机械通气的护理

机械通气的护理 机械通气临床应用与护理 , 机械通气的目的、适应征及禁忌症 , 机械通气的常用参数调节 , 各种通气模式特点 , 无创正压机械通气 , 通气策略的改变 , 呼吸机相关肺炎 , 人机对抗及机械通气的报警与处理 , 呼吸机的撤离及意外拔管 , 机械通气的护理 机械通气是在患者自然通气和/或氧合功能出现障碍时运用器械使患者恢复有效通气并改善氧合的支持手段，主要目的是为治疗原发病争取时间。 机械通气的目的 (一)机械通气的生理目的 1、支持或维护肺部的气体交换; ? 维护正常肺泡通气，使PaCo2和Ph保持在正常范围 ? 维持正常动脉血氧合，使PaO2、SaO2保持在能接受的范围， SaO2>90%， PaO2>60mmHg。 2、增加肺容量: ? 在吸气末使肺部扩张:每次呼吸后使肺部得到充分的扩张，以预防和治疗肺不张，并改善氧合和肺部顺应性。 ? 增加功能残气量(FRC):ARDS时使用PEEP 3、减少呼吸功: 气道阻力增加或肺顺应性降低、呼吸功增加时，机械通气可减轻呼吸功和呼吸肌群的负荷。 机械通气的临床目的 1.纠正低氧血症。 2.治疗急性呼吸性酸中毒，纠正危及生命的急性酸血症， *但不必要恢复 PaCo2至正常范围。 3.缓解呼吸窘迫，当原发疾病缓解和改善时，逆转患者的呼吸困难症状。 4.纠正呼吸肌群的疲劳。 5.手术麻醉过程中，ICU的某些操作和疾病的过程中，为安全使用镇静剂和/或神经肌肉阻断剂。 6.降低全身或心肌的氧耗量: *如心源性休克时，当呼吸肌群或其他肌群的活动，损害了全身氧释放并使心脏的负荷增加，应用机械通气可降低全身和心肌的氧耗量。 机械通气的适应证 (一)预防性通气治疗 预防性通气治疗能减少呼吸功和氧耗量，从而减轻心肺功能负荷。指征: 1.发生呼吸衰竭高度危险性的患者长时间休克;严重的颅外伤;严重的COPD患者腹部手术for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 后; 2.减轻心血管系统负荷 心脏术后; 治疗性通气治疗 出现呼吸衰竭的表现，如呼吸困难、呼吸将停止或已停止、意识障碍、循环功能不全时; 不能维持有效的自主呼吸， 呼吸功能已受严重影响，可应用机械通气。 呼吸系疾病所致呼吸衰竭 ? COPD急性加重所致呼吸衰竭，有缺氧和CO2潴留症状，紫绀、烦躁不安、神志恍惚和嗜睡等。 . 但这类患者常能耐受缺氧和CO2潴留，一般先保守治疗，如控制感染，改善通气。不急于机械通气治疗。 . 如保守治疗无效，呼衰加重，pH，7.2~7.25;呼吸频率，30-40次?分，PaCO2上升快，PaO2，45?Hg，出现呼吸抑制、严重神志障碍时可应用机械通气(无创通气或常规机械通气) ?继发于严重创伤、休克、感染之后出现的ARDS。 呼吸早期低氧血症。如FiO2为0.6时，PaO2，60?Hg，可考虑机械通气治疗。 ?严重胸部外伤后合并呼吸衰竭，肺部手术后出现急性呼吸功能不全时。 ?急性肺充血或肺水肿经保守治疗无效者，科应用机械通气，如急性心肌梗死或充血性心力衰竭合并呼吸衰竭，此类呼吸衰竭主要为低氧血症，可应用机械通气促进氧合作用，并减少肺水。 肺外原因所致的呼吸衰竭 ?中枢神经系统疾病引起的呼吸中枢功能不全，进而导致急性呼吸衰竭，如颅内高压、脑炎、脑外伤、脑血管意外、药物中毒、镇静剂或麻醉药剂过量等。 ?神经肌肉疾患所致的呼吸衰竭:如重症肌无力、格林-巴利综合征等，由于神经传导功能受损，从而影响了呼吸机的活动，导致通气不足、缺氧和CO2潴留。 ?心脏骤停复苏后，为预防发生呼吸功能衰竭，可短期应用机械通气。 机械通气的禁忌症 随着通气技术进展，无绝对禁忌症 相对禁忌症: 巨大肺大泡或肺囊肿，若机械通气治疗，可使大泡或肺囊肿内压力升高，有发生破裂及发生气胸的可能。 张力性气胸伴,不伴纵膈气肿，没有进行适当引流时。 通气可把血块压入小气道。此时应先吸净气管内的血块，使气道通畅后再行机械通气治疗。 活动性肺结核出现播散时。 参数调节 吸入氧浓度FiO2 机械通气初，吸入氧浓度设定在较高的水平 FiO2调至0.7-1.0，保证组织适当的氧合。 ? 测第一次血气后，FiO2逐渐降低，使PaO2维持可接受水平，即PaO2，60?Hg。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet ? FiO2在0.6以上才能维持SaO2，应考虑使用PEEP。 ?连续监测血氧饱和度，作为调节依据。 潮气量 常规设定VT为10-15ml,?体重。机械通气的VT大于自主呼吸的VT5-8ml,kg体重，目的为预防肺泡塌陷。 如肺已充气过度，应使用较小的VT，如严重的支气管痉挛，以及肺顺应性显著减少的疾病。较大VT可导致呼气峰压(PIP)的明显增加，易并发气压伤。 ARDS时，较大VT可使吸入气体分布不均，在顺应性好的肺区，气体分布较多，导致无明显病变的肺泡过度扩张，产生生理死腔的增加以及并发气压伤。 以上情况应用VT，10ml,?(6~8ml,?) 呼出气潮气量(EVT) 最正确测定接受通气量的方法:呼出气潮气量(EVT)。 如使用PSV模式，由于肺部的病变或损伤，实际潮气量可随每次的呼吸而变化。 如应用容量切换型呼吸机，由于管路中漏气或气道周围漏气，或有支气管胸膜漏，以及管路中的气体压缩等原因，可造成一定量的潮气量丧失。 实际上所接受的VT，在各种通气模式中，需通过监测EVT来确定。 如EVT偏离预先设定的VT超过100ml，应检查整个呼吸机系统和患者的病情变化。 呼吸频率(RR) RR设置，接近生理呼吸频率，即10-20次?分。 呼吸机的运行过程中，应根据PaCO2和pH以及自主呼吸的情况，随时调整呼吸频率。 通气治疗初需完全通气支持。按潮气量大小来决定RR。 每分钟通气量=呼吸频率×潮气量 如患者参于了呼吸，则RR应降低，使每分钟通气量能维持正常的酸碱状态。 COPD患者，使用较慢的RR，由于RR降低，可有更充分的时间来呼出气体。气体陷闭减少。 肺顺应性较差(ARDS)的患者可使用较快频率，及较小潮气量以防止因气道压力增加而产生的气压伤。 灵敏度(Sensitivity) 吸气流量的触发有:压力触发和流量触发 (一)压力触发(Pressure- Trigger) 触发呼吸时，管道内压力降至一定水平，吸气时管道中所形成压力必须低于基线压力。 灵敏度设置:低于吸气末压力2 cm H2 O。 灵敏度设置应较容易地触发呼吸机。如用较大力量触发呼吸机，或产生气流的时间发生延缓，则可增加呼吸肌群工作强度。 触发灵敏度太高，患者可一次接一次的触发 流量触发(Flow- Trigger) 压力触发型呼吸机，患者需要作一定的功，才能触发通气。所作功用于产生一定的负压(-0.5~-2cmH20作功需要一定的延缓时间(100ms) 流量触发型呼吸机，不需要患者作功来触发呼吸机，无延缓时间。基础流速5-10/min，触发for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 流速在 基 础 流 速 下 1-3/min。 吸呼比(I: E) I:E是吸气与呼气时间的比例，通常I:E设定在1:2，即:在整个呼吸周期中，吸气时间占33%，呼气时间占66%。 ?较短的吸气时间才能扩张大部分顺应性较好的肺泡，以减少死腔: ?如果吸气时间较长，则可能增加平均气道压力，而影响血流动力学。个别COPD患者可用I;E为I;3或I;4进行机械通气，因较长的呼气时间可使呼气更完全，减少气体陷闭。 呼气末正压(PEEP) 常用PEEP为5-20 H2 O。 *PEEP复原不张的肺泡，阻止肺泡和小气道在呼气时关闭，并能将肺水从肺泡内重新分布到肺血管外。 *PEEP降低肺内分流，增加功能残气量改善肺顺应性，减少氧弥散距离， 增加氧合。 PEEP应用指征 PEEP预防和恢复肺不张，对长期卧床者适用 *如Pa O2?60mm Hg, SaO2,90%，而FiO2在0.6 以上，应用PEEP后，能用较低的FiO2获得较好氧合作用 相对禁忌症: ?单侧肺部疾病时应用PEEP，可致健侧肺泡过度膨胀。而使病变肺增加死腔和血流灌注受损，并使通气不良的肺组织增加肺内分流。 ?COPD功能残气量增加与气体陷闭，PEEP增加胸腔内压力，且有潜在肺部气压伤和心输出量下降的危险性。 绝对禁忌症: 气胸(未处理)，气管胸膜漏和颅内压升高等。 PEEP的应用和撤离 *最初PEEP 5 cm H2 O，后再一句情况增加，改变PEEP后20分钟，测定血气。 *最佳PEEP:PEEP较低SaO2,90%， Pa O2,60mm Hg， FiO2,0.6且不影响氧释放到周围组织。 *PEEP使心输出量下降，损害氧向组织释放，降低PEEP， FiO2适当增加。 *高水平PEEP将过度哭张肺泡，造成肺毛细血管床明显压迫，增加死腔，加重高碳酸血症。 PEEP的撤离 当FiO20.6以下，血流动力学稳定，病情得以控制，可逐渐撤离PEEP。 PEEP应以2~3cm H2 O逐渐下调，每次调整PEEP后，应对氧合作用作恰当估价。 PEEP每次下降之后，应稳定6小时以上。 突然完全撤离PEEP可立即发生低氧血症，这与气道的闭合有关。 通气模式 辅助/控制型(A/C:CMV) 半自主型:同步间歇指令呼吸SIMV for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 自主型(Spontaneous) 完全通气与部分通气支持 (一)完全通气支持 控制机械通气(CMV)、辅助/控制模式(A/C)时，呼吸机提供维持有效肺泡通气所需的全部工作量。 * 不需患者进行自主呼吸以吸入气体及排除CO2。 控制机械通气 Controlled Mechanical Ventilation, CMV ? 定义:CMV时，患者接受预设通气频率及潮气量，不能触发机械呼吸。 ?CMV 的优缺点: 不能进行自主呼吸，会引起患者与呼吸机的不同步，须应用镇定剂。肺泡通气和呼吸对酸-碱平衡的调节作用，完全由医生所控制.长期使用 CMV，患者的呼吸肌会衰弱和萎缩，将造成呼吸机的撤离困难。 CMV 监护 ?吸气峰压 (PIP): PIP将随着肺顺应性和气道阻力的变化而变化。 ?呼出气潮气量(EVT)如果EVT偏离潮气量100ml以上则需寻找潮气量丧失的原因。 ?酸碱平衡:完全由临床医生所控制。 ?患者-呼吸机不同步。 辅助,控制模式 (Assist,Control Mode，A,C) 定义:呼吸机以预定频率释放出预定潮气量。在呼吸机触发呼吸的期间，患者也能触发自主呼吸，当呼吸机感知患者自主呼吸时，释放出一次预先决定的潮气量。 允许患者控制呼吸频率，不能改变自主改变自主呼吸的潮气量。 患者所作的呼吸功仅仅是吸气时产生一定的负压，触发呼吸机，设置适当流速率和灵敏度，患者所作的呼吸功可相当少。 A,C模式时的监护 ?吸气峰压(PIP); ?呼出气潮气量(EVT); ?患者在机械通气时的舒服程度。 ?患者在发生自主呼吸时，监测气道压力并调节灵敏度，允许患者使用较小的触发呼吸努力。 ?调节流速率满足吸气需要。使用A,C模式时，触发灵敏度和流速率为影响患者呼吸功的主要因素。 ?密切监视酸碱平衡，如有过度通气，科考虑应用镇静剂 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 同步间歇强制通气 1.定义:在呼吸机设定的强制通气期间，患者能触发自主呼吸，自主呼吸潮气量的大小与产生的呼吸力量有关。 SIMV 时能主动控制呼吸频率和潮气量。 SIMV能与自主呼吸配合，减少拮抗。 呼吸机萎缩的可能性较小。 血流动力学效应少，与平均气道压力低有关。 SIMV 缺点 ?如自主呼吸良好，会使SIMV频率增加，超过原先设置的频率; ?同步触发的强制通气量，再加上患者自主呼吸的潮气量可导致通气量的增加。如患者的自主呼吸的潮气量为200ml，设定的呼吸机SIMV潮气量为600ml，则此时的一次潮气量可达800ml。 ?如病情恶化，自主呼吸突然停止，则可发生通气不足。 ?由于自主呼吸存在一定程度上可增加呼吸功，如使用不当将导致呼吸肌群的疲劳。 SIMV的监护 ?呼吸频率:如呼吸频率增加，应重新测定自主呼吸的潮气量，一般来说，自主呼吸的潮气量为6-8ml/kg。如发生浅而速的通气，可造成肺不张、肺顺应性的下降并增加呼吸功。 ?吸气峰压(PIP) ?强制通气的潮气量和自主呼吸的潮气量。 ?患者舒适程度:患者自觉不能从呼吸机获得足够气体，应仔细检查灵敏度和流速率是否适当。 持续气道正压 1.定义:CPAP应用于有自主呼吸者，在呼吸周期的全过程中使用正压的一种通气模式。 CPAP常用于撤离呼吸机，患者有稳定的呼吸驱动力和适当潮气量，与SIMV交换使用。 减轻肺不张，维持和增加呼吸肌群的强度。 引起心输出量下降，增加胸腔内压力和导致肺部气压伤。 CPAP作用原理 CPAP在呼气末给予正压支持，可防止肺泡塌陷，改善功能残气量(FRC)并提高氧合作用。 CPAP生理作用等于PEEP 区别为CPAP是自主呼吸的情况下，基础压力升高的一种通气模式:而PEEP也是基础压力升高的一种通气，但同时也应有其它方式的呼吸支持(如:A/C，SIMV，PSV等)。 CPAP时的监护 ?呼吸频率(RR):RR应少于25次/分 ?湖出气潮气量(EVT):EVT应为5-8ml/kg，如小于5ml/kg，说明患者的呼吸肌群没有足够的力量来产生适当的潮气量。这时应改用其它通气模式，如PSV，SIMV或A/C。 患者舒适程度:如患者主诉不能得到足够的气量，应适当调整流速率。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 压力支持 1.定义: PSV是指患者自主呼吸触发吸气，呼吸机以预定压力释放出气流，整个吸气过程保持一定压力。 患者应有可靠的呼吸驱动。 PSV不需设定VT，由患者吸气力量和压力支持水平，以及患者和呼吸机整个系统顺应性和阻力等因素决定。 PSV可单独应用或与SIMV联合。SIMV和PSV联合时，万一发生呼吸暂停，患者会得到预定的强制通气支持。 PSV监护 1.呼出气潮气量(EVT):EVT降低可能发生肺不张。肺顺应性下降，气道阻力增加，呼吸肌群肌力弱，支气管胸膜漏。 2.呼吸频率(RR):RR应小于25次/分。 无创伤正压支持通气 NIPSV，也称为双水平气道正压通气(BIPAP)，同时设定气道内吸气正压水平(IPAP)和呼气正压水平(EPAP)。 与常规呼吸机比较，IPAP等于PS，BPAP等于PEEP。 能提供适当通气支持，而无需气管插管或气管切开 提供吸气辅助，潮气量放大，对微弱呼吸肌群提供帮助; 本质上等于PS，差别在与NIPSV为一种流量触发的系统，应用时需通过鼻面罩来进行。 NIPSV成功治疗的关键因素 疾病严重指数较低 无缺齿 口周漏气较少 意识清楚 能够与无创通气机相配合 高碳酸血症不十分严重 酸血症不十分显著(PH>7.1) 无创通气后2小时，能改善生命指征和血气 通气策略的改变 ?通气参数选择:符合病理生理:VT5-12ml/kg:RR:15-25次/分 严格限制平台压，Pplat<35cm H2O: 合理加用PEEP ?通气模式的选择:应用“定压型”模式，PCV，PSV，PSV+SIMV，防止肺泡内压急骤增高和呼吸机所致肺损伤。 ?适当延长吸气时间，降低吸气峰流速水平，以预防峰流速过高而产生的气道压力增加。 ?减少强制通气，促进机械通气和自主呼吸协调配合 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 呼吸机相关性肺炎 是指机械通气至少48小时或人工气管拔管48小时以内发生的肺炎，主要是细菌性肺炎。 VAP感染的原因:?呼吸道和全身防御机制受损;?污染器械及不严格的无菌操作;?胃内容物的反流及口腔分泌物的吸入;?生物被膜形成。 VAP诊断标准:发热、咳脓性痰、白细胞增加、X线胸片上出现新的浸润影。肺炎的组织学证据;阳性血和胸水培养并与气管内吸引物培养发现的致病菌一致。 呼吸机相关性肺炎—预防 ?尽早撤机，缩短上机时间，以“肺部感染控制窗”为切换点，实施有创-无创序贯通气治疗; ?加强消毒隔离; ?气道分泌物的及时清楚及防止吸入; ?加强营养支持。 ?合理使用抗生素。 患者与呼吸机对抗或非同步 临床上患者有明显的呼吸困难、烦躁不安、鼻翼扇动、心动过速、多汗和血压升高等症状。 呼吸机上各种报警参数触发:气道压力增加、潮气量降低、氧饱和度降低，血流动力学不稳，可伴有心律紊乱，甚至会出现休克或窒息。 与呼吸机有关的因素: ?灵敏度设置太高或太低; ?吸气峰流速速率设置不当; ?通气支持不恰当或氧输送存在某些问题; ?呼吸机管道中漏气或患者—呼吸机脱落。 患者与呼吸机对抗或非同步 与患者相关因素: ?人工气道问题:气囊疝入，插管上移 ?气道阻力增加:支气管痉挛，气道内分泌物增加; ?肺部顺应性急剧改变:张力性气胸，肺水肿; ?呼吸驱动力改变:中枢神经高通气，呼吸肌疲劳; ?通气/灌注比例:肺栓塞; ?烦躁不安和焦虑:不适当的镇静，疼痛等有关。 机械通气的报警与识别 一、压力过高: 原因:气道阻塞、支气管痉挛、人工气道部分脱出、气胸、人机对抗、肺顺应性降低、气道导管滑入一侧支气管、设置不当。 处理:排除原因、给予药物、调整触发灵敏度、改变呼吸机设置等。 二、压力过低: 原因:管路脱落或漏气、压缩机、氧气源。 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 呼吸机常见报警原因及处理 呼吸机发出警报的处理 有呼吸窘迫时: 断开呼吸机，使用人工球囊 检查管路+呼吸机参数检测 吸痰 若为气胸或气道阻塞，需要立即解决 无呼吸窘迫时: 找出警报的讯息 撤机前的准备 有效治疗急性呼衰的直接原因:感染、肺水肿、气管痉挛。 充分撤机准备中枢神经系统有适宜的呼吸驱动力，纠正感染中毒和电解质紊乱所致的脑病 增强呼吸肌群强度:补充营养，提高血浆蛋白水平，使呼吸机适应撤机后的工作负荷。 应及早改用部分通气支持，预防呼吸肌群的废用性萎缩，改善心功能，使血流动力学保持在正常状态。 撤机标准 1.氧合指标 FIO2<0.5时，PaO2>70mmHg， 并且PEEP<5cm H2O; 或PaO2/FIO2>200; 2.通气指标: for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 血气分析示:PaCO235-45mmHg PH为7.3-7.45; 呼吸功能:评价呼吸肌群的强度和耐力。 ?分钟通气量(MV):6L/分，<10L分理想指标。 ?潮气量(VT):VT>300ml ?呼吸频率(RR):<25次/分 /L(VT单位为L),f/VT<80，撤机?呼吸频率和潮气量的比例(f/VT):正常40—60次/分 较容易:80—105需谨慎撤机:>105撤机困难。 ?肺活量(VC):达到10—15ml/kg。 撤机的方式 病情较轻，短期或间歇使用呼吸机者，可试验停机一小时，观察临床表现和血气分析，如无明显异常即可撤机，无需过度阶段。 长期使用机械通气者，可在加强氧疗的基础上，采用间歇停机的方法，停机前作好充分准备，清理呼吸道分泌物，增加吸氧浓度。停机宜在上午进行，开始停机5—10分钟，每天3—5次，观察生命体征、血气分析的变化。如无异常可逐渐增加停机次数和时间，条件成熟后可完全停机。 CPAP撤机 撤机时应用CPAP，患者所作呼吸功是增加的。 最初使用时间仅为5分钟，以后随着呼吸功能的改善可增加CPAP的时间。 在间歇期仍使用完全机械通气支持。 应用CPAP时应逐渐降低正压水平，当CPAP减至3—5cmH20患者能自主呼吸2—4小时以上，撤机基本成功。 IMV 模式撤机 允许患者在呼吸机强制通气的间期进行自主呼吸，逐渐降低强制通气的次数而进行撤机。 降低的次数取决于患者的反映和耐受程度。 IMV撤机时，机械通气的呼吸部分逐渐减少，而自主呼吸的部分逐渐增多，直到完全过度到自主呼吸。 IMV频率降到2—4次/分，维持2—4小时，可改用T管或CPAP模式或直接完全撤机。 PSV 撤机 降低吸气压力支持水平，加大呼吸肌负荷。对心肺功能和呼吸肌群强度较差者适用。 患者控制呼吸频率、潮气量、吸气流量和吸气时间，舒适程度和耐受性较好。有支气管痉挛或分泌物较多时，则潮气量降低。 撤机开始，调节吸气压力，使VT达到10—12ml/kg，随后下调压力水平，下调数值取决于患者耐受性和各项监测结果。 吸气压力6—10cm H2O时，稳定4—6小时后可撤机。 SIMV与PSV联合应用撤机 可使撤机更为平稳， ,开始时使用SIMV提供80%的通气量，PSV为6cm H20以上，以克服呼吸机管道阻力， ,逐渐向下调节SIM频率，当下调至2—4次/分后，将PSV压力水平下调至6—10cm for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet H2O，稳定4—6小时可撤机。 撤机失败 以下情况应恢复机械通气，12—24小时后再尝试: ?f>30-35次/分，胸腹部矛盾呼吸或辅助肌群，EVT<5ml/kg:SaO2降低。 ?血流动力学:心率变化>20次/分、心绞痛、心率不齐(房颤、室性异位心率)ST改变或血压下降超过20mmHg、皮温改变。 ?神经症状:焦虑、躁动、嗜睡，有低氧或高碳酸血症。 ?f/VT>80时，放慢撤机速度或暂停，若f/VT>105，需恢复机械通气。 拔 管 成功地撤机后，即要考虑拔管。 其时机为患者的呼吸功能进一步恢复，感染控制、痰量减少，具备相当的咳嗽能力，吞咽功能正常。 行气管切开的患者，气管套管拔管前要经过一段换管、堵管的准备时间。 其间可观察患者的临床表现，决定是否再继续保留气管套管的一段时间。 拔管前应彻底吸痰，术前宜禁食，为防止喉头水肿，拔管前1—2小时注射地塞米松5—10mg。 拔管前，行气囊上滞留物清除，抽出气囊的气体。于深吸气末迅速将导管拔出。 拔管后给予吸氧，术后2小时内不要进食，密切注意患者呼吸、循环和意识的变化。 部分患者在拔管后可考虑在短期内给予无创伤性机械通气，以减少拔管后的并发症 意外拔管 无拔管指征人工气道意外脱出 原因: 病人烦躁或意识不清 固定不当 呼吸机管道牵拉 气管切开管过短 意外拔管紧急处理 立即重建人工气道 气管切开3—5天，窦道未形成，先气管插管 气管插管困难者，用面罩加压给氧或口对口人工呼吸 机械通气的护理 气管插管的护理:妥善固定，双肺听诊，口腔护理，过程牙齿颗数 气管切开的护理:观察伤口，无菌操作，导管固定适宜 气管湿化:温度，湿度 吸痰:吸痰管的选择，吸痰时机，吸痰的方法(吸痰，无菌操作) 气囊的管理:及时检查是否充气不足或漏气，定时气囊上滞留物清除 血气分析与SpO2检测:先检查接头及仪器，再考虑影响(动脉硬化、严重贫血，末梢循环，指甲油，灰指甲等)，最后考虑低氧，检测血气。 精心的护理有助于患者的康复 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet