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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