1、Diazepam作品人工氣道之氣囊管理江蘇盛澤醫院EICU 周穎云目錄頁 Contents PageTitleTitleReferenceReferenceConclusionConclusionManage Manage of of BalloonBalloonPrefacePreface人工氣道是保證氣道通暢的有效手段，在搶人工氣道是保證氣道通暢的有效手段，在搶救中發揮極為重要的作用救中發揮極為重要的作用. .建立人工氣道，特別是氣管插管后，患建立人工氣道，特別是氣管插管后，患者的吞咽受限，口腔分泌物及胃食道反者的吞咽受限，口腔分泌物及胃食道反流物受氣囊阻隔滯留于氣囊上方，會形流物受氣囊阻

2、隔滯留于氣囊上方，會形成氣囊上滯留物。成氣囊上滯留物。PrefacePreface國內外研究結果顯示，氣囊上滯留物是呼吸機相關性肺炎（國內外研究結果顯示，氣囊上滯留物是呼吸機相關性肺炎（ventilator ventilator associated pnemnonia,VAPassociated pnemnonia,VAP）病原的重要來源）病原的重要來源11PrefaceThe management of balloon is The management of balloon is an important part of an important part of artificial a

3、irway managementartificial airway management氣囊管理是人工氣道管理中的一個重要環節你還在用這種方你還在用這種方法管理氣囊嗎？法管理氣囊嗎？PrefaceManage of BalloonTypeTypePressurePressureNursingNursing3 31 12 2Manage of BalloonType2淘汰 順應性較好順應性較好橢圓形橢圓形與氣管粘膜接與氣管粘膜接觸面積較大觸面積較大囊內壓力等于大氣壓囊內壓力等于大氣壓自動調節氣囊的充盈度自動調節氣囊的充盈度損傷較小損傷較小High volume low-High volume l

4、ow-pressure balloonpressure balloon 高容低壓氣囊高容低壓氣囊Low volume high-Low volume high-pressure balloonpressure balloon 低容高壓氣囊低容高壓氣囊Constant pressure Constant pressure balloonballoon等壓氣囊等壓氣囊Pressure研究結果顯示：患者在接受氣管插管前8d內，氣囊壓力低于20cmH2O導致誤吸率明顯上升，成為發生VAP的獨立危險因素【4】Manage of Balloon壓力理想壓力3保持有效封閉氣囊與氣管間隙的最小壓力保持有效封閉

5、氣囊與氣管間隙的最小壓力, ,又又可防止氣囊對粘膜的壓迫性損傷。可防止氣囊對粘膜的壓迫性損傷。Manage of BalloonAir pressure should be keep inAir pressure should be keep in2530cmh2o將人工氣道氣囊內壓力保持在2530cmh2o Chinese Society of Critical Care Chinese Society of Critical Care Medicine(CSCCM)adviseMedicine(CSCCM)advise: :壓力影響因素Patients with clinical airb

6、ags pressure Patients with clinical airbags pressure fluctuations may be related to intervention fluctuations may be related to intervention 臨床患者氣囊壓力波動可能與干預有關 Sputum suctionSputum suction 吸痰 Swallowing reflex Swallowing reflex 吞咽反射 Position etc. Position etc. 體位等Manage of Balloon壓力影響因素 有吞咽反射的患者壓力明顯有

7、吞咽反射的患者壓力明顯低于無吞咽反射的患者低于無吞咽反射的患者 壓力壓力由低到高由低到高依次依次為半臥位、平臥位、為半臥位、平臥位、左側臥位、右側臥位左側臥位、右側臥位Adjust the air Adjust the air pressure pressure a after the fter the sputum suctionsputum suction 吸痰后應及時調整囊內壓力For the existence of For the existence of swallowing reflex patients swallowing reflex patients should be

8、gas injection should be gas injection correction after 4 hourscorrection after 4 hours 對于存在吞咽反射的患者4小時后應注氣校正semireclinisemireclining positionng position半臥位Manage of Balloon吸痰時氣囊內吸痰時氣囊內的壓力升高的壓力升高壓力監測Timing 劉亞芳等劉亞芳等44研究表明人工氣囊壓力研究表明人工氣囊壓力4 4小時內衰減不明顯小時內衰減不明顯。趙靜。趙靜月月55等也認為氣囊壓力等也認為氣囊壓力每每隔隔4 4小時應注氣校正小時應注氣校正

9、1 1次次，以保證在安全范圍內。以保證在安全范圍內。Manage of BalloonManage of Balloontouch judge method （TJM） 觸摸判斷法Quantitative aeration method（MOV MLT）定量充氣法cuff pressure measurement（CPM）氣囊壓力表測量壓力監測不能采用根據經驗判定充氣的指觸法給予氣囊充氣(推薦級別:C級)不宜常規采用MOV給予氣囊充氣，在無法測量氣囊壓的情況下，可臨時采用(推薦級別:E級)推薦級別A級NursingNursingdeflate the balloondeflate the ba

10、lloon氣囊的放氣techknowledge of techknowledge of subglottic secretion clean subglottic secretion clean upup囊上滯留物的清除inflate the ballooninflate the balloon氣囊的充氣judge the air-leak of the judge the air-leak of the balloonballoon氣囊漏氣的判斷Manage of Balloon氣囊的護理-充氣 最小閉合容量 (MOV) 最小漏氣技術（MLT) 氣囊充氣后吸氣時無氣體漏出 氣囊充氣后吸氣時有

11、少量氣體漏出 1.將聽診器放于氣管處,向氣囊 1.同MOV 內注氣直到聽不到漏氣聲 2.抽出0.5ml氣體，可聞及少量 2.抽出氣體，從0.1ml開始，直到 漏氣聲 吸氣時聽到少量漏氣聲 3.再緩慢注氣，直到吸氣時聽不 到漏氣聲 Manage of Balloon不推薦17氣囊的放氣1 1氣囊放氣后1h內氣囊壓力壓迫過的黏膜毛細血管血流難以恢復 2 2氣囊放氣時易導致上方積液流入下呼吸道造成肺部感染或窒息, 且影響有效的機械通氣3 3常規定時放、充氣使醫務人員忽視充氣容積或壓力的調整, 反而會充氣過多壓力過高Manage of Balloon181324氣囊漏氣的判斷Air pressure

12、Air pressure is too lowis too low 氣囊壓力過低The patient cheeks The patient cheeks are muscle tremorare muscle tremor 病人兩腮肌肉顫動The neck is heard in The neck is heard in the throatthe throat頸部聽到喉鳴音Ventilator with low Ventilator with low gas flow alarmgas flow alarm 呼吸機低通氣量報警Manage of Balloonthreat to life囊

13、上滯留物清除Manage of Balloon使用簡易呼吸器清除囊上滯留物頭低足高位頭低足高位病人吸氣末呼氣初病人吸氣末呼氣初給予較大潮氣量給予較大潮氣量同時放氣同時放氣再充氣再充氣氣囊周圍形成較大的沖力氣囊周圍形成較大的沖力將其上方的分泌物將其上方的分泌物沖到口咽部，有利沖到口咽部，有利于充分吸凈于充分吸凈陶兆武等認為6對氣囊上間斷沖洗或持續引流能有效清除滯留物可沖洗氣管導管持續聲門下分泌物吸引技術Manage of Balloon預防VAP發生，應定期清除氣囊上滯留物，尤其是氣囊放氣前（推薦級別：A級）清除氣囊上滯留物可采用帶聲門下吸引的人工氣道（推薦級別：A級）宜進行間斷吸引（推薦級別：

14、D級）Cluster balloon management strategies to prevent VAPCluster balloon management strategies to prevent VAP 集束化氣囊管理策略預防vap1 1、Air pressure table monitoring pressureAir pressure table monitoring pressure 專用氣囊測壓表監測氣囊壓力2 2、Before the nasogastric monitoring pressureBefore the nasogastric monitoring pres

15、sure 鼻飼前監測氣囊壓力3 3、After Sputum aspiration monitoring pressureAfter Sputum aspiration monitoring pressure 吸痰后監測氣囊壓力4 4、Every 4h monitoring air pressureEvery 4h monitoring air pressure 每4h監測氣囊壓力5 5、Does not perform balloon deflated regularlyDoes not perform balloon deflated regularly 不執行氣囊定時放氣EICU ann

16、ual continuous quality improvement project in 2016EICU annual continuous quality improvement project in 2016 2016年EICU的年度持續質量改進項目Scientific use of Scientific use of air bag pressure air bag pressure gaugegauge科學利用氣囊測壓表Artificial airway Artificial airway care is a key care is a key factor in the fact

17、or in the success or failure success or failure of the rescueof the rescue人工氣道護理的好壞是搶救成功與否的關鍵因素之一Strengthen theory Strengthen theory and technology and technology training to ensure training to ensure effective effective implementation of implementation of mechanical mechanical ventilationventilation加強理論與技術培訓以確保機械通氣的有效實施ConclusionConclusion過渡頁 Transition Page1Frosr SA,Azeem A,Alexandrou E,et al.Subglottic secretion drainage for preventing ventilator associated pneumonia:a meta-analysisJ.Aust Crit Care.2013,26:180-1882宋志芳主編.現代呼吸機治療學.北京:人民軍醫出版社,2005:235.高數海