1、COPD的機械通氣的機械通氣COPD患者的肺泡過度充盈患者的肺泡過度充盈Sutherland ER, Cherniack RM. Management of Chronic Obstructive Pulmonary Disease. N Engl J Med 2004; 350: 2689-97時間常數時間常數( ) = R x C測定肺組織充盈或排空的速度反映肺組織對壓力變化的反應速度時間常數時間常數( )Time/Tau吸氣相吸氣相呼氣相呼氣相Pressure時間常數時間常數( )PA(t) = (Pplat - PEEP) e-ktk = 1/ =1/(R x C)V(t) = Vt

2、x e-ktk = 1/ =1/(R x C)時間常數時間常數( )時間常數成人(正常值)2 x 0.10 = 0.20”術后氣管插管成人患者5 x 0.06 = 0.30”COPD成人患者15 x 0.06 = 0.90”ARDS成人患者8 x 0.03 = 0.24”ARDS患兒5 x 0.01 = 0.05”動態過度充盈動態過度充盈: DHIinspexpTimeTidal volumeTrapped gasLung VolumeFRCObstructed LungsNormal Stiff Lungs機械通氣的適應證機械通氣的適應證: COPD呼吸肌疲勞且瀕臨呼吸停止盡管進行充分的保守

3、治療, PaCO2仍進行性升高勞累和(或)高碳酸血癥導致意識狀態惡化高濃度吸氧治療無效的低氧血癥痰液清除障礙導致病情惡化呼吸驟停COPD患者的病理生理改變患者的病理生理改變內源性PEEP過高n肺泡過度膨脹n胸腔內壓過高 回心血量減少 休克機械通氣時的機械通氣時的PEEPiVt 10 12 ml/kg, f 12 15 bpm, I:E 1:2 3DHI和和PEEPi的影響因素的影響因素DHI和和PEEPi的影響因素的影響因素機械通氣參數的設置機械通氣參數的設置: COPD潮氣量吸氣流速吸呼比 / 吸氣時間 / 呼氣時間呼吸頻率COPD: 不同吸氣氣流的比較不同吸氣氣流的比較Shieh Chin

4、g Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspirator

5、y Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Resp

6、iratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Vent

7、ilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD: 不同吸氣氣流的比較不同吸氣氣流的比較

8、結論COPD患者機械通氣的最佳吸氣氣流為減速氣流通過選擇適宜的吸氣氣流, 有可能改善上述患者的通氣Shieh Ching Yang, MD, FCCP; and Sze Piao Yang. Effects of Inspiratory Flow Waveforms on Lung Mechanics, Gas Exchange, and Respiratory Metabolism in COPD Patients During Mechanical Ventilation. Chest 2002; 122: 20962104COPD機械通氣策略機械通氣策略降低內源性PEEP的方法n外源性P

9、EEP ?n延長呼氣時間u增加吸氣流速u縮短吸氣末暫停u降低呼吸頻率呼氣流速呼氣流速PalvPEEPFlow = P / Raw= (Palv PEEP) / RawFlowPEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6CompliancePEEP與呼氣流速與呼氣流速Savian C,

10、Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6Compliance P Flow PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During M

11、anual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑PEEPPEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6PEEP半徑半徑流速流速? P 流速流速 PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J

12、. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg

13、 2005; 100: 1112-6PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on P

14、eak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑 Flow PEEP與呼氣流速與呼氣流速Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6半徑半徑 PEEPPEEP與呼氣流速與呼氣流速Savian C

15、, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2005; 100: 1112-6PEEP半徑半徑 流速流速 P 流速流速 COPD穩定期患者穩定期患者(n = 9)年齡(yr)70 FEV1 (%pred)30 FVC (%pred)53 RV (%pred)186 FEV1/VC (%)44 TLC (%pred)103 TLCO (%pred)46 PaO2

16、PaCO2 ODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, ins

17、piratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ

18、, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, a

19、nd lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ, Catcheside PG, J

20、ordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2002;57:533-539COPD穩定期穩定期: PEEPODonoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in

21、severe stable COPD. Thorax 2002;57:533-539總結對于處于穩定期的嚴重COPD患者, 應用高水平的CPAP能夠n降低PEEPi及肌肉活動指標n肺容積顯著增加COPD急性期患者急性期患者(n = 10)Gurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498年齡(yr)64 6身高(cm)167 6體重(kg)72 2

22、1體重(%pred)96 27FiO2 (%)48 9 COPD急性期急性期: PEEPGurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanically ventilated COPD patients. Eur Respir J 2001; 18: 491-498COPD急性期急性期: PEEPGurin C, Fournier G, Milic-Emili J. Effects of PEEP on inspiratory resistance in mechanica

23、lly ventilated COPD patients. Eur Respir J 2001; 18: 491-498COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ve

24、ntilation Crit Care Med 2005; 33: 1519-1528RR 6 bpmRR 9 bpmCOPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ven

25、tilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Car

26、e Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1

27、519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEE

28、P與呼氣流速與呼氣流速Caramez MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Carame

29、z MP, Borges JB, Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD: PEEP與呼氣流速與呼氣流速Caramez MP, Borges JB,

30、Tucci MR, Okamoto VN, Carvalho CR, Kacmarek RM, Malhotra A, Velasco IT, Amato MBP. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528結論對于部分氣道梗阻的患者而言, 應用控制通氣過程中, 設置外源性PEEP能夠緩解過度充盈基礎疾病, 機械力學指標或呼吸

31、機設置均無法預測上述結果逐漸增加PEEP并觀察平臺壓力改變, 是減少副作用的合理方法Assessment of Pulmonary HyperinflationTimeTidal volumeTrapped gasLung VolumeFRCTidal vol.Tidal hyper-inflationApneaTidal VentilationCOPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinfl

32、ation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370Tinsp RR Texp PEEPi COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pul

33、monary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-137016.1

34、 19.0 20.8 7.0 6.3 6.4 2.1 2.4 2.3 COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時間縮短吸氣時間Laghi F, Sega

35、l J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370為何需要設置吸氣末暫停為何需要設置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighPENDELLUFT

36、during thePlateau Phase為何需要設置吸氣末暫停為何需要設置吸氣末暫停PressureFlowPeakPlateauPEEPinspirationexpirationCompliancelowhighNo PENDELLUFTbecause of constant flow flowCOPD: 縮短吸氣時間縮短吸氣時間Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with

37、 Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370COPD: 縮短吸氣時間縮短吸氣時間機械通氣患者常常呼吸頻數, 肺過度充盈n提高吸氣流速, 可以縮短吸氣時間, 盡管呼吸頻率加快, 但能夠延長呼氣時間, 降低呼吸做功n延長吸氣暫停能夠降低呼吸頻率, 卻引發肺過度充盈, 呼吸做功增加Laghi F, Segal J, Choe WK, Tobin MJ. Effect of Imposed Inflation Time on Respiratory Frequency and Hyperinflation in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2001; 163: 1365-1370嚴重氣流梗阻患者的處理嚴重氣流梗阻患者的處理增加流量不能顯著延長