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

Ulawulo lwe-Ventilator: ukukhupha umoya kwisigulana

By UCristiano Antonino On Feb 24, 2023

I-invasive mechanical ventilation lungenelelo olusetyenziswa rhoqo kwizigulana ezigula kakhulu ezifuna inkxaso yokuphefumula okanye ukukhuselwa kwendlela yomoya.

I-ventilator ivumela utshintshiselwano lwegesi ukuba lugcinwe ngelixa olunye unyango lulawulwa ukuphucula iimeko zekliniki

Lo msebenzi uphonononga izibonakaliso, ukuchasana, ulawulo, kunye neengxaki ezinokuthi zibekho ze-invasive mechanical ventilation kwaye ugxininisa ukubaluleka kweqela le-interprofessional ekulawuleni ukhathalelo lwezigulane ezifuna inkxaso ye-ventilatory.

Isidingo sokungena komoya ngoomatshini sesinye sezona zizathu zixhaphakileyo zokwamkelwa e-ICU.[1][2][3]

IZOLUHLI, IIBHEDI ZOMHLABA, IZITHULU ZOKUPHUMEZELA IMIPHUMVU, IZIHLALO ZOKUPHUMA: IIMVELISO ZESPENSER KWI-DOUBLE BOOTH KWI-EXPO EXPO

Kubalulekile ukuqonda amagama athile asisiseko ukuqonda ukungena komoya ngoomatshini

Uvalo: Ukutshintshana komoya phakathi kwemiphunga nomoya (indawo engqongileyo okanye ebonelelwa ngesixhobo sokungenisa umoya), ngamanye amazwi, yinkqubo yokuhambisa umoya ngaphakathi nangaphandle kwimiphunga.

Impembelelo yayo ebaluleke kakhulu kukukhutshwa kwe-carbon dioxide (CO2) emzimbeni, kungekhona ukwanda kwe-oksijini kwigazi.

Kwiimeko zeklinikhi, ukungena komoya kulinganiswa njengokungena komoya okufutshane, kubalwe njengesantya sokuphefumula (RR) amaxesha omthamo we-tidal volume (Vt).

Kwisigulana esinomatshini wokungena umoya, umxholo we-CO2 wegazi unokutshintshwa ngokuguqula umthamo we-tidal okanye izinga lokuphefumula.

Ukukhutshwa kweoksijini: Ungenelelo olubonelela ngokunyuka kwe-oksijini yokuhanjiswa kwimiphunga kwaye ngaloo ndlela ukuya kumjikelezo.

Kwisigulane esinomatshini, oku kunokufezekiswa ngokunyusa iqhezu le-oksijini ephefumlelweyo (i-FiO 2%) okanye uxinzelelo oluhle lokuphelelwa umoya (PEEP).

I-PeEP: Uxinzelelo olulungileyo oluseleyo kwindlela yomoya ekupheleni komjikelezo wokuphefumula (ukuphela kokuphelelwa yisikhathi) kukhulu kunoxinzelelo lwe-atmospheric kwizigulane ezinomshini wokuphefumula.

Ukufumana inkcazo epheleleyo yokusetyenziswa kwe-PEEP, bona inqaku elinesihloko esithi "Positive End-Expiratory Pressure (PEEP)" kwiimbekiselo zebhayibhilografi ekupheleni kweli nqaku.

Umthamo wamaza: Umthamo womoya ophumayo ungena nawuphuma emiphungeni kumjikelo ngamnye wokuphefumla.

I-FiO2: Ipesenti ye-oksijini kumxube womoya ohanjiswa kwisigulane.

Ukuhamba: Ireyithi ngeelitha ngomzuzu apho i-ventilator ihambisa ukuphefumla.

Ukuthobela: Ukutshintsha umthamo ohlulwe ngokutshintsha koxinzelelo. Kwi-physiology yokuphefumula, ukuthotyelwa ngokupheleleyo ngumxube wokuthotyelwa kodonga lwemiphunga kunye nesifuba, kuba ezi zinto zimbini azikwazi ukwahlula kwisigulane.

Kuba umoya wokungena ngoomatshini uvumela ugqirha ukuba atshintshe umoya wesigulana kunye ne-oxygen, idlala indima ebalulekileyo kwi-hypoxic ebukhali kunye nokusilela kokuphefumla kwe-hypercapnic kunye ne-asidi enzima okanye i-alkalosis ye-metabolic.[4][5]

I-Physiology ye-ventilation yomatshini

Ukungena komoya ngoomatshini kuneziphumo ezininzi kubuchwephesha bemiphunga.

I-physiology yokuphefumula eqhelekileyo isebenza njengenkqubo yoxinzelelo olubi.

Xa i-diaphragm ityhala phantsi ngexesha lokuphefumlelwa, uxinzelelo olubi lwenziwa kwi-pleural cavity, ethi yona idale uxinzelelo olubi kwiindlela zomoya ezitsala umoya emiphungeni.

Olu xinzelelo lufanayo lwe-intrathoracic lunciphisa uxinzelelo lwe-atrial yasekunene (RA) kwaye luvelise umphumo wokufunxa kwi-inferior vena cava (IVC), ukwandisa ukubuya kwe-venous.

Ukusetyenziswa koxinzelelo lomoya olulungileyo kuguqula le physiology.

Uxinzelelo olulungileyo oluveliswa yi-ventilator ludluliselwa kumoya ophezulu kwaye ekugqibeleni kwi-alveoli; oku, kwakhona, idluliselwa kwi-alveolar space kunye ne-thoracic cavity, idala uxinzelelo oluhle (okanye ubuncinane uxinzelelo oluncinci olusezantsi) kwindawo ye-pleural.

Ukunyuka koxinzelelo lwe-RA kunye nokuncipha kokubuya kwe-venous kuvelisa ukuhla kokulayisha kwangaphambili.

Oku kuneempembelelo ezimbini zokunciphisa i-cardiac output: igazi elincinci kwi-ventricle elungileyo lithetha ukuba igazi elincinci lifikelela kwi-ventricle yasekhohlo kwaye igazi elincinci lingampontshwa, linciphise ukuphuma kwentliziyo.

Ukulayishwa kwangaphambili okuphantsi kuthetha ukuba intliziyo isebenza kwindawo engaphantsi kwe-acceleration curve, ivelisa umsebenzi ophantsi kunye nokunciphisa ukukhutshwa kwentliziyo, okuya kubangela ukuhla koxinzelelo lwe-arterial (MAP) ukuba akukho mpendulo yembuyekezo ngokunyuka. inkqubo yokumelana nemithambo yegazi (SVR).

Oku kuqwalaselwa kubaluleke kakhulu kwizigulane ezingenakukwazi ukwandisa i-SVR, njengezigulane ezinokutshatyalaliswa kokusabalalisa (i-septic, i-neurogenic, okanye i-anaphylactic).

Kwelinye icala, uxinzelelo olulungileyo lokuphefumla ngoomatshini kunokunciphisa kakhulu umsebenzi wokuphefumla.

Oku, kunciphisa ukuhamba kwegazi kwizihlunu zokuphefumla kwaye iphinde isasazeke kumalungu abaluleke kakhulu.

Ukunciphisa umsebenzi wezihlunu zokuphefumla kwakhona kunciphisa ukuveliswa kwe-CO2 kunye ne-lactate kule misipha, inceda ukuphucula i-acidosis.

Iziphumo zoxinzelelo oluhle lokungena komoya kwi-venous ukubuya kunokuba luncedo kwizigulana ezine-cardiogenic pulmonary edema.

Kwezi zigulana ezinomthamo omninzi, ukunciphisa ukubuya kwe-venous kuya kunciphisa ngokuthe ngqo inani le-edema ye-pulmonary eveliswayo, ukunciphisa ukuphuma kwentliziyo efanelekileyo.

Kwangaxeshanye, ukuncitshiswa kokubuya kwe-venous kunokuphucula ukugqithiswa kwe-ventricular yasekhohlo, kuyibeka kwindawo enenzuzo ngakumbi kwijika le-Frank-Starling kunye nokuphucula ukuphuma kwentliziyo.

Ulawulo olululo lokungenisa umoya ngoomatshini lukwafuna ukuqonda uxinzelelo lwemiphunga kunye nokuthotyelwa kwemiphunga.

Ukuthotyelwa kwesiqhelo kwemiphunga kumalunga ne-100 ml/cmH20.

Oku kuthetha ukuba kumphunga oqhelekileyo, ukulawulwa kwe-500 ml yomoya ngomoya wokuphefumula okulungileyo kuya kwandisa uxinzelelo lwe-alveolar nge-5 cm H2O.

Ngokuchasene noko, ukulawulwa koxinzelelo olulungileyo lwe-5 cm H2O kuya kuvelisa ukwanda komthamo wemiphunga we-500 mL.

Xa usebenza ngemiphunga engaqhelekanga, ukuthobela kusenokuba phezulu okanye kube ngaphantsi kakhulu.

Nasiphi na isifo esitshabalalisa i-lung parenchyma, njenge-emphysema, siya kwandisa ukuthotyelwa, ngelixa nasiphi na isifo esenza imiphunga eqinile.i-ARDS, inyumoniya, i-pulmonary edema, i-pulmonary fibrosis) iya kunciphisa ukuthotyelwa kwemiphunga.

Ingxaki ngemiphunga eqinile kukuba ukunyuka okuncinci kumthamo kunokuvelisa ukunyuka okukhulu koxinzelelo kwaye kubangele i-barotrauma.

Oku kuvelisa ingxaki kwizigulana ezine-hypercapnia okanye i-acidosis, njengoko umoya wokungenisa umoya ngomzuzu unokufuna ukwandiswa ukulungisa ezi ngxaki.

Ukonyuka komyinge wokuphefumla kunokulawula oku kunyuka kwemizuzu yokungena komoya, kodwa ukuba oku akunakwenzeka, ukonyusa umthamo wamaza kunokwandisa uxinzelelo kunye nokudala i-barotrauma.

Kukho iingcinezelo ezimbini ezibalulekileyo kwinkqubo ekufuneka zigcinwe engqondweni xa ufaka umoya wesigulana ngomatshini:

Uxinzelelo oluphezulu luxinzelelo olufikelelwa ngexesha lokuphefumlelwa xa umoya utyhalelwa emiphungeni kwaye ngumlinganiselo wokuxhathisa kwindlela yomoya.
Uxinzelelo lwePlateau luxinzelelo olumileyo olufikelelwe ekupheleni kwempembelelo epheleleyo. Ukulinganisa uxinzelelo lweplateau, ikhefu elikhuthazayo kufuneka lenziwe kwi-ventilator ukuvumela uxinzelelo ukuba lulingane ngenkqubo. Uxinzelelo lwe-Plateau ngumlinganiselo woxinzelelo lwe-alveolar kunye nokuthotyelwa kwemiphunga. Uxinzelelo oluqhelekileyo lweplateau lungaphantsi kwe-30 cm H20, ngelixa uxinzelelo oluphezulu lunokuvelisa i-barotrauma.

Iimpawu zokungenisa umoya ngoomatshini

Olona phawu luqhelekileyo lwe-intubation kunye ne-mechanical ventilation kwiimeko zokungaphumeleli kokuphefumla, mhlawumbi i-hypoxic okanye i-hypercapnic.

Ezinye izibonakaliso ezibalulekileyo kukuhla komgangatho wengqondo kunye nokungakwazi ukukhusela indlela yomoya, uxinzelelo lokuphefumula oluye lwasilela ukuphefumla umoya ococekileyo, iimeko ze-hemoptysis enkulu, i-angioedema enzima, okanye nayiphi na imeko yokuphazamiseka kwendlela yomoya njengokutsha kweendlela zomoya, ukubanjwa kwentliziyo kunye nokothuka.

Iimpawu eziqhelekileyo ezikhethiweyo zokungena komoya ngoomatshini lutyando kunye nokuphazamiseka kwe-neuromuscular.

Ukungqinelana

Akukho zichasana ngokuthe ngqo kwi-ventilation yomatshini, njengoko kuyindlela yokusindisa ubomi kwisigulane esigula kakhulu, kwaye zonke izigulane kufuneka zinikwe ithuba lokuzuza kuyo xa kuyimfuneko.

Ukuphela kokuchasana ngokupheleleyo kumatshini wokungena komoya ukuba kuchasene nomnqweno ochaziweyo wesigulana wamanyathelo okugcina ubomi okwenziwa.

Ukuphela kwento echasene nesalamane kukuba umoya ongekho mva ukhoyo kwaye ukusetyenziswa kwawo kulindeleke ukuba kusonjululwe imfuno yokungena komoya ngoomatshini.

Oku kufuneka kuqalwe kuqala, njengoko kuneengxaki ezimbalwa kunokungena komoya ngoomatshini.

Amanyathelo amaninzi kufuneka athathwe ukuqalisa ukuphefumla ngoomatshini

Kuyimfuneko ukuqinisekisa ukubekwa ngokuchanekileyo kwe-tube endotracheal.

Oku kungenziwa nge-end-tidal capnography okanye ngendibaniselwano yeziphumo zeklinikhi kunye neradiyoloji.

Kuyimfuneko ukuqinisekisa inkxaso eyaneleyo ye-cardiovascular kunye ne-fluids okanye i-vasopressors, njengoko kuboniswe kwimeko-nge-case basis.

Qinisekisa ukuba i-sedation eyaneleyo kunye ne-analgesia ikhona.

Ityhubhu yeplastiki emqaleni wesigulane ibuhlungu kwaye ayikhululeki, kwaye ukuba isigulane asiphumli okanye siyasokola kunye netyhubhu okanye umoya, kuya kuba nzima kakhulu ukulawula iiparitha ezahlukeneyo zokungenisa umoya kunye ne-oxygen.

Iindlela zokungenisa umoya

Emva kokufaka i-intubating isigulana kunye nokumdibanisa ne-ventilator, lixesha lokukhetha ukuba yeyiphi indlela yokungenisa umoya oza kuyisebenzisa.

Ukuze oku kwenziwe rhoqo ukuze kungenelwe umguli, kufuneka kuqondwe imigaqo emininzi.

Njengoko kukhankanyiwe ngaphambili, ukuthotyelwa yinguqu yevolumu eyahlulwe ngokutshintsha koxinzelelo.

Xa ufaka umoya wesigulana ngoomatshini, unokukhetha indlela i-ventilator eya kukuhambisa ngayo ukuphefumla.

I-ventilator inokusetwa ukuba inike isixa esimiselweyo somthamo okanye isixa esimiselweyo soxinzelelo, kwaye kuya kugqirha ukuba athathe isigqibo sokuba yeyiphi eyona luncedo kumguli.

Xa sikhetha ukuhanjiswa kwe-ventilator, sikhetha ukuba yeyiphi eya kuba yinguqu exhomekeke kuyo kwaye iya kuba yinguqu ezimeleyo kwi-equation yokuthotyelwa kwemiphunga.

Ukuba sikhetha ukuqala isigulane kwi-volume-controlled ventilation, i-ventilator iya kuhlala ihambisa inani elifanayo lomthamo (i-independent variable), ngelixa uxinzelelo olwenziweyo luya kuxhomekeka ekuthotyelweni.

Ukuba ukuthotyelwa kubi, uxinzelelo luya kuba phezulu kwaye i-barotrauma ingenzeka.

Ngakolunye uhlangothi, ukuba sithatha isigqibo sokuqalisa isigulane kwi-ventilation elawulwa ngoxinzelelo, i-ventilator iya kuhlala ihambisa uxinzelelo olufanayo ngexesha lomjikelezo wokuphefumula.

Nangona kunjalo, umthamo we-tidal umthamo uya kuxhomekeka ekuthotyelweni kwemiphunga, kwaye kwiimeko apho ukuthotyelwa kutshintsha rhoqo (njengakwi-asthma), oku kuya kuvelisa umthamo we-tidal ongathembekanga kwaye kunokubangela i-hypercapnia okanye i-hyperventilation.

Emva kokukhetha indlela yokuhambisa umoya (ngoxinzelelo okanye umthamo), ugqirha kufuneka anqume ukuba yeyiphi imo yokungena umoya oza kuyisebenzisa.

Oku kuthetha ukukhetha ukuba umatshini wokuphefumla uya kunceda konke ukuphefumla kwesigulana, okunye ukuphefumla kwesigulana, okanye akukho nanye, nokuba umatshini wokuphefumla uya kuzisa ukuphefumla nokuba isigulana asiphefumli ngokwaso.

Ezinye iiparamitha ekufuneka ziqwalaselwe ngumyinge wokuhanjiswa kokuphefumla (ukuhamba), i-waveform yokuqukuqela (i-wave wave ehlayo ilingisa ukuphefumla kwe-physiological kwaye ikhululekile ngakumbi kwisigulana, ngelixa i-square waveforms, apho ukuhamba kuhanjiswe ngesantya esiphezulu kuyo yonke impembelelo, azikhululeki ngakumbi kwisigulana kodwa zibonelela ngamaxesha akhawulezayo okuphefumla), kunye nesantya apho ukuphefumla kuhanjiswa.

Zonke ezi parameters kufuneka zihlengahlengiswe ukuze kufumaneke ukuthuthuzeleka kwesigulana, iigesi zegazi ezifunwayo, kunye nokuphepha ukubanjwa komoya.

Kukho iindlela ezininzi zokungenisa umoya ezahluka kancinci enye kwenye. Kolu hlaziyo siza kugxila kwiindlela eziqhelekileyo zokungenisa umoya kunye nokusetyenziswa kwazo kweklinikhi.

Iindlela zokungenisa umoya ziquka ukuncedisa (AC), inkxaso yoxinzelelo (PS), i-synchronized intermittent mandatory ventilation (SIMV), kunye ne-airway pressure release release (APRV).

Ukuncediswa komoya (AC)

Ulawulo lokuncedisa apho i-ventilator incedisa isigulane ngokubonelela ngenkxaso yokuphefumula nganye isigulane esithathayo (le nxalenye yokuncedisa), ngelixa i-ventilator inokulawula izinga lokuphefumula ukuba liwela ngaphantsi kwezinga elimiselweyo (inxalenye yokulawula).

Kulawulo loncedo, ukuba i-frequency isetelwe kwi-12 kwaye isigulana siphefumla nge-18, i-ventilator iya kunceda ngokuphefumla kwe-18, kodwa ukuba i-frequency yehla ukuya kwi-8, i-ventilator iya kuthatha ulawulo lwezinga lokuphefumla kwaye ithathe ukuphefumla kwe-12. ngomzuzu.

Ekuncedeni ukulawula umoya, ukuphefumla kunokuziswa nokuba ngumthamo okanye ngoxinzelelo

Oku kubizwa ngokuba yi-volume-controlled ventilation okanye i-ventilation elawulwa ngoxinzelelo.

Ukuyigcina ilula kwaye uqonde ukuba ekubeni umoya we-ventilation udla ngokuba ngumba obaluleke kakhulu kunoxinzelelo kunye nokulawulwa kwevolumu ngokuqhelekileyo kusetyenziswa ngokuqhelekileyo kunokulawula uxinzelelo, kuba intsalela yolu hlaziyo siza kusebenzisa igama elithi "ulawulo lwevolumu" ngokungafaniyo xa sithetha ngokuncedisa ukulawula.

Ulawulo lokuncedisa (ulawulo lwevolumu) yindlela yokukhetha esetyenziswa kwii-ICU ezininzi e-United States kuba kulula ukuyisebenzisa.

Iisetingi ezine (izinga lokuphefumla, ivolumu yomsindo, i-FiO2, kunye ne-PEEP) inokulungelelaniswa lula kwi-ventilator. Umthamo ohanjiswe yi-ventilator kumoya ngamnye kulawulo oluncedisiweyo uya kuhlala ufana, kungakhathaliseki ukuba umoya oqaliswe ngumguli okanye i-ventilator kunye nokuthotyelwa, ukuphakama okanye ukunyanzeliswa kweplateau emiphungeni.

Umoya ngamnye unokumiselwa ixesha (ukuba izinga lokuphefumula kwesigulane lingaphantsi kunesimo somoya, umatshini uya kuhambisa ukuphefumula ngexesha elibekiweyo) okanye uqhutywe ngumguli, xa kwenzeka ukuba isigulane siqalise umoya ngokwakhe.

Oku kwenza ukuba ulawulo oluncedisayo lube yimowudi ekhululekile kakhulu kwisigulana, njengoko yonke imizamo yakhe iya kongezwa yi-ventilator.

Emva kokwenza utshintsho kwi-ventilator okanye emva kokuqala isigulane kwi-ventilation yomatshini, iigesi zegazi ze-arterial kufuneka zihlolwe ngokucophelela kwaye i-oksijini ye-saturation kwi-monitor kufuneka ilandelwe ukugqiba ukuba ngaba kukho utshintsho olongezelelweyo olufuna ukwenziwa kwi-ventilator.

Iinzuzo zemowudi ye-AC kukwandisa induduzo, ukulungiswa lula kwe-acidosis yokuphefumula / i-alkalosis, kunye nomsebenzi ophantsi wokuphefumla kwisigulana.

Ukungalungi kubandakanya ukuba ekubeni le ndlela yomjikelezo wevolumu, uxinzelelo alukwazi ukulawulwa ngokuthe ngqo, olunokubangela ukuba i-barotrauma, isigulane siphuhlise i-hyperventilation kunye nokuphefumula, i-autoPEEP, kunye ne-alkalosis yokuphefumula.

Ukufumana inkcazo epheleleyo yolawulo oluncediswayo, jonga inqaku elinesihloko esithi "Ukungenisa umoya, uLawulo oluNcedayo" [6], kwiNgxelo yeBhayibhiliyografi ekupheleni kweli nqaku.

Ukungenisa umoya okunyanzelekileyo okungahambelaniyo (SIMV)

I-SIMV yenye indlela yokungenisa umoya esetyenziswa rhoqo, nangona ukusetyenziswa kwayo kuye kwangasetyenziswa ngenxa yokungathembeki kwemithamo yamanzi kunye nokungabikho kweziphumo ezingcono kune-AC.

“Ungqamaniso” luthetha ukuba isixhobo sokuphefumla silungelelanisa ukuhanjiswa kokuphefumla kwayo kwimigudu yesigulana. “Ukuphefumla” kuthetha ukuba ayizizo zonke iimpefumlo ezixhaswayo kwaye “ukuphefumla okunyanzelekileyo” kuthetha ukuba, njengakwimeko ye-CA, kukhethwe amaza omoya amiselwe kwangaphambili kwaye umatshini wokuphefumla uhambisa oku kuphefumla kunyanzelekileyo ngomzuzu ngamnye nokuba ithini na imizamo yokuphefumla yesigulana.

Ukuphefumula okunyanzeliswayo kunokubangelwa isigulane okanye ixesha ukuba i-RR yesigulane ihamba kancinci kune-RR ye-ventilator (njengakwimeko ye-CA).

Umahluko ukusuka kwi-AC kukuba kwi-SIMV i-ventilator iya kuhambisa kuphela ukuphefumla ukuba i-frequency isetelwe ukuhambisa; Nakuphi na ukuphefumla okuthatyathwe sisigulana ngaphezulu kwesi sihlandlo akuzukufumana umthamo we-tidal okanye inkxaso epheleleyo yocinezelo.

Oku kuthetha ukuba ngomphefumlo ngamnye othathwe sisigulana ngaphezu kwe-RR emiselweyo, umthamo we-tidal ohanjiswa sisigulane uya kuxhomekeka kuphela ekuthotyelweni kwemiphunga yesigulane kunye nomgudu.

Oku kucetywayo njengendlela "yokuqeqesha" i-diaphragm ukuze kugcinwe ithoni ye-muscle kunye nokulunyulwa kwezigulane kwi-ventilator ngokukhawuleza.

Nangona kunjalo, uphando oluninzi alubonisi nzuzo ye-SIMV. Ukongeza, i-SIMV ivelisa umsebenzi wokuphefumla ngakumbi kune-AC, enefuthe elibi kwiziphumo kwaye ivelise ukukhathala kokuphefumla.

Umgaqo oqhelekileyo wesithupha omele ulandelwe kukuba isigulane siya kukhululwa kwi-ventilator xa sele silungile, kwaye akukho ndlela ekhethekileyo yokungenisa umoya eya kuyenza ngokukhawuleza.

Okwangoku, kungcono ukugcina isigulana sikhululekile ngokusemandleni, kwaye i-SIMV isenokungabi yeyona ndlela ilungileyo yokufezekisa oku.

Umoya weNkxaso yoxinzelelo (PSV)

I-PSV yimowudi yokungenisa umoya ethembele ngokupheleleyo ekuphefumleni okwenziwa sisigulana.

Njengoko igama libonisa, yindlela yokungenisa umoya eqhutywa ngoxinzelelo.

Kule modi, konke ukuphefumla kuqalwa sisigulana, njengoko i-ventilator ayinayo ireyithi yokugcina, ngoko ke umphefumlo ngamnye kufuneka uqaliswe sisigulana. Kule modi, i-ventilator iyatshintsha ukusuka kolunye uxinzelelo ukuya kwelinye (PEEP kunye noxinzelelo lwenkxaso).

I-PEEP luxinzelelo oluseleyo ekupheleni kokuphefumla, ngelixa inkxaso yoxinzelelo luxinzelelo olungaphezulu kwe-PEEP apho i-ventilator iya kulawula ngexesha lokuphefumula ngalunye ukugcina umoya.

Oku kuthetha ukuba ukuba isigulane sibekwe kwi-PSV 10/5, baya kufumana i-5 cm H2O ye-PEEP kwaye ngexesha lokuphefumlelwa baya kufumana i-15 cm ye-H2O yenkxaso (i-10 PS ngaphezu kwe-PEEP).

Ngenxa yokuba akukho rhoqo ukugcinwa, le modi ayinakusetyenziswa kwizigulana ezilahlekelwe zingqondo, ukothuka okanye ukubanjwa kwentliziyo.

Umthamo wangoku uxhomekeke kuphela kwimigudu yesigulana kunye nokuthotyelwa kwemiphunga.

I-PSV ihlala isetyenziselwa ukulunyulwa kwi-ventilator, njengoko inyusa nje iinzame zokuphefumla zesigulana ngaphandle kokubonelela ngevolumu emiselweyo okanye izinga lokuphefumla.

Eyona nto ingalunganga ye-PSV kukungathembeki komthamo we-tidal, onokuthi uvelise ukugcinwa kwe-CO2 kunye ne-acidosis, kunye nomsebenzi ophezulu wokuphefumla onokubangela ukukhathala kokuphefumla.

Ukusombulula le ngxaki, i-algorithm entsha yenzelwe i-PSV, ebizwa ngokuba yi-volume-supported ventilation (VSV).

I-VSV yimodi efana ne-PSV, kodwa kule modi umthamo wangoku usetyenziswa njengolawulo lwempendulo, ekubeni inkxaso ye-pressor enikwe isigulane ihlala ilungiswa ngokuhambelana nomthamo wangoku. Kolu seto, ukuba umthamo we-tidal uyancipha, i-ventilator iya konyusa inkxaso yocinezelo ukunciphisa umthamo we-tidal, ngelixa ukuba umthamo we-tidal wonyusa inkxaso yocinezelo iya kuncipha ukugcina ivolumu ye-tidal kufutshane nomzuzu ofunekayo wokuphefumla.

Obunye ubungqina bubonisa ukuba ukusetyenziswa kwe-VSV kunokunciphisa ixesha lokuphefumla elincediswayo, ixesha lokulunyulwa lilonke kunye nexesha elipheleleyo le-T-piece, kunye nokunciphisa imfuno yokuthomalalisa.

Umoya wokukhupha umoya womoya (APRV)

Njengoko igama libonisa, kwimodi ye-APRV, i-ventilator ihambisa uxinzelelo oluphezulu rhoqo kwi-airway, eqinisekisa i-oxygenation, kunye ne-ventilation eyenziwa ngokukhupha olu xinzelelo.

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Le modi isandula ukufumana ukuthandwa njengenye indlela yezigulana ezine-ARDS ekunzima ukuba i-oxygen, apho ezinye iindlela zokungenisa umoya zisilela ukufezekisa iinjongo zabo.

I-APRV ichazwe njengoxinzelelo oluqhubekayo lwe-airway (CPAP) kunye nesigaba sokukhululwa kwesikhashana.

Oku kuthetha ukuba i-ventilator isebenzisa uxinzelelo oluphezulu oluqhubekayo (P high) kwixesha elimiselweyo (T high) kwaye liyikhulule, ngokuqhelekileyo libuyela ku-zero (P low) ixesha elifutshane kakhulu (T low).

Ingcamango emva koku kukuba ngexesha le-T ephezulu (egubungela i-80% -95% yomjikelezo), kukho ukugaywa rhoqo kwe-alveolar, ephucula i-oxygenation ngenxa yokuba ixesha eligcinwe kuxinzelelo oluphezulu lide kakhulu kunezinye iintlobo zomoya (iqhinga lokuvula imiphunga). ).

Oku kunciphisa ukunyuka kwamaxabiso okuphindaphindiweyo kunye nokunciphisa imiphunga okwenzeka kunye nezinye iindlela zokungenisa umoya, ukuthintela ukwenzakala okubangelwa yi-ventilator-induced lung.

Ngeli xesha (T high) isigulane sikhululekile ukuphefumla ngokuzenzekelayo (nto leyo eyenza ukuba akhululeke), kodwa uya kutsala umthamo ophantsi wamaza ngenxa yokuba ukuphefumla ngokuchasene noxinzelelo olunjalo kunzima kakhulu. Emva koko, xa i-T iphezulu ifikelelwe, uxinzelelo kwi-ventilator yehla ukuya kwi-P low (ngokuqhelekileyo zero).

Umoya ke uyakhutshwa kumgaqo womoya, ukuvumela ukuphefumla okungapheliyo de kufike u-T low kwaye i-ventilator ikhuphe omnye umoya.

Ukuthintela ukuwa kwe-airway ngeli xesha, i-T ephantsi ibekwe ngokufutshane, ngokuqhelekileyo malunga ne-0.4-0.8 imizuzwana.

Kule meko, xa uxinzelelo lwe-ventilator lubekwe kwi-zero, i-elastic recoil yemiphunga ityhalela umoya ngaphandle, kodwa ixesha alide ngokwaneleyo ukukhupha wonke umoya emiphungeni, ngoko uxinzelelo lwe-alveolar kunye ne-airway alufikeleli kwi-zero. kwaye ukudilika kwendlela yomoya akwenzeki.

Eli xesha lidla ngokubekwa ukwenzela ukuba i-T ephantsi iphele xa ukuphuma kwe-exhalation kwehla ukuya kwi-50% yokuhamba kokuqala.

Ukungena komoya ngomzuzu, ngoko ke, kuya kuxhomekeka kwi-T ephantsi kunye nomthamo we-tidal wesigulane ngexesha lokuphakama kwe-T

Iimpawu zokusetyenziswa kwe-APRV:

I-ARDS kunzima ukuyikhupha nge-AC
Ukwenzakala okuqatha kwemiphunga
I-atelectasis yasemva kokusebenza.

Izinto eziluncedo ze-APRV:

I-APRV yindlela elungileyo yokungena komoya okhusela imiphunga.

Ukukwazi ukuseta i-P ephezulu kuthetha ukuba umqhubi unolawulo phezu koxinzelelo lwe-plateau, olunokunciphisa kakhulu iziganeko ze-barotrauma.

Njengoko isigulane siqala imizamo yakhe yokuphefumula, kukho ukuhanjiswa kwegesi okungcono ngenxa yomdlalo ongcono we-V / Q.

Uxinzelelo oluphezulu oluthe rhoqo luthetha ukwanda kwabasebenzi (iqhinga lokuvula imiphunga).

I-APRV inokuphucula i-oxygenation kwizigulane ezine-ARDS ezinzima ukuba zifake i-oxygen nge-AC.

I-APRV inokunciphisa imfuno ye-sedation kunye ne-neuromuscular blocking agents, njengoko isigulane sinokukhululeka ngakumbi xa kuthelekiswa nezinye iindlela.

Izinto ezingeloncedo kunye ne-contraindications:

Kuba ukuphefumla okuzenzekelayo kungumba obalulekileyo we-APRV, ayifanelekanga kwizigulane ezilaliswe kakhulu.

Akukho datha malunga nokusetyenziswa kwe-APRV kwi-neuromuscular disorders okanye isifo se-obstructive lung, kwaye ukusetyenziswa kwayo kufuneka kuphetshwe kwezi zigulana.

Ngokwethiyori, uxinzelelo oluphezulu lwe-intrathoracic lunokuvelisa uxinzelelo oluphezulu lwe-pulmonary artery kunye ne-intracardiac shunts embi kwizigulana ezine-Eisenmenger's physiology.

Ukuqiqa okuqinileyo kwezonyango kuyafuneka xa ukhetha i-APRV njengendlela yokungena komoya kwiindlela eziqhelekileyo ezifana ne-AC.

Olunye ulwazi malunga neenkcukacha zeendlela ezahlukeneyo zokungenisa umoya kunye nokusekwa kwazo kunokufumaneka kumanqaku kwimowudi nganye yokungenisa umoya.

Ukusetyenziswa kwe-ventilator

Ukusetwa kokuqala kwe-ventilator kunokwahluka kakhulu kuxhomekeke kwimbangela ye-intubation kunye nenjongo yolu hlaziyo.

Nangona kunjalo, kukho ezinye iisetingi ezisisiseko kwiimeko ezininzi.

Eyona ndlela ixhaphakileyo yokuphefumla enokusetyenziswa kwisigulana esisanda kufakwa yimowudi ye-AC.

Imowudi ye-AC inika intuthuzelo elungileyo kunye nolawulo olulula lwezinye zeeparamitha ezibalulekileyo ze-physiological.

Iqala nge-FiO2 ye-100% kwaye iyancipha ngokukhokelwa yi-pulse oximetry okanye i-ABG, njengoko kufanelekile.

Umoya ophantsi we-ventilation ophantsi ubonakaliswe njengokukhusela imiphunga kungekuphela nje kwi-ARDS kodwa nakwezinye iintlobo zezifo.

Ukuqala isigulane ngomthamo ophantsi ophantsi (i-6 ukuya kwi-8 mL / Kg ubunzima bomzimba obufanelekileyo) kunciphisa iziganeko zokulimala kwe-lung-induced lung (VILI).

Soloko usebenzisa isicwangciso-qhinga sokukhusela imiphunga, njengoko amanzi aphezulu anenzuzo encinci kwaye anyuse uxinzelelo lwe-chear kwi-alveoli kwaye inokubangela ukulimala kwemiphunga.

I-RR yokuqala kufuneka ikhululeke kwisigulane: 10-12 bpm yanele.

Isilumkiso esibaluleke kakhulu sichaphazela izigulana ezine-acidosis enzima.

Kwezi zigulana, umoya wokungena komoya ngomzuzu kufuneka ubuncinci uhambelane ne-pre-intubation ventilation, kuba kungenjalo i-acidosis iba mandundu kwaye inokubangela iingxaki ezinjengokubanjwa kwentliziyo.

Ukuhamba kufuneka kuqaliswe okanye ngaphezulu kwe-60 L / min ukuphepha i-autoPEEP

Qala nge-PEEP ephantsi ye-5 cm ye-H2O kwaye ukwandise ngokunyamezela kwesigulane kwinjongo ye-oxygenation.

Nika ingqalelo ngokukhawuleza uxinzelelo lwegazi kunye nokuthuthuzela kwesigulane.

I-ABG kufuneka ifunyanwe kwimizuzu engama-30 emva kwe-intubation kunye nezicwangciso ze-ventilator kufuneka zilungelelaniswe ngokweziphumo ze-ABG.

Uxinzelelo oluphezulu kunye neplateau kufuneka lujongwe kwisixhobo sokungenisa umoya ukuqinisekisa ukuba akukho ngxaki ngoxinzelelo lwendlela yomoya okanye uxinzelelo lwe-alveolar ukunqanda umonakalo owenziwe ngumphunga.

Ingqalelo kufuneka ihlawulwe kwiigophe zevolumu kwisiboniso se-ventilator, njengoko ufundo olubonisa ukuba ijika alibuyeli kwi-zero xa ukukhupha umoya kubonisa ukuphefumla okungaphelelanga kunye nophuhliso lwe-auto-PEEP; ngoko ke, izilungiso kufuneka zenziwe kwisixhobo sokungenisa umoya ngokukhawuleza.[7][8]

Ukulungisa ingxaki kwi-Ventilator

Ngokuqondwa kakuhle kweekhonsepthi ezixoxiwe, ukulawula iingxaki ze-ventilator kunye nokusombulula ingxaki kufuneka kube yinto yesibini.

Olona lungiso luqhelekileyo ekufuneka lwenziwe ekungeneni komoya lubandakanya i-hypoxemia kunye ne-hypercapnia okanye i-hyperventilation:

I-Hypoxia: i-oxygenation ixhomekeke kwi-FiO2 kunye ne-PEEP (i-T ephezulu kunye ne-P ephezulu ye-APRV).

Ukulungisa i-hypoxia, ukwandisa enye yale parameters kufuneka kwandise i-oxygenation.

Ingqwalasela ekhethekileyo kufuneka ihlawulwe kwimiphumo emibi enokwenzeka yokunyuka kwe-PEEP, enokubangela ukuba i-barotrauma kunye ne-hypotension.

Ukwandisa i-FiO2 ayikho inkxalabo, njengoko i-FiO2 ephakamileyo ingabangela umonakalo we-oxidative kwi-alveoli.

Enye inkalo ebalulekileyo yolawulo lomxholo we-oksijeni kukumisela injongo ye-oxygenation.

Ngokuqhelekileyo, kunenzuzo encinci ukugcina i-oxygen saturation ngaphezu kwe-92-94%, ngaphandle, umzekelo, kwiimeko ze-carbon monoxide poisoning.

Ukuhla ngokukhawuleza kwe-oksijini ye-saturation kufuneka kuphakamise ukukrokrelwa kwe-tube malpositioning, i-pulmonary embolism, i-pneumothorax, i-pulmonary edema, i-atelectasis, okanye ukuphuhliswa kweeplagi ze-mucus.

Hypercapnia: Ukutshintsha umxholo we-CO2 yegazi, umoya we-alveolar kufuneka uguqulwe.

Oku kunokwenziwa ngokuguqula umthamo wamaza okanye izinga lokuphefumla (i-T ephantsi kunye ne-P ephantsi kwi-APRV).

Ukwandisa izinga okanye umthamo we-tidal, kunye nokunyuka kwe-T ephantsi, kwandisa umoya kunye nokunciphisa i-CO2.

Ukhathalelo kufuneka luthathwe ngokunyuka kwamaza, njengoko kuya kwandisa ubungakanani bendawo efileyo kwaye isenokungasebenzi njengomthamo wamaza.

Xa unyusa umthamo okanye ukuphindaphinda, ingqalelo ekhethekileyo kufuneka ihlawulwe kwi-flow-volume loop ukuphepha ukuphuhliswa kwe-auto-PEEP.

Uxinzelelo oluphezulu: Iingcinezelo ezimbini zibalulekile kwinkqubo: uxinzelelo oluphezulu kunye noxinzelelo lweplateau.

Uxinzelelo oluphezulu ngumlinganiselo wokumelana nomoya kunye nokuthotyelwa kwaye kubandakanya ityhubhu kunye nomthi we-bronchial.

Uxinzelelo lwe-Plateau lubonisa uxinzelelo lwe-alveolar kwaye ngaloo ndlela ukuthotyelwa kwemiphunga.

Ukuba kukho ukwanda koxinzelelo oluphezulu, inyathelo lokuqala kukuthatha ikhefu elikhuthazayo kwaye ujonge i-plateau.

Uxinzelelo oluphezulu kunye noxinzelelo oluqhelekileyo lwethafa: ukuchasana kwendlela yomoya ephezulu kunye nokuthotyelwa okuqhelekileyo

Izizathu ezinokwenzeka: (1) I-Twisted ET tube-Isisombululo ku-untwist ityhubhu; sebenzisa isitshixo sokuluma ukuba isigulane siluma ityhubhu, (2) iplagi ye-Mucus-Isisombululo kukufuna isigulane, (3) I-Bronchospasm-Isisombululo kukulawula i-bronchodilators.

Incopho ephezulu kunye nethafa eliphezulu: Iingxaki zokuthotyelwa

Izizathu ezinokubakho zibandakanya:

Main trunk intubation-Isisombululo kukuhoxisa ityhubhu ye-ET. Ukufumana ukuxilongwa, uya kufumana isigulana esinezandi zokuphefumula ezisecaleni kunye ne-contralateral lung off (atelectatic lung).
I-Pneumothorax: Ukuxilongwa kuya kwenziwa ngokumamela izandi zokuphefumula ngokuzimeleyo kunye nokufumana i-contralateral hyperresonant lung. Kwizigulane ezine-intubated, ukubekwa kwetyhubhu yesifuba kubalulekile, njengoko uxinzelelo olulungileyo luya kuyenza ibe mandundu ngakumbi i-pneumothorax.
I-Atelectasis: Ulawulo lokuqala lubandakanya i-chest percussion kunye ne-recruitment maneuvers. I-bronchoscopy ingasetyenziselwa kwiimeko ezixhathisayo.
I-Pulmonary edema: I-Diuresis, i-inotropes, i-PEEP ephakamileyo.
I-ARDS: Sebenzisa umthamo ophantsi wamaza kunye nomoya ophezulu we-PEEP.
I-Dynamic hyperinflation okanye i-auto-PEEP: yinkqubo apho omnye womoya ophefumlelweyo awukhutshwanga ngokupheleleyo ekupheleni komjikelo wokuphefumula.
Ukuqokelelana komoya ovalelweyo kwandisa uxinzelelo lwemiphunga kwaye kubangela i-barotrauma kunye ne-hypotension.
Isigulana siya kuba nzima ukukhupha umoya.
Ukuthintela nokusombulula i-self-PEEP, ixesha elaneleyo kufuneka livunyelwe ukuba umoya uphume emiphungeni ngexesha lokuphefumla.

Injongo kulawulo kukucutha umlinganiselo okhuthazayo/wokuphelelwa ngamandla; oku kunokufezekiswa ngokunciphisa izinga lokuphefumula, ukunciphisa umthamo wokuphefumula (umthamo ophezulu uya kufuna ixesha elide lokushiya imiphunga), kunye nokwandisa ukuhamba kokuphefumula (ukuba umoya uhanjiswa ngokukhawuleza, ixesha lokuphefumula lifutshane kwaye ixesha lokuphefumula liya kuba ixesha elide kulo naliphi na izinga lokuphefumla).

Isiphumo esifanayo sinokufezekiswa ngokusebenzisa i-square waveform for inspiratory flow; oku kuthetha ukuba sinokuseta i-ventilator ukuhambisa konke ukuhamba ukusuka ekuqaleni ukuya ekupheleni kwempembelelo.

Obunye ubuchule obunokubekwa kukuqinisekisa ukuthomalalisa okwaneleyo ukuze kuthintelwe ukungena komoya kumguli kunye nokusetyenziswa kwebronchodilators kunye ne-steroids ukunciphisa ukuvalwa kwendlela yomoya.

Ukuba i-auto-PEEP inzima kwaye ibangela ukwehla koxinzelelo lwegazi, ukukhulula isigulana kwisixhobo sokungenisa umoya kunye nokuvumela wonke umoya ukuba ukhutshwe kunokuba ngumlinganiselo wokusindisa ubomi.

Ukufumana inkcazo epheleleyo yolawulo lwe-auto-PEEP, bona inqaku elinesihloko esithi "Positive End-Expiratory Pressure (PEEP)."

Enye ingxaki eqhelekileyo efunyanwa kwizigulana ezifumana umoya wokuphefumla ngoomatshini sisigulana-i-dysynchrony, edla ngokubizwa ngokuba "ngumzabalazo we-ventilator."

Izizathu ezibalulekileyo ziquka i-hypoxia, i-self-PEEP, ukungaphumeleli ukuhlangabezana ne-oxygenation yesigulane okanye iimfuno zomoya, intlungu, kunye nokungahambi kakuhle.

Emva kokulawula izizathu ezibalulekileyo ezifana ne-pneumothorax okanye i-atelectasis, qwalasela induduzo yesigulane kunye nokuqinisekisa ukuthotywa okwaneleyo kunye ne-analgesia.

Cinga ngokutshintsha imo yokungena komoya, njengoko ezinye izigulana zinokuphendula bhetele kwiindlela ezahlukeneyo zokuphefumla.

Ingqwalasela ekhethekileyo kufuneka ihlawulwe kwiisetingi zokungenisa umoya phantsi kwezi meko zilandelayo:

I-COPD yimeko ekhethekileyo, njengoko imiphunga ye-COPD ecocekileyo inokuthotyelwa okuphezulu, okubangela ukuthambekela okuphezulu kokuthintelwa kokuhamba komoya okuguquguqukayo ngenxa yokudilika kwendlela yomoya kunye nokungena komoya, okwenza izigulane zeCOPD zithande kakhulu ukuphuhlisa i-auto-PEEP. Ukusebenzisa isicwangciso sokukhusela umoya kunye nokuhamba okuphezulu kunye nezinga eliphantsi lokuphefumula kunokunceda ukukhusela i-self-PEEP. Enye inkalo ebalulekileyo ekufuneka iqwalaselwe kwi-hypercapnic engapheliyo yokungaphumeleli kokuphefumla (ngenxa yeCOPD okanye esinye isizathu) kukuba akuyimfuneko ukulungisa i-CO2 ukuyibuyisela kwimeko yesiqhelo, njengoko ezi zigulana zihlala zinembuyekezo ye-metabolic yeengxaki zabo zokuphefumla. Ukuba isigulane singena kumanqanaba aqhelekileyo e-CO2, i-bicarbonate yakhe iyancipha kwaye, xa ikhutshwe, ingena ngokukhawuleza kwi-acidosis yokuphefumula ngenxa yokuba izintso azikwazi ukuphendula ngokukhawuleza njengoko imiphunga kunye ne-CO2 ibuyela kwisiseko, ebangela ukungaphumeleli kokuphefumula kunye nokubuyisela kwakhona. Ukuphepha oku, iithagethi zeCO2 kufuneka zimiselwe ngokusekelwe kwi-pH kunye nesiseko esaziwayo okanye esibalwe ngaphambili.
I-asthma: Njenge-COPD, izigulane ezine-asthma zithandwa kakhulu ekubanjweni komoya, nangona isizathu sahluke ngokwe-pathophysiologically. Kwi-asthma, ukungena emoyeni kubangelwa ukuvuvukala, i-bronchospasm kunye neeplagi ze-mucus, kungekhona ukuwa kwe-airway. Iqhinga lokuthintela i-PEEP iyafana naleyo isetyenziswa kwiCOPD.
I-Cardiogenic pulmonary edema: i-PEEP ephakamileyo inokunciphisa ukubuya kwe-venous kwaye incede ukusombulula i-edema ye-pulmonary, kunye nokukhuthaza ukuphuma kwentliziyo. Inkxalabo kufuneka ibe kukuqinisekisa ukuba isigulane sine-diuretic eyaneleyo ngaphambi kokuba i-extubating, njengoko ukususwa koxinzelelo oluhle kunokunyusa i-edema entsha ye-pulmonary.
I-ARDS luhlobo lwe-noncardiogenic pulmonary edema. Isicwangciso semiphunga evulekileyo kunye ne-PEEP ephezulu kunye nomthamo ophantsi wamaza ubonakaliswe ukuphucula ukusweleka.
I-Pulmonary embolism yimeko enzima. Ezi zigulana zixhomekeke kumthwalo wangaphambili kakhulu ngenxa yokunyuka okuqatha koxinzelelo lwe-atrial yasekunene. Intubation yezi zigulana iya kwandisa uxinzelelo lwe-RA kwaye inciphise ngakumbi ukubuya kwe-venous, kunye nomngcipheko wokothuka. Ukuba akukho ndlela yokuphepha intubation, ingqalelo kufuneka ihlawulwe kwixinzelelo lwegazi kunye nolawulo lwe-vasopressor kufuneka luqaliswe ngokukhawuleza.
I-acidosis esulungekileyo embi kakhulu yingxaki. Xa ufaka i-intubating ezi zi gulane, ingqwalasela esondeleyo kufuneka ihlawulwe kumzuzu wabo wokungena umoya we-pre-intubation. Ukuba le ventilation ayibonelelwanga xa ukuxhaswa komatshini kuqalwa, i-pH iya kuhla ngakumbi, enokuthi ibangele ukubanjwa kwentliziyo.

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