Emergency Live | Manual Ventilation, 5 Things to Keep in Mind image 2

Kasamalidwe ka mpweya wabwino: kupumitsa mpweya wodwala

By Cristiano Antonino On Feb 24, 2023

Invasive mechanical ventilation ndi njira yomwe imagwiritsidwa ntchito kawirikawiri kwa odwala omwe akudwala kwambiri omwe amafunikira kupuma kapena chitetezo cha mpweya.

Mpweya wolowera mpweya umalola kusinthana kwa gasi kusamalidwa pomwe mankhwala ena amaperekedwa kuti apititse patsogolo matenda

Ntchitoyi imayang'ananso zomwe zikuwonetsa, zotsutsana, zowongolera, komanso zovuta zomwe zingachitike chifukwa cha mpweya wovutitsa wamakina ndikugogomezera kufunikira kwa gulu la akatswiri pakuwongolera chisamaliro cha odwala omwe amafunikira thandizo la mpweya wabwino.

Kufunika kwa mpweya wabwino wamakina ndi chimodzi mwazinthu zomwe zimachititsa kuti anthu alowe ku ICU. [1] [2] [3]

MA STRETCHERS, SPINE BOARD, ZIVENTILATORS ZA MWA MALUNGU, MIPANDE YOCHOKERA: ZOPHUNZITSA ZA SPENCER MU DOUBLE BOOTH PA EMERGENCY EXPO

Ndikofunikira kumvetsetsa mawu ena ofunikira kuti mumvetsetse mpweya wabwino wamakina

Mpweya: Kusinthana kwa mpweya pakati pa mapapu ndi mpweya (wozungulira kapena woperekedwa ndi mpweya wabwino), mwa kuyankhula kwina, ndi njira yosuntha mpweya kulowa ndi kutuluka m'mapapo.

Chofunikira kwambiri ndikuchotsa mpweya woipa (CO2) m'thupi, osati kuchuluka kwa okosijeni m'magazi.

M'malo azachipatala, mpweya wabwino umayesedwa ngati mpweya wocheperako, womwe umawerengedwa ngati kuchuluka kwa kupuma (RR) times tidal volume (Vt).

Wodwala yemwe ali ndi mpweya wabwino, zomwe zili m'magazi a CO2 zimatha kusinthidwa posintha kuchuluka kwa mafunde kapena kupuma.

Kutulutsa mpweya: Zochita zomwe zimapereka kuwonjezereka kwa oxygen ku mapapo ndipo motero kumayenda.

Mu odwala omwe ali ndi mpweya wabwino, izi zingatheke powonjezera kagawo kakang'ono ka mpweya wouziridwa (FiO 2%) kapena kupanikizika kwabwino kwa mapeto a kupuma (PEEP).

PEEP: Kuthamanga kwabwino komwe kumatsalira mumsewu wa mpweya kumapeto kwa kupuma kwa mpweya (kumapeto kwa kutha) ndi kwakukulu kuposa kupanikizika kwa mlengalenga mwa odwala omwe amapangidwa ndi mpweya wabwino.

Kuti mumve zambiri za kugwiritsiridwa ntchito kwa PEEP, onani nkhani yamutu wakuti “Positive End-Expiratory Pressure (PEEP)” m’mabuku omwe ali kumapeto kwa nkhaniyi.

Kuchuluka kwa mafunde: Mpweya wochuluka wa mpweya umalowa ndi kutuluka m'mapapo pa kupuma kulikonse.

FiO2: Peresenti ya mpweya mu mpweya wosakaniza umene umaperekedwa kwa wodwalayo.

Kuyenda: Mulingo wa malita pa mphindi imodzi pomwe mpweya wolowera mpweya umatulutsa mpweya.

Kutsatira: Kusintha kwa voliyumu kugawanika ndi kusintha kwa kuthamanga. Mu kupuma kwa thupi, kutsata kwathunthu ndikusakanikirana kwa mapapo ndi pachifuwa kutsata khoma, popeza zinthu ziwirizi sizingasiyanitsidwe mwa wodwala.

Chifukwa makina mpweya mpweya amalola dokotala kusintha wodwalayo mpweya wabwino ndi oxygenation, ndi mbali yofunika kwambiri hypoxic ndi hypercapnic kupuma kulephera ndi kwambiri acidosis kapena kagayidwe kachakudya alkalosis.[4][5]

Physiology ya makina mpweya wabwino

Mpweya wamakina uli ndi zotsatira zingapo pamakaniko am'mapapo.

Normal kupuma physiology imagwira ntchito ngati kupanikizika koipa.

Pamene diaphragm ikukankhira pansi panthawi ya kudzoza, kupanikizika koipa kumapangidwa mu pleural cavity, zomwe zimapangitsa kuti mpweya ukhale wovuta m'njira zomwe zimakokera mpweya m'mapapo.

Kuthamanga komweku kwa intrathoracic kumachepetsa kuthamanga kwa atriamu (RA) ndipo kumapangitsa kuyamwa kwa inferior vena cava (IVC), kuonjezera kubwerera kwa venous.

Kugwiritsa ntchito mpweya wabwino kumasintha mawonekedwe awa.

Kuthamanga kwabwino kopangidwa ndi mpweya wabwino kumaperekedwa kumtunda wapamwamba ndipo pamapeto pake ku alveoli; Izi zimaperekedwa ku alveolar space ndi thoracic cavity, zomwe zimapangitsa kuti pakhale kupanikizika (kapena kutsika kochepa koipa) mu pleural space.

Kuwonjezeka kwa kuthamanga kwa RA ndi kuchepa kwa venous kubwerera kumapangitsa kuchepa kwa preload.

Izi zimakhala ndi zotsatira ziwiri zochepetsera kutulutsa kwa mtima: magazi ochepa mu ventricle yoyenera amatanthauza kuti magazi ochepa amafika kumanzere kwa ventricle ndipo magazi ochepa amatha kuponyedwa kunja, kuchepetsa kutuluka kwa mtima.

Kutsitsa kwapang'onopang'ono kumatanthauza kuti mtima ukugwira ntchito pamlingo wocheperako pamayendedwe othamanga, kutulutsa ntchito yocheperako komanso kuchepetsa kutulutsa kwamtima, zomwe zimabweretsa kutsika kwapakati (MAP) ngati palibe kubweza chifukwa chowonjezereka. systemic vascular resistance (SVR).

Izi ndizofunikira kwambiri kwa odwala omwe sangathe kuwonjezera SVR, monga odwala omwe ali ndi mantha ogawa (septic, neurogenic, kapena anaphylactic).

Kumbali ina, kuthamanga kwabwino kwa makina mpweya wabwino kumatha kuchepetsa kwambiri ntchito ya kupuma.

Izi, zimachepetsanso kutuluka kwa magazi ku minofu yopuma ndikugawanso ku ziwalo zofunika kwambiri.

Kuchepetsa ntchito ya minofu yopuma kumachepetsanso m'badwo wa CO2 ndi lactate kuchokera ku minofu iyi, zomwe zimathandiza kukonza acidosis.

Zotsatira za mpweya wabwino wamakina pakubwera kwa venous zitha kukhala zothandiza kwa odwala omwe ali ndi cardiogenic pulmonary edema.

Odwalawa omwe ali ndi kuchuluka kwakukulu, kuchepetsa kubwerera kwa venous kumachepetsa mwachindunji kuchuluka kwa edema ya m'mapapo yomwe imapangidwa, kuchepetsa kutulutsa kwamtima wabwino.

Nthawi yomweyo, kuchepetsa kubweza kwa venous kungapangitse kuchulukirachulukira kwa ventricular kumanzere, ndikuyika pamalo abwino kwambiri pamapindikira a Frank-Starling ndikuwonjezera kutulutsa kwamtima.

Kuwongolera bwino kwa mpweya wabwino wamakina kumafunanso kumvetsetsa kupsinjika kwa m'mapapo ndi kutsata mapapo.

Kutsatira kwabwino kwa mapapo ndi pafupifupi 100 ml/cmH20.

Izi zikutanthauza kuti m'mapapo abwinobwino, makonzedwe a 500 ml ya mpweya ndi mpweya wabwino amawonjezera kuthamanga kwa alveolar ndi 5 cm H2O.

Kumbali ina, makonzedwe abwino a 5 cm H2O adzapanga kuwonjezeka kwa mapapu a 500 ml.

Pogwira ntchito ndi mapapu osachiritsika, kumvera kumatha kukhala kwakukulu kapena kutsika kwambiri.

Matenda aliwonse omwe amawononga mapapo parenchyma, monga emphysema, amawonjezera kutsata, pomwe matenda aliwonse omwe amapanga mapapu olimba (ARDS, chibayo, pulmonary edema, pulmonary fibrosis) zidzachepetsa kutsata kwa mapapo.

Vuto la mapapu olimba ndikuti kuwonjezeka pang'ono kwa voliyumu kungapangitse kuwonjezeka kwakukulu ndikuyambitsa barotrauma.

Izi zimabweretsa vuto kwa odwala omwe ali ndi hypercapnia kapena acidosis, chifukwa mpweya wocheperako ungafunike kuwonjezedwa kuti athetse vutoli.

Kuwonjezeka kwa kupuma kungathe kuchepetsa kuwonjezereka kwa mpweya wabwino, koma ngati izi sizingatheke, kuwonjezereka kwa mafunde kungapangitse kupanikizika kwa mapiri ndikupanga barotrauma.

Pali zovuta ziwiri zofunika m'dongosolo zomwe muyenera kukumbukira mukamapumira wodwala pamakina:

Kuthamanga kwapamwamba kwambiri ndi kuthamanga komwe kumafikira panthawi ya kudzoza pamene mpweya umakankhidwira m'mapapo ndipo ndi chizindikiro cha kukana kwa mpweya.
Kuthamanga kwa Plateau ndiko kuthamanga kwa static komwe kumafikira kumapeto kwa kudzoza kwathunthu. Kuti muyese kuthamanga kwa mapiri, kupuma kolimbikitsa kuyenera kuchitidwa pa mpweya wabwino kuti mulole kupanikizika kufanane ndi dongosolo. Kuthamanga kwa Plateau ndi muyeso wa kuthamanga kwa alveolar ndi kutsata mapapo. Kuthamanga kwapamwamba kwamtunda kumakhala kochepa kuposa 30 cm H20, pamene kuthamanga kwakukulu kungapangitse barotrauma.

Zizindikiro zamakina mpweya wabwino

Chizindikiro chodziwika bwino cha intubation ndi mpweya wabwino wamakina ndi pamene mukulephera kupuma movutikira, mwina hypoxic kapena hypercapnic.

Zizindikiro zina zofunika ndizo kuchepa kwa chidziwitso chifukwa cholephera kuteteza njira ya mpweya, kuvutika kupuma komwe kwalephera kupuma bwino, matenda aakulu a hemoptysis, angioedema, kapena vuto lililonse la mayendedwe a mpweya monga kutentha kwa mpweya, kumangidwa kwa mtima, ndi kugwedezeka.

Zizindikiro zodziwika bwino za mpweya wabwino wamakina ndi opaleshoni ndi matenda a neuromuscular.

Contraindications

Palibe zotsutsana mwachindunji ndi mpweya wabwino wa makina, chifukwa ndi njira yopulumutsira moyo kwa wodwala wodwala kwambiri, ndipo odwala onse ayenera kupatsidwa mwayi wopindula nawo ngati kuli kofunikira.

The kokha mtheradi contraindication kwa makina mpweya wabwino ngati izo n'zosemphana ndi wodwalayo ananena chikhumbo cha yokumba zochirikiza moyo miyeso.

Chokhacho chokhacho chotsutsana ndi chakuti ngati mpweya wosasunthika ulipo ndipo ntchito yake ikuyembekezeka kuthetsa kufunikira kwa mpweya wabwino wamakina.

Izi ziyenera kuyambika kaye, chifukwa zimakhala ndi zovuta zochepa poyerekeza ndi mpweya wabwino wamakina.

Pali zinthu zingapo zomwe ziyenera kuchitidwa kuti ayambitse mpweya wabwino wa makina

Ndikofunikira kutsimikizira kuyika kolondola kwa chubu cha endotracheal.

Izi zitha kuchitidwa ndi end-tidal capnography kapena kuphatikiza zachipatala ndi ma radiology.

Ndikofunikira kuonetsetsa chithandizo chokwanira chamtima ndi madzi kapena vasopressors, monga momwe zimasonyezedwera pazochitika ndizochitika.

Onetsetsani kuti sedation yokwanira ndi analgesia zilipo.

Pulasitiki ya pulasitiki pakhosi la wodwalayo imakhala yowawa komanso yosasangalatsa, ndipo ngati wodwalayo sakupuma kapena akulimbana ndi chubu kapena mpweya wabwino, zimakhala zovuta kwambiri kuti azitha kulamulira magawo osiyanasiyana a mpweya wabwino komanso mpweya wabwino.

Mpweya wabwino modes

Mukalowetsa wodwala ndikumulumikiza ku mpweya wabwino, ndi nthawi yoti musankhe njira yolowera mpweya yomwe mungagwiritse ntchito.

Kuti tichite zimenezi mosasinthasintha kuti wodwalayo apindule, mfundo zingapo ziyenera kumvetsetsedwa.

Monga tanenera kale, kutsata ndiko kusintha kwa voliyumu komwe kumagawidwa ndi kusintha kwa kuthamanga.

Mukamapereka mpweya wabwino kwa wodwala, mutha kusankha momwe mpweya wabwino umaperekera mpweya.

Mpweya wolowera mpweya ukhoza kukhazikitsidwa kuti upereke kuchuluka kwa voliyumu yodziwikiratu kapena kupanikizika kodziwikiratu, ndipo zili kwa dokotala kusankha chomwe chili chopindulitsa kwambiri kwa wodwalayo.

Posankha njira yoperekera mpweya wabwino, timasankha yomwe ingakhale yosiyana komanso yomwe ingakhale yosiyana payokha mu equation yoyendera mapapo.

Ngati tisankha kuyambitsa wodwalayo pa mpweya woyendetsedwa ndi voliyumu, mpweya wabwino nthawi zonse umapereka kuchuluka kwa voliyumu (kusiyana kodziyimira pawokha), pomwe kupanikizika komwe kumapangidwa kudzadalira kutsata.

Ngati kutsata kuli koyipa, kupanikizika kudzakhala kwakukulu ndipo barotrauma ikhoza kuchitika.

Kumbali ina, ngati tiganiza zoyambitsa wodwalayo pa mpweya woyendetsedwa ndi mphamvu, mpweya wabwino umapereka mphamvu yomweyo panthawi yopuma.

Komabe, kuchuluka kwa mafunde kudzadalira kutsatiridwa ndi mapapo, ndipo ngati kutsatira kumasintha pafupipafupi (monga mphumu), izi zimatulutsa mafunde osadalirika ndipo zingayambitse hypercapnia kapena hyperventilation.

Pambuyo posankha njira yoperekera mpweya (mwa kukakamiza kapena voliyumu), dokotala ayenera kusankha njira yoyenera yogwiritsira ntchito mpweya.

Izi zikutanthauza kusankha ngati makinawo amathandizira kupuma konse kwa wodwalayo, kupuma kwina kwa wodwalayo, kapena ayi, komanso ngati makinawo angapereke mpweya ngakhale wodwalayo sakupuma yekha.

Zina zomwe ziyenera kuganiziridwa ndi kuchuluka kwa mpweya wotulutsa (kuthamanga), mawonekedwe a mafunde (mafunde otsika amatsanzira kupuma kwa thupi ndipo amakhala omasuka kwa wodwala, pamene mafunde amtundu wa square, momwe kutuluka kwake kumaperekedwa pamlingo waukulu panthawi yonse ya kudzoza, sakhala omasuka kwa wodwalayo koma amapereka nthawi yopumira mwachangu), komanso kuchuluka komwe mpweya umaperekedwa.

Magawo onsewa ayenera kusinthidwa kuti apeze chitonthozo cha odwala, mpweya wofunikira wamagazi, ndikupewa kutsekeka kwa mpweya.

Pali mitundu ingapo ya mpweya wabwino yomwe imasiyana pang'ono ndi mzake. Mu ndemangayi tiwona njira zodziwika bwino za mpweya wabwino komanso kugwiritsa ntchito kwawo kuchipatala.

Mpweya wabwino umaphatikizapo kuwongolera (AC), chithandizo cha kuthamanga (PS), synchronized intermittent mandatory ventilation (SIMV), ndi airway pressure release ventilation (APRV).

Kuthandizira mpweya wabwino (AC)

Kuwongolera kothandizira ndiko komwe mpweya wothandizira umathandiza wodwalayo popereka chithandizo cha mpweya uliwonse umene wodwala amatenga (iyi ndi gawo lothandizira), pamene mpweya wodutsa mpweya umatha kulamulira mpweya wopuma ngati ugwera pansi pa mlingo wokhazikitsidwa (gawo lolamulira).

Pakuwongolera kothandizira, ngati ma frequency akhazikitsidwa ku 12 ndipo wodwala akupuma pa 18, mpweya wolowera mpweya umathandizira ndi mpweya 18, koma ngati pafupipafupi kutsika mpaka 8, mpweya wolowera mpweya umayang'anira kupuma ndikupuma 12. pamphindi.

Pothandizira mpweya wabwino, mpweya ukhoza kuperekedwa ndi mphamvu kapena mphamvu

Izi zimatchedwa mpweya woyendetsedwa ndi voliyumu kapena mpweya woyendetsedwa ndi mphamvu.

Kuti zikhale zosavuta komanso kumvetsetsa kuti popeza mpweya wabwino nthawi zambiri umakhala wofunika kwambiri kusiyana ndi kukakamiza ndi kuwongolera mphamvu kumagwiritsidwa ntchito kwambiri kuposa kuwongolera kukakamiza, chifukwa chotsalira cha ndemangayi tidzagwiritsa ntchito mawu oti "kuwongolera voliyumu" mosiyana tikamalankhula za kuwongolera thandizo.

Kuwongolera kothandizira (kuwongolera voliyumu) ndi njira yosankha yomwe imagwiritsidwa ntchito m'ma ICU ambiri ku United States chifukwa ndiyosavuta kugwiritsa ntchito.

Zokonda zinayi (kupuma, kuchuluka kwa mafunde, FiO2, ndi PEEP) zitha kusinthidwa mosavuta mu mpweya wabwino. Voliyumu yoperekedwa ndi mpweya wabwino mu mpweya uliwonse mu chithandizo chothandizira nthawi zonse idzakhala yofanana, mosasamala kanthu za mpweya woyambitsidwa ndi wodwala kapena mpweya wabwino komanso kutsata, nsonga kapena kupyola m'mapapo m'mapapo.

Mpweya uliwonse ukhoza kuikidwa nthawi yake (ngati kupuma kwa wodwalayo kuli kochepa kusiyana ndi momwe mpweya umakhalira, makinawo amapereka mpweya pa nthawi yokhazikika) kapena kuyambitsidwa ndi wodwalayo, ngati wodwalayo ayamba kupuma yekha.

Izi zimapangitsa kuwongolera kothandizira kukhala njira yabwino kwambiri kwa wodwalayo, chifukwa kuyesetsa kwake kulikonse kumathandizidwa ndi mpweya wabwino.

Pambuyo popanga kusintha kwa mpweya wabwino kapena mutatha kuyambitsa wodwala pa makina opangira mpweya wabwino, mpweya wamagazi wamagazi uyenera kuyang'aniridwa mosamala ndipo kudzaza kwa okosijeni pa polojekiti kuyenera kutsatiridwa kuti mudziwe ngati pali kusintha kwina kofunikira pa mpweya wabwino.

Ubwino wa AC mode ndi chitonthozo chowonjezereka, kuwongolera kosavuta kwa kupuma acidosis/alkalosis, ndi kuchepa kwa kupuma kwa wodwalayo.

Zoyipa zimaphatikizapo mfundo yakuti popeza iyi ndi njira yozungulira voliyumu, kupanikizika sikungathe kuyendetsedwa mwachindunji, zomwe zingayambitse barotrauma, wodwalayo akhoza kukhala ndi hyperventilation ndi kupuma kwa mpweya, autoPEEP, ndi kupuma kwa alkalosis.

Kuti mumve zambiri za kuwongolera kothandizidwa, onani nkhani yamutu wakuti “Ventilation, Assisted Control” [6], mu gawo la Bibliographical References kumapeto kwa nkhaniyi.

Mpweya Wovomerezeka Wophatikizika Wovomerezeka (SIMV)

SIMV ndi njira ina yomwe imagwiritsidwa ntchito mobwerezabwereza, ngakhale kuti kugwiritsidwa ntchito kwake sikunagwiritsidwe ntchito chifukwa cha kuchuluka kwa madzi odalirika komanso kusowa kwa zotsatira zabwino kuposa AC.

“Kulunzanitsidwa” kumatanthauza kuti cholumikizira mpweya chimasinthira kutulutsa kwa mpweya wake mogwirizana ndi zoyesayesa za wodwalayo. “Kupumira kwapang’onopang’ono” kumatanthauza kuti si kupuma konse kumene kumachirikizidwa ndipo “kupuma kofunikira” kumatanthauza kuti, monga momwe zimakhalira ndi CA, mafupipafupi odziŵikiratu amasankhidwa ndipo mpweya wolowera mpweya umapereka mpweya wofunikirawu mphindi iliyonse mosasamala kanthu za kuyesetsa kwa kupuma kwa wodwalayo.

Kupuma kovomerezeka kumatha kuyambitsidwa ndi wodwala kapena nthawi ngati RR ya wodwalayo ili pang'onopang'ono kuposa RR ya mpweya wabwino (monga momwe zilili ndi CA).

Kusiyanitsa kwa AC ndikuti mu SIMV mpweya wolowera mpweya umangopereka mpweya womwe ma frequency akhazikitsidwa kuti apereke; Mpweya uliwonse womwe wodwala amawutenga pamwamba pa ma frequency awa sangalandire voliyumu yamadzi kapena kuthandizira kwathunthu.

Izi zikutanthauza kuti mpweya uliwonse womwe wodwala amatengedwa pamwamba pa RR, kuchuluka kwa mafunde operekedwa ndi wodwalayo kumangodalira kutsata ndi kuyesetsa kwa mapapo a wodwalayo.

Izi zaperekedwa ngati njira yophunzitsira "diaphragm" kuti asunge minofu ndikuyamwitsa odwala kuchokera ku mpweya wabwino.

Komabe, kafukufuku wambiri sanawonetse phindu la SIMV. Kuonjezera apo, SIMV imapanga ntchito yopuma yochuluka kuposa AC, yomwe imakhala ndi zotsatira zoipa pa zotsatira ndipo imayambitsa kutopa kwa kupuma.

Lamulo lachala chachikulu lomwe liyenera kutsatiridwa ndi lakuti wodwalayo amatulutsidwa kuchokera ku makina opangira mpweya pamene ali wokonzeka, ndipo palibe njira yeniyeni yopititsira mpweya yomwe ingapangitse mofulumira.

Pakalipano, ndi bwino kuti wodwalayo akhale womasuka momwe angathere, ndipo SIMV sangakhale njira yabwino kwambiri yochitira izi.

Pressure Support Ventilation (PSV)

PSV ndi njira yopumira mpweya yomwe imadalira kwathunthu mpweya woyendetsedwa ndi odwala.

Monga momwe dzinalo likusonyezera, ndi njira yodutsa mpweya yoyendetsedwa ndi mphamvu.

Munjira iyi, mpweya wonse umayambitsidwa ndi wodwala, popeza mpweya wolowera mpweya ulibe malire, kotero mpweya uliwonse uyenera kuyambitsidwa ndi wodwalayo. Munjira iyi, mpweya wolowera mpweya umasinthasintha kuchoka ku kukanikiza kwina kupita kwina (PEEP ndi kukakamiza kothandizira).

PEEP ndi kukakamiza komwe kumatsalira kumapeto kwa mpweya, pamene kuthandizira kupanikizika ndi kupanikizika pamwamba pa PEEP komwe mpweya wolowera mpweya umayendetsa panthawi iliyonse kuti mpweya ukhale wabwino.

Izi zikutanthauza kuti ngati wodwala atayikidwa mu PSV 10/5, adzalandira 5 cm H2O ya PEEP ndipo panthawi ya kudzoza adzalandira 15 cm H2O yothandizira (10 PS pamwamba pa PEEP).

Chifukwa palibe pafupipafupi zosunga zobwezeretsera, njirayi singagwiritsidwe ntchito kwa odwala omwe ataya chidziwitso, kugwedezeka kapena kumangidwa kwamtima.

Ma voliyumu apano amadalira pakuchita khama kwa wodwalayo komanso kutsata kwake m'mapapo.

PSV imagwiritsidwa ntchito nthawi zambiri kuletsa kuyamwa kuchokera ku makina opangira mpweya, chifukwa imangowonjezera kupuma kwa wodwalayo popanda kupereka kuchuluka kwa mafunde kapena kupuma.

Choyipa chachikulu cha PSV ndi kusadalirika kwa kuchuluka kwa mafunde, komwe kungapangitse CO2 kusunga ndi acidosis, komanso kupuma kwakukulu komwe kungayambitse kutopa kwa kupuma.

Pofuna kuthetsa vutoli, algorithm yatsopano idapangidwa ya PSV, yotchedwa voliyumu-supported ventilation (VSV).

VSV ndi njira yofanana ndi PSV, koma munjira iyi voliyumu yamakono imagwiritsidwa ntchito ngati chiwongolero cha mayankho, chifukwa chothandizira chosindikizira chomwe chimaperekedwa kwa wodwalayo chimasinthidwa nthawi zonse malinga ndi voliyumu yamakono. Munthawi imeneyi, ngati kuchuluka kwa mafunde kumachepa, mpweya wolowera mpweya umawonjezera chothandizira kuti muchepetse kuchuluka kwa mafunde, pomwe kuchuluka kwa mafunde kumawonjezera mphamvu yosindikizira imachepa kuti voliyumu ya mafunde ikhale pafupi ndi mpweya womwe mukufuna.

Umboni wina umasonyeza kuti kugwiritsa ntchito VSV kungachepetse nthawi yothandizira mpweya wabwino, nthawi yonse yoyamwitsa ndi nthawi yonse ya T-piece, komanso kuchepetsa kufunikira kwa sedation.

Kutulutsa mpweya wothamanga kwa Airway (APRV)

Monga momwe dzinalo likusonyezera, mumayendedwe a APRV, mpweya wodutsa mpweya umapereka kuthamanga kwapamwamba kosalekeza mumsewu wa mpweya, zomwe zimatsimikizira kuti mpweya wa oxygen, ndipo mpweya umachitidwa potulutsa kupanikizika kumeneku.

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Njirayi posachedwapa yatchuka ngati njira ina kwa odwala omwe ali ndi ARDS omwe amavutika kuti apeze okosijeni, omwe njira zina zopumira mpweya zimalephera kukwaniritsa zolinga zawo.

APRV yafotokozedwa ngati kupanikizika kosalekeza kwa airway (CPAP) komwe kumakhala ndi gawo lotulutsa pang'onopang'ono.

Izi zikutanthauza kuti mpweya wabwino umagwiritsa ntchito kuthamanga kwapamwamba kosalekeza (P mkulu) kwa nthawi yoikika (T high) ndiyeno nkumamasula, kawirikawiri kubwerera ku ziro (P low) kwa nthawi yochepa kwambiri (T low).

Lingaliro kumbuyo izi ndi kuti pa T mkulu (zophimba 80% -95% ya mkombero), pali nthawi zonse alveolar kulemba anthu, amene bwino oxygenation chifukwa nthawi anakhalabe pa kuthamanga kwambiri ndi yaitali kuposa nthawi ya mitundu ina mpweya mpweya (lotseguka m'mapapo njira. ).

Izi zimachepetsa kukwera kwa inflation mobwerezabwereza ndi kuphulika kwa mapapo komwe kumachitika ndi njira zina zopumira mpweya, kuteteza kuvulala kopangidwa ndi mpweya wopangidwa ndi mpweya.

Panthawi imeneyi (T mkulu) wodwala amakhala ndi ufulu wopuma (zomwe zimamupangitsa kukhala womasuka), koma amakoka mafunde otsika chifukwa kupuma movutikira koteroko kumakhala kovuta kwambiri. Kenako, T ikafika pamwamba, kukakamiza kwa mpweya wabwino kumatsikira ku P low (nthawi zambiri ziro).

Mpweya umatulutsidwa kuchokera mumsewu wa mpweya, zomwe zimalola kuti mpweya utuluke mpaka T low ufike ndipo mpweya wolowera mpweya umatulutsa mpweya wina.

Pofuna kupewa kugwa kwa ndege panthawiyi, T yotsika imayikidwa mwachidule, kawirikawiri mozungulira masekondi 0.4-0.8.

Pamenepa, mphamvu ya mpweya wolowera mpweya ikafika pa ziro, zotanuka za m'mapapo zimakankhira mpweya kunja, koma nthawi siitali yokwanira kuti mpweya wonse utuluke m'mapapo, kotero kuti kupanikizika kwa alveolar ndi airway sikufika ziro. ndipo kugwa kwa airway sikuchitika.

Nthawiyi nthawi zambiri imayikidwa kotero kuti otsika T amatha pamene kutuluka kwa mpweya kumatsikira ku 50% ya kutuluka koyamba.

Chifukwa chake, mpweya wabwino pamphindi umatengera kutsika kwa T komanso kuchuluka kwa mafunde a wodwalayo panthawi ya T mkulu

Zizindikiro zogwiritsira ntchito APRV:

ARDS ndizovuta kutulutsa okosijeni ndi AC
Kuvulala koopsa m'mapapo
Postoperative atelectasis.

Ubwino wa APRV:

APRV ndi njira yabwino yopangira mpweya woteteza m'mapapo.

Kukhoza kukhazikitsa P mkulu kumatanthauza kuti wogwiritsa ntchitoyo ali ndi mphamvu pazitsulo zamapiri, zomwe zingathe kuchepetsa kwambiri zochitika za barotrauma.

Pamene wodwalayo akuyamba kuyesetsa kwake kupuma, pali kugawa bwino kwa gasi chifukwa cha machesi abwino a V / Q.

Kuthamanga kwapang'onopang'ono kumatanthawuza kuwonjezeka kwa ntchito (njira yotsegula m'mapapo).

APRV ikhoza kupititsa patsogolo oxygenation kwa odwala omwe ali ndi ARDS omwe amavutika kuti apeze oxygenation ndi AC.

APRV ikhoza kuchepetsa kufunikira kwa sedation ndi neuromuscular blocking agents, monga momwe wodwalayo angakhale womasuka poyerekeza ndi njira zina.

Ubwino ndi contraindications:

Chifukwa kupuma mwachisawawa ndi gawo lofunika kwambiri la APRV, sikoyenera kwa odwala omwe agonekedwa kwambiri.

Palibe chidziwitso chokhudza kugwiritsidwa ntchito kwa APRV pamavuto a neuromuscular kapena obstructive mapapu, ndipo kugwiritsidwa ntchito kwake kuyenera kupewedwa mwa anthu odwalawa.

Mwachidziwitso, kupanikizika kosalekeza kwa intrathoracic kungayambitse kuthamanga kwa mtsempha wa m'mapapo ndi kuwonjezereka kwa intracardiac shunts mwa odwala omwe ali ndi Eisenmenger's physiology.

Lingaliro lamphamvu lazachipatala limafunikira posankha APRV ngati njira yolowera mpweya m'njira zodziwika bwino monga AC.

Zambiri pazambiri zamitundu yosiyanasiyana ya mpweya wabwino komanso mawonekedwe ake angapezeke m'nkhani zamtundu uliwonse wa mpweya wabwino.

Kugwiritsa ntchito mpweya wabwino

Kuyika koyambirira kwa mpweya wabwino kumatha kusiyanasiyana kutengera chomwe chimayambitsa intubation komanso cholinga cha kuwunikaku.

Komabe, pali zosintha zina zofunika nthawi zambiri.

Njira yodziwika bwino yolowera mpweya yomwe mungagwiritse ntchito wodwala yemwe wangolowa kumene ndi AC mode.

Mawonekedwe a AC amapereka chitonthozo chabwino komanso kuwongolera kosavuta kwazinthu zina zofunika kwambiri za thupi.

Imayamba ndi FiO2 ya 100% ndipo imatsika motsogozedwa ndi pulse oximetry kapena ABG, ngati kuli koyenera.

Kutsika kwa mpweya wabwino wa mafunde kwasonyezedwa kuti kumateteza mapapo osati mu ARDS komanso matenda amitundu ina.

Kuyamba wodwala ndi kutsika kwamadzi (6 mpaka 8 mL / Kg kulemera kwa thupi) kumachepetsa kuvulala kwamapapu opangidwa ndi mpweya (VILI).

Nthawi zonse gwiritsani ntchito njira yodzitetezera m'mapapo, chifukwa kuchuluka kwa mafunde kumakhalabe ndi phindu lochepa komanso kumawonjezera kumeta ubweya mu alveoli ndipo kungayambitse kuvulala kwamapapo.

RR yoyamba iyenera kukhala yabwino kwa wodwalayo: 10-12 bpm ndi yokwanira.

Chenjezo lofunika kwambiri limakhudza odwala omwe ali ndi vuto la metabolic acidosis.

Kwa odwalawa, mpweya wokwanira pa mphindi imodzi uyenera kufanana ndi mpweya usanalowe, chifukwa apo ayi acidosis imakula kwambiri ndipo imatha kuyambitsa zovuta monga kumangidwa kwa mtima.

Kuyenda kuyenera kuyambika kapena kupitirira 60 L/min kuti mupewe autoPEEP

Yambani ndi otsika PEEP wa 5 masentimita H2O ndi kuonjezera malinga ndi kulolerana kwa wodwalayo kwa oxygenation cholinga.

Samalirani kwambiri kuthamanga kwa magazi ndi chitonthozo cha odwala.

ABG iyenera kupezedwa 30 min pambuyo pa intubation ndi zosintha za mpweya wabwino ziyenera kusinthidwa malinga ndi zotsatira za ABG.

Kupsyinjika kwapamwamba ndi kumtunda kuyenera kuyang'aniridwa pa chothandizira mpweya kuti zitsimikizire kuti palibe vuto ndi kukana kwa mpweya kapena mpweya wa alveolar kuteteza kuwonongeka kwa mapapo chifukwa cha mpweya wabwino.

Chisamaliro chiyenera kuperekedwa ku ma curve a voliyumu pa chiwonetsero cha mpweya wabwino, monga kuwerenga komwe kukuwonetsa kuti piritsi silibwerera ku ziro mukatulutsa mpweya ndikuwonetsa kutulutsa kosakwanira komanso kukula kwa auto-PEEP; choncho, zokonza ziyenera kupangidwa kwa mpweya wabwino nthawi yomweyo.[7][8]

Kuthetsa mavuto a Ventilator

Pomvetsetsa bwino zomwe zakambidwa, kuyang'anira zovuta za mpweya wabwino ndi kuthetsa mavuto kuyenera kukhala chikhalidwe chachiwiri.

Zowongolera zodziwika bwino zopangira mpweya wabwino zimaphatikizapo hypoxemia ndi hypercapnia kapena hyperventilation:

Hypoxia: oxygenation imadalira FiO2 ndi PEEP (high T ndi mkulu P kwa APRV).

Pofuna kukonza hypoxia, kuwonjezera chimodzi mwazinthuzi kuyenera kuonjezera mpweya.

Chisamaliro chapadera chiyenera kuperekedwa ku zotsatira zowopsa za kuwonjezeka kwa PEEP, zomwe zingayambitse barotrauma ndi hypotension.

Kuchulukitsa kwa FiO2 sikuli kopanda nkhawa, chifukwa FiO2 yokwezeka imatha kuwononga oxidative mu alveoli.

Chinthu china chofunika kwambiri pa kayendetsedwe ka mpweya wa oxygen ndikukhazikitsa cholinga cha oxygenation.

Nthawi zambiri, sikuthandiza kwenikweni kukhalabe ndi mpweya wabwino kuposa 92-94%, kupatula, mwachitsanzo, pakachitika poizoni wa carbon monoxide.

Kutsika kwadzidzidzi kwa mpweya wa okosijeni kuyenera kuyambitsa kukayikira kwa chubu malpositioning, pulmonary embolism, pneumothorax, pulmonary edema, atelectasis, kapena kukula kwa mapulagi a ntchofu.

Hypercapnia: Kusintha kwa CO2 m'magazi, mpweya wabwino wa alveolar uyenera kusinthidwa.

Izi zitha kuchitika posintha kuchuluka kwa mafunde kapena kupuma (kutsika kwa T ndi kutsika kwa P mu APRV).

Kuchulukitsa kuchuluka kapena kuchuluka kwa mafunde, komanso kutsika kwa T, kumawonjezera mpweya wabwino komanso kumachepetsa CO2.

Chisamaliro chiyenera kuchitidwa ndi kuchuluka kwafupipafupi, chifukwa chidzawonjezeranso kuchuluka kwa malo akufa ndipo sizingakhale zogwira mtima ngati kuchuluka kwa mafunde.

Mukakulitsa voliyumu kapena ma frequency, chidwi chapadera chiyenera kuperekedwa ku loop-volume loop kupewa kukula kwa auto-PEEP.

Zovuta kwambiri: Zokakamiza ziwiri ndizofunikira m'dongosolo: kuthamanga kwapamwamba komanso kuthamanga kwamapiri.

Kuthamanga kwapamwamba ndi muyeso wa kukana kwa mpweya ndi kutsata ndipo kumaphatikizapo chubu ndi mtengo wa bronchial.

Kupanikizika kwa Plateau kumawonetsa kuthamanga kwa alveolar ndipo motero kutsata kwamapapo.

Ngati pali kuwonjezeka kwa kuthamanga kwapamwamba, sitepe yoyamba ndiyo kupuma kolimbikitsa ndikuyang'ana mapiri.

Kuthamanga kwapamwamba kwambiri komanso kuthamanga kwabwino kwa mapiri: high airway kukana ndi kutsata mwachizolowezi

Zomwe zingatheke: (1) Chopotoka ET chubu-Yankho lake ndikuchotsa chubu; gwiritsani ntchito loko ngati wodwala aluma chubu, (2) Ntchentche pulagi-Yankho lake ndi kulakalaka wodwalayo, (3) Bronchospasm-Yankho lake ndi kupereka bronchodilators.

Chiwopsezo chachikulu komanso chokwera kwambiri: zovuta zotsata

Zomwe zingayambitse ndi izi:

Main trunk intubation-Yankho lake ndikuchotsa chubu la ET. Kuti muzindikire, mupeza wodwala yemwe ali ndi phokoso lokhala ndi mpweya wokhazikika komanso mapapu akunja (atelectatic lung).
Pneumothorax: Kuzindikira kudzapangidwa mwa kumvetsera kumveka kwa mpweya ndikupeza mapapu a hyperresonant. Odwala omwe ali ndi intuba, kuyika chubu pachifuwa ndikofunikira, chifukwa kuthamanga kwabwino kumangowonjezera pneumothorax.
Atelectasis: Kuwongolera koyambirira kumakhala ndi kugunda pachifuwa komanso kuyendetsa ntchito. Bronchoscopy ingagwiritsidwe ntchito pazochitika zosamva.
Pulmonary edema: Diuresis, inotropes, PEEP yokwera.
ARDS: Gwiritsani ntchito voliyumu yotsika komanso mpweya wabwino wa PEEP.
Dynamic hyperinflation kapena auto-PEEP: ndi njira yomwe mpweya wina wopumira sumatuluka mokwanira kumapeto kwa kupuma.
Kuchulukana kwa mpweya wotsekeka kumawonjezera kupanikizika kwa mapapo ndikuyambitsa barotrauma ndi hypotension.
Wodwalayo adzakhala ovuta kutulutsa mpweya.
Kuti mupewe ndi kuthetsa PEEP, nthawi yokwanira iyenera kuloledwa kuti mpweya uchoke m'mapapu panthawi yopuma.

Cholinga cha kasamalidwe ndi kuchepetsa chiŵerengero cha inspiratory / expiratory ratio; Izi zitha kutheka pochepetsa kupuma, kuchepetsa kuchuluka kwa mafunde (kuchuluka kwa voliyumu kudzafuna nthawi yayitali kuti ichoke m'mapapo), komanso kuwonjezereka kwa mpweya wotuluka (ngati mpweya uperekedwa mwachangu, nthawi yopumira imakhala yochepa ndipo nthawi yopuma idzakhala motalika pamlingo uliwonse wa kupuma).

Zotsatira zomwezo zitha kukwaniritsidwa pogwiritsa ntchito mawonekedwe a square waveform kuti azitha kuyenda molimbikitsa; izi zikutanthauza kuti titha kukhazikitsa mpweya wabwino kuti upereke kuyenda konse kuyambira pachiyambi mpaka kumapeto kwa kudzoza.

Njira zina zomwe zingatheke ndikuwonetsetsa kuti pakhale mpweya wokwanira kuti wodwalayo asatuluke mpweya wabwino komanso kugwiritsa ntchito bronchodilator ndi steroids kuti achepetse kutsekeka kwa mpweya.

Ngati auto-PEEP ndi yoopsa ndipo imayambitsa hypotension, kuchotsa wodwalayo ku makina olowera mpweya ndikulola mpweya wonse kutuluka kungakhale njira yopulumutsa moyo.

Kuti mumve zambiri za kasamalidwe ka auto-PEEP, onani nkhani yakuti “Positive End-Expiratory Pressure (PEEP).”

Vuto linanso lomwe limakumana ndi odwala omwe akudutsa mpweya wabwino ndi odwala-ventilator dyssynchrony, omwe nthawi zambiri amatchedwa "kulimbana ndi mpweya wabwino."

Zoyambitsa zofunikira zimaphatikizapo hypoxia, self-PEEP, kulephera kukwaniritsa zofunikira za mpweya wa wodwalayo kapena mpweya wabwino, kupweteka, ndi kusapeza bwino.

Pambuyo pochotsa zifukwa zofunika monga pneumothorax kapena atelectasis, ganizirani za chitonthozo cha odwala ndikuonetsetsa kuti pali sedation yokwanira ndi analgesia.

Lingalirani kusintha kanjira ka mpweya wabwino, chifukwa odwala ena amatha kuyankha bwino panjira zosiyanasiyana.

Chisamaliro chapadera chiyenera kuperekedwa ku zoikamo mpweya wabwino muzochitika izi:

COPD ndi vuto lapadera, chifukwa mapapu oyera a COPD amakhala ndi kutsata kwakukulu, zomwe zimayambitsa chizolowezi chachikulu cha kutsekeka kwa mpweya chifukwa cha kugwa kwa mpweya komanso kutsekeka kwa mpweya, zomwe zimapangitsa odwala COPD kukhala okonda kwambiri kupanga auto-PEEP. Kugwiritsa ntchito njira yodzitetezera yolowera mpweya ndikuyenda kwambiri komanso kupuma pang'ono kungathandize kupewa kudzipatulira kwaPEEP. Mfundo ina yofunika kuiganizira pakulephera kupuma kwapang'onopang'ono (chifukwa cha COPD kapena chifukwa china) ndikuti sikofunikira kukonza CO2 kuti ibwerere mwakale, popeza odwalawa nthawi zambiri amakhala ndi chipukuta misozi pamavuto awo opuma. Wodwala akapatsidwa mpweya wabwino wa CO2, bicarbonate yake imachepa ndipo, ikatulutsidwa, imapita mofulumira ku kupuma kwa acidosis chifukwa impso sizingayankhe mofulumira monga momwe mapapo ndi CO2 imabwerera ku chiyambi, zomwe zimapangitsa kupuma kulephera komanso kubwezeretsanso. Kuti mupewe izi, milingo ya CO2 iyenera kutsimikiziridwa kutengera pH ndi zomwe zidadziwika kale kapena zowerengeredwa.
Mphumu: Monga momwe zilili ndi COPD, odwala mphumu amatha kugwidwa ndi mpweya, ngakhale kuti chifukwa chake ndi chosiyana. Mu mphumu, kutsekeka kwa mpweya kumachitika ndi kutupa, bronchospasm ndi mapulagi a ntchentche, osati kugwa kwa mpweya. Njira yopewera PEEP ndi yofanana ndi yomwe imagwiritsidwa ntchito mu COPD.
Cardiogenic pulmonary edema: PEEP yokwera imatha kuchepetsa kubwerera kwa venous ndikuthandizira kuthetsa edema ya m'mapapo, komanso kulimbikitsa kutulutsa mtima. Chodetsa nkhaŵa chiyenera kukhala kuonetsetsa kuti wodwalayo ali ndi diuretic mokwanira asanatuluke, chifukwa kuchotsa kupanikizika kwabwino kungayambitse edema yatsopano ya m'mapapo.
ARDS ndi mtundu wa noncardiogenic pulmonary edema. Njira yotsegula m'mapapo yokhala ndi PEEP yokwera komanso kuchuluka kwa mafunde otsika yawonetsedwa kuti ipititse patsogolo kufa.
Pulmonary embolism ndizovuta. Odwalawa amadalira kwambiri kudzaza kale chifukwa cha kukwera kwakukulu kwa kuthamanga kwa atrium yoyenera. Kulowetsedwa kwa odwalawa kumawonjezera kupanikizika kwa RA ndikuchepetsanso kubwerera kwa venous, ndi chiopsezo cha kugwedezeka. Ngati palibe njira yopewera intubation, chidwi chiyenera kuperekedwa ku kuthamanga kwa magazi ndipo makonzedwe a vasopressor ayenera kuyambika mwamsanga.
Vuto lalikulu la metabolic acidosis ndizovuta. Pamene mukulowetsa odwalawa, samalani kwambiri ndi mpweya wawo wa pre-intubation. Ngati mpweya woterewu sunaperekedwe pamene chithandizo cha makina chikuyambika, pH idzatsika kwambiri, zomwe zingayambitse kumangidwa kwa mtima.

Maumboni a m'Baibulo

Metersky ML, Kalil AC. Kasamalidwe ka Chibayo Chogwirizana ndi Ventilator: Malangizo. Clin Chest Med. 2018 Dec;39(4):797-808. [Adasankhidwa]
Chomton M, Brossier D, Sauthier M, Vallières E, Dubois J, Emeriaud G, Jouvet P. Ventilator-Associated Pneumonia and Events in Pediatric Intensive Care: Phunziro la Single Center. Pediatr Crit Care Med. 2018 Dec;19(12):1106-1113. [Adasankhidwa]
Vandana Kalwaje E, Rello J. Ulamuliro wa chibayo chogwirizana ndi mpweya wabwino: Kufunika kwa njira yamunthu. Katswiri wa Rev Anti Infect Ther. 2018 Aug;16(8):641-653. [Adasankhidwa]
Jansson MM, Syrjälä HP, Talman K, Meriläinen MH, Ala-Kokko TI. Chidziwitso cha anamwino odziwika bwino, kutsatira, ndi zolepheretsa kulowa mgulu la makina apadera olowera mpweya. Ndine J Woyang'anira. 2018 Sep;46(9):1051-1056. [Adasankhidwa]
Piraino T, Fan E. Hypoxemia yoopsa kwambiri pa nthawi ya mpweya wabwino. Curr Opin Crit Care. 2017 Dec;23(6):541-548. [Adasankhidwa]
Mora Carpio AL, Mora JI. StatPearls [Intaneti]. Kusindikiza kwa StatPearls; Treasure Island (FL): Apr 28, 2022. Ventilation Assist Control. [Adasankhidwa]
Kumar ST, Yassin A, Bhowmick T, Dixit D. Malangizo Ochokera ku 2016 Malangizo Otsogolera Akuluakulu Omwe Ali ndi Chipatala Chopezeka ndi Chipatala kapena Ventilator-Associated Pneumonia. P T. 2017 Dec;42(12):767-772. [Nkhani yaulere ya PMC] [Adasankhidwa]
Del Sorbo L, Goligher EC, McAuley DF, Rubenfeld GD, Brochard LJ, Gattinoni L, Slutsky AS, Fan E. Mechanical Ventilation in Adults with Acute Respiratory Distress Syndrome. Chidule cha Umboni Woyeserera wa Upangiri Wothandizira Zachipatala. Ann Am Thorac Soc. 2017 Oct;14(Zowonjezera_4):S261-S270. [Adasankhidwa]
Chao CM, Lai CC, Chan KS, Cheng KC, Ho CH, Chen CM, Chou W. Njira zosiyanasiyana zoyendetsera ntchito zosiyanasiyana komanso kupititsa patsogolo khalidwe labwino kuti achepetse kuphulika kosakonzekera m'magulu akuluakulu osamalira odwala kwambiri: Zaka za 15. Medicine (Baltimore). 2017 Jul;96(27):e6877. [Nkhani yaulere ya PMC] [Adasankhidwa]
Badnjevic A, Gurbeta L, Jimenez ER, Iadanza E. Kuyesedwa kwa ma mechanical ventilators ndi ma incubators akhanda m'mabungwe azachipatala. Technol Health Care. 2017;25(2):237-250. [Adasankhidwa]