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谈长期家庭无创机械通气的应用

作者:首都医科大学附属北京安贞医院呼吸内科 刘双 
此文章来源于

 

诊治老年患者时的5个“明智选择”
诊治老年患者时的5个“明智选择”

 

  DIANXINGBINGLI

  BINGLI1:MANZUFEIHUANZHE

  HUANZHENANXING,62SUI,JIWANGMANXINGKESOU、KETANSHI30YUNIAN,HUODONGHOUCHUANXI20YUNIAN,FEIYUANXINGXINZANGBING5~6NIAN,PINFANZHUYUANZHILIAO。

  2010NIANHUANZHESHOULIANGHOUCHUXIANKECHUANJIAZHONG,FARE, QUANSHENFUZHONG、SHAONIAO1GEYUE,RUYUANSHIYIYISHIBUQING,KAOLV“FEIXINGNAOBING”。JIYUQIGUANCHAGUANHUXIJIFUZHUHUXI,ZHILIAOHOUHAOZHUAN,JIANGYOUCHUANGTONGQIGAIWEIWUCHUANGHUXIJI。ZHENDUANWEIMANXINGZUSAIXINGFEIJIBING(COPD,MANZUFEI),FEIYUANXINGXINZANGBING。

  HUANZHECHUYUANHOUJIXUCAIYONGWUCHUANGHUXIJIJINXINGZHILIAO,BINGZHUANZHENZHISHEQUWEISHENGFUWUZHONGXIN。QUANKEYISHENGDINGQIJIATINGSUIFANG,ZHIDAOHUANZHEZHENGQUEYINGYONGHUXIJI。JIN3NIAN,HUANZHEWEIZAIZHUYUANZHILIAO。

  BINGLI2:OSASHUANZHE

  HUANZHENANXING,54SUI,YINBAITIANSHISHUI2NIANJIUZHEN。JIWANGGAOXUEYASHI20NIAN,XIYAN20ZHI/RI×30NIAN。FAPANG、SHUIJUEDAHAN10NIAN。JINNIAN,QIPEIOUFAXIANHUANZHEHANSHENGBUJUNYUN,SHUIMIANSHIPINFANFASHENGHUXIZANTING。

  CHATI TIWEN36.6℃,MAIBO 84 CI/FEN,HUXIPINLV 18 CI/FEN,XUEYA165/100 mmHg,TIZHONG90 kg。

  动脉血气分析 血氧分压(PaO2)59 mmHg, 二氧化碳分压(PaCO2)58 mmHg,睡眠呼吸监测诊断为阻塞性睡眠呼吸暂停综合征(OSAS)。

  治疗 给予家庭应用,双水平压力支持模式(BiPAP),吸气压力12 cmH2O,呼气压力6 cmH2O,每晚入睡前开始至清晨应用鼻罩辅助呼吸,患者白天嗜睡症状显著改善,睡眠良好。复查血气分析显示: pH 7.383,PaO72.3 mmHg ,PCO34.6 mmHg,可正常从事日常工作,未再发生白天嗜睡。

  JIATINGWUCHUANGJIXIETONGQIDESHIYINGZHENGHETEDIAN

  JIN20NIANLAI,YIJIATINGJIXIETONGQIZHILIAOMANXINGHUXISHUAIJIEDEBILIZAISHIJIEFANWEINEIKUAISUZENGZHANG,QIZHONGWUCHUANGJIXIETONGQIDEYINGYONGJIAOWEIPUBIAN。WUCHUANGTONGQIZHUYAOTONGGUOBIZHAO、KOUBIMIANZHAOJINXINGWUCHUANGZHENGYATONGQI(NPPV)。WUCHUANGZHENGYATONGQIDEZUIDAYOUDIANSHIWUXUJIANLIYOUCHUANGDERENGONGQIDAO。

  WUCHUANGZHENGYATONGQISHIYINGZHENG WUCHUANGZHENGYATONGQIZHUYAOSHIHEYUSHUIMIANHUXIZHANGAI、QINGZHONGDUHUXISHUAIJIE,WUJINJICHAGUANZHIZHENG、SHENGMINGTIZHENGXIANGDUIWENDINGHEWUNPPVJINJIZHENGDEHUANZHE。JIAYONGWUCHUANGHUXIJIDEYINGYONGBAOKUOCHIXUQIDAOZHENGYATONGQI(CPAP)HESHUANGSHUIPINGQIDAOZHENGYATONGQI(BiPAP)。

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  CHIXUQIDAOZHENGYATONGQIDETEDIAN ZHEIZHONGTONGQIMOSHIKEZAIZHENGGEHUXIZHOUQIZHONGTIGONGHENGDINGDEDISHUIPINGYALI。 YUANLISHITONGGUOCHIXUZHENGXIANGDEQIYASHIHUANZHESHANGHUXIDAOBAOCHITONGCHANG。CHIXUQIDAOZHENGYATONGQIKEYIZENGJIAFEIRONGJI,TIGAOHUANZHEYANGHESHUIPING。

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  XIQIXIANGYALI(IPAP)SHIZAIXIQIXIANGTIGONGYALIZHICHI。YIDANHUXIZHOUQIDEXIQIXIANGBEICHUFA,IPAPKEXIANGFEINEITIGONGZHENGYAQILIU,CUSHIFEIKUOZHANG。

  HUQIXIANGYALI (EPAP)KEFUYUANTONGQIHOUKUOZHANGDEFEI,YEKEJIANGHUCHUDEQITICONGHUANLUHUQIKOUZHONGPAICHU,JINERBANGZHUQINGCHUDIAOMIANZHAOZHONGCANLIUDEQITI。EPAPYIKEBANGZHUMANZUFEIHUANZHEKEFUNEIYUANXINGHUQIMOZHENGYAHECHUFAHUXIJI。YALIZHICHISHUIPINGDENGYUQIDAOZHENGYAXIQIYUQIDAOZHENGYAHUQIDECHAZHI。

  RUHESHIYONGJIATINGHUXIJI

  如何调整呼吸机,使患者感到舒适十分重要。首先应该保证患者能够自主咳痰,清除呼吸道痰液;维持血氧饱和度(SaO2)>95%;IPAP降低患者呼吸功消耗,增加潮气量,提高肺泡气体交换能力。

  呼吸机参数设置 对于大多数患者,可按照5 ml/kg估算正常潮气量,吸气压的选择范围在10~20 cmH2O。EPAP可以防止肺泡在呼气时塌陷,提高肺泡功能,呼气压的选择范围在4~10 cmH2O,但应考虑患者腹胀和横膈膜的情况。初始呼吸机参数的调整一般从低到高,逐渐上调,以避免人机对抗。只要患者感到呼吸机调整舒适,其自身就能够掌握控制无创通气的方法,并了解呼吸机的工作特点。

  XUANZEHESHIMIANZHAO XUANZEHESHIDEMIANZHAOKEMINGXIANTIGAOHUANZHEDEZHILIAOTONGBUXING。LINCHUANGSHANGCHANGYONGMIANZHAOBAOKUOBIZHAO、KOUBIMIANZHAO、BISAIHEQUANLIANMIANZHAO。RUGUOMIANZHAOBUGOUSHUSHIHEMIBI,KEDAOZHIHUANZHEFANGQIWUCHUANGTONGQIZHILIAO。YINCIMIANZHAODEXUANZEFEICHANGZHONGYAO。

  在保证面罩密闭性的前提下,应尽可能放松头带,给予高流量氧气(慢阻肺患者除外),用较低的压力(IPAP 8 cmH2O,EPAP4 cmH2O)让患者逐渐适应双水平无创通气,降低呼吸肌做功。