1、The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机的使用及撤机呼吸机的使用及撤机 路伟娜路伟娜 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机系统简图呼吸机系统简图 成立时间：2009年 科室人员配置：主任：傅水桥 护士长：徐珏华 目前医生10人，
2、护士28人，其中副主任医师2人，主 治医师4人，住院医师4人。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸模式呼吸模式 辅助/控制型(A/C:Assist/Control;CMV)半自主型:同步间歇指令呼吸SIMV 自主型(Spontaneous)The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The
3、 Customers Come First 辅助辅助/控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸 临床应用：病人基本没有自主呼吸临床应用：病人基本没有自主呼吸 呼吸机根据临床医生的设定参数供气：呼吸机根据临床医生的设定参数供气：潮气量或压力潮气量或压力 流速和流速波形，或吸气时间流速和流速波形，或吸气时间 呼吸频率呼吸频率 由机器启动，也可由病人同步触发通气由机器启动，也可由病人同步触发通气 Time Pressure The Needs of The Patients and The Customers Come FirstThe Needs of The Patients a
4、nd The Customers Come First 辅助辅助/控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸 一.控制通气（controlled mechanical ventilation,CMV）呼吸机完全替代自主呼吸的通气方式 1.容量控制通气（volume controlled mechanical,VCV）特点：能保证潮气量的供给，完全替代自主呼吸，有利于呼吸机休息；易发生人机对抗、通气不足或同期过度，不利于呼吸机锻炼 2.压力控制通气（pressure controlled mechanical,PCV）特点：通气功能差、气道压力高的患者；用于ARDS有利于改善换气；
5、新生儿、婴幼儿补偿漏气 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 辅助辅助/控制模式控制模式(A/C):(A/C):机控呼吸机控呼吸 二、辅助通气（Assisted ventilation,AV）关键是预设触发灵敏度和潮气量或吸气压力要恰当 三、辅助控制通气（A/C）病人有自主呼吸时，机器随呼吸启动，一旦自发呼吸在一段时间内不发生时，机械通气自动由辅助转为控制性通气。它属于间歇正压通气。The Needs of The
6、Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 半自主型半自主型:同步间隙指令通气同步间隙指令通气 (SIMV)(SIMV)临床应用：病人有一定频率的自主呼吸 由呼吸机强制通气和自主呼吸组合而成 强制通气是由机器启动(IMV)或病人触发(SIMV)在自主呼吸时，病人决定潮气量和呼吸频率 机器启动机器启动的强制通气的强制通气 病人触发的强制通气病人触发的强制通气 自主呼吸自主呼吸 病人触发病人触发 Time Pressure The Needs of The P
7、atients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 半自主型半自主型:同步间隙指令通气同步间隙指令通气 (SIMV)(SIMV)属于辅助通气方式，呼吸机于一定的间歇时间自主呼吸导致气道内负压信号，同步送出气流，间歇进行辅助通气。即（可自主呼吸）若干次自主呼吸后给一次正压通气，保证每分钟通气量，IMV的呼吸频率承认一般小于10次/分。The Needs of The Patients and The Customers Come FirstThe Needs of T
8、he Patients and The Customers Come First 自主型自主型(Spontaneous)(Spontaneous)临床应用：病人有足够的自主呼吸频率临床应用：病人有足够的自主呼吸频率 定义定义 要求有主动的自主呼吸驱动力要求有主动的自主呼吸驱动力 持续气道内正压通气持续气道内正压通气(CPAP)(CPAP)：在自主呼吸的前：在自主呼吸的前提下，在整个呼吸周期内人为地施以一定程度提下，在整个呼吸周期内人为地施以一定程度的气道内正压。可防止气道内萎陷的气道内正压。可防止气道内萎陷。可提供或不提供吸气支持可提供或不提供吸气支持(PSV)(PSV)呼吸机的工作都有病人自
9、主呼吸来控制。呼吸机的工作都有病人自主呼吸来控制。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机参数呼吸机参数 时间参数时间参数 压力参数压力参数 容量参数容量参数 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机参数设置呼吸机参数设置 时间参数
10、：呼吸频率（f）、吸呼比（I/E）容量参数：分钟通气量(Minute Volume，MV)潮气量(Tidal Volume，VT)，VTI，VTE 流量触发灵敏度(Trigger，L/min)压力参数:吸气压力水平(Pi)吸气末正压（Pplateau)呼气末正压(PEEP)平均气道压(Pmean)气道峰压(Ppeak)The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机参数设置呼吸机参数设置 潮气量 VT 正常肺功能患者：8
11、-12ml/kg COPD或者ARDS患者小潮气量通气：6-8ml/kg 平台压30cmH2O 呼吸频率（RR）：1218次/分 每分通气量呼吸频率潮气量 正常成人约为69L 吸入气氧浓度（FiO2）：能维持理想PaO2的最低FiO2 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机参数设置呼吸机参数设置 吸呼比（I/E）：通常设定在1：1.5-2.5 阻塞性肺疾病：延长呼气时间，有利于CO2排出，如 COPD和哮喘的患
12、者，I：E常小于1：2 限制性疾病：延长吸起时间，有利于改善氧合，如ARDS可适当增加I：E，甚至采用反比通 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 呼吸机参数设置呼吸机参数设置 吸气压力水平 控制压力水平：在PCV 模式下，需设定吸气压力水平。吸气压力水平的高低取决于病人需要潮气量的大小。压力支持水平：在应用PSV模式时，压力支持水平可通过病人自主呼吸频率和病人所需潮气量来设定。参照依据：如病人自主呼吸频率和潮气量可
13、维持在1525次min、612ml/kg，那么认为设定的压力水平是恰当的。The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First The Needs of The Patients and The Customers C
14、ome FirstThe Needs of The Patients and The Customers Come First The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First The Needs of The P
15、atients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 撤机难易程度分级撤机难易程度分级 简单或容易撤机（60%-70%）困难撤机（20%-25%）直到3次撤机或第一次撤机后7天内才撤机的患者 呼吸机依赖（5%-15%）需要3次以上撤机或第一次撤机后超过7天以上才撤机的患者 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers C
16、ome First 规范化撤机规范化撤机 机械通气患者的每日筛查 自主呼吸实验（SBT）气道自洁能力和气道通畅能力的评估 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First 每日筛查每日筛查 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First SBTSBT的实施的实施 The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and The Customers Come First SBTSBT The Needs of The Patients and The Customers Come FirstThe Needs of The Patients and