Ciwon Ciwon Hankali (ARDS): far, iskar inji, saka idanu
Mummunan ciwon nunfashi (saboda haka ma'anar 'ARDS') cuta ce ta numfashi wanda ke haifar da dalilai daban-daban kuma yana da alaƙa da lalacewa ta hanyar alveolar capillaries wanda ke haifar da gazawar numfashi mai tsanani tare da hypoxaemia na arterial refractory ga gudanarwar oxygen.
Don haka ARDS yana da alaƙa da raguwar ƙwayar iskar oxygen a cikin jini, wanda ke da juriya ga maganin O2, watau wannan maida hankali baya tashi bayan gudanar da iskar oxygen ga majiyyaci.
Rashin gazawar numfashi na hypoxaemic yana faruwa ne saboda rauni na membrane na alveolar-capillary, wanda ke haɓaka haɓakar bugun jini na huhu, wanda ke haifar da interstitial da edema na alveolar.
MASU TSIRA, HUKUNCI, KUJERAR KAURI: SPENCER KAYAN AKAN BOOTH BIYU A EXPO na Gaggawa
Maganin ARDS shine, asali, tallafi kuma ya ƙunshi
- maganin abin da ya haifar da ARDS;
- kula da isassun oxygenation nama (shafi da taimako na zuciya);
- tallafin abinci mai gina jiki.
ARDS ciwo ne da ke haifar da abubuwa daban-daban masu tasowa da ke haifar da lalacewar huhu iri ɗaya
A kan wasu abubuwan da ke haifar da ARDS ba zai yiwu a shiga tsakani ba, amma a lokuta inda hakan zai yiwu (kamar a cikin yanayin girgiza ko sepsis), da wuri da ingantaccen magani ya zama mahimmanci don iyakance girman ciwon da kuma ƙara yawan ciwon. yuwuwar tsira na majiyyaci.
Maganin harhada magunguna na ARDS yana nufin gyara matsalolin da ke tattare da su da kuma ba da tallafi ga aikin zuciya da jijiyoyin jini (misali maganin rigakafi don magance kamuwa da cuta da vasopressors don magance hauhawar jini).
Iskar oxygenation nama ya dogara da isassun iskar oxygen (O2del), wanda shine aikin matakan oxygen na jijiya da fitarwar zuciya.
Wannan yana nuna cewa duka samun iska da aikin zuciya suna da mahimmanci ga rayuwa mai haƙuri.
Matsi na ƙarshe na ƙarshe (PEEP) iskar injin yana da mahimmanci don tabbatar da isasshen iskar oxygenation a cikin marasa lafiya tare da ARDS.
Ingantacciyar iska mai ƙarfi, duk da haka, na iya, tare da ingantaccen iskar oxygen, rage fitarwar zuciya (duba ƙasa). Haɓakawa a cikin iskar oxygenation na jijiya ba ta da amfani ko kaɗan idan haɓakar lokaci ɗaya a cikin matsa lamba na intrathoracic yana haifar da raguwa daidai a cikin fitarwar zuciya.
Sakamakon haka, matsakaicin matakin PEEP da majiyyaci ke jurewa gabaɗaya ya dogara ne akan aikin zuciya.
Tsananin ARDS na iya haifar da mutuwa saboda hypoxia nama lokacin da mafi yawan maganin ruwa da magungunan vasopressor ba su inganta ingantaccen fitarwar zuciya don matakin PEEP da aka ba da shi don tabbatar da ingantaccen musayar gas na huhu.
A cikin mafi tsanani marasa lafiya, musamman ma waɗanda ke fuskantar iska, yanayin rashin abinci mai gina jiki yakan haifar.
Sakamakon rashin abinci mai gina jiki a kan huhu sun hada da: rigakafi (raguwar macrophage da T-lymphocyte aiki), rage yawan motsa jiki ta hanyar hypoxia da hypercapnia, rashin aikin surfactant, rage yawan ƙwayar intercostal da diaphragm, raguwar ƙwayar tsoka na numfashi, dangane da jiki. Ayyukan catabolic, don haka rashin abinci mai gina jiki zai iya rinjayar abubuwa masu yawa masu mahimmanci, ba kawai don tasiri na kulawa da tallafi ba, har ma don yaye daga injin iska.
Idan za ta yiwu, ciyar da ciki (gudanar da abinci ta bututun hanci) ya fi dacewa; amma idan aikin hanji ya lalace, ciyarwar parenteral (jiki) ya zama dole don ciyar da majiyyaci isasshen furotin, mai, carbohydrates, bitamin da ma'adanai.
Iskar injina a cikin ARDS
Samun iska na inji da PEEP ba su hana kai tsaye ko magance ARDS ba amma, a maimakon haka, kiyaye majiyyaci a raye har sai an warware matsalar cutar kuma an dawo da isassun aikin huhu.
Babban jigon ci gaba da samun iska na injina (CMV) yayin ARDS ya ƙunshi iskar 'mai dogaro da ƙarar' na al'ada ta amfani da juzu'i na 10-15 ml/kg.
A cikin matsanancin yanayi na cutar, ana amfani da cikakken taimako na numfashi (yawanci ta hanyar 'taimakon kulawa' samun iska ko iska mai tilastawa ta tsaka-tsaki [IMV]).
Yawancin taimako na numfashi na ɗan lokaci ana ba da shi yayin farfadowa ko yaye daga na'urar iska.
PEEP na iya haifar da dawowar samun iska a yankunan atelectasis, yana canza wuraren da aka rufe a baya zuwa sassan numfashi na aiki, yana haifar da ingantacciyar iskar oxygenation a ƙaramin juzu'i na hurarrun oxygen (FiO2).
Samun iska na riga-kafin alveoli shima yana ƙara ƙarfin aikin saura (FRC) da yarda da huhu.
Gabaɗaya, makasudin CMV tare da PEEP shine cimma PaO2 mafi girma fiye da 60 mmHg a FiO2 na ƙasa da 0.60.
Kodayake PEEP yana da mahimmanci don kiyaye isassun iskar gas na huhu a cikin marasa lafiya tare da ARDS, sakamako masu illa yana yiwuwa.
Rage yarda da huhu saboda alveolar overdistension, raguwar dawowar jijiyoyi da fitarwar zuciya, ƙara yawan PVR, haɓakar ventricular na dama, ko barotrauma na iya faruwa.
Don waɗannan dalilai, ana ba da shawarar matakan PEEP 'mafi kyau'.
Mafi kyawun matakin PEEP gabaɗaya an bayyana shi azaman ƙimar da aka sami mafi kyawun O2del a FiO2 ƙasa da 0.60.
Ƙimar PEEP da ke inganta iskar oxygen amma rage yawan fitarwar zuciya ba su da kyau, saboda a wannan yanayin kuma O2del ya rage.
Wani ɓangaren matsa lamba na iskar oxygen a cikin jini mai gauraye (PvO2) yana ba da bayani kan iskar oxygenation na nama.
PvO2 da ke ƙasa da 35 mmHg yana nuni da iskar oxygenation na nama.
Ragewar fitarwa na zuciya (wanda zai iya faruwa a lokacin PEEP) yana haifar da ƙananan PvO2.
Don wannan dalili, ana iya amfani da PvO2 don ƙayyade mafi kyawun PEEP.
Rashin gazawar PEEP tare da CMV na al'ada shine dalilin da ya fi dacewa don canzawa zuwa samun iska tare da juzu'i mai ban sha'awa ko babba (I: E).
Juya I:E rabon iskar iska a halin yanzu ana aiwatar da shi fiye da sau da yawa fiye da yawan iskar shaka.
Yana ba da sakamako mafi kyau tare da maras lafiya gurɓataccen lokaci kuma na'urar iska ta sanya lokaci don kowane sabon aikin numfashi yana farawa da zarar fitar da ta gabata ta kai matakin PEEP mafi kyau.
Za a iya rage yawan numfashi ta hanyar tsawaita rashin jin daɗi.
Wannan yakan haifar da raguwa a cikin ma'anar intrathoracic matsa lamba, duk da karuwa a cikin PEEP, kuma ta haka ya haifar da haɓakawa a cikin O2del wanda aka yi ta hanyar karuwa a cikin fitarwa na zuciya.
Matsakaicin matsi mai ƙarfi (HFPPV), babban oscillation mai girma (HFO), da iskar ‘jet’ mai ƙarfi (HFJV) hanyoyi ne waɗanda wasu lokuta suke iya haɓaka iskar iska da iskar oxygen ba tare da yin amfani da ƙarar huhu ko matsi ba.
HFJV kawai an yi amfani da shi sosai a cikin jiyya na ARDS, ba tare da fa'ida mai mahimmanci akan CMV na al'ada tare da PEEP da aka nuna a ƙarshe ba.
An yi nazarin Membrane extracorporeal oxygenation (ECMO) a cikin 1970s a matsayin hanyar da za ta iya ba da garantin isashshen iskar oxygen ba tare da yin amfani da kowane nau'i na iskar injuna ba, barin huhu ya sami waraka daga raunukan da ke da alhakin ARDS ba tare da sanya shi ga damuwa da matsi mai kyau ke wakilta ba. samun iska.
Abin baƙin cikin shine, marasa lafiya sun yi tsanani sosai har ba su amsa da kyau ga samun iska na al'ada ba don haka sun cancanci samun ECMO, suna da mummunan raunuka na huhu wanda har yanzu suna fama da fibrosis na huhu kuma ba su dawo da aikin huhu na yau da kullum ba.
Yaye iskar inji a cikin ARDS
Kafin cire majiyyaci daga na'urar hura iska, ya zama dole a tabbatar da yiwuwar tsira ba tare da taimakon numfashi ba.
Fihirisar injina kamar matsakaicin matsa lamba (MIP), iya aiki mai mahimmanci (VC), da ƙarar tidal (VT) ba tare da bata lokaci ba suna tantance ƙarfin majiyyaci na jigilar iska a ciki da waje daga cikin ƙirji.
Babu ɗayan waɗannan matakan, duk da haka, da ke ba da bayanai game da juriya na tsokar numfashi don yin aiki.
Wasu fihirisar ilimin lissafi, irin su pH, mataccen sararin samaniya zuwa ƙimar ƙarar ruwa, P (Aa) O2, matsayin abinci mai gina jiki, kwanciyar hankali na zuciya da jijiyoyin jini, da ma'aunin acid-base na rayuwa yana nuna yanayin gabaɗayan mai haƙuri da ikonsa na jure damuwa na yaye daga injin iska. .
Yaye daga iska na inji yana faruwa a hankali, don tabbatar da cewa yanayin mai haƙuri ya isa don tabbatar da numfashi ba tare da bata lokaci ba, kafin cire cannula na endotracheal.
Wannan lokaci yakan fara ne lokacin da majiyyaci ya sami kwanciyar hankali a likitanci, tare da FiO2 na ƙasa da 0.40, PEEP na 5 cm H2O ko ƙasa da haka kuma sigogin numfashi, da aka ambata a baya, suna nuna dama mai ma'ana na sake dawowa da samun iska.
IMV sanannen hanya ce don yaye marasa lafiya tare da ARDS, saboda yana ba da damar yin amfani da PEEP mai sauƙi har sai an cire shi, yana barin majiyyaci a hankali don jure ƙoƙarin da ake buƙata na numfashi ba tare da bata lokaci ba.
A lokacin wannan lokacin yaye, kulawa da hankali yana da mahimmanci don tabbatar da nasara.
Canje-canje a cikin hawan jini, ƙarar zuciya ko ƙimar numfashi, rage yawan iskar oxygen jijiya kamar yadda aka auna ta hanyar oximetry na bugun jini, da munanan ayyukan tunani duk suna nuna gazawar hanya.
Rage raguwar yaye a hankali na iya taimakawa hana gazawar da ke da alaƙa da gajiyawar tsoka, wanda zai iya faruwa yayin dawo da numfashi mai cin gashin kansa.
Saka idanu a lokacin ARDS
Kulawar jijiya na huhu yana ba da damar auna fitarwar zuciya da ƙididdige O2del da PvO2.
Waɗannan sigogi suna da mahimmanci don maganin yuwuwar rikice-rikicen haemodynamic.
Sa ido kan jijiya na huhu kuma yana ba da damar auna matsi na cika ventricular na dama (CVP) da matsi na cikon ventricular na hagu (PCWP), waɗanda ke da fa'ida masu amfani don tantance mafi kyawun fitarwar zuciya.
Catheterization na huhu arterial catheterization na haemodynamic ya zama mahimmanci a yayin da hawan jini ya faɗi ƙasa don buƙatar magani tare da magungunan vasoactive (misali dopamine, norepinephrine) ko kuma idan aikin huhu ya lalace har zuwa inda ake buƙatar PEEP fiye da 10 cm H2O.
Ko da gano rashin kwanciyar hankali na matsi, kamar buƙatar manyan infusions na ruwa, a cikin majinyacin da ya riga ya kasance cikin mawuyacin hali na zuciya ko yanayin numfashi, na iya buƙatar sanya catheter na huhu na huhu da saka idanu na haemodynamic, tun kafin magungunan vasoactive suna buƙatar zama. gudanarwa.
Ingantacciyar iska mai matsi na iya canza bayanan saka idanu na haemodynamic, wanda zai haifar da haɓaka ƙima a cikin ƙimar PEEP.
Ana iya watsa ƙimar PEEP masu girma zuwa catheter na saka idanu kuma su kasance da alhakin haɓaka ƙimar CVP da PCWP da ba su dace da gaskiya ba (43).
Wannan yana yiwuwa idan tip catheter yana kusa da bangon kirji na baya (yanki na I), tare da mai haƙuri.
Yanki na I shine yankin huhun mara lalacewa, inda jijiyoyin jini ke raguwa kaɗan.
Idan ƙarshen catheter ya kasance a matakin ɗayan su, ƙimar PCWP za ta yi tasiri sosai ta matsananciyar alveolar, don haka ba daidai ba ne.
Yanki na III yayi daidai da mafi ƙarancin huhu, inda jijiyoyin jini suke kusan bazuwa.
Idan ƙarshen catheter yana cikin wannan yanki, ma'aunin da aka ɗauka zai zama ɗan ƙaramin tasiri ne kawai ta matsananciyar iska.
Za'a iya tabbatar da sanya catheter a matakin yanki na III ta hanyar ɗaukar X-ray na ƙirji na gefe, wanda zai nuna tip catheter a ƙasan atrium na hagu.
Ƙa'ida ta Static (Cst) tana ba da bayanai masu amfani akan huhu da taurin bangon ƙirji, yayin da ingantaccen yarda (Cdyn) ke tantance juriya na iska.
Ana ƙididdige Cst ta hanyar rarraba ƙarar tidal (VT) ta tsaye (Plateau) matsa lamba (Pstat) debe PEEP (Cst = VT/Pstat - PEEP).
Ana ƙididdige Pstat a yayin ɗan gajeren numfashi na numfashi bayan mafi girman numfashi.
A aikace, ana iya samun wannan ta amfani da umarnin dakatar da na'urar hura wutar lantarki ko ta hanyar rufe layin karewa na da'ira.
Ana duba matsa lamba akan manometer na iska yayin apnea kuma dole ne ya kasance ƙasa da matsakaicin matsi na iska (Ppk).
Ana ƙididdige yarda mai ƙarfi ta irin wannan hanya, kodayake a cikin wannan yanayin ana amfani da Ppk maimakon matsa lamba (Cdyn = VT/Ppk - PEEP).
Cst na al'ada yana tsakanin 60 da 100 ml/cm H2O kuma ana iya rage shi zuwa kusa da 15 ko 20 ml/cm H20 a lokuta masu tsanani na ciwon huhu, edema na huhu, atelectasis, fibrosis da ARDS.
Tunda ana buƙatar wani matsa lamba don shawo kan juriya na iska yayin samun iska, wani ɓangare na matsakaicin matsa lamba da aka haɓaka yayin numfashi na inji yana wakiltar juriyar kwararar da aka fuskanta a cikin hanyoyin iska da na'urorin iska.
Don haka, Cdyn yana auna rashin lafiyar gaba ɗaya ta hanyar iska saboda canje-canje a cikin yarda da juriya.
Cdyn na al'ada yana tsakanin 35 da 55 ml / cm H2O, amma cututtuka guda ɗaya zasu iya cutar da su da suka rage Cstat, da kuma abubuwan da zasu iya canza juriya (bronchoconstriction, edema na iska, riƙewar ɓoyewa, matsawa ta iska ta hanyar neoplasm).
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