Samun iska mai haɗari shine shiga tsakani da ake amfani da shi akai-akai a cikin majinyata marasa lafiya waɗanda ke buƙatar tallafin numfashi ko kariya ta iska

Mai ba da iska yana ba da damar musayar iskar gas yayin da ake gudanar da wasu jiyya don inganta yanayin asibiti

Wannan aikin yana duba alamomi, contraindications, gudanarwa, da kuma yiwuwar rikitarwa na iska mai haɗari na inji kuma yana jaddada mahimmancin ƙungiyar masu aiki a cikin kula da marasa lafiya da ke buƙatar tallafin iska.

Bukatar samun iska na inji shine ɗayan mafi yawan abubuwan da ke haifar da shigar da ICU.[1][2][3]

MASU TSIRA, KWALLON KAYAN KAYAN KADUNA, MATSAYIN HUKUNCI, KUJERAR KAURI: KAYAN SPENCER A CIKIN BOTH BIYU A EXPO na gaggawa

Yana da mahimmanci don fahimtar wasu ƙa'idodi na asali don fahimtar iskar inji

Samun iska: Musayar iskar tsakanin huhu da iska (na yanayi ko kuma na'urar iska ta kawota), wato tsarin tafiyar da iska a ciki da wajen huhu.

Mafi mahimmancin tasirinsa shine kawar da carbon dioxide (CO2) daga jiki, ba karuwar iskar oxygen a cikin jini ba.

A cikin saitunan asibiti, ana auna iskar iska azaman iskar minti kaɗan, ana ƙididdige shi azaman ƙimar juzu'i (RR) sau tidal (Vt).

A cikin majiyyaci na injina, ana iya canza abun ciki na CO2 na jini ta hanyar canza ƙarar ruwa ko yawan numfashi.

Oxygenation: Matsalolin da ke ba da ƙarin isar da iskar oxygen zuwa huhu don haka zuwa wurare dabam dabam.

A cikin majinyacin da ke da iska mai ƙarfi, ana iya samun wannan ta hanyar haɓaka juzu'in iskar oxygen (FiO 2%) ko matsi na ƙarshe na ƙarshe (PEEP).

PEEP: Matsi mai kyau da ya rage a cikin hanyar iska a ƙarshen sake zagayowar numfashi (ƙarshen ƙarewa) ya fi ƙarfin yanayi a cikin marasa lafiya na inji.

Don cikakken bayanin yadda ake amfani da PEEP, duba labarin mai taken "Matsi na Ƙarshen Ƙarshen Ƙarshe (PEEP)" a cikin nassoshi na bibliographical a ƙarshen wannan labarin.

Ƙaƙƙarfan motsi: Ƙarfin iska yana motsawa a ciki da waje a cikin huhu a kowane zagaye na numfashi.

FiO2: Kashi na iskar oxygen a cikin cakudawar iska wanda aka kai ga majiyyaci.

Gudura: Ƙididdiga a cikin lita a cikin minti daya inda mai ba da iska ya ba da numfashi.

Yardaje: Canji a cikin ƙarar da aka raba ta canjin matsa lamba. A cikin ilimin halittar jiki na numfashi, jimlar yarda shine cakuda haɗin huhu da katangar ƙirji, tunda waɗannan abubuwa biyu ba za a iya raba su cikin majiyyaci ba.

Saboda iskar injin na ba da izinin likita don canza iskar mara lafiya da iskar oxygen, yana taka muhimmiyar rawa a cikin matsanancin hypoxic da hypercapnic gazawar numfashi da matsanancin acidosis ko alkalosis na rayuwa.[4][5].

Ilimin ilimin halittar jiki na samun iska

Samun iska na inji yana da tasiri da yawa akan injinan huhu.

Ilimin ilimin lissafin numfashi na al'ada yana aiki azaman tsarin matsa lamba mara kyau.

Lokacin da diaphragm ya matsa ƙasa a lokacin wahayi, ana haifar da matsananciyar matsa lamba a cikin rami na pleural, wanda, bi da bi, yana haifar da mummunan matsi a cikin hanyoyin iska wanda ke jawo iska zuwa cikin huhu.

Wannan matsi mara kyau na intrathoracic yana rage matsa lamba na dama (RA) kuma yana haifar da tasirin tsotsa akan ƙananan vena cava (IVC), yana ƙaruwa da dawowar venous.

Yin amfani da iskar matsa lamba mai kyau yana canza wannan ilimin lissafi.

Ingantacciyar matsi da mai iska ke haifar da shi ana watsa shi zuwa babbar hanyar iska kuma daga ƙarshe zuwa alveoli; wannan, bi da bi, ana daukar kwayar cutar zuwa sararin alveolar da thoracic cavity, yana haifar da matsi mai kyau (ko akalla ƙananan matsa lamba) a cikin sararin samaniya.

Ƙara yawan matsa lamba na RA da raguwa a cikin dawowar venous yana haifar da raguwa a cikin ƙaddamarwa.

Wannan yana da tasiri guda biyu na rage fitowar zuciya: ƙarancin jini a cikin ventricle na dama yana nufin ƙarancin jini yana kaiwa ga ventricle na hagu kuma ana iya fitar da ƙasa kaɗan, yana rage fitowar zuciya.

Ƙarƙashin ƙaddamarwa yana nufin cewa zuciya tana aiki a wani wuri mara kyau a kan hanzarin hanzari, samar da aikin da ba shi da kyau da kuma kara rage yawan fitarwar zuciya, wanda zai haifar da raguwa a cikin matsananciyar ma'auni (MAP) idan ba a sami amsa ta hanyar karuwa ba. Tsarin juriya na jijiyoyin jini (SVR).

Wannan muhimmin mahimmanci ne a cikin marasa lafiya waɗanda ba za su iya ƙara SVR ba, kamar a cikin marasa lafiya tare da rawar jiki (septic, neurogenic, ko anaphylactic).

A gefe guda, ingantacciyar iskar injuna na iya rage yawan aikin numfashi.

Wannan, bi da bi, yana rage kwararar jini zuwa tsokoki na numfashi kuma yana sake rarraba shi zuwa ga mafi mahimmancin gabobin.

Rage aikin tsokoki na numfashi kuma yana rage samar da CO2 da lactate daga waɗannan tsokoki, yana taimakawa wajen inganta acidosis.

Tasirin ingantacciyar iska ta injin matsi mai ƙarfi akan dawowar venous na iya zama da amfani a cikin marasa lafiya da edema na huhu na cardiogenic.

A cikin waɗannan marasa lafiya tare da ƙarar girma, rage dawowar venous zai rage kai tsaye adadin edema na huhu da aka haifar, yana rage fitowar bugun zuciya daidai.

A lokaci guda, raguwar dawowar jijiyoyi na iya inganta haɓakar ventricle na hagu, yana sanya shi a wuri mafi fa'ida akan madaidaicin Frank-Starling kuma maiyuwa inganta fitarwar zuciya.

Gudanar da ingantaccen iskar injin yana buƙatar fahimtar matsi na huhu da kuma bin huhu.

Madaidaicin yarda da huhu shine kusan 100 ml/cmH20.

Wannan yana nufin cewa a cikin huhu na al'ada, gudanar da 500 ml na iska ta hanyar samun iska mai kyau zai kara karfin alveolar ta 5 cm H2O.

Sabanin haka, gudanar da ingantaccen matsin lamba na 5 cm H2O zai haifar da haɓakar ƙwayar huhu na 500 ml.

Lokacin aiki tare da huhu mara kyau, yardawar na iya zama mafi girma ko ƙasa da yawa.

Duk wata cuta da ke lalata huhu parenchyma, kamar emphysema, zai ƙara yarda, yayin da duk wata cuta da ke haifar da huhu mai ƙarfi (ARDS, ciwon huhu, edema na huhu, fibrosis na huhu) zai rage yarda da huhu.

Matsalar tare da ƙananan huhu shine ƙananan ƙarar ƙararrawa na iya haifar da karuwa mai yawa a matsa lamba kuma ya haifar da barotrauma.

Wannan yana haifar da matsala a cikin marasa lafiya tare da hypercapnia ko acidosis, saboda ana iya buƙatar samun iska na minti daya don gyara waɗannan matsalolin.

Ƙara yawan adadin numfashi zai iya sarrafa wannan karuwa a cikin samun iska na minti daya, amma idan wannan ba zai yiwu ba, ƙara yawan ƙarar ruwa zai iya ƙara matsin lamba kuma ya haifar da barotrauma.

Akwai matsi masu mahimmanci guda biyu a cikin tsarin don kiyayewa lokacin da ake hura majinyaci ta injina:

• Matsin kololuwa shine matsi da ake samu yayin wahayi lokacin da ake tura iska cikin huhu kuma shine ma'aunin juriya na iska.
• Matsin Plateau shine matsi na tsaye da aka kai a ƙarshen cikakken wahayi. Don auna matsi na plateau, dole ne a yi ɗan dakatai mai ban sha'awa akan na'urar iska don ba da damar matsa lamba ta daidaita ta tsarin. Matsin Plateau ma'auni ne na matsa lamba na alveolar da kuma yarda da huhu. Matsalolin plateau na yau da kullun yana ƙasa da 30 cm H20, yayin da matsa lamba mafi girma na iya haifar da barotrauma.

Alamomi don samun iska na inji

Alamun da aka fi sani don shigar da intubation da iskar inji shine a lokuta na gazawar numfashi mai tsanani, ko dai hypoxic ko hypercapnic.

Sauran mahimman alamu sun rage matakin hankali tare da rashin iyawa don kare hanyar iska, damuwa na numfashi wanda ya kasa samun iska mai kyau mara zafi, lokuta na babban hemoptysis, angioedema mai tsanani, ko duk wani yanayin rashin daidaituwa na hanyar iska kamar konewar iska, kama zuciya, da girgiza.

Alamun zaɓi na gama gari don samun iska na inji sune tiyata da cututtukan neuromuscular.

contraindications

Babu wata takaddama kai tsaye ga samun iska ta injina, saboda matakan ceton rai ne a cikin majinyata mai tsananin rashin lafiya, kuma ya kamata a ba wa duk marasa lafiya damar cin gajiyar sa idan ya cancanta.

Iyakar cikakkiyar hani ga iskar injina shine idan ya saba wa sha'awar da majiyyaci ya bayyana na matakan dorewar rayuwa ta wucin gadi.

Iyakar abin da ke da alaƙa kawai shine idan akwai iskar da ba ta ɓarna ba kuma ana tsammanin amfani da shi don warware buƙatar iskar inji.

Ya kamata a fara wannan da farko, saboda yana da ƙarancin rikitarwa fiye da samun iska.

Ya kamata a ɗauki matakai da yawa don fara samun iska

Wajibi ne don tabbatar da daidaitaccen wuri na bututun endotracheal.

Ana iya yin wannan ta hanyar ɗaukar hoto na ƙarshe ko kuma ta hanyar haɗin binciken asibiti da na rediyo.

Wajibi ne a tabbatar da isasshen goyon bayan zuciya da jijiyoyin jini tare da ruwaye ko vasopressors, kamar yadda aka nuna akan kowane hali.

Tabbatar cewa ana samun isassun jin daɗi da analgesia.

Bututun filastik a cikin makogwaro na majiyyaci yana da zafi da rashin jin daɗi, kuma idan mai haƙuri ba shi da hutawa ko ya yi fama da bututu ko samun iska, zai zama da wahala a sarrafa sigogi daban-daban na samun iska da iskar oxygen.

Yanayin iska

Bayan shigar da mara lafiya tare da haɗa shi ko ita zuwa na'urar hurawa, lokaci ya yi da za a zaɓi yanayin da za a yi amfani da shi.

Domin yin wannan akai-akai don amfanin majiyyaci, ana buƙatar fahimtar ƙa'idodi da yawa.

Kamar yadda aka ambata a baya, yarda shine canjin ƙarar da aka raba ta canjin matsa lamba.

Lokacin da injina ke hura majinyaci, zaku iya zaɓar yadda na'urar iska zata isar da numfashi.

Za a iya saita na'urar iska don isar da ƙayyadaddun adadin ƙarar ko ƙaddarar adadin matsa lamba, kuma ya rage ga likita ya yanke shawarar abin da ya fi amfani ga majiyyaci.

Lokacin zabar isar da iska, za mu zaɓi wanda zai zama madaidaicin abin dogaro kuma wanda zai zama madaidaicin mai zaman kansa a cikin ma'aunin yarda da huhu.

Idan muka zaɓa don fara majiyyaci a kan iskar da ke sarrafa ƙararrawa, mai ba da iska koyaushe zai ba da adadin adadin adadin (mai zaman kansa), yayin da matsa lamba da aka haifar zai dogara ne akan yarda.

Idan yarda ba shi da kyau, matsa lamba zai zama babba kuma barotrauma na iya faruwa.

A gefe guda, idan muka yanke shawarar fara majiyyaci a kan iskar da ake sarrafa matsi, na'urar za ta ba da irin wannan matsin lamba yayin zagayowar numfashi.

Duk da haka, ƙarar ruwa zai dogara ne akan yarda da huhu, kuma a lokuta inda yarda yakan canza akai-akai (kamar a cikin asma), wannan zai haifar da ƙididdiga marasa ƙarfi kuma yana iya haifar da hypercapnia ko hyperventilation.

Bayan zaɓar yanayin isar da numfashi (ta matsa lamba ko ƙara), likita dole ne ya yanke shawarar wane yanayin samun iska don amfani.

Wannan yana nufin zabar ko na’urar da za ta taimaka wa duk numfashin majiyyaci, da wasu numfashin maras lafiya, ko babu, da kuma ko na’urar za ta isar da numfashi ko da majiyyaci ba ya numfashi da kan sa.

Sauran sigogin da za a yi la'akari da su sune ƙimar isar da numfashi (gudanarwa), yanayin motsi na gudana (ƙaddamarwar raƙuman ruwa tana kwaikwayi numfashin ilimin lissafi kuma ya fi dacewa ga mai haƙuri, yayin da nau'ikan raƙuman ruwa na murabba'i, wanda a cikinsa ana isar da kwararar a matsakaicin ƙimar cikin wahayi, sun fi jin daɗi ga majiyyaci amma suna samar da lokutan inhalation da sauri), da yawan isar da numfashi.

Duk waɗannan sigogi dole ne a daidaita su don samun kwanciyar hankali na haƙuri, iskar gas ɗin da ake so, da kuma guje wa kama iska.

Akwai hanyoyin samun iska da yawa waɗanda suka bambanta kaɗan daga juna. A cikin wannan bita za mu mai da hankali kan mafi yawan hanyoyin samun iska da kuma amfani da su na asibiti.

Hanyoyin samun iska sun haɗa da kulawar taimako (AC), goyon bayan matsa lamba (PS), daidaitawar iskar iska ta wajibi (SIMV), da iska mai sakin iska (APRV).

Taimakon samun iska (AC)

Taimakawa kulawa shine inda na'urar numfashi ke taimaka wa majiyyaci ta hanyar ba da tallafi ga kowane numfashin da majiyyaci ke ɗauka (wannan shine ɓangaren taimako), yayin da mai ba da iska yana da iko akan yawan numfashi idan ya faɗi ƙasa da adadin da aka saita (bangaren sarrafawa).

A cikin kulawar taimako, idan an saita mitar zuwa 12 kuma majiyyaci yana numfashi a 18, injin na'urar zai taimaka tare da numfashi 18, amma idan mitar ta ragu zuwa 8, na'urar za ta dauki nauyin numfashi kuma ya dauki numfashi 12. a minti daya.

A cikin isar da iskar taimako, ana iya isar da numfashi da ko dai ƙara ko matsa lamba

Ana kiran wannan a matsayin iskar da ake sarrafa ƙarar ko iska mai sarrafa matsi.

Don kiyaye shi mai sauƙi kuma fahimtar cewa tun da samun iska ya zama mafi mahimmancin batu fiye da matsa lamba kuma ana amfani da sarrafa ƙarar fiye da sarrafa matsa lamba, don ragowar wannan bita za mu yi amfani da kalmar "ikon juzu'i" a musanya yayin magana game da kulawar taimako.

Ikon taimako (ikon ƙarar ƙara) shine yanayin zaɓin da aka yi amfani da shi a yawancin ICUs a cikin Amurka saboda yana da sauƙin amfani.

Saituna huɗu (yawan numfashi, ƙarar ruwa, FiO2, da PEEP) ana iya daidaita su cikin sauƙi a cikin injin iska. Ƙarfin da na'urar da ke bayarwa a cikin kowane numfashi a cikin kulawar taimako koyaushe zai kasance iri ɗaya ne, ba tare da la'akari da numfashin da majiyyaci ko mai ba da iska ya fara ba da kuma yarda, kololuwa ko matsa lamba a cikin huhu.

Kowane numfashi na iya zama lokaci (idan yawan numfashin majiyyaci ya yi kasa da na'urar iska, injin zai isar da numfashi a wani lokaci da aka saita) ko majiyyaci ya motsa shi, idan majiyyaci ya fara numfashi da kansa.

Wannan yana sa ikon sarrafa taimako ya zama yanayi mai daɗi sosai ga majiyyaci, saboda duk ƙoƙarinsa za a ƙara shi da injin iska.

Bayan yin canje-canje ga na'urar iska ko kuma bayan fara majiyyaci akan iskar injina, yakamata a bincika iskar jinin jijiya a hankali kuma a bi saturation na iskar oxygen akan na'urar don tantance ko ana buƙatar ƙarin canje-canje ga na'urar.

Abubuwan amfani da yanayin AC suna haɓaka ta'aziyya, sauƙin gyara acidosis na numfashi / alkalosis, da ƙarancin aikin numfashi ga mai haƙuri.

Rashin hasara sun haɗa da gaskiyar cewa tun da wannan yanayin yanayin sake zagayowar girma ne, ba za a iya sarrafa matsalolin kai tsaye ba, wanda zai iya haifar da barotrauma, mai haƙuri na iya haɓaka haɓakar iska tare da stacking na numfashi, autoPEEP, da alkalosis na numfashi.

Don cikakken bayanin kulawar da aka taimaka, duba labarin mai taken “Hanyar iska, Taimakon Taimakon” [6], a cikin ɓangaren Maganar Littafi Mai Tsarki a ƙarshen wannan labarin.

Haɗa aiki tare da Mandarfafa Mitar iska (SIMV)

SIMV wani tsarin samun iska ne da ake amfani da shi akai-akai, ko da yake amfani da shi ya faɗo cikin rashin amfani saboda ƙarancin ingantattun ɗigon ruwa da rashin ingantaccen sakamako fiye da AC.

“A daidaitawa” yana nufin cewa na’urar hura iska tana daidaita isar da nunfashinsa ga ƙoƙarin majiyyaci. “Mai tsaka-tsaki” yana nufin cewa ba lallai ne a tallafa wa dukkan numfashi ba kuma “wajibi na samun iska” yana nufin cewa, kamar yadda yake a cikin CA, ana zaɓar mitar da aka riga aka kayyade kuma na’urar na’urar tana isar da waɗannan nunfashi na wajibi kowane minti daya ba tare da la’akari da ƙoƙarin numfashin mara lafiya ba.

Za a iya haifar da numfashi na wajibi ta haƙuri ko lokaci idan RR na majiyyaci ya yi hankali fiye da RR na injin iska (kamar yadda yake a cikin CA).

Bambancin da AC shine cewa a cikin SIMV mai ɗaukar iska zai isar da numfashin da aka saita mitar don isar da shi; duk numfashin da majiyyaci ya yi sama da wannan mitar ba zai sami ƙarar ruwa ko cikakken goyon bayan latsa ba.

Wannan yana nufin cewa ga kowane numfashin da majiyyaci ya ɗauka sama da saitin RR, ƙarar ruwa da majiyyaci ke bayarwa zai dogara ne kawai akan yarda da huhu na majiyyaci da ƙoƙarinsa.

An gabatar da wannan a matsayin hanya don "horar da" diaphragm don kiyaye sautin tsoka da kuma yaye marasa lafiya daga na'urar iska da sauri.

Koyaya, yawancin bincike sun nuna babu fa'idar SIMV. Bugu da ƙari, SIMV yana haifar da aikin numfashi fiye da AC, wanda ke da mummunar tasiri akan sakamako kuma yana haifar da gajiya na numfashi.

Babban tsarin yatsan yatsa da za a bi shi ne cewa za a saki majiyyaci daga na'urar iska lokacin da ya shirya, kuma babu takamaiman yanayin iskar da zai sa ya yi sauri.

A halin yanzu, yana da kyau a kiyaye mara lafiya kamar yadda zai yiwu, kuma SIMV bazai zama mafi kyawun yanayin don cimma wannan ba.

Taimakon Matsi (PSV)

PSV yanayin samun iska ne wanda ya dogara gabaɗaya akan numfashin da mai haƙuri ya kunna.

Kamar yadda sunan ke nunawa, yanayin samun iska ne da ke motsa matsi.

A cikin wannan yanayin, duk numfashi yana farawa ta majiyyaci, kamar yadda na'urar iska ba ta da adadin ajiyar kuɗi, don haka kowane numfashi dole ne ya fara da majiyyaci. A cikin wannan yanayin, injin iska yana canzawa daga matsa lamba ɗaya zuwa wani (PEEP da matsin tallafi).

PEEP shine matsin da ya rage a ƙarshen numfashi, yayin da goyon bayan matsa lamba shine matsi a sama da PEEP wanda na'urar numfashi zai gudanar yayin kowane numfashi don ci gaba da samun iska.

Wannan yana nufin cewa idan an saita mai haƙuri a cikin PSV 10/5, za su sami 5 cm H2O na PEEP kuma a lokacin wahayi za su sami 15 cm H2O na tallafi (10 PS sama da PEEP).

Saboda babu mitar ajiyar ajiya, wannan yanayin ba za a iya amfani da shi ba a cikin marasa lafiya tare da asarar sani, girgiza ko kama zuciya.

Juzu'i na yanzu sun dogara ne kawai akan ƙarfin majiyyaci da bin huhu.

Ana amfani da PSV sau da yawa don yaye daga na'urar iska, saboda kawai yana ƙara ƙoƙarin numfashi na majiyyaci ba tare da samar da ƙayyadadden ƙarar ruwa ba ko ƙimar numfashi.

Babban hasara na PSV shine rashin dogaro na ƙarar ruwa, wanda zai iya haifar da riƙewar CO2 da acidosis, da babban aikin numfashi wanda zai iya haifar da gajiyawar numfashi.

Don magance wannan matsala, an ƙirƙiri sabon algorithm don PSV, mai suna Volume-supported ventilation (VSV).

VSV wani yanayi ne mai kama da PSV, amma a cikin wannan yanayin ana amfani da ƙarar halin yanzu a matsayin kulawar amsawa, a cikin cewa goyon bayan latsawa da aka ba wa majiyyaci ana daidaitawa akai-akai bisa ga ƙarar yanzu. A cikin wannan saitin, idan ƙarar tidal ɗin ya ragu, na'urar za ta ƙara goyon bayan latsa don rage ƙarar igiyar ruwa, yayin da idan ƙarar ƙararrawa ta ƙaru goyon bayan latsa zai ragu don kiyaye ƙarar tidal kusa da iskar da ake so.

Wasu shaidun sun nuna cewa yin amfani da VSV na iya rage taimakon lokacin samun iska, jimlar lokacin yaye da jimlar T-yanki, da kuma rage buƙatar kwantar da hankali.

Sakin iska mai karfin iska (APRV)

Kamar yadda sunan ya nuna, a cikin yanayin APRV, mai iska yana ba da matsa lamba mai yawa a cikin iska, wanda ke tabbatar da iskar oxygen, kuma ana yin iska ta hanyar sakin wannan matsa lamba.

Wannan yanayin kwanan nan ya sami shahara a matsayin madadin marasa lafiya da ARDS waɗanda ke da wahalar iskar oxygen, waɗanda sauran hanyoyin samun iska sun kasa cimma burinsu.

An kwatanta APRV a matsayin ci gaba da matsa lamba mai kyau na iska (CPAP) tare da lokacin sakin lokaci.

Wannan yana nufin cewa na'urar iska tana shafa matsa lamba mai tsayi (P high) na tsayayyen lokaci (T high) sannan ya sake shi, yawanci yana komawa sifili (P low) na ɗan gajeren lokaci (T low).

Manufar da ke bayan wannan ita ce, a lokacin T high (rufe 80% -95% na sake zagayowar), akwai m alveolar daukar ma'aikata, wanda inganta oxygenation saboda lokacin kiyayewa a high matsa lamba ya fi tsayi fiye da lokacin sauran nau'in samun iska (bude dabarun huhu). ).

Wannan yana rage maimaita hauhawar farashin kaya da raguwar huhu da ke faruwa tare da wasu hanyoyin samun iska, yana hana raunin huhun da ke haifar da iska.

A wannan lokacin (T high) majiyyaci yana da 'yancin yin numfashi ba tare da bata lokaci ba (wanda ke sa shi jin daɗi), amma zai ja ƙarancin ruwa mai ƙarfi saboda fitar da irin wannan matsi yana da wahala. Sa'an nan, lokacin da girman T ya kai, matsa lamba a cikin injin iska yana raguwa zuwa P low (yawanci zero).

Daga nan sai a fitar da iska daga iskar iska, wanda zai ba da damar fitar da numfashi har sai an kai T kasa kuma na'urar ta sake fitar da wani numfashi.

Don hana rushewar hanyar iska a wannan lokacin, ana saita ƙananan T a taƙaice, yawanci kusan 0.4-0.8 seconds.

A wannan yanayin, lokacin da aka saita matsa lamba na iska zuwa sifili, jujjuyawar huhu na huhu yana tura iska zuwa waje, amma lokacin bai daɗe ba don fitar da dukkan iska daga cikin huhu, don haka matsi na alveolar da iska ba su kai sifili ba. kuma rugujewar hanyar iska baya faruwa.

Yawancin lokaci ana saita wannan lokacin don ƙananan T ya ƙare lokacin da fitar da numfashi ya ragu zuwa 50% na farkon gudana.

Samun iska a cikin minti daya, saboda haka, zai dogara ne akan ƙananan T da ƙarar majinyacin lokacin T high

Alamomi don amfani da APRV:

• ARDS yana da wahalar oxygenate tare da AC
• M rauni na huhu
• Bayan aikin atelectasis.

Amfanin APRV:

APRV hanya ce mai kyau don samun iska mai karewa.

Ikon saita babban P yana nufin cewa mai aiki yana da iko akan matsa lamba na plateau, wanda zai iya rage yawan abin da ya faru na barotrauma.

Yayin da mai haƙuri ya fara ƙoƙarin numfashinsa, akwai mafi kyawun rarraba iskar gas saboda mafi kyawun wasan V/Q.

Babban matsin lamba na yau da kullun yana nufin ƙarin ɗaukar ma'aikata (dabarun buɗaɗɗen huhu).

APRV na iya inganta oxygenation a cikin marasa lafiya tare da ARDS waɗanda ke da wuyar oxygenate tare da AC.

APRV na iya rage buƙatar kwantar da hankali da magungunan neuromuscular blocking, kamar yadda mai haƙuri zai iya samun kwanciyar hankali idan aka kwatanta da sauran hanyoyin.

Rashin amfani da contraindications:

Saboda numfashin nan da nan wani muhimmin al'amari ne na APRV, bai dace da marasa lafiya da aka kwantar da su ba.

Babu bayanai game da amfani da APRV a cikin cututtukan neuromuscular ko cutar huhu mai hanawa, kuma ya kamata a guji amfani da shi a cikin waɗannan yawan marasa lafiya.

A bisa ka'ida, yawan matsa lamba na intrathoracic na yau da kullun na iya haifar da hawan jini na huhu da kuma kara tsananta shunts na zuciya a cikin marasa lafiya da Eisenmenger's Physiology.

Ana buƙatar dalili mai ƙarfi na asibiti lokacin zabar APRV azaman yanayin samun iska akan ƙarin hanyoyin al'ada kamar AC.

Ana iya samun ƙarin bayani game da cikakkun bayanai na hanyoyin samun iska daban-daban da saitin su a cikin labaran akan kowane takamaiman yanayin iska.

Amfani da na'urar iska

Saitin farko na na'urar iska na iya bambanta sosai dangane da dalilin shigar da ciki da kuma manufar wannan bita.

Koyaya, akwai wasu saitunan asali don yawancin lokuta.

Mafi na kowa yanayin iska don amfani da shi a cikin sabon majiyyaci shine yanayin AC.

Yanayin AC yana ba da ta'aziyya mai kyau da sauƙin sarrafa wasu mahimman sigogin ilimin lissafi.

Yana farawa da FiO2 na 100% kuma yana raguwa ta hanyar pulse oximetry ko ABG, kamar yadda ya dace.

An nuna ƙarancin iskar iska mai ƙarfi na huhu ba kawai a cikin ARDS ba har ma da wasu nau'ikan cututtuka.

Fara majiyyaci tare da ƙananan ƙarar ruwa (6 zuwa 8 mL/Kg madaidaicin nauyin jiki) yana rage yawan raunin da ya haifar da cutar huhu (VILI).

Koyaushe yi amfani da dabarun kariyar huhu, kamar yadda mafi girman adadin ruwa ba su da fa'ida kaɗan kuma yana ƙaruwa da damuwa a cikin alveoli kuma yana iya haifar da rauni na huhu.

RR na farko ya kamata ya zama dadi ga mai haƙuri: 10-12 bpm ya isa.

Muhimmiyar faɗakarwa ta shafi marasa lafiya tare da matsanancin acidosis na rayuwa.

Ga waɗannan marasa lafiya, samun iska a cikin minti ɗaya dole ne aƙalla ya dace da iskar da aka riga aka shigar, domin in ba haka ba acidosis yana daɗa muni kuma yana iya haifar da rikitarwa kamar kamawar zuciya.

Ya kamata a fara gudana a ko sama da 60 L/min don guje wa autoPEEP

Fara tare da ƙananan PEEP na 5 cm H2O kuma ƙara bisa ga haƙurin haƙuri ga burin oxygenation.

Kula da hankali sosai ga hawan jini da jin daɗin haƙuri.

Ya kamata a sami ABG 30 min bayan intubation kuma ya kamata a daidaita saitunan iska bisa ga sakamakon ABG.

Ya kamata a duba matsi na kololuwa da plateau akan na'urar don tabbatar da cewa babu matsala tare da juriya na iska ko matsa lamba na alveolar don hana lalacewar huhun da injin ya haifar.

Ya kamata a ba da hankali ga maɗaukakin ƙararrawa a kan nunin iska, kamar yadda karatun da ke nuna cewa kullun baya komawa sifili a kan numfashi yana nuna rashin cikawar numfashi da ci gaban auto-PEEP; don haka sai a yi gyara ga na’urar busar da iska nan take[7][8].

Gyara matsalar injin iska

Tare da kyakkyawar fahimtar ra'ayoyin da aka tattauna, sarrafa rikice-rikice na iska da matsala ya kamata ya zama yanayi na biyu.

Mafi yawan gyare-gyaren da za a yi don samun iska sun haɗa da hypoxemia da hypercapnia ko hyperventilation:

Hypoxia: oxygenation ya dogara da FiO2 da PEEP (high T da high P don APRV).

Don gyara hypoxia, haɓaka kowane ɗayan waɗannan sigogi ya kamata ya haɓaka oxygenation.

Ya kamata a biya kulawa ta musamman ga yiwuwar mummunan sakamako na karuwar PEEP, wanda zai iya haifar da barotrauma da hypotension.

Ƙara FiO2 ba tare da damuwa ba ne, kamar yadda FiO2 mai girma zai iya haifar da lalacewar oxidative a cikin alveoli.

Wani muhimmin al'amari na kula da abun ciki na oxygen shine kafa burin oxygenation.

Gabaɗaya, yana da ɗan fa'ida don kula da jikewar iskar oxygen sama da 92-94%, sai dai, alal misali, a lokuta na guba na carbon monoxide.

Faɗuwar iskar oxygen ba zato ba tsammani ya kamata ya haifar da tuhuma game da rashin daidaituwa na bututu, kumburin huhu, pneumothorax, edema na huhu, atelectasis, ko haɓakar matosai.

Hypercapnia: Don canza abun ciki na CO2 na jini, dole ne a canza iskar alveolar.

Ana iya yin wannan ta hanyar canza ƙarar ruwa ko ƙimar numfashi (ƙananan T da ƙananan P a cikin APRV).

Ƙara yawan ƙimar ko ƙarar ruwa, da kuma ƙara yawan T low, yana ƙaruwa da samun iska kuma yana rage CO2.

Dole ne a kula tare da ƙara yawan mita, saboda zai kuma ƙara yawan matattun sararin samaniya kuma maiyuwa ba zai yi tasiri kamar ƙarar ruwa ba.

Lokacin ƙara girma ko mita, dole ne a biya kulawa ta musamman ga madauki-ƙarar madauki don guje wa haɓakar auto-PEEP.

Babban matsi: Matsaloli guda biyu suna da mahimmanci a cikin tsarin: matsa lamba mafi girma da matsin lamba.

Matsin kololuwa ma'auni ne na juriya da bin hanyar iska kuma ya haɗa da bututu da bishiyar buroshi.

Matsalolin Plateau suna nuna matsi na alveolar don haka bin huhu.

Idan an sami karuwa a matsa lamba, mataki na farko shine a dakata mai ban sha'awa kuma a duba tudu.

Babban matsin lamba da matsa lamba na al'ada: babban juriya na iska da kuma yarda da al'ada

Dalilai masu yiwuwa: (1) Twisted ET tube-Maganin shine warware bututu; Yi amfani da makullin cizo idan majiyyaci ya ciji bututu, (2) Tushen ƙusa-Maganin shine don shaƙatawa mara lafiya, (3) Bronchospasm-Maganin shine gudanar da bronchodilators.

Babban kololuwa da tudu mai tsayi: matsalolin yarda

Dalilai masu yiwuwa sun haɗa da:

• Babban intubation na gangar jikin-Maganin shine a janye bututun ET. Don ganewar asali, za ku sami majiyyaci tare da sautin numfashi guda ɗaya da kuma huhun huhun da ba ya sabawa (atelectatic huhu).
• Pneumothorax: Za a yi ganewar asali ta hanyar sauraron sautin numfashi ba tare da la'akari da gano huhu mai karfin jini ba. A cikin marasa lafiya na ciki, sanya bututun ƙirji yana da mahimmanci, saboda matsi mai kyau zai ƙara tsananta pneumothorax.
• Atelectasis: Gudanarwa na farko ya ƙunshi bugun ƙirji da dabarun daukar ma'aikata. Ana iya amfani da Bronchoscopy a lokuta masu juriya.
• Pulmonary edema: diuresis, inotropes, girman PEEP.
• ARDS: Yi amfani da ƙaramar ƙarar igiyar ruwa da babban iskar PEEP.
• Dynamic hyperinflation ko auto-PEEP: wani tsari ne wanda wasu daga cikin iskar da ake shaka ba su cika fitar da su ba a karshen yanayin numfashi.
• Tarin iskar da aka kama yana kara karfin huhu kuma yana haifar da barotrauma da hypotension.
• Mai haƙuri zai yi wahala ya sha iska.
• Don hanawa da warware PEEP kai tsaye, dole ne a ba da isasshen lokaci don iska ta bar huhu yayin fitar numfashi.

Makasudin gudanarwa shine rage yawan haɓakawa / haɓakawa; Ana iya samun wannan ta hanyar rage yawan numfashi, rage yawan ƙarar ruwa (ƙara mafi girma zai buƙaci lokaci mai tsawo don barin huhu), da kuma ƙara yawan motsa jiki (idan an isar da iska da sauri, lokacin yin wahayi ya fi guntu kuma lokacin ƙarewa zai kasance. tsayi a kowane nau'in numfashi).

Za'a iya samun irin wannan tasiri ta hanyar yin amfani da nau'in raƙuman murabba'in don kwararar kuzari; wannan yana nufin cewa za mu iya saita na'urar iska don isar da dukkan kwarara daga farkon zuwa ƙarshen wahayi.

Sauran fasahohin da za a iya sanyawa suna tabbatar da isasshen kwanciyar hankali don hana hawan jini na majiyyaci da kuma yin amfani da bronchodilators da steroids don rage ƙuntataccen iska.

Idan auto-PEEP yana da tsanani kuma yana haifar da hauhawar jini, cire haɗin majiyyaci daga na'urar iska da barin duk iskan da za a fitar na iya zama ma'aunin ceton rai.

Don cikakken bayanin kula da auto-PEEP, duba labarin mai taken "Matsi na Ƙarshen Ƙarshen Ƙarshe (PEEP)."

Wata matsalar gama gari da ake ci karo da ita a cikin marasa lafiya da ke juyar da iskar injuna ita ce dyssynchrony mai haƙuri-ventilator, yawanci ana kiranta da "gwagwarmayar iska."

Muhimman dalilai sun haɗa da hypoxia, PEEP na kai, gazawar saduwa da iskar oxygenation na mai haƙuri ko buƙatun samun iska, zafi, da rashin jin daɗi.

Bayan yanke hukunci game da dalilai masu mahimmanci irin su pneumothorax ko atelectasis, yi la'akari da ta'aziyya mai haƙuri kuma tabbatar da isasshen jin dadi da analgesia.

Yi la'akari da canza yanayin samun iska, kamar yadda wasu marasa lafiya zasu iya amsa mafi kyau ga yanayin samun iska daban-daban.

Ya kamata a biya kulawa ta musamman ga saitunan samun iska a ƙarƙashin yanayi masu zuwa:

• COPD wani lamari ne na musamman, kamar yadda huhu na COPD mai tsabta yana da babban yarda, wanda ke haifar da babban hali na toshewar iska mai tsauri saboda rushewar iska da kuma kama iska, yana sa marasa lafiya na COPD suna da wuyar haɓaka auto-PEEP. Yin amfani da dabarun rigakafin iska tare da babban kwarara da ƙarancin numfashi na iya taimakawa hana PEEP kai tsaye. Wani muhimmin al'amari da za a yi la'akari da shi a cikin gazawar numfashi na hypercapnic na yau da kullum (saboda COPD ko wani dalili) shine cewa ba lallai ba ne don gyara CO2 don dawo da shi zuwa al'ada, kamar yadda waɗannan marasa lafiya sukan sami ramuwa na rayuwa don matsalolin numfashi. Idan mai haƙuri yana da iska zuwa matakan CO2 na al'ada, bicarbonate ɗinsa yana raguwa kuma, lokacin da aka cire shi, ya shiga cikin acidosis na numfashi da sauri saboda kodan ba zai iya amsawa da sauri kamar yadda huhu da CO2 suka dawo zuwa asali, yana haifar da gazawar numfashi da sake dawowa. Don guje wa wannan, dole ne a ƙayyade maƙasudin CO2 bisa pH da tushen da aka sani ko ƙididdigewa a baya.
• Asthma: Kamar yadda yake tare da COPD, marasa lafiya da ciwon asma suna da wuyar shiga cikin iska, kodayake dalili ya bambanta da pathophysiologically. A cikin asma, kamawar iska yana haifar da kumburi, bronchospasm da matosai, ba rugujewar iska ba. Dabarun hana PEEP da kai yayi kama da wanda aka yi amfani da shi a COPD.
• Cardiogenic huhu edema: dagagge PEEP iya rage venous dawo da kuma taimaka warware huhu edema, kazalika da inganta zuciya fitarwa. Abin damuwa ya kamata ya kasance don tabbatar da cewa mai haƙuri yana da isasshen diuretic kafin cirewa, saboda kawar da matsi mai kyau na iya haifar da sabon edema na huhu.
• ARDS wani nau'i ne na edema na huhu mara zuciya. An nuna dabarun buɗaɗɗen huhu tare da babban PEEP da ƙananan ƙaramar ruwa don inganta mace-mace.
• Cutar kumburin huhu abu ne mai wahala. Waɗannan majiyyatan sun dogara sosai saboda matsanancin hauhawar matsa lamba na dama. Shigar da waɗannan marasa lafiya zai ƙara matsa lamba na RA kuma ya ƙara rage dawowar venous, tare da haɗarin haɗari na girgiza. Idan babu hanyar da za a kauce wa shigar da ciki, ya kamata a kula da hawan jini kuma a fara gudanar da aikin vasopressor da sauri.
• Tsananin tsantsataccen acidosis na rayuwa shine matsala. Lokacin shigar da waɗannan marasa lafiya, ya kamata a mai da hankali sosai ga samun iska na mintina kafin shigar su. Idan ba a samar da wannan iskar ba lokacin da aka fara tallafin injina, pH zai ƙara faɗuwa, wanda zai iya haifar da kama zuciya.

Bayanan Littafi Mai Tsarki

1. Metersky ML, Kalil AC. Gudanar da Ciwon huhu mai Haɗin Ciki: Jagorori. Clin Chest Med. 2018 Dec;39(4): 797-808. [PubMed]
2. Chomton M, Brossier D, Sauthier M, Vallières E, Dubois J, Emeriaud G, Jouvet P. Ventilator-Associated Pneumonia da Abubuwan da ke faruwa a cikin Kula da Yara na Yara: Nazarin Cibiya Guda. Pediatr Crit Care Med. 2018 Dec;19(12): 1106-1113. [PubMed]
3. Vandana Kalwaje E, Rello J. Gudanar da ciwon huhu mai alaƙa da iska: Buƙatar hanyar keɓancewa. Kwararre Rev Anti Infect Ther. 2018 Aug;16(8): 641-653. [PubMed]
4. Jansson MM, Syrjälä HP, Talman K, Meriläinen MH, Ala-Kokko TI. Ilimin ma'aikatan jinya masu mahimmanci na, riko da shi, da kuma shingen shinge na musamman na cibiyoyi na iska. Am J Cutar Kula da Lafiya. 2018 Sep;46(9): 1051-1056. [PubMed]
5. Piraino T, Fan E. Mummunan hypoxemia mai barazanar rai yayin samun iska na inji. Curr Opin Crit Care. 2017 Dec;23(6): 541-548. [PubMed]
6. Mora Carpio AL, Mora JI. StatPearls [Internet]. Bugawa na StatPearls; Tsibirin Treasure (FL): Afrilu 28, 2022. Kula da Taimakon Taimakon Iska. [PubMed]
7. Kumar ST, Yassin A, Bhowmick T, Dixit D. Shawarwari Daga Jagororin 2016 don Gudanar da Manya Tare da Asibiti-Samu ko Ciwon huhu. P T. 2017 Dec;42(12): 767-772. [PMC free article] [PubMed]
8. Del Sorbo L, Goligher EC, McAuley DF, Rubenfeld GD, Brochard LJ, Gattinoni L, Slutsky AS, Fan E. Mechanical Ventilation a cikin Manya tare da Cutar Cutar Cutar Cutar Cutar Cutar. Takaitacciyar Shaidar Gwaji don Jagoran Ayyukan Kula da Lafiya. Ann Am Thorac Soc. 2017 Oct;14(Kari_4):S261-S270. [PubMed]
9. Chao CM, Lai CC, Chan KS, Cheng KC, Ho CH, Chen CM, Chou W. Multidisciplinary shisshigi da kuma ci gaba da ingancin inganta don rage rashin shiri extubation a cikin manya m kula da sassa: A 15 shekaru gwaninta. Medicine (Baltimore). 2017 Jul;96(27): e6877. [PMC free article] [PubMed]
10. Badnjevic A, Gurbeta L, Jimenez ER, Iadanza E. Gwajin injina na injina da incubators na jarirai a cibiyoyin kiwon lafiya. Technol Kiwon Lafiya. 2017.25(2): 237-250. [PubMed]

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