04 venugopal tv

Nhng tin b trong thng kh nhn toDr. Venugopal Reddy. MD, EDIC, FCARCSIAssociate Professor of Anesthesia & CCMDirector of Surgical Critical Care MedicinePenn State College of Medicine Hershey Medical Center, HersheyPennsylvania, USA

Kiu kim sot kp2000: ARDS Network. Th my vi th tch thpTruyn thng so vi Kim sot kpKim sot kp t iu chnh p lc t th tch kh lu thng Vi-trong-mt-nhp th (PC to VC)Th-thKt hp c 2

Nhng tin b trong thng kh nhn to

LoiMy thTnKim sot kp nhp th ti nhp th (Pressure limited time cycled)ServoDrgerPuritanPRVCAuto flowVolume Control+Kim sot kp nhp th ti nhp th (pressure limited flow cycle)ServoDrgerVolume supportProportional assist ventilationKiu cho php t thDrger-Evita 4Servo Maquet BiPAP and APRVBi VentKim sot kp nhp th ti nhp thHamilton GalileoAdaptive Support ventilation

Thng kh kim sot th tch iu chnh p lcThng kh kim sot th tch

Volume Control vs PRVCPressure Regulated Volume Control ventilation

ControlTriggerLimitVolumePatient or timePressureTargetCycleLowest pressure for set volumeTime

Nhp th th nghim (5 cm H2O above PEEP) p lc tng dn t th tch kh lu thng ci t p lc ti a c th Nhp th da vo ci t trc VE, f, and TI Khi VT tng ng gi tr ci t, p lc c gi hng nhNu th tch ci t ban u tng, p lc s gimKim sot th tch iu chnh p lc (PRVC)

PRVC: Tin bm bo VT v VE vi PIP ti thiup lc t ng iu chnh vi nhng thay i trong n hi v tr khng phiGim cng h hp WOBVE c sn p ng yu cu bnh o meet patient demandCi thin trao i kh vi gim dngPhn tch tng nhp thHn ch chn thng th tch v ng gim thng kh

PRVC: Bt lip lc bm da vo VT trc v nhng thay i N lc bnh nhn ngt qung VT thay ip lc trung bnh ng th thay iC th gy ra hoc lm nng thm auto-PEEPTng t ngt nhp th hoc nhu cu c th gy ra mt s gim thng kh h tr Charles Gomersall 2003

PRVC: Ch nhNhng bnh nhn i hi p lc dng thp nht v m bo mt VT thch hpKhi p lc th vo thay i do p lc trong bng (laparoscopy, robotic)ALI/ARDSBnh nhn i hi MV cao v/hoc thay iBnh nhn thay i n hi phi hoc sc cn phi

H tr p lcH tr th tch

Thng kh h tr th tch Servo5 cm H2OH tr p lcApnea

ControlTriggerLimitTargetCyclePressurePatientPressureVolumeFlow

H tr th tch 1. VS nhp th th nghim (5 cm H2O)2. p lc tng chm cho ti khi t ch th tch3. p lc ti a c th l 5 cm H2O di p lc nh 4. VT cao hn VT ci t tao ra kt qu trong p lc thp5. Bnh nhn c th khi pht nhp th6. Nu ngng th c pht hin, my th chuyn sang PRVC

H tr th tch : ServoBt uBnh nhn khi pht (p lc hoc dng)p lc ch, nhp th theo dng VT c dng nh l phn hi iu chnh PST ng gim PS khi cnPS thay i vi mi nhp thCnh bo p lc cao ngn nga PS qua mcBnh nhn th su hn, my th cho gim p lcBnh nhn sinh ra t p lc, my th cho h tr nhiu hnBack up (nu tn s qu thp) v PRVC hoc VC

H tr th tch(VS)Li chm bo VT v VENhp th PS s dng p lc i hi thp nht Nhp th t ng ca bnh nhn cng h hp bnh nhn WOBCho php bnh nhn kim sot thi gian I:EPhn tch tng nhp thDng kh th vo thay i p ng yu cu

H tr th tch(VS)Bt lii hi t thVT la chn c th qu rng hoc nh vi bnh nhnThay i p lc trung bnh ng th Auto-PEEP c th nh hng chc nng thch ngMt s tng t ngt nhp th hoc nhu cu c th gy ra mt s gim thng kh h tr

H tr th tch (VS)Ch nhBnh nhn nhp t th m i hi VE ti thiuBnh nhn c n lc th m cn h tr thch ngBnh nhn m khng ng th vi my thDng cho bnh nhn sn sng cai my

Kim sot p lc o ngc t l thng kh (PC-IRV)p lc ng th khi pht thng kh (APRV)Thng kh kim sot p lc vi t s I:E bnh thng

p lc ng th khi pht thng kh (APRV)

p lc ng th khi pht thng kh(APRV) Drger Mt phin bn m rng ca BIPAPThng kh gia 2 p lcPC-IRV vi bo tn nhp t thNgng th: Thng kh PC-IRVAPRV khc thng kh thng thng nh th no?Thng thng: p lc ng th cao t ng c sAPRV: th ra t p lc cao ti p l thp trong mt thi gian rt ngn

APRV: Danh phpIRV nhp t thPhigh: p lc th vo + p lc Plow (p lc nh)low: p lc th ra (PEEP)Thigh:Thi gian trong khi th vo(thi gian th vo)Tlow: Thi gian x (thi gian th ra)

p lc ng th khi pht thng kh(APRV)Li ch p lc cao: huy ng ph nang, oxi ho tt hn, duy tr p lc ph nang trung bnhp lc thp: thng kh ph nang v o thi CO2Cho php nhp t th trong kiu IRV mode Phn b kh tt hn cho vng phi ph thucHuy ng ph nang m chm Tnh mch v v CO Cng h hp

p lc ng th khi pht thng kh(APRV)Ch nhARDSGim oxi muXp phiPEEP caoCi tP highp lc cao nguyn ca thng kh thng thng T highThi gian th vo (5.5-6.5 sec)P low0 cm H20(PEEP) (c auto-PEEP)T Low0.4-0.8 sec T Low nn bng khong 40%-50% dng nh th raKhng nn dng th ra tr v 0

p lc ng th khi pht thng kh(APRV)Bt li v nguy cVT thay i vi thay i n hi v sc cn phi C th c hi cho bnh nh c sc cn th ra cao (vd: COPD hoc hen)Ch : nhng bnh nhn huyt ng khng n nhTng RV sau ti, v PHTNhp t th trong th T low: tng WOBLm trm trng thm d kh (BPF)Auto-PEEP thng xut hin

Thng kh PC Thng kh PS SIMVThng kh h tr thch ng

Thng kh h tr thch ng(ASV)H thng iu khin vng knCh c my th Hamilton Galileo

Thng kh h tr thch ng(ASV)i x nhP.S.V: nu nhp th bnh nhn cao hn nhp th chPCV: Ngng thSIMV khi nhp th bnh nhn thp hn nhp th ch

Bt uKhi nimDuy trWeaning

Thng kh h tr thch ng(ASV)Lm sngNhp cn nng chun ca bnh nhn IBWMong mun Ve t 100% ngha l 100ml/min/kgch l % th tch phtp lc cao nguyn ti a, PEEP, FIO2, Cai my: gim % ci t VEMy thMy chn 1 thut ton. t 100 mL/kg/minKim tra nhp th o n hi, sc cn v auto-PEEP

Thng kh h tr thch ng(ASV) : Li chm bo VT v VETi thiu cng h hp bnh nhn WOBMy th thay i theo bnh nhnNgn nga th nhanh, auto-PEEP, v kh thCai my tin hnh t ngThay i dng p ng nhu cuLm chm sng dng kh Phn tch theo tng nhp th

Thng kh h tr thch ng(ASV) : Bt liKhng cho php ci t trc tip VT, RR, I:E ratioKhng c kh nng nhn ra v iu chnh nhng thay i ph nang VDC th teo c h hpp lc trung bnh ng th thay i Bnh nh b COPD, c th cn TE di hn Mt s tng t ngt nhp th hoc nhu cu c th gy ra mt s gim thng kh h trThut ton c xu hng thng kh vi VT thp & tn s th cao

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