呼吸重癥鎮(zhèn)靜課件

呼吸重癥患者目標(biāo)化鎮(zhèn)靜此ppt下載后可自行編輯呼吸重癥存在呼吸系統(tǒng)器質(zhì)性損害

原發(fā)或者繼發(fā)

通氣（PaCO2

上升）或

氧合（PaO2下降）呼吸重癥機(jī)械通氣患者M(jìn)edSciMonit.

2013Jun3;19:424-9.＝54％呼吸機(jī)治療糾正呼吸系統(tǒng)器質(zhì)性損害帶來的問題

呼吸生理變化

呼吸病理生理（功能）的變化給呼吸系統(tǒng)帶來新的器質(zhì)性損害

呼吸病理生理（功能）的變化

全身病理生理的變化（炎癥反應(yīng)）呼吸重癥患者的鎮(zhèn)靜目的保證機(jī)械通氣的有效性降低機(jī)械通氣的損害作用避免鎮(zhèn)靜治療的不良影響內(nèi)容提要：呼吸重癥患者的目標(biāo)鎮(zhèn)靜急性呼吸衰竭的經(jīng)典代表

通氣：AECOPD（PaCO2

上升）

氧合：ALI／ARDS（PaO2下降）有創(chuàng)或無創(chuàng)通氣時(shí)的鎮(zhèn)靜策略AECOPD患者的鎮(zhèn)靜1呼吸生理改變AECOPD患者的鎮(zhèn)靜1呼吸生理改變用力呼氣增加呼吸做功痰咳喘StressAECOPD患者的鎮(zhèn)靜保證機(jī)械通氣有效改善肺泡通氣降低交感應(yīng)激反應(yīng)降低機(jī)械通氣的損害作用（氣壓傷）避免鎮(zhèn)靜的不良作用AECOPD患者的鎮(zhèn)靜保證機(jī)械通氣有效改善肺泡通氣輕

度重

度呼吸頻率<25次／分>35次／分PEEP<8CmH2O>12CmH2OPeakP<20CmH2O>30CmH2OPaCO2<60mmHg>70mmHg鎮(zhèn)靜目標(biāo)RASS－2～＋1RASS－5～－3AECOPD鎮(zhèn)靜流程圖AECOPD重度輕度MV支持條件

評(píng)估RASS-3~-5RASS-2~+1鎮(zhèn)靜目標(biāo)

評(píng)估Weaning呼吸重癥患者的目標(biāo)鎮(zhèn)靜急性呼吸衰竭的經(jīng)典代表

通氣：AECOPD（PaCO2

上升）

氧合：ALI／ARDS（PaO2下降）ALI／ARDS患者的鎮(zhèn)靜3呼吸生理改變“Stretch”“Shear”AirwayTrauma20406080100Pressure[cmH2O]102030406050TotalLungCapacity[%]R=22%R=81%R=100%R=93%00R=0%R=59%PelosiAJRCCM2001LowerLevelArmIncreasedCollapseHigherLevelArmIncreasedbarotraumaARDS:小潮氣量保護(hù)性通氣策略改善肺順應(yīng)性：人機(jī)協(xié)調(diào)的問題，肌緊張問題降低交感張力減少M(fèi)V相關(guān)肺損傷避免鎮(zhèn)靜不良反應(yīng)ARDS需要鎮(zhèn)靜解決的問題ARDS：嚴(yán)重程度與MV支持條件mild

moderate

severeLowtidalvolumeverylowtidalvolumeLowPEEPRecruitmentmaneuvershigherPEEPPronePositionInhaledNOECMO30025020015010050PaO2/FiO2ALI/ARDS鎮(zhèn)靜流程圖ALI/ARDS中度到重度

輕

度

MV支持條件

評(píng)估RASS-3~-5＋肌松RASS-2~+1鎮(zhèn)靜目標(biāo)

評(píng)估Weaning每日多次評(píng)估患者的機(jī)械通氣條件

盡可能及時(shí)降低呼吸機(jī)條件至脫機(jī)。每2小時(shí)評(píng)估相應(yīng)需要的鎮(zhèn)靜深度盡可能實(shí)現(xiàn)與保持與MV條件相匹配的鎮(zhèn)靜深度目標(biāo)，避免過淺或過度鎮(zhèn)靜。AECOPD與ARDS患者鎮(zhèn)靜的相同點(diǎn)Impactofventilatoradjustmentandsedation-analgesiapracticesonsevereasynchronyinpatientsventilatedinassist-controlmode.

ChanquesG,KressJP,PohlmanA,etal.Breath-stackingasynchronyduringassist-control-modeventilationmaybeassociatedwithincreasedtidalvolumeandalveolarpressurethatcouldcontributetoventilator-inducedlunginjury.Methodstoreducebreathstackinghavenotbeenwellstudied.Theobjectiveofthisinvestigationwastoevaluate1)whichinterventionswereusedbymanagingclinicianstoaddressseverebreathstacking;and2)howeffectivethesemeasureswere.評(píng)估機(jī)械通氣條件和呼吸機(jī)設(shè)置調(diào)節(jié)CritCareMed.2013Sep;41(9):2177-87CONCLUSIONS:Comparedwithincreasingsedation-analgesia,adaptingtheventilatortopatientbreathingeffortreducesbreath-stackingasynchronysignificantlyandoftendramatically.Theseresultssupportanalgorithmbeginningwithventilatoradjustmenttorationalizethemanagementofseverebreath-stackingasynchronyinICUpatients.CritCareMed.2013Sep;41(9):2177-87CommentinPatient-ventilatorasynchrony:adapttheventilator,notthepatient![CritCareMed.2013]CritCareMed.2014Jan;42(1):205-7.doi:10.1097/CCM.0b013e3182a51ecd.Howmuchsedationcanthosesmartventilatorshandle?Patient-ventilatorsynchronyrevisited*.TaniosMA.Reducingdeepsedationanddeliriuminacutelunginjurypatients:aqualityimprovementproject.HagerDNetal.WeundertookanICU-widestructuredqualityimprovementprojecttodecreasesedationanddelirium.DESIGN:Prospectivequalityimprovementprojectincomparisonwitharetrospectiveacutelunginjurycontrolgroup.SETTING:Sixteen-bedmedicalICUinanacademicteachinghospitalwithpre-existinguseofgoal-directedsedationwithdailyinterruptionofsedativeinfusions.PATIENTS:Consecutiveacutelunginjurypatients.CritCareMed.2013Jun;41(6):1435-42.INTERVENTIONA"4Es"framework(engage,educate,execute,evaluate)wasusedaspartofthequalityimprovementprocess.Anewsedationprotocolwascreatedandimplemented,whichrecommendsatargetRASSof0(alertandcalm)andrequiresfailureofintermittentsedativedosingpriortostartingcontinuousinfusions.Inaddition,twice-dailydeliriumscreeningusingtheCAM-ICUwasintroducedintoroutinepractice.CONCLUSION:Throughastructuredqualityimprovementprocess,useofsedativeinfusionscanbesubstantiallydecreasedanddaysawakewithoutdeliriumsignificantlyincreased,eveninseverelyill,mechanicallyventilatedpatientswithacutelunginjury鎮(zhèn)靜解決的呼吸生理問題不同

（中到重度）

AECOPD:使患者耐受呼吸機(jī)治療，即保持小氣道開放之目的，盡可能保留自主呼吸、咳嗽反射和纖毛運(yùn)動(dòng)。ARDS：

有效抑制自主呼吸（必要時(shí)肌松），最小程度保留咳嗽反射（改善肺順應(yīng)性和呼吸機(jī)機(jī)相關(guān)肺損傷）。AECOPD與ARDS患者鎮(zhèn)靜的不同點(diǎn)AECOPD鎮(zhèn)靜：缺乏證據(jù)Stepwisesedationforelderlypatientswithmild/moderateCOPDduringuppergastrointestinalendoscopy.WorldJGastroenterol.2013Aug7;19(29):4791-8.WorldJGastroenterol.2013Aug7;19(29):4791-8.NMBAinARDS:asystematicreviewandmeta-analysisofRCTsAlhazzanietal.CriticalCare2013,17:R43CCMNEJMCCMOxygenationat24to72hoursForestplotcomparingneuromuscularblockersandplaceboforbarotraumaoutcomeDurationofmechanicalventilationMortality鎮(zhèn)靜劑帶來的藥物相關(guān)損害不同AECOPD:氣道反應(yīng)性ARDS：

炎癥反應(yīng)與免疫調(diào)節(jié)，過度鎮(zhèn)靜

AECOPD與ARDS患者鎮(zhèn)靜的不同點(diǎn)鎮(zhèn)靜鎮(zhèn)痛藥物對(duì)支氣管平滑肌的作用咪唑安定：舒張作用（1）

Kil

N,

et

al.

The

effects

of

midazolam

on

pediatric

patients

with

asthma.

Pediatr

Dent.

2003,25(2):137-142.（2）

Hirota

K,

et

al.

Midazolam

reverses

histamineinduced

bronchoconstriction

in

dogs.

Can

J

Anaesth.

1997

,44(10):1115-1119.Propofol:有保護(hù)作用，但也有誘發(fā)哮喘報(bào)道NishiyamaT,.Propofol-inducedbronchoconstriction:twocasereports.AnesthAnalg,2001,93(3):645–646右美托咪啶：保護(hù)作用嗎啡：誘發(fā)支氣管痙攣AECOPD鎮(zhèn)靜流程圖AECOPD重度輕度MV支持條件

評(píng)估RASS-3~-5RASS-2~+1鎮(zhèn)靜目標(biāo)

評(píng)估策

略：恰當(dāng)淺鎮(zhèn)靜避免使用：?jiǎn)岱龋鸾M胺釋放的肌松劑鎮(zhèn)靜藥物：咪唑安定有優(yōu)勢(shì)（交感張力的降低，支氣管舒張）WeaningALI/ARDS鎮(zhèn)靜流程圖ALI/ARDS中度到重度

輕

度

MV支持條件

評(píng)估RASS-3~-5＋肌松RASS-2~+1鎮(zhèn)靜目標(biāo)

評(píng)估Weaning策略：重癥ARDS采用深鎮(zhèn)靜＋肌松，當(dāng)MV條件呈現(xiàn)下降趨勢(shì)，選擇更易監(jiān)測(cè)和調(diào)節(jié)鎮(zhèn)靜深度的鎮(zhèn)靜劑，如丙泊酚，右美托咪啶，也可以采用咪唑安定－丙泊酚（或右美）序貫。呼吸重癥患者的目標(biāo)鎮(zhèn)靜內(nèi)容急性呼吸衰竭的經(jīng)典代表

通氣：AECOPD（PaCO2

上升）

氧合：ALI／ARDS（PaO2下降）有創(chuàng)或無創(chuàng)通氣時(shí)的鎮(zhèn)靜策略有創(chuàng)通氣無創(chuàng)通氣鎮(zhèn)靜對(duì)于無創(chuàng)機(jī)械通氣是非常重要的SEDATIONDURINGNONINVASIVEVENTILATIONWhateverthesedativeused,thegoalistoachievesedationtoapointwherethepatientsareawakeandarousableandcomfortable.MinervaAnestesiol.2012Jul;78(7):842-6多數(shù)醫(yī)生對(duì)在NPPV期間使用鎮(zhèn)靜劑

CritCareMed2007;35:2298–2302First-choicesedationregimensforpatientswithacuterespiratoryfailuretreatedwithNIVCritCareMed2007;35:2298–2302FactorsmostinfluencingchoiceofsedationagentsCritCareMed2007;35:2298–2302CritCareMed2007;35:2298–2302無創(chuàng)通氣在急性呼吸衰竭患者中的使用越來越多，但是關(guān)于NIV期間鎮(zhèn)靜治療的現(xiàn)狀研究數(shù)據(jù)很少。有研究表明：持續(xù)靜脈輸入單個(gè)鎮(zhèn)靜藥物能夠減少病人的不適，而且不會(huì)對(duì)呼吸和血流動(dòng)力學(xué)產(chǎn)生明顯的影響，另外鎮(zhèn)靜后換氣也會(huì)有所改善。Surveyofsedationpracticesduringnoninvasivepositive-pressureventilatio