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    呼吸器的基本概念

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    呼吸器ventilator 胸腔科
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      TinyNotes last edited by TinyNotes

      機械通氣(Ventilation)的分類

      (1) 負壓通氣

      • 以鐵肺為代表,

      • 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。

      • 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

      • 包括插管;非侵入性正壓通氣(NIPV)

      • 吸氣期:外界給予正壓(Pawo>0),大於肺泡壓,氣體流入肺部

      • 肺泡壓持續增加,當壓力等於Pawo時,達成平衡,氣體不再流入

      • 吐氣期:外界給較小的正壓,由於肺泡壓仍大,使得氣體流出

      • 直到兩者壓力達到平衡,吐氣期才結束

      (3) 高頻通氣

      • 給予非常高的通氣速率,加上低於正常的通氣volume

      • HFPPV高頻正壓通氣:每分鐘給60-100

      • HFJV高頻噴射通氣(jet ventilation):每分鐘100~600

      • 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

      • 外界ventilation的壓力:呼吸器調的pressure

      • 胸廓的反彈壓:彈性X容積

      • 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

      • 控制每次打的壓力,容積則相對應改變

      • 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

      • 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?

      • 時間:時間一到,就開始進行換氣

      • 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

      • 容積循環控制:打完設定的容積,一個循環結束 (VC mode)

      • 時間循環控制:預設的時間結束後,一個循環結束 (PC mode)

      • 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

      • 持續給予正壓的呼吸,依照引動方式可以分成兩大類

      • Time trigger:固定時間,持續給予正壓的呼吸

      • 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

      • 兩個正壓通氣時間隔較長,能夠訓練病人的呼吸

      • IMV:intermittent mandatory ventilation:固定時間間隔,給予呼吸

      • SIMV:synchronized IMV:配合病人的呼吸,提高同步性,減少fighting

      總結

      • 依據控制的變項:VC;PC;VRPC;PRVC

      • 依據啟動的因子:time trigger/ patient trigger

      • 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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