Dzimwe nguva zvakakosha kushamisika kana zvinhu zvatinonzwa, kuona uye kunzwa zviri chaizvo sezvataifunga kuti ndizvo. Dr Alan Garner anotarisa pfungwa dzako paunopinda muchipfuva uye unoshamisika kana zvese zvakatwasuka kumberi sezvatinoda kufunga?

Ngatitangei chinyorwa ichi nekutaura pamberi chaipo kuti izvi ndezvemaronda echipfuva. Kana zvisiri izvo zvawanga uchifunga saka inguva yekutarira kumwe kunhu.

Chandinoda kukurukura ndechekuongororwa kwekiriniki kwetension pneumothorax mumunda. Chikonzero chenhaurirano ndechekuti ndinotenda kuti yakanyanyisa kuongororwa. Pandakashanda kuUK 6 makore apfuura zvaiita sekunetsana kwaionekwa nguva zhinji uye chikonzero chakapihwa yaive ruzha sezvavaityora pleura nemaforceps. Sezvo murwere aifefeterwa nemhepo panguva iyoyo inzwi rinofanira kunge raive mhepo ichimhanya ichibuda munzvimbo yepleural sezvo intrathoracic pressure yavo yaive yakanaka mukati mekufema chaiko?

Rangarira kuti isu hatigone kuvimba sei nemanzwi anobatanidzwa mukuongororwa kwekiriniki munzvimbo yeprehospital nekuti ivo havana kuvimbika zvakanyanya? Haa ini ndaiudzwa kuti uyu aigara ari right. 'Nguva dzose' ishoko guru mumishonga

Ndinozivawo imwe nyaya apo murwere ane pfuti imwe chete epigastric ronda kubva kune yakaderera velocity chombo akaita intubation uyezve bilateral chigunwe thoracostomies. Kutaura panguva iyoyo kwaiva kuti chiremba weprehospital, uyo pasina mubvunzo akapinda mazviri zvose nokutenda kwakanaka, akataura kuti panguva yethoracostomies vakawana pneumothorax kune rumwe rutivi uye kushushikana kune rumwe rutivi.

Nekudaro pakufungidzira nekuvhiyiwa purojekiti yakabva yangodzokera murwatata uye hapana padhuze nehemithorax kana diaphragm. Chokwadi kukuvara chete kwakaonekwa kune chero chikamu chechipfuva aive maronda ethoracostomy pachawo. Zvekare murwere ane intubated saka intrathoracic pressure inofanira kunge yaive yakanaka here? Kana mapapu akanzwa pasi saka yaifanira kunge iri pneumothorax? Uye kana paive neruzha pakutyora pleura panofanira kunge paine makakatanwa?

Zviripachena muchiitiko chechipiri zviratidzo zvairasisa saka chii chiri kuitika pano? Ngatiise parutivi kwechipiri matambudziko ekutanga kuongororwa kwepneumothorax uye kuisa pfungwa pamanzwiro nemunwe uye inzwi kune nzeve. Zvingave here kuti humwe humbowo hwatakatungamirwa kuti titende hunotiudza kuti tiri kubata nepneumothorax inogona kutsausa vane ruzivo, vakanyatsodzidziswa varapi?

Diving In

Pamwe ndakaita mamwe madhiri echipfuva akawanda kupfuura mazhinji. Chikamu icho chikonzero cheanopfuura makore makumi maviri munzvimbo yeprehospital asi ini pamwe ndakaita zvakatowanda pandakanga ndiri munyori wekunyoresa 20 gore rapfuura. Ndakapedza mwedzi mitanhatu ndichishanda kune varapi vanoverengeka vanofema uye ndakaisa mijenya yakawanda (kunyanya kune inouraya effusions) muvarwere vaive vasina pneumothorax ndisati ndatanga. Zvaiva zvakajairika kunzwa ruzha sezvo pleura yakapazwa sezvo mhepo yaipinda mukati. Asi izvi zvanga zviri muvarwere vanongofema mweya uye izvo zvakasiyana handiti?

Zviripachena kuti tinofanira kudzokera kuphysiology kuti tione kuti chii chiri kufambisa kufamba kwemhepo kupinda kana kubuda mugomba ratakagadzira kuti tione kuti ruzha rwatiri kunzwa mhepo iri kupinda here, kana kuti mhepo iri kubuda.

Dzokera kuBasics

Transpulmonary pressure ndiyo pressure gradient inotyaira kufefetera kwakajairika. Ndiwo musiyano pakati pe alveolar pressure uye intrapleural pressure mu mapapu.

P_tp =P_alv - P_ip. Ipo P_tp ari transpulmonary pressure, P_alv is alveolar pressure, uye P_ip inonzi intrapleural pressure.

(Kana iwe uchida zvishoma pane ino Hupenyu hwakanakisa muFast Lane ine zvishoma pane transpulmonary pressure pano.)

Zvakare zvinoitika kuti iwe unogona kuwana google preview yeJohn West's classic textbook pakufema physiology. Tora chinguva uende uye unakirwe Mufananidzo 4-9 papeji 59. 

Unogona kuona kubva papanera B (ndaizvireva, enda undotarisa) kuti intrapleural pressure inosiyana pakati pe -5 ne -8 cmH.₂O padanho repakati pemapapu panguva yekufema kwakajairika. Iyo inogara isina kunaka uye imhaka yekudzoreredza kwemapapu ayo ari kupikiswa nemadziro echipfuva. Izvo zvishoma zvakashata munzvimbo dzinotsamira dzemapapu (kuderedza saizi yealveolar) uye yakawanda yakaipa paapex (kuwedzera alveolar size).

Ngatiwedzere Mhepo

Mumamiriro ezvinhu epneumothorax duku mhepo iri munzvimbo yepleural inoita kuti intrapleural pressure isanyanya kuipa uye mutsauko wekufambisa kwekufambisa kwemhepo unoderedzwa. Kana iyo pneumothorax yakanyatsozaruka kumhepo yakadai seine ronda re thoracostomy yakazaruka iyo intrapleural pressure yakaenzana nemhepo yemhepo, iyo elastic recoil yemapapu inokonzera kuparara kwakakwana uye kufefetedza nekuwedzera kwechipfuva hazvibviri - positive airway pressure inofanira kuiswa.

Haisi iyo mamiriro epneumothorax inonyanya kunetsa ini. Kana ivo vane hypoxic kana hypotensive uye murwere ane pneumothorax chifuva chinofanira kuderedzwa - yakakwana isina-brainer. Mubvunzo ndewokuti nei varapi vakanaka vachibvisa zvipfuva zvakajairika uye vachifunga kuti pakanga paine pneumothorax kana kushushikana paive pasina? Iyo physiology inotisvitsa ikoko?

Mwoyo murefu

Kutanga ngatitarisei murwere asina-intubated ane kufema kwakajairika uye pasina pneumothorax. Aya ndiwo mamiriro ezvinhu nevarwere vane hutsinye hwakaipa hwandaiisa madhiraini mumakore apfuura. Pano iyo alveolar pressure haina kumbopfuura cmH₂O kana maviri akanaka kana asina kunaka. The intrapleural pressure zvisinei -5 kusvika -8 cmH₂O. Naizvozvo hazvina basa kuti ndechipi chikamu chekufema chaunotyora pleura, pressure gradient iri pakati pepleural space neatmosphere haina kunaka uye mweya unopinda mukati.

Iyo gradient yakakura mukufemerwa kana alveolar pressure isina kunaka (uye saka iyo yakazara kumanikidza kuri kutenderera -8 cmH.₂O) uye zvishoma zvisina kunaka panguva yekupera kana zvakanyanya kufanana -5 cmH₂O. Zvisinei, hazvina kunaka nguva dzose. Hazvina mhosva kuti ndeipi chikamu chekufema kwaunotyora pleura, mweya uchayerera uchipinda munzvimbo yepleural uye elastic recoil yemapapu inoityaira kudonha. Kana ukanzwa ruzha sezvandaiwanzoita, imhepo inopinda mukati, ronda repachifuva rekuyamwa. Imwe iatrogenic.

Murwere Vaviri

Handifungi kuti pane angave ane nyaya nezvinhu kusvika pari zvino. Saka ngatienderere mberi kune murwere ane intubated asina pneumothorax. Ndiri kuzofungidzira pano kuti hakuna kupikisa kwakawanda kwemhepo mumurwere wedu wekushungurudzika (zvisingarevi kuti havana chinokonzera chirwere chemapapu, anaphylaxis kune induction mishonga yawakapa kana kuvhara kwakagara mubronchus huru. /ETT) sezvo zvichiita kuti nhaurirano ive nyore kufunga kuti kuramba kushoma (hakuna maturo maererano neDaleks) uye kudzvanywa kwauri kuona pane yako yemagetsi geji inotumirwa zvakanyanya kune alveoli.

Tichitarisa yedu transpulmonary pressure equation, kunze kwekunge iyo airway pressure uye nekudaro alveolar pressure yakakwira kudarika 5 cmH.₂O ipapo iyo gradient panguva yaunovhura iyo pleura inoreva kuti mweya uri kuenda pinda iyo pleural cavity. (Kana vane hukuru hwekudzivisa mhepo izvi zvinogona kuitika nemhepo yakakwirira kwazvo).

Ingova nemboni yeziso nekukurumidza yenguva ino yekumanikidza chati yeyakajairwa vhoriyamu cycled ventilator isina PEEP (uye bhegi rinozvipinza-inflating rinopa yakafanana kunyange yakawanda inoshanduka trace). Uye ini nemaune handina PEEP mune ino chati. PEEP haigoni kuva chinhu chekutanga chatinosvika kune murwere we hypotensive trauma watichangobva kupinza apo isu tine hanya pamusoro pekugona kwepneumothorax.

Nemapapu emazuva ose kudzvinyirirwa kwepamusoro apa kungangoita 20 cmH₂O. Ndeipi chikamu chehuwandu hwekufema kutenderera kwemhepo (uye naizvozvo alveolar pressure mumurwere wedu ane kushomeka kwemhepo) inogona kunge iri pasi pe5 cmH₂O? Kana yako diki prehospital ventilator ine ingangoita 1: 2 I: E reshiyo sezvinoita vazhinji, saka mhinduro ndiyo yakawanda yacho.

Mune mamwe mazwi kunze kwekunge uine PEEP inokwana 5 cmH₂O kunyangwe mune yako intubated murwere iyo transpulmonary pressure haina kunaka kwehafu yakanaka yekufema kutenderera. Pakati pehafu yenguva yekufema, kana iwe ukanzwa ruzha paunenge uchityora pleura uri kunzwa mhepo ichimhanya. IN.

Iyo elastic recoil yemapapu ndicho chikonzero chekuti iwe unonzwa kuti mapapu adonha panguva yaunoburitsa simba rekunze woisa chigunwe chako mukati kunze kwekunge uine imwe PEEP mukutamba.

Zvino handisi kuti hapasati pave nenguva apo mhepo yanga isingamhanyire mukati. Handifungi zvakawanda nezveshoko rokuti “nguva dzose” mukurapa, rangarira? Ndiri kungopa zano kuti izvo zvatinoziva nezve physiology zvingapokana kuti pane chikamu chakasimba chenguva iyo iyo transpulmonary pressure gradient haina kunaka kana iwe uchityora iyo pleura, zvinoreva kuti panogona kunge paine chikamu chakanaka chezviitiko apo. izvo "zvimwe" zviratidzo zvekiriniki zvinova zvishoma zvakavimbika.

Kuratidzira kweizvi naamai veese akazaruka thoracotomies (mu cadaver) tarisa iyi vhidhiyo.

Iyo cadaver yakaiswa mukati, "rupo" pleural decompression ronda ragadzirwa, uye pakupera kwega kwega mapapu anodonha pasi kunze kwekunge PEEP yaiswa. Uye cherechedza kuti kuputsika kwapera pane imwe neimwe kupera.

Chero bedzi thoracostomy yakakura zvakakwana kuti utaure zvakasununguka nemhepo (uye kana uri kuvimba nenzira yakazaruka ye "munwe" pane kuisa mudhiraini inoda kuva yakakura kana kuti inogona kudzorera zvakare), paunoisa yako. munwe mukati panguva yekupera kwenguva mapapu anodonha kunze kwekunge paine huwandu hunonzwisisika hwePEEP inotsemuka zvinhu zvakavhurika zvinoyevedza.

Ichadhirika ingave yatove usati wagadzira ronda kana kuti zvakaitika iwe uchiwaridza mapfumo uye kuita buri rekutaurirana. Nguva iri pakati pekugadzira buri uye kuwana iyo pfungwa yekukwira kumusoro kana mapapu pasi nemunwe inguva yakakwana yekuti mapapu adonhe. Zvinoita senge ichi chiratidzo chekiriniki chinogona kunge chisingakuudze chinhu nezve mamiriro ekutamba ronda risati ragadzirwa.

Saka ruzha runogona kunyengera uye kunzwa mapapu akadonha zvinongoreva kuti mapapu akadzokera shure sezvo pleura yakavhurwa. Unogona here kuvimbisa kuti ndechipi chikamu chekufema icho murwere anga ari pawakagadzira gomba iro? Kunze kwekunge wanga uine 5 cmH₂O (uye pamwe zvimwe) PEEP panguva yawakatyora pleura kana yezviratidzo izvi haireve chero chinhu.

Zvino, chii?

Zvekare, handisi kutaura zvinhu zvakaita sekuti “nguva dzose” kana “hazvina kumboitika”. Zvandiri kutaura ndezvekuti panogona kunge paine grey yakawanda yakatenderedza aya makiriniki zviratidzo pane zvingaite sezviri kutanga.

Saka unoziva sei kana vaine pneumothorax? Kwandiri izvo zvinenge nguva dzose ne ultrasound ikozvino. Handizive kuti ndakakwanisa sei 15 yeaya 20+ makore ekutarisira prehospital pasina imwe. Dzimwe nguva hongu scan yacho ine equivocal uye unofanirwa kufona zvichibva pane zviratidzo zvaunoona uye mamiriro emurwere asi ini ndinoona izvi zvisingaite zvakanyanya neakanaka high frequency linear probe.

Uye kana iri tension mucherechedzo uyu is abnormal physiology, kunyanya BP. Kana decompressing chipfuva inogadzirisa physiology saka vaive netension. Kana zvisina kudaro ivo vaive nepneumothorax iri nyore - kana kuti hapana zvachose. Nekuti ruzha rwawakanzwa uchityora pleura ungangove mweya uchipinda kana kubuda muchivako, kunzwa ruzha hakukubatsiri chero nzira. Elvis akambopinda muchivako zvachose here?

Notes:

Ndakanga ndine akangwara Dr Blair Munford ongororo murwi wefiziology pano kuti ive nechokwadi chekuti inowirirana.

Mushure meiyo link kune LITFL bit pane transpulmonary pressure zvakare? Wobva waenda kurudyi pano.

Uye hunyanzvi hwaJohn West (zvakanaka rinenge peji rataurwa) ndiro pano.

Mufananidzo uya waNahni une nzeve huru wakaiswa kune Creative Commons chikamu cheflickr naAllan Henderson uye haina kuchinjwa pano.

Ah, uye kana wanga usingazive anoshamisa John West, Adelaide mukomana akaitwa zvakanaka, akarekodha hurukuro yake yese series kuti uende undoona. Nekuti kana iwe wave mumakore ako makumi masere ungangove uchibatsira kudzidzo yekurapa saizvozvi, handiti?

Verenga Uyewo:

Tracheal Intubation: Rini, Sei Uye Sei Kugadzira Yakagadzirwa YeMhepo YeMurwere

Chii Chinonzi Transient Tachypnoea YeMwana Achangoberekwa, Kana Neonatal Wet Lung Syndrome?

Source:

Chengetedza ndege Collettive