医学课件有创与无创正压通气

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1、呼吸危重症进展--呼吸支持解放军总医院呼吸病中心刘又宁liuyn301@126.comhttp://www.301hospitalrespirology.com.cn2021/6/301正压机械通气的目的正压机械通气能够解决肺的通气和部分换气功能能够有效改善和维持氧合和促进二氧化碳排出，为疾病的恢复赢得时机进行正压机械通气时，在达到上述目的同时，应采取有效的措施尽量减小机械通气相关副作用2呼吸机所致肺损伤(Ventilatorinducedlunginjury,VILI)ConceptofVILI机械通气患者机械通气过程中出现肺泡的反复萎陷

2、/复张和/或肺的过度膨胀而继发的肺实质损伤肺的基础疾病会增加发生VILI的几率，尤其是ARDS/ALI患者RespirCare.2005;50(5):6493HistoryofVILI从基础到临床IntensiveCareMed.2006;32:24–334Largetidalvolume:Volutrauma1HighplateauPressure:Barotrauma2Lowendexpiratorypressure:Atelectrauma3AlveolarShearStress:Biotrauma4RiskfactorsofVILI

3、5AcuteRespiratoryFailureClassificationALI/ARDSNonALI/ARDS:AECOPD,Asthma,Acutecardiogenicpulmonaryedema,pulmonaryfibrosis,pulmonaryembolism,………6RespirCare.2001;46(2):130-148LowtidalvolumeventilationShouldTidalVolumeBe6mL/kgPredictedBodyWeightinVirtuallyAllPatientsWithAcuteR

4、espiratoryFailure?7Lowtidalvolumeventilation:ALI/ARDS8ARDSNet.NEngJMed2000;342:1301-1308.Lowtidalvolumeventilation:ALI/ARDS9Mortality*-Lowvs.TraditionalTidalVolumeVT:6.2±0.8ml/kgVT:11.8±0.8ml/kgP=0.007deathbeforedischargehomeandbreathingwithoutassistanceARDSNet.NEngJMed20

5、00;342:1301-1308.Lowtidalvolumeventilation:ALI/ARDS10ARDSNet.NEngJMed2000;342:1301-1308.EichackerPQ,etal.AmJRespirCritCareMed.2002;166:1510-1514.Day10152025303540TraditionalVTLowVTDay3Day7Plateaupressure(cmH2O)Pplat-Lowvs.TraditionalTidalVolume33±925±734±926±737±926±7Lowti

6、dalvolumeventilation:ALI/ARDS11ABA:PatientsofthemoreprotectedB:PatientsoftheLessprotectedRed:hyperinflated(between–901and–1,000HU)Blue:normallyaerated(between–501and–900HU)Yellow:poorlyaerated(between–101and–500HU)Green:nonaerated(between100and–100HU)AmJRespirCritCareMed.2

7、007;175:160–166VT:6.0ml/kgPEEP:9-12cmH2OLowtidalvolumeventilation:ALI/ARDS12AirTrappingInspirationExpirationVolume(ml)Flow(L/min)DoesnotreturntobaselineNormalAbnormalLowtidalvolumeventilation:AECOPD&Asthma13潮气量（VT）或气道压力（Paw）目标潮气量达到6-8ml/kg即可，或使平台压不超过30cmH2O和/或气道峰压不超过35-40c

8、mH2O，以避免DPH的进一步加重和气压伤的发生同时要配合一定的通气频率以保证基本的分钟通气量，使PaCO2值逐渐恢复到缓解期水平，以避免PaCO2下降过快而导致的碱中毒的发生通