格林巴利综合征等神经系统损害及COPD导致