Invasive mechanical ventilation inowanzoshandiswa kupindira kune vanorwara zvakanyanya vanoda rubatsiro rwekufema kana kuchengetedzwa kwemhepo.

Iyo vhezheni inobvumira kuchinjana kwegasi kuti ichengetwe nepo mamwe marapirwo achiitwa kuvandudza mamiriro ekiriniki

Ichi chiitiko chinoongorora zvinoratidzwa, zvinopesana, manejimendi, uye zvinogona kunetsa zve invasive mechanical ventilation uye inosimbisa kukosha kweiyo interprofessional timu mukutarisira kuchengetwa kwevarwere vanoda rubatsiro rwemhepo.

Iko kudiwa kwekufefetedza kwemuchina ndechimwe chezvikonzero zvinowanzoitika zvekupinda muICU.[1][2][3]

ZVINHU ZVINHU ZVINHU ZVINOTAURWA, MABHADHO EKUPEPA, MALUNGU VENTILATORS, MACHEYA EKUBVISA: SPENCER PRODUCTS MUDOUBLE BOOTH PAEMERGENCY EXPO

Izvo zvakakosha kuti unzwisise mamwe mazwi ekutanga kuti unzwisise mechanical ventilation

Kubhururuka: Kutsinhana kwemweya pakati pemapapu nemhepo (ambient kana kupihwa nemhepo inofefetera), nemamwe mazwi, inzira yekufambisa mweya mukati nekubuda mumapapu.

Mhedzisiro yaro inonyanya kukosha ndeyekubviswa kwecarbon dioxide (CO2) kubva mumuviri, kwete kuwedzera kweokisijeni yemukati muropa.

Mumakiriniki marongero, kufefetedza kunoyerwa seminiti kufefetedza, kuverengerwa sekufema mwero (RR) nguva tidal volume (Vt).

Mumurwere ane mechanically ventilated, ropa CO2 content inogona kuchinjwa nekushandura tidal volume kana kufema.

Oxygenation: Kupindira kunopa kuwedzera kuendeswa kweokisijeni kumapapu uye nekudaro kutenderera.

Mumurwere ane mechanically ventilated, izvi zvinogona kuwanikwa nekuwedzera chikamu cheokisijeni yakafuridzirwa (FiO 2%) kana kuti yakanaka kupera-expiratory pressure (PEEP).

PeEP: Kudzvinyirirwa kwakanaka kwakasara mumhepo pakupera kwemhepo yekufema (kuguma kwekupera) kwakakura kudarika mhepo yemhepo muvarwere vane mechanically ventilated.

Kuti uwane tsananguro izere yekushandiswa kwePEEP, ona chinyorwa chakanzi "Positive End-Expiratory Pressure (PEEP)" muzvinyorwa zvebhaibheri panoperera chinyorwa chino.

Tidal vhoriyamu: Huwandu hwemhepo yaifamba ichipinda nekubuda mumapapu mumhepo yega yega yekufema.

FiO2: Pezana yeokisijeni mumusanganiswa wemhepo inounzwa kumurwere.

Kuyerera: Ratidza marita paminiti apo mhepo inoburitsa mweya.

Kuenderana: Shanduko yevhoriyamu yakakamurwa nekushanduka kwekumanikidza. Mukufema physiology, kutevedzera zvakakwana musanganiswa wemapapu nechipfuva kutevedzera madziro, sezvo zvinhu zviviri izvi hazvigone kupatsanurwa mumurwere.

Nekuda kwekuti mechanical ventilation inobvumira chiremba kushandura mhepo yemurwere uye oxygenation, inoita basa rakakosha muacute hypoxic uye hypercapnic kutadza kufema uye yakanyanya acidosis kana metabolic alkalosis.[4][5]

Physiology ye mechanical ventilation

Mechanical ventilation ine akati wandei mhedzisiro pamapapu mechanics.

Normal kufema physiology inoshanda seyakaipa yekumanikidza system.

Kana iyo diaphragm inosundira pasi panguva yekufemerwa, kudzvanywa kwakashata kunogadzirwa mu pleural cavity, iyo, iyo inozoita, inogadzira kudzvinyirira kwakashata mumhepo inokwevera mweya mumapapu.

Iyi intrathoracic negative pressure inodzikira right atrial pressure (RA) uye inoburitsa kusveta paiferior vena cava (IVC), ichiwedzera kudzoka kwetsinga.

Iko kushandiswa kweiyo positive pressure ventilation inogadzirisa iyi physiology.

Kudzvinyirirwa kwakanaka kunoitwa nemhepo inofambisa mhepo kunoendeswa kumhepo yepamusoro uye pakupedzisira kune alveoli; izvi, zvakare, zvinoparidzirwa kune alveolar nzvimbo uye thoracic cavity, zvichiita kuti kumanikidzwa kwakanaka (kana kuti zvishoma kuderera kwakashata) munzvimbo yepleural.

Kuwedzera kweRA kudzvanywa uye kudzikira kwekudzoka kwevenous kunogadzira kudzikira kwekutanga.

Izvi zvine maitiro maviri ekuderedza kubuda kwemoyo: ropa shoma mumhepo yekurudyi zvinoreva kuti ropa shoma rinosvika kumhepo yekuruboshwe uye ropa shoma rinogona kudhonzwa kunze, kuderedza kubuda kwemoyo.

Kureba kwakaderera kunoreva kuti moyo uri kushanda pane imwe nzvimbo isinganyanyi kushanda payekumhanyisa curve, ichiita basa risingashande uye kuwedzera kuderedza kubuda kwemoyo, izvo zvinozoguma nekudonha kwezvinoreva arterial pressure (MAP) kana pasina muripo wemhinduro kuburikidza nekuwedzera. systemic vascular resistance (SVR).

Ichi chinhu chinonyanya kukosha kune varwere vangave vasingakwanisi kuwedzera SVR, zvakadai sevarwere vane distributive shock (septic, neurogenic, kana anaphylactic).

Kune rimwe divi, kudzvanywa kwakanaka kwema mechanical ventilation kunogona kuderedza zvakanyanya basa rekufema.

Izvi, zvakare, zvinoderedza kuyerera kweropa kune tsandanyama dzekufema uye kugovera kune nhengo dzakanyanya kukosha.

Kuderedza basa remamhasuru ekufema kunoderedzawo chizvarwa che CO2 uye lactate kubva mumhasuru idzi, zvichibatsira kuvandudza acidosis.

Mhedzisiro yeyakanaka kumanikidza mechanical ventilation pane venous kudzoka inogona kubatsira kune varwere vane cardiogenic pulmonary edema.

Mune varwere ava vane vhoriyamu yakawandisa, kudzikisa venous kudzoka kunoderedza zvakananga huwandu hwepulmonary edema inogadzirwa, ichidzikisa kuburitsa kwemoyo chaiko.

Panguva imwecheteyo, kuderedzwa kwe venous kudzoka kunogona kuvandudza kuruboshwe kwe ventricular overdistension, kuchiisa pane imwe nzvimbo inobatsira paFrank-Starling curve uye pamwe nekuvandudza kubuda kwemoyo.

Kutarisira kwakaringana kwema mechanical ventilation kunodawo kunzwisisa kwepulmonary pressure uye kutevedzera mapapu.

Kutevedzera mapapu kwakajairika kunenge 100 ml/cmH20.

Izvi zvinoreva kuti mumapapu akajairwa, kutonga kwe500 ml yemhepo kuburikidza nemhepo yakanaka yekufefetera kuchawedzera alveolar pressure ne5cm H2O.

Sezvineiwo, kutonga kwekumanikidza kwakanaka kwe5 cm H2O kuchaunza kuwedzera kwevhoriyamu yemapapu ye500 mL.

Paunenge uchishanda nemapapu asina kujairika, kuterera kunogona kunge kwakakwira zvakanyanya kana kuderera zvakanyanya.

Chero chirwere chinoparadza mapapu parenchyma, senge emphysema, inowedzera kuterera, nepo chero chirwere chinoburitsa mapapu akaomarara.ARDS, mabayo, pulmonary edema, pulmonary fibrosis) inoderedza kutevedza kwemapapu.

Dambudziko nemapapu akaomarara nderekuti kuwedzera kudiki kwevhoriyamu kunogona kuunza kuwedzera kukuru kwekumanikidza uye kukonzera barotrauma.

Izvi zvinounza dambudziko muvarwere vane hypercapnia kana acidosis, sezvo kufefetera kweminiti kungangoda kuwedzerwa kugadzirisa matambudziko aya.

Kuwedzera kufema kwekufema kunogona kugadzirisa kuwedzera uku kweminiti yekufema, asi kana izvi zvisingagoneke, kuwedzera kwehuwandu hwemhepo kunogona kuwedzera kudzvinyirirwa kweplateau uye kugadzira barotrauma.

Pane maviri akakosha kumanikidzwa muhurongwa hwekuchengeta mupfungwa kana muchina uchifemesa murwere:

• Peak pressure ndiyo dzvinyiriro inosvikwa panguva yekufemerwa kana mweya wasundirwa mumapapu uye chiyero chekudzivirira kwenzira yemhepo.
• Plateau pressure ndiyo static pressure inosvika pakupera kwekufemerwa kwakazara. Kuyera kudzvanywa kwemubani, kumbomira kufemerwa kunofanirwa kuitwa pamhepo inofefetera kubvumira kudzvanywa kuti kuenzane kuburikidza nehurongwa. Plateau pressure chiyero che alveolar pressure uye kutevedzera mapapu. Normal plateau pressure iri pasi pe 30 cm H20, nepo kudzvinyirirwa kwepamusoro kunogona kuunza barotrauma.

Zviratidzo zve mechanical ventilation

Chiratidzo chinonyanyozivikanwa cheintubation uye mechanical ventilation iri muzviitiko zvekutadza kufema kwakanyanya, kungave hypoxic kana hypercapnic.

Zvimwe zviratidzo zvakakosha kuderera kwemazinga ekuziva nekusakwanisa kuchengetedza nzira yekufema, kushushikana kwekufema uko kwakundikana kusingapindike zvakanaka kupinza mhepo, zviitiko zvehemoptysis yakakura, angioedema yakakomba, kana chero chiitiko chekufamba kwemhepo sekutsva kwemhepo, kusungwa kwemoyo, uye kuvhunduka.

Zvakajairwa zvinosarudzika zviratidzo zvema mechanical ventilation kuvhiyiwa uye neuromuscular disorders.

Contraindications

Iko hakuna kupesana kwakananga kune mechanical ventilation, sezvo iri chiyero chekuchengetedza hupenyu mumurwere anorwara zvakanyanya, uye varwere vose vanofanira kupiwa mukana wekubatsirwa nawo kana zvichidiwa.

Iyo chete mhedziso contraindication kune mechanic ventilation ndeye kana inopesana nechishuwo chakataurwa chemurwere chemaitiro ekugadzirisa hupenyu.

Iyo chete hukama contraindication ndeye kana noninvasive ventilation iripo uye kushandiswa kwayo kunotarisirwa kugadzirisa kudiwa kwe mechanical ventilation.

Izvi zvinofanirwa kutanga zvatangwa, sezvo zvine mashoma matambudziko pane mechanical ventilation.

Matanho akati wandei anofanirwa kutorwa kutanga mechanical ventilation

Izvo zvinodiwa kuti uone kuiswa kwakaringana kweiyo endotracheal chubhu.

Izvi zvinogona kuitwa ne end-tidal capnography kana nemusanganiswa wekiriniki uye neradiological kuwanikwa.

Izvo zvinodikanwa kuve nechokwadi chakaringana chetsigiro yemoyo ine zvinwiwa kana vasopressors, sezvinoratidzwa pane imwe nyaya-ne-case hwaro.

Iva nechokwadi chokuti sedation yakakwana uye analgesia iripo.

Iyo yepurasitiki chubhu muhuro yemurwere inorwadza uye haina kugadzikana, uye kana murwere asina kugadzikana kana kunetseka nechubhu kana kufefetera, zvichava zvakanyanya kuoma kudzora maparameta akasiyana ekufema uye oxygenation.

Mhepo yekufefetedza nzira

Mushure mekupinza murwere uye kumubatanidza kumhepo inofefetera, inguva yekusarudza kuti ndeipi nzira yekufefetera yekushandisa.

Kuti izvi zviitwe nguva dzose kuitira kubatsira murwere, mitemo yakawanda inoda kunzwisiswa.

Sezvambotaurwa, kutevedzera ndiko kushanduka kwevhoriyamu yakakamurwa nekuchinja kwekumanikidza.

Paunenge uchifemesa murwere nemuchina, unogona kusarudza kuti mhepo inofefetera sei.

Iyo mhepo inofefetera inogona kusetwa kuendesa huwandu hwakafanotemerwa hwevhoriyamu kana kufanotemerwa huwandu hwekumanikidza, uye zviri kuna chiremba kuti asarudze kuti ndeipi inonyanya kubatsira kumurwere.

Pakusarudza kufambisa kwemhepo, isu tinosarudza kuti ndeipi ichave inotsamira shanduko uye inove yakazvimirira musiyano mumapapu ekuteerera equation.

Kana tikasarudza kutanga murwere pavhoriyamu-inodzorwa nemhepo, iyo inofefetera inogara ichiendesa yakaenzana vhoriyamu (yakasununguka inoshanduka), nepo kumanikidzwa kunogadzirwa kuchaenderana nekuteerera.

Kana kutevedzera kwakashata, kumanikidzwa kuchava kwakakwirira uye barotrauma inogona kuitika.

Kune rumwe rutivi, kana tikafunga kutanga murwere pamhepo-inodzorwa nemhepo, mhepo inofefetera inogara ichiunza kudzvanywa kwakafanana panguva yekufema.

Nekudaro, huwandu hwemhepo hunoenderana nekuteerera kwemapapu, uye mumamiriro ezvinhu apo kutevedzera kunochinja nguva zhinji (senge asthma), izvi zvinoburitsa zvisingavimbike mavhoriyamu uye zvinogona kukonzera hypercapnia kana hyperventilation.

Mushure mekusarudza nzira yekufema (kuburikidza nekumanikidza kana vhoriyamu), chiremba anofanira kusarudza kuti ndeipi nzira yekufambisa mhepo yekushandisa.

Izvi zvinoreva kusarudza kana muchina wekufema uchibatsira kufema kwese kwemurwere, kumwe kufema kwemurwere, kana kusafema, uye kuti mhepo inofefetera ichabatsira here kana murwere asiri kufema ega.

Mamwe maparamendi ekufunga nezve chiyero chekufema kwekufema (kuyerera), iyo waveform yekuyerera (iyo inodzikira waveform inotevedzera physiological kufema uye inonyanya kugadzikana kune murwere, nepo square waveforms, umo kuyerera kunounzwa pamwero wepamusoro mukati mekufuridzirwa, hazvina kugadzikana kumurwere asi zvinopa nguva yekufema nekukurumidza), uye mwero wekupihwa kwekufema.

Ese aya ma paramita anofanirwa kugadziridzwa kuti awane kunyaradzwa kwemurwere, anodiwa magasi eropa, uye kudzivirira kuvharirwa kwemhepo.

Kune akati wandei mamodhi emhepo anosiyana zvishoma kubva kune mumwe. Muchidzidzo ichi tichatarisa pane akajairika nzira dzekufemesa uye kushandiswa kwavo kwekiriniki.

Ventilation modes dzinosanganisira yekubatsira kudzora (AC), tsigiro yetsigiro (PS), yakawiriraniswa intermittent inosungirwa kufefetera (SIMV), uye airway kumanikidza kuburitsa mhepo (APRV).

Kubatsirwa kwemhepo (AC)

Kubatsira kudzora ndiko uko mhepo yekufema inobatsira murwere nekupa rutsigiro rwemweya wega wega murwere anotora (ichi chikamu chekubatsira), nepo mhepo ine simba pamusoro pekufema kwekufema kana ikawira pasi peyero yakatarwa (chikamu chekutonga).

Mukutonga kwekubatsira, kana frequency yakaiswa kugumi nemaviri uye murwere achifema pagumi nemasere, mhepo inofefetera inozobatsira nekufema gumi nemasere, asi kana frequency yadonha kusvika pa12, mhepo inofefetera inotora kutonga kwekufema uye kutora gumi nemaviri kufema. paminiti.

Mukubatsira-kudzora kufefetera, kufema kunogona kuendeswa nevhoriyamu kana kudzvanywa

Izvi zvinonzi vhoriyamu-controlled ventilation kana pressure-controlled ventilation.

Kuzvichengeta zviri nyore uye kunzwisisa kuti sezvo kufefetedza kunowanzova nyaya yakakosha kupfuura kudzvanywa uye kutonga kwevhoriyamu kunonyanya kushandiswa pane kudzvanya kudzora, kune yasara yeongororo iyi tichashandisa izwi rekuti "vhoriyamu control" zvakasiyana kana tichitaura nezvekubatsira kutonga.

Iyo yekubatsira kutonga (vhoriyamu kutonga) ndiyo nzira yesarudzo inoshandiswa mumaICU mazhinji muUnited States nekuti iri nyore kushandisa.

Zvirongwa zvina (chiyero chekufema, tidal volume, FiO2, uye PEEP) inogona kugadziridzwa zviri nyore mumhepo inofefetera. Iro vhoriyamu inounzwa nemhepo inofema mumhepo imwe neimwe mukubatsirwa kutonga ichagara yakafanana, zvisinei nekufema kwakatangwa nemurwere kana mhepo inofefetera uye kuteedzera, peak kana mapani kumanikidza mumapapu.

Kufema kwega kwega kunogona kuverengerwa nguva (kana kufema kwemurwere kwakadzikira pane kunenge kwaita mhepo, muchina unoburitsa mweya panguva yakatarwa) kana kumutswa nemurwere, kana murwere akatanga kufema ega.

Izvi zvinoita kuti kudzora kwekubatsira kuve kwakagadzikana kwazvo kumurwere, sezvo kuedza kwake kwese kuchizowedzerwa neventilator.

Mushure mekuita shanduko kumhepo inofefetera kana mushure mekutanga murwere pane mechanical ventilation, iyo arterial ropa magasi anofanirwa kunyatsotariswa uye kuzara kweokisijeni pamutariro kunofanira kuteverwa kuti uone kana paine zvimwe shanduko inoda kuitwa kune inofefetera.

Zvakanakira iyo AC modhi kuwedzera kunyaradza, kururamisa kuri nyore kwekufema acidosis/alkalosis, uye kushomeka kwekufema kwemurwere.

Kukanganisa kunosanganisira chokwadi chekuti sezvo iyi iri vhoriyamu-kutenderera modhi, kudzvinyirira hakugone kudzorwa zvakananga, izvo zvinogona kukonzera barotrauma, murwere anogona kukura hyperventilation nekufema stacking, autoPEEP, uye kufema alkalosis.

Kuti uwane tsananguro izere yerubatsiro rwekudzora, ona chinyorwa chakanzi “Kufefetedza, Kubatsira Kudzora” [6], muchikamu cheBibliographical References panoperera chinyorwa chino.

Yakawiriraniswa Intermittent Inosungirwa Kufefetedza (SIMV)

SIMV imwe inogara ichishandiswa kufefetera modhi, kunyangwe kushandiswa kwayo kwave kusashandiswa nekuda kwekusavimbika kwemvura zhinji uye kushaikwa kwezvibereko zviri nani pane AC.

“Yakawiriraniswa” zvinoreva kuti mhepo inofefetera inogadzirisa kuburitsa kwekufema kwayo kune kuedza kwemurwere. “Intermittent” zvinoreva kuti hakusi kufema kwese kunotsigirwa uye “kufemerwa nemhepo” zvinoreva kuti, sepanyaya yeCA, nguva yakafanotemerwa inosarudzwa uye mhepo inofefetera inoburitsa kufema kwese kwese kwese zvisinei nekuedza kwemurwere kufema.

Kufema kunosungirwa kunogona kukonzerwa nemurwere kana nguva kana RR yemurwere inononoka kupfuura RR yemhepo inofefetera (sezvakaita nyaya yeCA).

Musiyano kubva ku AC ndewekuti muSIMV mhepo inofefetera inoburitsa chete mafemo ayo frequency inotarwa kuendesa; chero kufema kunotorwa nemurwere pamusoro peiyo frequency hakugamuchire vhoriyamu yemhepo kana tsigiro yakazara yepressor.

Izvi zvinoreva kuti pakufema kwega kwega kunotorwa nemurwere pamusoro peiyo yakatarwa RR, huwandu hwemhepo hunounzwa nemurwere hunoenderana chete nekuteerera kwemapapu emurwere uye kushanda nesimba.

Izvi zvakatsanangurwa senzira ye "kudzidzisa" iyo diaphragm kuitira kuchengetedza tsandanyama toni uye kurumudza varwere kubva pamhepo inofefetera nekukurumidza.

Zvisinei, zvidzidzo zvakawanda hazvina kuratidza kubatsirwa kweSIMV. Pamusoro pezvo, SIMV inogadzira basa rekufema rakawanda kupfuura AC, iro rine kukanganisa pamhedzisiro uye rinoburitsa kuneta kwekufema.

Mutemo mukuru wezvigunwe zvekutevera ndewekuti murwere anosunungurwa kubva mumhepo inofefetera kana agadzirira, uye hapana nzira chaiyo yekufema ichaita kuti ikurumidze.

Panguva ino, zvakanakisa kuchengeta murwere akasununguka sezvinobvira, uye SIMV inogona kunge isiri iyo yakanakisa nzira yekuita izvi.

Pressure Support Ventilation (PSV)

PSV inzira yekufefetera iyo inotsamira zvizere pakufema kwemurwere.

Sezvinoratidzwa nezita racho, ndeyekumanikidza-inotyairwa kufefetera modhi.

Mune iyi modhi, kufema kwese kunotangwa nemurwere, sezvo mhepo inofefetera isina chiyero chekuchengetedza, saka mweya wega wega unofanirwa kutangwa nemurwere. Mune iyi modhi, iyo vhezheni inochinja kubva kune imwe kumanikidza kuenda kune imwe (PEEP uye tsigiro yekumanikidza).

PEEP ndiyo dzvinyiriro inosara pakupera kwekufema, nepo tsigiro yetsigiro iri pamusoro pePEEP iyo inofemerwa nemhepo panguva yekufema kwega kwega kuchengetedza mhepo.

Izvi zvinoreva kuti kana murwere akaiswa muPSV 10/5, achagamuchira 5 cm H2O yePEEP uye panguva yekufemerwa vachagamuchira 15 cm H2O yekutsigirwa (10 PS pamusoro pePEEP).

Nekuti hapana backup frequency, iyi modhi haigone kushandiswa muvarwere vane kurasikirwa kwekuziva, kuvhunduka kana kusungwa kwemoyo.

Mavhoriyamu aripo anoenderana chete nekushanda kwemurwere uye kutevedzera mapapu.

PSV inowanzo shandiswa kurumurwa kubva mumhepo inofefetera, sezvo ichingowedzera kufema kwemurwere pasina kupa vhoriyamu yakafanotemerwa kana kufema.

Chinhu chikuru chakashata chePSV kusavimbika kwehuwandu hwemvura, iyo inogona kuunza CO2 kuchengetedza uye acidosis, uye basa repamusoro rekufema rinogona kukonzera kuneta kwekufema.

Kugadzirisa dambudziko iri, algorithm nyowani yakagadzirwa yePSV, inonzi vhoriyamu inotsigirwa nemhepo (VSV).

VSV imodhi yakafanana nePSV, asi mune iyi mamiriro vhoriyamu yemazuva ano inoshandiswa sekutonga kwemhinduro, mukuti tsigiro yekutsikisa inopiwa kumurwere inogara ichigadziriswa maererano nehuwandu hwezvino. Muchigadziro ichi, kana vhoriyamu yemvura yadzikira, mhepo inofefetera inozowedzera tsigiro yekutsikisa kuti ideredze vhoriyamu, nepo kana vhoriyamu ikawedzera rutsigiro rwekudzvanya runodzikira kuchengetedza vhoriyamu yemhepo padyo neinodiwa miniti yekufema.

Humwe humbowo hunoratidza kuti kushandiswa kweVSV kunogona kuderedza rubatsiro rwekufemesa nguva, nguva yekurumurwa yakazara uye nguva yese yeT-chidimbu, pamwe nekuderedza kudiwa kwekunyaradza.

Airway pressure release release (APRV)

Sezvinoratidzwa nezita racho, muAPRV modhi, mhepo inofefetera inoburitsa inogara ichimanikidza mumhepo, iyo inovimbisa oxygenation, uye kufefetera kunoitwa nekuburitsa iyi kudzvanywa.

Iyi modhi ichangobva kuwana mukurumbira seimwe nzira yevarwere vane ARDS vanoomerwa neokisijeni, mune mamwe mamodhi emhepo anotadza kuzadzisa zvinangwa zvavo.

APRV yakatsanangurwa seinoenderera mberi yakanaka airway pressure (CPAP) ine inopindirana yekuburitsa chikamu.

Izvi zvinoreva kuti mhepo inofefetera inoshandisa kuenderera kwepamusoro (P yakakwirira) kwenguva yakatarwa (T yakakwirira) uye yobva yaisunungura, kazhinji ichidzokera kune zero (P pasi) kwenguva pfupi (T yakaderera).

Pfungwa iri shure kweizvi ndeyokuti panguva yeT yakakwirira (inofukidza 80% -95% yekutenderera), pane nguva dzose alveolar recruitment, iyo inovandudza oxygenation nokuti nguva inochengetwa pakumanikidzwa kwepamusoro yakareba kupfuura panguva yemamwe marudzi emhepo (yakazaruka mapapu nzira. )

Izvi zvinoderedza kudzokorora kukwira kwemitengo uye deflation yemapapu inoitika nedzimwe nzira dzekufemesa, kudzivirira kukuvara kwemapapu kunokonzerwa nemhepo.

Munguva iyi (T yakakwirira) murwere akasununguka kufema zvega (izvo zvinoita kuti agadzikane), asi anodhonza mhepo yakaderera nokuti kufema kunopikisa kwakadaro kunonyanya kuoma. Zvino, kana T yakakwira yasvikwa, kudzvanywa mumhepo yekufema kunodonha kuP low (kazhinji zero).

Mhepo inozoburitswa kubva panzira yemhepo, ichibvumira kufema kusinganzwisisike kusvika T low yasvikwa uye mhepo inofefetera ichiburitsa mumwe mweya.

Kudzivirira kudonha kwemhepo panguva iyi, iyo yakaderera T inoiswa muchidimbu, kazhinji inotenderedza 0.4-0.8 masekonzi.

Muchiitiko ichi, kana mhepo yekufema yaiswa pa zero, iyo elastic recoil yemapapu inosundira mhepo kunze, asi nguva haina kureba zvakakwana kuti mweya wese ubude mumapapu, saka alveolar uye airway pressure haisvike zero. uye kudonha kwemhepo hakuitike.

Iyi nguva inowanzogadzirirwa kuitira kuti yakaderera T inopera apo kubuda kwemhepo kunodonha kusvika ku50% yekutanga kuyerera.

Kufefetedza kwemhepo paminiti, saka, kuchaenderana neT yakaderera uye huwandu hwemhepo yemurwere panguva yeT yakakwirira

Zviratidzo zvekushandiswa kweAPRV:

• ARDS yakaoma kuisa oxygen ne AC
• Kukuvara kwakanyanya kwemapapu
• Postoperative atelectasis.

Zvakanakira zve APRV:

APRV inzira yakanaka yekudzivirira kufema kwemapapu.

Kukwanisa kuisa P yakakwirira kunoreva kuti mufambisi ane simba pamusoro pemapani ekumanikidza, izvo zvinogona kuderedza zvakanyanya kuitika kwebarotrauma.

Sezvo murwere anotanga kuedza kwake kufema, kune kugovera gasi zviri nani nekuda kwemutambo weV / Q uri nani.

Constant high pressure inoreva kuwedzera kutsvaga (open lung strategy).

APRV inogona kuvandudza oxygenation kune varwere vane ARDS avo vakaoma kuisa oxygenate neAC.

APRV inogona kuderedza kudiwa kwe sedation uye neuromuscular blocking agents, sezvo murwere angave akasununguka kana achienzaniswa nemamwe maitiro.

Zvakaipa uye contraindications:

Nekuti kufema kwega kwega chinhu chakakosha cheAPRV, hazvina kunaka kune varwere vakanyanya kugadzikana.

Iko hakuna data pamusoro pekushandiswa kweAPRV mune neuromuscular disorders kana obstructive mapapu chirwere, uye kushandiswa kwayo kunofanira kudzivirirwa muhuwandu hwevarwere.

Nechepfungwa, kugara kwakakwira intrathoracic kumanikidza kunogona kuunza yakakwira pulmonary artery pressure uye yakawedzera intracardiac shunts muvarwere vane Eisenmenger's physiology.

Kufunga kwakasimba kwekiriniki kunodiwa pakusarudza APRV senzira yekufemesa pamusoro pedzimwe nzira dzakajairwa dzakadai seAC.

Rumwe ruzivo pamusoro pezvakasiyana-siyana zvemhepo modhi uye marongero awo anogona kuwanikwa mune zvinyorwa pane imwe neimwe chaiyo yemhepo modhi.

Kushandisa ventilator

Kuiswa kwekutanga kweventilator kunogona kusiyanisa zvakanyanya zvichienderana nechikonzero cheintubation uye chinangwa chekuongorora uku.

Nekudaro, kune mamwe ekutanga marongero ezviitiko zvakawanda.

Iyo yakajairika mhepo yekufefetera modhi yekushandisa mumurwere achangobva kuvharwa ndeye AC modhi.

Iyo AC modhi inopa nyaradzo yakanaka uye kudzora kuri nyore kwemamwe akanyanya kukosha physiological paramita.

Inotanga neFiO2 ye100% uye inoderera inotungamirirwa nepulse oximetry kana ABG, sezvakakodzera.

Low tidal volume ventilation yakaratidzwa kuve inodzivirira mapapu kwete muARDS chete asiwo mune mamwe marudzi ezvirwere.

Kutanga murwere ane yakaderera tidal volume (6 kusvika 8 mL / Kg yakanakira uremu hwemuviri) inoderedza chiitiko chemhepo-induced mapapu kukuvara (VILI).

Gara uchishandisa nzira yekudzivirira mapapu, sezvo mavhoriyamu akakwira ane bhenefiti shoma uye anowedzera shear kusagadzikana mualveoli uye anogona kukonzera kukuvara kwemapapu.

RR yekutanga inofanira kuva yakasununguka kune murwere: 10-12 bpm yakakwana.

Yakakosha caveat ine chekuita nevarwere vane yakanyanya metabolic acidosis.

Kune varwere ava, kufefetedza paminiti kunofanirwa kuenderana ne pre-intubation ventilation, sezvisizvo acidosis inowedzera uye inogona kukonzera matambudziko akadai sekusungwa kwemoyo.

Kuyerera kunofanirwa kutangwa kana pamusoro pe60 L/min kudzivirira autoPEEP

Tanga nePEEP yakaderera ye5 cm H2O uye kuwedzera maererano nekushivirira kwemurwere kune chinangwa cheokisijeni.

Nyatsoteerera kuropa uye kunyaradza murwere.

Iyo ABG inofanirwa kuwanikwa makumi matatu maminetsi mushure mekupinda mukati uye magadzirirwo emhepo anofanira kugadziridzwa zvinoenderana neABG mhinduro.

Kudzvinyirirwa kwepamusoro nepakati kunofanirwa kutariswa pamhepo inofefetera kuti ive nechokwadi chekuti hapana matambudziko nekupokana nemhepo kana alveolar pressure kudzivirira kukuvadzwa kwemapapu kunokonzerwa nemhepo.

Kuchenjerera kunofanira kubhadharwa kune vhoriyamu curves pane vhezheni inoratidzwa, sekuverenga kunoratidza kuti curve haidzokeri zero pakufemesa kunoratidza kufema kusina kukwana uye kuvandudzwa kwe auto-PEEP; saka, gadziriso dzinofanira kuitwa kumhepo inofefetera nekukurumidza.[7][8]

Ventilator kugadzirisa dambudziko

Nekunzwisisa kwakanaka kweiyo pfungwa dzakakurukurwa, kutonga kunetsa kweventilator uye kugadzirisa dambudziko kunofanirwa kuve kwechipiri.

Magadzirirwo akanyanya kuitwa kumhepo yekufema anosanganisira hypoxemia uye hypercapnia kana hyperventilation:

Hypoxia: oxygenation inoenderana neFiO2 uye PEEP (yakakwirira T uye yakakwirira P yeAPRV).

Kugadzirisa hypoxia, kuwedzera imwe yeiyi paramita kunofanirwa kuwedzera oxygenation.

Kunyanya kukoshesa kunofanira kubhadharwa kune zvinogona kuipa zvinokonzerwa nekuwedzera kwePEEP, izvo zvinogona kukonzera barotrauma uye hypotension.

Kuwedzera FiO2 hakusi pasina kunetseka, sezvo yakakwira FiO2 inogona kukonzera oxidative kukuvara mualveoli.

Chimwe chinhu chakakosha cheokisijeni yemukati manejimendi kumisa chinangwa cheokisijeni.

Kazhinji, hazvibatsiri zvishoma kuchengetedza oksijeni saturation pamusoro pe92-94%, kunze kwe, semuenzaniso, muzviitiko zve carbon monoxide poisoning.

Kudonha kamwe kamwe mukuzara kweokisijeni kunofanirwa kumutsa kunyumwira kwechubhu malpositioning, pulmonary embolism, pneumothorax, pulmonary edema, atelectasis, kana kuvandudzwa kwemucus plugs.

Hypercapnia: Kuti uchinje ropa CO2 content, alveolar ventilation inofanira kuchinjwa.

Izvi zvinogona kuitwa nekushandura vhoriyamu yemvura kana kufema mwero (yakaderera T uye yakaderera P muAPRV).

Kuwedzera chiyero kana kuti tidal volume, pamwe nekuwedzera T pasi, inowedzera mhepo uye inoderedza CO2.

Kuchengetedza kunofanirwa kutorwa nekuwedzera frequency, sezvo ichizowedzera huwandu hwenzvimbo yakafa uye inogona kusashanda sehuwandu hwemvura.

Kana uchiwedzera vhoriyamu kana frequency, kutarisisa kwakanyanya kunofanirwa kubhadharwa kune inoyerera-vhoriyamu loop kudzivirira kuvandudzwa kweauto-PEEP.

High pressures: Dzvinyiriro mbiri dzakakosha muhurongwa: peak pressure uye plateau pressure.

Peak pressure chiyero chekuramba kwemhepo uye kutevedzera uye inosanganisira chubhu uye bronchial muti.

Plateau pressure inoratidza alveolar pressure nekudaro kutevedzera mapapu.

Kana paine kuwedzera kwekumanikidza kwepamusoro, danho rekutanga kutora kufemerwa kumbomira uye kutarisa bani.

High peak pressure uye yakajairika plateau pressure: high airway resistance uye kutevedzera zvakajairika

Zvikonzero zvinogona kuitika: (1) Twisted ET chubhu-Mushonga wacho ndeyekusunungura chubhu; shandisa chivharo chekuruma kana murwere akaruma chubhu, (2) Mucus plug-Mushonga ndeyekushuvira murwere, (3) Bronchospasm-Mushonga ndeyekuisa bronchodilators.

Yakakwira peak uye yakakwirira nzvimbo: Matambudziko ekuteerera

Zvimwe zvikonzero zvinogona kusanganisira:

• Main trunk intubation-Iyo mhinduro ndeyekudzosera iyo ET chubhu. Kuti uongorore, iwe unowana murwere ane unilateral mweya wekufema uye contralateral bapu kubva (atelectatic lung).
• Pneumothorax: Kuongororwa kuchaitwa nekuteerera kufema kunonzwika unilaterally uye kutsvaga contralateral hyperresonant lung. Mune varwere vane intubated, kuiswa kwechubhu yechipfuva kwakakosha, sezvo kumanikidzwa kwakanaka kunongowedzera pneumothorax.
• Atelectasis: Kwekutanga manejimendi kunosanganisira chipfuva kubhuroka uye kufambisa maneuver. Bronchoscopy inogona kushandiswa mumatambudziko asingagumi.
• Pulmonary edema: Diuresis, inotropes, yakakwira PEEP.
• ARDS: Shandisa yakaderera tidal volume uye yakakwirira PEEP ventilation.
• Dynamic hyperinflation kana auto-PEEP: inzira iyo imwe yemhepo yakafemerwa haibudiswe zvizere pakupera kwekufema.
• Kuunganidzwa kwemweya wakavharirwa kunowedzera kumanikidzwa kwemapapu uye kunokonzera barotrauma uye hypotension.
• Murwere anozonetsa kufema.
• Kudzivirira uye kugadzirisa self-PEEP, nguva yakakwana inofanira kubvumirwa kuti mweya ubve mumapapu panguva yekufema.

Chinangwa muhutungamiri ndechekuderedza chiyero chekusimudzira / chekufema; izvi zvinogona kuwanikwa nekudzikisa kufema kwekufema, kuderera kwehuwandu hwemhepo (vhoriyamu yakakwirira inoda nguva yakareba kuti ibve mumapapu), uye kuwedzera kuyerera kwekufema (kana mweya ukapihwa nekukurumidza, nguva yekufema ipfupi uye nguva yekufema ichave. kureba panguva ipi neipi yekufema).

Mhedzisiro imwechete inogona kuwanikwa nekushandisa square waveform yekufemerwa kuyerera; izvi zvinoreva kuti isu tinogona kuseta iyo vhezheni kuendesa kuyerera kwese kubva pakutanga kusvika kumagumo ekufemerwa.

Humwe hunyanzvi hunogona kuiswa ndehwekuva nechokwadi chekunyaradza kwakakwana kudzivirira hyperventilation yemurwere uye kushandiswa kwebronchodilators uye steroids kuderedza kuvharwa kwemhepo.

Kana auto-PEEP yakakomba uye ichikonzera hypotension, kubvisa murwere kubva mumhepo inofefetera uye kubvumira mweya wese kuti ubudiswe kungave chiyero chinoponesa hupenyu.

Kuti uwane tsananguro izere yehutungamiri hweauto-PEEP, ona chinyorwa chakanzi "Positive End-Expiratory Pressure (PEEP)."

Rimwe dambudziko rinowanzosangana nevarwere vari kuita mekiniki yekufema ndeye murwere-ventilator dyssynchrony, inowanzonzi "ventilator kurwira."

Zvikonzero zvakakosha zvinosanganisira hypoxia, self-PEEP, kutadza kusangana nemurwere oxygenation kana mhepo zvinodiwa, kurwadziwa, uye kusagadzikana.

Mushure mekutonga zvikonzero zvakakosha zvakadai sepneumothorax kana atelectasis, funga kunyaradza kwevarwere uye chengetedza zvakakwana sedation uye analgesia.

Funga kushandura nzira yekufemesa, sezvo vamwe varwere vanogona kupindura zvirinani kune dzakasiyana nzira dzekufemesa.

Kunyanya kutarisisa kunofanirwa kubhadharwa kune marongero emhepo pasi pemamiriro anotevera:

• COPD inyaya yakakosha, sezvo mapapu akachena eCOPD ane kuteedzera kwakanyanya, izvo zvinokonzeresa hunhu hwepamusoro hwekuvharika kwemhepo nekuda kwekudonha kwenzira yemhepo uye kuvharirwa kwemhepo, zvichiita kuti varwere veCOPD vanyanye kukudziridza auto-PEEP. Kushandisa nzira yekudzivirira kufefetera nekuyerera kwakanyanya uye kuderera kwekufema kunogona kubatsira kudzivirira self-PEEP. Chimwe chinhu chakakosha chekufunga nezve chisingaperi hypercapnic kufema kutadza (nekuda kweCOPD kana chimwe chikonzero) ndechekuti hazvifanirwe kugadzirisa CO2 kuti idzose kune yakajairika, sezvo varwere ava vanowanzove nemetabolic muripo wematambudziko avo ekufema. Kana murwere achipinzwa mhepo kusvika kune yakajairika CO2 mazinga, bicarbonate yake inodzikira uye, kana yaburitswa, anokurumidza kupinda mukufema acidosis nekuti itsvo haigone kupindura nekukurumidza semapapu uye CO2 inodzokera kune yekutanga, zvichikonzera kutadza kufema uye kudzokazve. Kuti udzivise izvi, CO2 zvinangwa zvinofanirwa kutariswa zvichibva pane pH uye yaimbozivikanwa kana kuverengerwa yekutanga.
• Asthma: Sezvakaita neCOPD, varwere vane asthma vanonyanya kubatwa nemhepo, kunyange chikonzero chacho chiri pathophysiologically yakasiyana. Muasthma, kuvharirwa kwemhepo kunokonzerwa nekuzvimba, bronchospasm uye mucus plugs, kwete kudonha kwemhepo. Nzira yekudzivirira self-PEEP yakafanana neyo inoshandiswa muCOPD.
• Cardiogenic pulmonary edema: yakakwira PEEP inogona kuderedza venous kudzoka uye kubatsira kugadzirisa pulmonary edema, pamwe nekusimudzira kubuda kwemoyo. Chinetso chinofanira kunge chiri chekuona kuti murwere ane diuretic yakakwana asati aputika, sezvo kubviswa kwehutano hwakanaka kunogona kukonzera itsva pulmonary edema.
• ARDS imhando ye noncardiogenic pulmonary edema. Nzira yakavhurika yemapapu ine yakakwira PEEP uye yakaderera vhoriyamu yemvura yakaratidzwa kuvandudza kufa.
• Pulmonary embolism inzvimbo yakaoma. Varwere ava vanonyanya kutsamira-preload nekuda kwekukwira kwakanyanya mukudzvinyirirwa kweatrial chaiyo. Intubation yevarwere ava ichawedzera kudzvinyirirwa kweRA uye kuwedzera kudzikisa kudzoka kwevenous, nenjodzi yekunaya kuvhunduka. Kana pasina nzira yekudzivisa intubation, kutarisa kunofanira kubhadharwa kuropa uye vasopressor administration inofanira kutanga nokukurumidza.
• Yakanyanya pure metabolic acidosis idambudziko. Paunenge uchipinza varwere ava, kunyatsotarisisa kunofanirwa kubhadharwa kune yavo miniti pre-intubation ventilation. Kana kufefetedza uku kukasapihwa kana tsigiro yemuchina yatangwa, iyo pH inodonha zvakare, izvo zvinogona kukonzera kusungwa kwemoyo.

Zvinyorwa zveBhaibheri

1. Metersky ML, Kalil AC. Kutungamirirwa kweVentilator-Yakabatana Pneumonia: Mirayiridzo. 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 uye Zviitiko muPediatric Intensive Care: A Single Center Study. Pediatr Crit Care Med. 2018 Dec;19(12):1106-1113. [PubMed]
3. Vandana Kalwaje E, Rello J. Kutungamira kwe pneumonia-inosanganiswa nenyumoniya: Kudiwa kwemaitiro emunhu. Nyanzvi Rev Anti Infect Ther. 2018 Aug;16(8):641-653. [PubMed]
4. Jansson MM, Syrjälä HP, Talman K, Meriläinen MH, Ala-Kokko TI. Kuziva kwakakosha kwevanamukoti nezve, kutevedzera, uye zvipingamupinyi kune sangano-chaiyo mhepo yekufambisa bundle. Ndiri J Infect Control. 2018 Sep;46(9):1051-1056. [PubMed]
5. Piraino T, Fan E. Acute life-atreatry hypoxemia panguva ye mechanical ventilation. Curr Opin Crit Care. 2017 Dec;23(6):541-548. [PubMed]
6. Mora Carpio AL, Mora JI. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Kubvumbi 28, 2022. Ventilation Assist Control. [PubMed]
7. Kumar ST, Yassin A, Bhowmick T, Dixit D. Mazano Kubva ku2016 Mirayiridzo yeKutungamirirwa kweVakuru Vane Chipatara-Yakawana kana Ventilator-Inobatanidza Pneumonia. 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 muVakuru vane Acute Respiratory Distress Syndrome. Pfupiso yeUmboo hweKuedza hweClinical Practice Guideline. Ann Am Thorac Soc. 2017 Oct;14(Kuwedzera_4):S261-S270. [PubMed]
9. Chao CM, Lai CC, Chan KS, Cheng KC, Ho CH, Chen CM, Chou W. Multidisciplinary interventions uye kuenderera mberi kwekuvandudzwa kwehutano kuderedza kusvibiswa kusina kurongwa mumakamuri ekuchengeta zvakanyanya: Chiitiko chemakore gumi nemashanu. Medicine (Baltimore). 2017 Jul;96(27):e6877. [PMC free article] [PubMed]
10. Badnjevic A, Gurbeta L, Jimenez ER, Iadanza E. Kuedzwa kwema mechanical ventilators uye vacheche incubators mumasangano ehutano. Technol Hutano Kuchengetedza. 2017;25(2):237-250. [PubMed]

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