COPD患者的机械通气

时间：2025-04-21

http://COPD患者的机械通气

北京协和医院

杜斌

利益冲突(Conflicts of Interest)http:// Tyco

Draeger

Maquet

Hamilton

Taema

Viasys

http://

AECOPD的病理生理Airway inflammation Steroids Abx Airway narrowing & obstruction IPAP MV Frictional WOB

Shortened muscles, curvature

BDs

AutoPEEP

PEEP Elastic WOB

Air trapping IPAP MV? MV? Vt PaCO2 pH PaO2

muscle strength

VE VCO2

Mechanical Ventilation of COPD / Asthma | Bin Du

肺弹性回缩力不明原因的异常下降

呼气相吸气肌肉活动导致胸壁向外的回缩力异常升高

–气道阻力显著升高

气道半径缩小

呼气相声门裂狭窄

后果

–肺过度充盈（FRC增加到正常值的2倍）

–呼吸系统时间常数增加

Peress L, Sybrecht G, Macklem PT. The mechanism of increase in total lung capacity during acute asthma. Am J Med 1976; 61: 165-169McCarthy DS, Sigurdson M. Lung elastic recoil and reduced airflow in clinically stable asthma. Thorax 1980; 35: 298-302

Colebatch HJ, Finucane KE, Smith MM. Pulmonary conductance and elastic recoil relationships in asthma and emphysema. J Appl Physiol 1973; 34: 143-153Cormier Y, Lecours R, Legris C. Mechanisms of hyperinflation in asthma. Eur Respir J 1990; 3:619-624

Collett PW, Brancatisano T, Engel LA. Changes in the glottic aperture during bronchial asthma. Am Rev Respir Dis 1983; 128: 719-723

Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. Am Rev Respir Dis 1982; 126: 166-170

http://时间常数

(τ)

Lung http://动态过度充盈的发病机制Tidal volumeFRC

Trapped gasTime

Levy BD, Kitch B, Fanta CH. Medical and ventilatory management of status asthmaticus. Intensive Care Med 1998, 24:

http://动态过度充盈的发病机制

Hubmayr RD, Abel MD, Rehder K. Physiologic approach to mechanical ventilation. Crit Care Med 1990; 18: 103-113

http://动态过度充盈的监测

吸气末肺容积(VEI)

–60”窒息过程中从吸气末至静态FRC的呼气容积

–需要完全肌松

–与其他指标相比预测气压伤并无优势

autoPEEP

–低估实际autoPEEP

Pplat

–足够长的吸气暂停时间

–没有漏气

Oddo M, Feihl F, Schaller M, et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med 2006; 32: 501-510

Barberis L, Manno E, Guerin C. Effect of end-inspiratory pause duration on plateau pressure in mechanically ventilated

patients. Intensive care Med 2003; 29: 130-134

Barberis L, Manno E, Guerin C. Effect of end-inspiratory pause duration on plateau pressure in mechanically ventilated

patients. Intensive care Med 2003; 29: 130-134

http://autoPEEP与动态过度充盈

Oddo M, Feihl F, Schaller M, et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med 2006; 32: 501-510

http://肺泡通气：二室模型

P–P= k V1(t)2(t)k ≈C1R1–C2R2C1+ C2Hubmayr RD, Abel MD, Rehder K. Physiologic approach to mechanical ventilation. Crit Care Med 1990; 18: 103-113

http://COPD机械通气适应证

呼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

http://COPD机械通气的目的

缓解呼吸肌疲劳

加重，以免导致循环功能衰竭

http://COPD机械通气策略