Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Which patients with acute exacerbation [r]
Trang 1Sherstin T Lommatzsch, MD Assistant Professor of Medicine
National Jewish Health
Denver, CO
Trang 2 Phát hiện được triệu chứng của đợt cấp
Trang 3Điều trị ngoại trú
Trang 4 Chẩn đoán phân biệt
Trang 5• TRÁNH tăng oxy máu
• Cường beta giao cảm
Trang 7 Thông khí nhân tạo không xâm nhập áp lực dương
• Suy hô hấp tăng CO2 mất bù
Trang 8 Thông khí xâm nhập áp lực dương (IPPV)
Trang 9 Thông khí xâm nhập áp lực dương (IPPV)
• Quản lý
1 Lựa chọn bệnh nhân
• Triggering Modes
• Hỗ trợ Kiểm soát (AC)
• Thông khí ng ắt quãng theo yêu cầu /Hỗ trợ áp lực (IMV/PS)
• [ Thông khí hỗ trợ áp lực ] (PSV) – Không sử dụng giai đoạn cấp
• Điều chỉnh FiO2 để đạt PaO2 = 60mmH (SpO2 = 88-92%)
• An thần tối thiểu– Richland Aggitation Scale Score (RASS): zero - neg one
• Phục hồi chức năng hô hấp
2 Cơ học phổi và Thông khí không đồng bộ
3 Rút nội khí quản sớm
Thường cài đặt mode
SIMV
Thông khí kiểm soát ngắt quãng đồng thì
Trang 10 Thông khí nhân tạo xâm nhập (IPPV) – Đối tượng
• Hỗ trợ- Kiểm soát (AC) – Lựa chọn đầu tiên
• BS lâm sàng kiểm soát thông khí phút tối thiểu
• BS cài đặt Vt (5-7ml/Kg IBW)
• BS cài đ ặt tần số thở (4 BPM th ấ p hơn t ầ n s ố th ở c ủ a BN)
• T ần số thở của BN trên tần số thở cài đặt của BS-Cài đặt Vt
• Thông khí ngắt quãng theo yêu cầu với Hỗ trợ áp lực
• BS lâm sàng kiểm soát thông khí phút tối thiểu
• BS cài đặt Vt, tần số thở
• T ần số thở của BN trên tần số thở cài đặt của BS- Cài đặt Vt dựa vào tốc
độ dòng
• Thông khí hỗ trợ áp lực – KHÔNG khuyến cáo giai đoạn cấp
• Kiểm soát thông khí phút của bệnh nhân
• Xem xét t ần số thở của bệnh nhân và Vt
Trang 11 Thông khí nhân tạo áp lực dương xâm nhập (IPPV) – Không đồng thì
Trang 12 Thông khí nhân tạo áp lực dương xâm nhập (IPPV) – Không đồng thì
• COPD Bệnh lý tắc nghẽn Khí không thoát ra được
A Auto-PEEP (PEEP nội sinh)
• Thêm áp lực cuối thì thở ra
• Tiến hành giữ áp lực cuối thì thở ra
• Auto-PEEP = Giữ áp lực cuối thì thở ra – Cài đặt PEEP
• Áp dụng PEEP Khắc phục được tăng công hô hấp gây ra bởi Auto-PEEP
• Thêm PEEP vào để cài đặt PEEP
• Auto-PEEP (0.80) + Cài đặt PEEP
End-Exp Hold 12 cmH2O Set PEEP 5 cmH2O
Auto-PEEP 7 cmH2O
0.80 Applied PEEP 6 cmH2O
MỨc giá trị gợi
ý ban đầu
Ví dụ
Giải pháp
Trang 13 Thông khí nhân tạo áp lực dương xâm nhập (IPPV) – Không đồng thì
Hoặc
Trang 14 Thông khí nhân tạo áp lực dương xâm nhập (IPPV) – Không đồng thì
Trang 15 Thông khí nhân tạo xâm nhập (IPPV) – Rút nội khí quản
• Rút nội khí quản sớm
• Th ử cho BN tự thở (SBT)
• Tiến hành khi nào?
• Căn nguyên gây suy hô hấp vẫn còn
• Thông khí hỗ trợ tối thiểu ( FIO2 = 0.4, PEEP = 5cmH2O )
• Với tinh thần tỉnh táo và ít bài tiết đờm
• Nếu tự thở thất bại Rút NKQ cho thở BiPAP
Giảm:
Tỷ lệ tử vong Viêm phổi thở máy Thời gian thở máy
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Organized jointly by the American Thoracic Society, the European Respiratory Society, the EuropeanSociety of Intensive Care Medicine, and the SociÈtÈ
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