呼吸器的基本概念
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機械通氣(Ventilation)的分類
(1) 負壓通氣
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以鐵肺為代表,
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直接在胸廓上給予一個往外的壓力,進而產生胸腔內負壓,讓氣體從外界進入肺臟,較符合生理的機轉。
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在低血容者,作用在腹腔的負壓可能導致血液滯留,導致回心血不足
(2) 正壓通氣
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包括插管;非侵入性正壓通氣(NIPV)
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吸氣期:外界給予正壓(Pawo>0),大於肺泡壓,氣體流入肺部
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肺泡壓持續增加,當壓力等於Pawo時,達成平衡,氣體不再流入
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吐氣期:外界給較小的正壓,由於肺泡壓仍大,使得氣體流出
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直到兩者壓力達到平衡,吐氣期才結束
(3) 高頻通氣
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給予非常高的通氣速率,加上低於正常的通氣volume
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HFPPV高頻正壓通氣:每分鐘給60-100
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HFJV高頻噴射通氣(jet ventilation):每分鐘100~600
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HFOV高頻震盪通氣(oscillatory ventilation):可以使用到上千的速率
呼吸運動方程式
{肌肉運動產生的壓力}加上{外界ventilation的壓力}
= {胸廓的反彈壓}加上{克服流速阻力的壓力}-
肌肉運動產生的壓力:在麻醉中=0
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外界ventilation的壓力:呼吸器調的pressure
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胸廓的反彈壓:彈性X容積
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克服流速的阻力:阻力X流速
呼吸器的控制:VC;PC
根據上述的運動方程式,能夠改變的變相有四個,分別為外界壓力;容積;流速還有時間四個變項
(1) Volume control- 控制每次打的容積,壓力則相對應改變→最常使用
- 好處:可以控制每次打出去的容積,但壓力則不一定
- 在呼吸道阻力大的患者上,打出去的壓力可能會太高,增加barotrauma的風險!
要設定pressure limiting,避免壓力過大
(2) Pressure control
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控制每次打的壓力,容積則相對應改變
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可以控制每次打出去的壓力,所以可以避免barotrauma的發生,也能設定好適當的壓力來應對resistance→主要用在ARDS患者
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控制壓力,卻沒辦法確保容積→如果阻力太大可能容積會不足
(3)Time control
- 少用→高頻jet ventilator;oscillation等等
(4) 其他
- 上述是比較基本的model,後來也有一些PRVC (pressure related volume control)、VRPC (volume related pressure control)等,來達到更好的控制,相關的內容請點連結。
呼吸器的引動→是哪個因子決定呼吸器的動作?
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時間:時間一到,就開始進行換氣
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病人
感應到病人引動的壓力/流速變化→呼吸器進行換氣
需要設定靈敏度,設定適當的threshold
呼吸的終止→是哪個因子決定呼吸循環的結束
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容積循環控制:打完設定的容積,一個循環結束 (VC mode)
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時間循環控制:預設的時間結束後,一個循環結束 (PC mode)
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流速循環控制:流速下降到某個值後,一個循環結束
呼吸器的傳送模式
(1) CMV:continuous mandatory ventilation:持續強制通氣
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持續給予正壓的呼吸,依照引動方式可以分成兩大類
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Time trigger:固定時間,持續給予正壓的呼吸
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病人trigger:病人誘發的呼吸→也就是所謂的A/C (assist/control) mode
(2) IPPV:intermittent positive pressure ventilation:間歇正壓通氣
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兩個正壓通氣時間隔較長,能夠訓練病人的呼吸
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IMV:intermittent mandatory ventilation:固定時間間隔,給予呼吸
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SIMV:synchronized IMV:配合病人的呼吸,提高同步性,減少fighting
總結
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依據控制的變項:VC;PC;VRPC;PRVC
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依據啟動的因子:time trigger/ patient trigger
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依據通氣的模式:CMV (C, A/C);IPPV (IMV, SIMV)
Reference 呼吸器原理及應用,p45-62, p81-p104
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