适应性支持通气

适应性支持通气(ASV)北京协和医院利益冲突:ConflictsofInterest曾接受以下相关厂商的讲课费用:HamiltonMedicalCoviden(formerTyco)DraegerMedicalViasysHealth机械通气的演变32.9%25.5%0%10%20%30%40%1998Cohort2004CohortPatientswithmechanicalventilationEstebanA,AnzuetoA,FrutosF,etal.Characteristicsandoutcomesinadultpatientsreceivingmechanicalventilation.JAMA2002;287:345-355EstebanA,FergusonND,MeadeMO,etal.Evolutionofmechanicalventilationinresponsetoclinicalresearch.AmJRespirCritCareMed2008;177:170-1775,183/15,7574,968/19,505不同患者的呼吸机参数COPDARDSDay1Day3Day7Day1Day3Day7PIP,cmH2O31(9)31(9)32(9)34(9)33(8)33(9)Pplat,cmH2O22(6)22(6)23(7)28(7)27(7)26(7)Vt,ml/kg8.4(2.3)8.0(2.3)8.1(2.6)8.7(2.0)8.5(2.0)8.5(2.0)RR,bpm17(6)17(5)17(5)20(6)21(7)20(6)FIO252(18)46(13)50(18)74(21)63(21)59(22)withoutPEEP,n(%)218(47.6)128(45.2)33(38.8)34(16.0)14(8.0)8(9.7)PEEP,cmH2O5(2)5(2)6(3)8(4)9(3)9(3)EstebanA,AnzuetoA,FrutosF,etal.Characteristicsandoutcomesinadultpatientsreceivingmechanicalventilation.JAMA2002;287:345-355临床研究对ARDS呼吸机设置的影响1998Cohort(n=135)2004Cohort(n=198)pVt,ml/kgABWHigher,median(SD)10(9,11)8(7,10)0.001Lower,median(SD)8(7,9)6(5,8)0.001PEEP,cmH2OHigher,median(SD)10(8,12)12(8,15)0.001Lower,median(SD)5(0,8)5(0,8)0.66PIP,cmH2OHigher,median(SD)39(34,45)37(31,42)0.004Lower,median(SD)29(26,33)26(21,31)0.001Pplat,cmH2OHigher,median(SD)29(24,32)29(24,32)0.68Lower,median(SD)22(22,28)23(18,26)0.11EstebanA,FergusonND,MeadeMO,etal.Evolutionofmechanicalventilationinresponsetoclinicalresearch.AmJRespirCritCareMed2008;177:170-177模式潮气量吸呼比呼吸频率机械通气:人机不同步ACV(n=11)PSV(n=51)p不同步4.34.81.93.80.04无效触发3.04.91.83.70.38双触发1.22.30.10.40.01ThilleAW,RodriguezP,CabelloB,etal.Patient-ventilatorasynchronyduringassistedmechanicalventilation.IntensiveCareMed2006;32(10):1515-1522机械通气:人机不同步不同步指数(%)人机不同步事件数总呼吸频率(呼吸机频率+无效努力)人机不同步较多=不同步指数10%ThilleAW,RodriguezP,CabelloB,etal.Patient-ventilatorasynchronyduringassistedmechanicalventilation.IntensiveCareMed2006;32(10):1515-1522机械通气:人机不同步不同步指数10%(n=47)不同步指数10%(n=15)p机械通气天数7(3–20)25(9–42)0.005机械通气7天23(49%)13(87%)0.01气管切开2(4%)5(33%)0.007病死率15(32%)7(47%)0.36ThilleAW,RodriguezP,CabelloB,etal.Patient-ventilatorasynchronyduringassistedmechanicalventilation.IntensiveCareMed2006;32(10):1515-1522自动通气模式:适应性支持通气(ASV)ASV时的呼吸机设置最低(目标)分钟通气量理想体重(IBW)男性50.0+2.3(heightininches–60)女性45.5+2.3(heightininches–60)分钟通气量%(范围25–350%)IBW15kg%MinVolxIBW/1000IBW15kg%MinVolxIBW/500自动通气模式:适应性支持通气(ASV)相同分钟通气量时的不同呼吸方式RRVT自动通气模式:适应性支持通气(ASV)概念最佳呼吸方式=确定分钟通气量下的‘最小呼吸功’RRVTLeastWOB自动通气模式:适应性支持通气(ASV)OtisAB,FennWO,RahnH.Mechanicsofbreathinginman.JApplPhysiol1950;2:592-607WOBfelasticresistivetotaloptimalf自动通气模式:适应性支持通气(ASV)最佳呼吸方式的确定(Otis公式)22RCeMV–fxVDVD1+42RCe–1f=RCeexpiratorytimeconstantMVminuteventilationftotalrespiratoryrateVDdeadspaceOtisAB,FennWO,RahnH.Mechanicsofbreathinginman.JApplPhysiol1950;2:592-607自动通气模式:适应性支持通气(ASV)确定最小WOB(Otis公式)RRVTDefinedMVTargetRRTargetVT死腔:1mL/poundBWt(Radfordnomogram)呼气时间常数:测定指标分钟通气量:预先设置自动通气模式:适应性支持通气(ASV)ASV的安全限制参数低限高限吸气压力PEEP+5cmH2OPHIGH–10cmH2O潮气量4.4ml/kgBWt(2xVD)22ml/kgBWt(10xVD)指令频率绝对界限5bpm60bpm相对界限IBW15kg22x%MinVol/100IBW15kg45x%MinVol/100吸气时间RCexp或0.5sec2xRCexp或3sec呼气时间2xRCexp12secI:E比1:41:1自动通气模式:适应性支持通气(ASV)RRVTDefinedMVTargetRRTargetVT安全界限安全界限自动通气模式:适应性支持通气(ASV)RRVTDefinedMVTargetRRTargetVT安全界限容积伤/气压伤浅快呼吸窒息内源性PEEP自动通气模式:适应性支持通气(ASV)RRVT等MV曲线目标RR目标VT目标22RCeMV–fxVDVD1+42RCe–1f=体重分钟通气量%(MV,100%=100ml/kg/min)PIP,PEEP,FiO2流量容积曲线RCe呼吸力学(LSF)Crs,Rrs,PEEPiPinspI:E自动通气模式:适应性支持通气(ASV)RRVTPinspRRPinspRRPinspRRPinspRR目标有关ASV的文献ASV结合了不同通气模式的优点,且使用简单IottiG.A.,BraschiA.MinervaAnestesiol65(Suppl1)S719-723ASV可安全用于成人与儿童IottiG.A.,BraschiA.MinervaAnestesiol65(Suppl1)S719-723WatsonKF.RespirCare1999ParretL,StuckiP,ScalfaroP,etal.PedCritCareMed2000;1(1):P1.8.41LawsonRW,VinesDL,ShelledyDC.AARC47thInternationalRespiratoryCongress,Dec2001与控制通气相比,ASV的安全性相同,清除CO2更为有效IottiG,BelliatoM,PolitoA,etal.IntensiveCareMed2005;31:S168ASV可用于90%以上的ICU患者ArnalJM,NafatiC,WysockiM,etal.IntensiveCareMed2004;30:S84ASV缩短脱机时间SulzerCF,ChioléroR,ChassotPG,etal.Anesthesiology2001;95(6):1339-45CampbellRS,SinambanRP,JohannigmanJA,etal.RespirCare1998有关ASV的文献ASV改善人机协调TassauxD,DalmasE,GratadourP,etal.CritCareMed2002;30(4):801-807ASV减少医生工作负荷VogelsangCritCare2003,7(Suppl2):P173RevellyJP,PetterA,ChassotPG,eta.IntensiveCareMed2001;27(Supp2):S136ASV能够补偿漏气WatsonKF.RespirCare1999ASV自动选择与患者病情相符合的呼吸方式BelliatoM,PaloA,PaseroD,etal.IntlJArtifOrgans2004;27(8):709-716ASV可使用HelioxBrownMK,DuthieSE.RespirCare2000ASVvs.SIMV+PSVSIMV-PS1ASVSIMV-PS2Pmax,cmH2O285294285Pplat,cmH2O235284224mPaw,cmH2O123133123PEEPe,cmH2O4.124.324.22PEEPi,cmH2O2.412.312.21Crs,ml/cmH2O411540133912Rrs,insp,cmH2O/L/sec135166155Rrs,exp,cmH2O/L/sec145144144TassauxD,DalmasE,GratadourP,etal.Patient-ventilatorinteractioinsduringpartialventilatorysupport:apreliminarystudycomparingtheeffectsofadaptivesupportventilationwithsynchronizedintermittentmandatoryventilationplusinspiratorypressuresupport.CritCareMed2002;30:801-807ASVvs.SIMV+PSVSIMV-PS1ASVSIMV-PS2pH7.420.067.430.067.420.06PaCO2t