Transcript PEEP - amts.ge

Ffiltvebis xelovnuri ventilaciis
Tanamedrove meTodebi da reJimebi
Mmamuka CxaiZe. 2006 weli. Tbilisi
“… an opening must be attempted in the trunk of the trachea, into which a tube of
reed or cane should be put; you will then blow into this, so that the lung may rise
again… and the heart becomes strong…”
Andreas Vesalius (1555)
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1555 weli - dadebiTi wneviT ventilaciis pirveli koncefcia -–Vesalius
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1955 weli - dadebiTi wneviT pirveli, industriuli ventilatori –- Emerson
Company, Boston, Massachusetts.
aqedan daiwyo filtvebis xelovnuri ventilaciis (da intensiuri Terapiis)
era
Mmeqanikuri ventilacia aris intubirebuli
pacientis sicocxlis uzrunvelyofis damxmare da ara
Terapiuli meTodi
Consensus Conference on Mechanical Ventilation January 28-30, 1993, Northbrook, Illinois, USA.
Chairman - A . S . Slutsky - Canada. " Intensive Care
Medicine " - Reports, Guidelines and Recommendations.
1998
Kklinikuri situaciebi romlebic moiTxoven f.x.v.-as
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sasunTqi sistemis dazianeba –- ventilaciuri sunTqvis ukmarisoba
sunTqvis nervuli regulaciis moSla -–centraluri an periferiuli
qalasSida wnevis regulacia
K sunTqvaze daxarjuli muSaobis Semcireba -kritikul
mdgomareobaSi myofi pacientebi –
Qqirurgiuli operaciebi – - anesTeziis saWiroeba
f.x.v.-is amocanebi (miznebi)
A. Ffiziologiuri amocanebi
B. Kklinikuri amocanebi
f.x.v.-is fiziologiuri amocanebi:
1. SevinarCunoT da vmarToT filtvebSi gazTa normaluri cvla :
_ alveoluri ventilacia ( PaCO2, pH ) : ventilaciuri daxmarebis mTavari amocana,
umetes SemTxvevaSi, alveoluri ventilaciis normalizebaa (zog SemTxvevaSi
hiperventilacia an permisiuli hiperkapnia).
_ arteriuli oqsigenacia (PaO2, SaO2): mTavari amocanaa mivaRwioT da
SevinarCunoT arteriuli sisxlis oqsigenaciis done mocemuli klinikuri SemTxvevisTvis
misaReb cifrebze, Jangbadis dasaSvebi koncentraciis gamoyenebiT (klinikuri
SemTxvevebis umetesobisaTvis - es niSnavs SaO2 > 90% an PaO2 >
60mmHg)
f.x.v.-is fiziologiuri amocanebi:
2. gavzardoT filtvebis moculoba:
_ CasunTqvis bolos filtvebis adeqvaturi gaSla : mivaRwioT filtvebis sakmaris gaSlas yovel
CasunTqvaze, raTa Tavidan aviciloT SesaZlo, an vumkurnaloT arsebul ateleqtazebs
_ funqciuri rezidualuri (FRC) tevadobis normalizeba : raTa mivaRwioT f. r. t.- is
momatebas ( normalur maCveneblebamde ) an SevinarCunoT gazrdili f. r. t. PEEPis saSualebiT
f.x.v.-is fiziologiuri amocanebi:
3. SevamciroT an / da vakontroloT sunTqvaze daxarjuli muSaoba:
_
SevamciroT sasunTqi kunTebis datvirTva: rodesac pacients sunTqva gaZnelebuli
aqvs, sunTqvis procesi Zlier datvirTvas moiTxovs - gazrdili rezistentobis Tu
daqveiTebuli komplainsis gamo, Tanac es datvirTva naklebad efeqturia an saerTo
mdgomareobis simZimis gamo sasurvelia minimaluri energo danaxarjebi.
f.x.v.-is klinikuri amocanebi:
1. SevamciroT an movxsnaT hipoqsemia: gavzardoT PaO2 anu
SaO2, alveoluri ventilaciis gazrdiT, filtvebis moculobis momatebiT, Jangbadis
miwodebis gazrdiT an Jangbadis moxmarebis SemcirebiT, am Tu sxva meTodebiT
SevamciroT sicocxlisaTvis saSiSi hipoqsiis xarisxi.
2. SevamciroT an movxsnaT mw. respiratoruli acidozi: SevamciroT
”sicocxlisaTvis saSiSi “' acidemia da swrafad daviyvanoT PaCO2 normis farglebSi.
f.x.v.-is klinikuri amocanebi:
3. SevamciroT respiratoruli distresi:
raTa SevamciroT avadmyofisaTvis autaneli
diskomforti, sanam pirveladi avadmyofoba an disfunqcia likvidirebuli iqneba.
4. ateleqtazebis reversireba an maTi prevencia: Tavidan aviciloT an
gamovasworoT filtvebis arasruli gaSlis Sedegad ganviTarebuli klinikuri gverdiTi
movlenebi.
5. sasunTqi kunTebis gadaRlis Tavidan acileba: umetesoba SemTxvevebisa
es niSnavs sasunTqi kunTebis gadatvirTvis Semcirebas maSin, roca datvirTva Zalian
didia an roca sasurvelia am datvrTvis minimumade dayvana.
f.x.v.-is klinikuri amocanebi:
6. mogveces saSualeba sedacia an / da neirokunTovani blokada
gamoviyenoT:
roca saWiroa zogadi anesTezia, Rrma sedacia (manipulaciebis
dros), aseve im daavadebebis dros roca saWiroa Rrma sedacia, relaqsacia, spontanuri
sunTqvis daTrgunva.
7. mTeli organizmis an miokardiumis mier Jangbadis moxmarebis
Semcireba: SevamciroT
Jangbadis moxmareba maSin roca spontanuri sunTqva an
sxva kunTovani aqtivoba amcirebs sistemur Jangbadis miwodebas an gadatvirTavs
isedac gadatvirTul guls, mag. : kardiogenuri Soki an mZime mozrdilTa respiratoruli
distres sindromi (ARDS) .
f.x.v.-is klinikuri amocanebi:
8. SevamciroT intrakranialuri wneva:
gansakuTrebul situaciebSi (mw.
daxuruli Tavis travma), SevamciroT momatebuli qalas Sida wneva, kontrolirebadi
hiperventilaciiT.
9. davareguliroT gulmkerdis kedlis moZraoba:
iSviaT SemTxvevebSi
(gulmkerdis rezeqcia , masiuri umoZrao gulmkerdi) roca gulmkerds dakarguli aqvs
Tavisi ventilaciuri funqcia - raTa uzrunvelvyoT adeqvaturi ventilacia da filtvebis gaSla.
pacientis sunTqvis parametrebi
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sunTqvis wuTmoculoba (Minute Volume) -– haeris
narevi, romelic CaisunTqeba da amoisunTqeba erTi wuTis
ganmavlobaSi.
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sunTqviTi moculoba (Tidal Volume-T.V.) _ haeris
narevi, romelic CaisunTqeba erTjeradi mSvidi CasunTqvis dros
da amoisunTqeba filtvebis mier.
pacientis sunTqvis parametrebi
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sunTqvis sixSire (frecuency – f – R.R.) - wuTis
ganmavlobaSi CasunTqva - amosunTqvis raodenoba. cxadia, rom
M.V.= T.V. X f maSasadame, filtvebis wuT ventilacia mniSvnelovnad
aris damokidebuli sunTqvis sixSireze.
wneva sasunTq gzebSi (Airway pressure-P)
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CasunTqvis pikuri wneva (Peak inspiratory pressure - PIP )
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Pplatos wneva
(Plateau pressure)
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saSualo wneva
(Mean airway pressure - MAP)
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amosunTqvis bolos dadebiTi wneva
– PEEP)
(Positive end expiratory pressure
pacientis sunTqvis parametrebi
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CasunTqvis pikuri wneva ( Peak inspiratory pressure
– aris maqsimaluri wneva, romelic sasunTq gzebSi
haeris miwodebisas viTardeba.
- PIP )
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Pplatos wneva ( Plateau pressure ) –ganisazRvreba
rogorc CasunTqvis bolos dadebiTi wneva, romelic minimum 0,5
wamis ganmavlobaSi grZeldeba sasunTq gzebSi nulovani nakadis
pirobebSi.
pacientis sunTqvis parametrebi
–
gasaSualoebuli wneva sistemaSi ventilaciis Tanabar periodSi
ganisazRvreba, rogorc sahaero gzebis saSualo wneva.
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saSualo wneva (Mean airway pressure
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amosunTqvis bolos dadebiTi wneva (Positive end
MAP)
– aris wneva romelic viTardeba
sasunTq gzebSi amosunTqvis fazis damTavrebis bolos.
expiratory pressure - PEEP)
pacientis sunTqvis parametrebi
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sasunTq gzebSi haeris nakadi (Airway flow / Peak flow) -
sasunTq gzebSi haeris gatarebis siCqare. izomeba litri/wT-Si. realurad
izomeba haeris nakadi aparatis konturis distalur nawilSi, rac Seesabameba
nakads pacientis traqeaSi.
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CasunTqvis dro an CasunTqva/ amosunTqvis Sefardeba
(Inspiratory Time / I:E ratio)
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Jangbadis procentoba CasunTqul haerSi (FiO2) – misi
SerCeva damokidebulia mozandasaxul Jangbadis parcialur wnevaze
sisxlSi.
ventilaciis riTmis Camoyalibebis reJimebi
iZulebiTi
damxmare
{CMV,(s)CMV-PB,Siemens
A/A/C –Bear, IPPV-Drager }
spontanuri
{PS, Flow By, BiPAP,
CPAP, AVC, PAV}
------------------------------
------------------------
SIMV
ventilaciis meTodebi:
- VCV
- PCV
ventilaciis meTodebi
moculobis kontroliT ventilacia - VCV
ventilaciis meTodebi
wnevis kontroliT ventilacia - PCV
spontanuri sunTqvis cikli
damxmare ventilaciis meTodebi
Pressure support ventilation -
damxmare ventilacia
–wneviT
PSV VS PCV
Oopciuri:
Rise Time Factor –dro romelic eZleva ventilators raTa miaRwios SekveTil wnevas (CasunTqvis fazis drois
procentia)
Exhaled Sensitivity – CasunTqvis nakadis daRmavali fazis dasrulebis da amosunTqvis dawyebis SerCeva
(CasunTqvis pikuri nakadis procentia)
PEEP PEEP/ CPAP (Positive End – Expiratory Pressure /
Continius Positive Airway Pressure )–
amosunTqvis bolos
/
dadebiTi wneva
mudmivi dadebiTi wneva
BiPAP- BiFASIC positive airway pressure
mudmivi dadebiTi wnevis or doniani ventilacia
mrudi - wneva/moculoba
respiratoruli Terapiis mTavari principi:
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ventilatori yovelTvis unda iyos adaptirebuli pacientis
moTxovnilebasTan da ara piriqiT!
meqanikuri ventilaciis Sewyveta:
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Kklinkuri situaciidan gamomdinare SeiZleba iyos swrafi (“”Sewyveta”) an
neli (“gamosvla”) procesi
Aam dros sxvadasxva teqnika SeiZleba iyos gamoyenebuli (T- s magvari
miliT SPB, Pdabali donis PS, CPAP, SIMVan BiPAP Zalian dabali
sunTqvis sixSiriTda a.S.)
Kklinkuri situaciidan gamomdinare eqstubaciis kriteriumebi SeiZleba
varirebdes.
magram
qvemoT mowodebuli rekomendaciebi universaluria!
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Eeqims unda SeeZlos amoicnos sunTqvis ukmarisobis da pacientis
distresis niSnebi:
- mzardi taqipnea distresTan kombinaciaSi
- aJitireba, panika, diaforezi, taqikardia, hiper an hipotonia, –romlebic ar
moixsneba ventilatoruli daxmarebis gazrdis Semdegac
- respiratoruli acidemia – pH –is uecari vardna <7,25 –is qvemoT
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ra teqnikasac unda viyenebdeT, pacienti unda davicvaT
sunTqvaze zedmeti muSaobisagan, rasac ganapirobebs aparatis
sarqvelebis da konturis winaaRmdegobis gadalaxva
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Tu SIMV –-is viyenebT, gamosvlis siswrafes da xarisxs unda
ganapirobebdes pH, PCO2, sunTqvis sixSire, HR, distresis arseboba
Tu PSV- –is viyenebT:
- PS –is klebisas unda vixelmZRvaneloT sunTqvis sixSiriT ufro metad, vidre
CasunTqvis moculobiT
(rogorc wesi s.s unda iyos <<30)
- Tu pacienti inarCunebs normalur arteriul sisxlis gazebs da aris komfortulad
PS-is dabal cifrebze (mag.: 5 cmH2O) ar aris aucilebeli CamoviyvanoT es
daxmareba nulamde.
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Tu pacientis apartidan warmatebuli moxsna drois mokle periodSi ver
moxerxda, saWiroa sistemuri analizi, raTa aRmovaCinoT da
vumkurnaloT gamomwvev mizezebs, rogoricaa:
-
sunTqvaze zedmeti muSaoba aparatis winaaRmdegobis dasaZlevad (sarqvelebi,
konturi, e.t.mili, filtrebi da sxva)
respiratoruli faqtorebi (bronqospazmi, bronqorea, sunTqvis centris
medikamenturi daTrgunva, parenqimuli daavadeba)
Aararespiratoruli faqtorebi (gulsisxlZarRvovani disfunqcia, gazrdili metabolizmi,
mGJava-tutovani problemebi, hipofosfatemia, gamofitva, kvebis moSla)
-
-
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Ee.w. “Znelad “mosaxsnel”” pacientTan, visTanac f.x.v.-dan
gamosvla xdeba ramodenime dRis ganmavlobaSi, sasurvelia RamiT
gavzardoT respiratoruli daxmarebis done, raTa mivceT saSualeba
efeqturad daisvenos, rac gamoixateba ZiliT.
warmatebuli eqstubaciisTvis, garda spontanuri sunTqvis efeqturobisa,
aucilebelia pacients hqondes unari damoukideblad (an minimaluri
daxmarebiT) daicvas zemo sasunTqi gzebi da gaasufTavos isini
sekretisagan.
aparitidan gaZnelebuli gamosvlis SemTxvevaSi rekomendebulia 30-120 wTiani spontanuri sunTqvis unaris Semowmeba – - spontaneous
breathing trial (SBT):
- T-s magvari miliT
an
- PS-iT (CPAP < 5 cmH2O, PS -7-8 cmH2O)
mtkicebulebaTa umetesoba gviCvenebs am meTodebis Tanabar efeqturobas
warmatebuli eqstubaciisTvis, Tumca aris kvlevebi sadac pacientebi,
romlebic ver akmayofilebdnen eqstubaciis kriteriumebs T-s magvari miliT
warmatebulad daeqstubirdnen PS is saSualebiT
eqstubaciis Cveneba:
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StO2 > 95%
FiO2 < 0,5
PEEP < 5mmH2O
PaCO2 < 45 mmHg
Temp. < 38,5
Hb > 8mg/dl
C.O. normal (BP; HR;urine output,peripheral microperfusion)
Mmetabolizmi (energiis miwodeba) - damakmayofilebelia
Glasgow coma score >11
VT(spontan.) > 5ml/kg.
RR< 140% of normal rate bavSvebSi
xvelis refleqsi da Zala damakmayofilebeli
(an < 35 - didebSi).
zogierT klinikur SemTxvevaSi, zogierTi parametri SeiZleba ar iyos mowodebul
zRvrebSi, magram eqstubacia mainc gakeTdes eqimis dasabuTebuli gadawyvetilebis
gamo!
Kklinikuri rekomendaciebi:
ARDS – mwvave (mozrdilTa) respiratoruli distres sindromi:
ARDSNET –is SemoTavazebuli ventilaciis marTvis protokoli –e.w.filtvis proteqciuli strategia
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SeamcireT sasunTqi moculoba 6 ml/kg-mde sxeulis savaraudo wonaze gadaTvliT
SeinarCuneT Pplat < 30 sm wylis sveti
SeamcireT Tv 4 ml/kg-mde sxeulis savaraudo wonaze* gadaTvliT, raTa SeamciroT Pplat Tu
es aucilebelia (permisiuli hiperkapnia)
SeinarCuneT SaO2/SpO2 88-95% anu PaO2 > 60mmHg.
SearCieT PEEP FiO2 –is moTxovnilebis mixedviT Semdegnairad:
FiO2 0.3 0.4
PEEP 5
5
0.4
8
0.5
8
0.5
10
0.6
10
0.7
10
0.7
12
0.7
14
0.8
14
0.9
14
0.9
16
0.9
18
1.0
20-24
ARDS
1. mizani: SeinarCune//gaaumjobese oqsigenacia da ventilacia. AamisTvis
gGamoiyene: ventilaciis is meTodi, romelic SenTvis kargadaa cnobili.
2. dasaSvebi saturacia > 90%
3. dasaSvebi platos wneva < 35 cmH2O.
4. filtvis dacvis TvalsazrisiT dasaSvebia e.w. permisiuli hiperkapnia
5. maRali PEEP- zrdis FRC da aumjobesebs oqsigenacias. mMisi SerCeva
xdeba empiriulad (yovel konkretul SemTxvevaSi individualurad). Mmisi
gamoyenebisas xSirad Seamowme SesaZlo uaryofiTi gverdiTi movlenebi.
ARDS
6. gGamoiyene minimaluri, dasaSvebi FiO2. situaciaSi, sadac maRali wneva da
FiO2-is maRali koncentraciaa aucilebeli, SeiZleba davuSvaT StO2 mcired <
90%.
7. Tu oqsigenizacia rCeba aradeqvaturi –- gamoiyene Rrma sedacia, relaqsacia,
sxeulis mdebareobis cvla.
Jangbadis miwodebis sxva faqtorebi - gulis wuT moculoba da hemoglobinis
Semcveloba sisxlSi aseve gasaTvaliswinebelia.
bronqoplevraluri fistula
1. Dxeli SevuwyoT defeqtis daxurvas:
-
-
-
Ggamoiyene minimaluri CasunTqvis moculoba, rac uzrunvelyofs adeqvatur ventilacias
Ggamoiyene ventilaciis is meTodi, romelic uzrunvelyofs minimalur pikur da plato wnevebs,
adeqvaturo ventilaciisTvis
ifiqre permisiul hiperkapniaze, raTa Seamciro CasunTqvis moculoba/ /wneva
Mminimumamde Seamcire
PEEPPEEPPEEP
2. Hhaeris didi Jonvis SemTxvevaSi, Tu ver Sli filtvs an
oqsigenacia/ventilacia aradamakmayofilebelia, ifiqre filtvebis
damoukidebel ventilaciaze an HFJV.
Tavis travma
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Tu qalasSida wneva momatebulia daiWire PaCO2 25-30 mmHg an
cvale ventilaciis reJimi qalas Sida wnevis saWiro cifrebamde. qalasSida
wnevis monitoringi sasurvelia.
SeinarCune normokarbia Tavis travmian avadmyofebSi Tu qalasSida
wneva normaluria an Tu misi monitoringi SeuZlebelia.
roca momatebuli qalasSida wnevis gamo iyenebdi hiperventilacias,
normokarbiaze dabruneba unda iyos TandaTanobiTi (24-48 sT-is
ganmavlobaSi).
miokardiumis iSemia da SegubebiTi gulis
ukmarisoba
1. miokardiumis iSemiis dros amoirCie meq.vent.-iis iseTi tipi,
romelic minimumamde daiyvans sunTqvaze datvirTvas.
2. roca sicocxlisTvis saSiSi hipoqsemia Tan axlavs SegubebiT gulis
ukmarisobas Seafase dadebiTi wneviT ventilaciis potenciuri efeqti,
venuri dabrunebis Semcirebis da oqsigenizaciis gaumjobesebis
TvalsazrisiT.
3. unda Sefasdes dadebiTi wneviT ventilaciis gavlena
hemodinamikaze.
nerv-kunTovani daavadebebi
didi CasunTqvis moculebebi 12-15ml/kg SedarebiT maRali
PEEP-iT (10 cmH2O mde) Tu mis gareSe SeiZleba saWiro iyos
dispneis mosaxsnelad. inspiraciuli moTxovnilebebis
dasakmayofileblad SesaZloa maRali pikuri nakadi > 60 l/wT.
iyos saWiro.
2. sasunTqi kunTebis SesaZleblobis mixedviT gamoiyene sruli an
nawilobrivi meq. ventilacia.
1.
sahaero gzebis obstruqciuli daavadeba
1. ar arsebobs mtkicebuleba erTi ventilatoruli reJimis upiratesobisa
meoresTan SedarebiT. gamoiyene is reJimi romelic SenTvis
yvelaze ufro nacnobia da avadmyofs miscems Svebas.
2. cvale CasunTqvis nakadi ise rom maqsimalurad daakmayofilo
pacientis moTxovnilebebi.
sahaero gzebis obstruqciuli daavadeba
3. akontrole da minimumamde daiyvane filtvebis dinamiuri
gadawelva (AutoPEEP):
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a) misaRebia is minimaluri wuTventilacia, rac uzrunvelyofs dasaSveb gazTa
cvlas da iZleva maqsimalur amosunTqvis dros. aseTi manevrebia:
Seamcire wuTventialcia
gazarde amosunTqvis dro
hiperkapniis daSveba.
roca filtvis dinamiuri gadawelvas aqvs adgili da pacienti imyofeba asistirebad meq.
ventilaciaze mcire odenobis ventilatorulma PEEP- ma SeiZleba kargad imoqmedos
sunTqvis muSaobis Sesamcireblad. Tumca Tu ventilatoris PEEP aWarbebs
autoPEEP-s es aucileblad gamoiwvevs zedmet gadawelvas da garTulebebs.
sahaero gzebis obstruqciuli daavadeba
4. CasunTqvis bolos plato-wneva albaT ar mouxdeba s.g.o.d-ian
avadmyofs,radgan plato iwvevs filtvis gadawelvas, Cven gvjera rom
didebSi plato wneva<<35cmH2O usafrTxo iqneba Tumca misi
gavlena gamosavalze ucnobia. platos wnevis gazomvisas pacienti
unda iyos sedirebuli da paralizebuli.
5. mMoculobis kontroliT asistirebadi venetilacia, rogorc sawyisi taqtika,
fxizlad myof pacietTan, SeiZleba asocirebuli iyos filtvis gadawelvis
mniSvnelovan riskTan da unda moveridoT.
sahaero gzebis obstruqciuli daavadeba
asTma
(1) sarwmunoa rom maRali plato da maRali pikuri CasunTqvis
wneva saSiSia asTmian avadmyofebSi radganac isini kidev ufro
gazrdian gadawelvas,Cven girCevT minimumamde daiyvanoT es
wnevebi asTmis dros, samwuxarod CasunTqvis maqsimaluri
wneva Zalian aris damokidebuli e.t milis zomaze da CasunTqvis
nakadis siCqareze.
sahaero gzebis obstruqciuli daavadeba
asTma
(2) miuSvi PCO maRal cifrebze, sanam pH misaReb zRvrebSia.
2
(3) zogjer sedacia da relaqsacia aucilebelia, radganac pacient /aparatis
disinqronizacias aqvs adgili, sedacia//paralizis Semdeg Semcirdeba ra
aqtiuri eqxpiratoruli Zalisxmeva-SesaZloa Semcirdes sasunTqi gzebis
kolafsic. Aasocirebuli CO2 –-is produqciis Semcireba
(gansakuTrebiT sasunTqi muskulaturis xarjze) zogjer aseve
dadebiTi efeqtia/.
sahaero gzebis obstruqciuli daavadeba
filtvis qronikuli obstruqciuli daavadeba
aseTi pacientebis meq. ventilaciis dros (sunTqvis mw.
ukmarisobisas) rogorc wesi ar aris aucilebeli maRali CasunTqvis
wneva da naxSirorJangis gamodevnac did problemas ar unda
warmoadgendes. Tu aseTi problema gaCnda unda ifiqro
Tanaarsebul paTologiebze (pnevmoToraqsi, filtvis SeSupeba,
Zlieri bronqospazmi, naxvelis sacobebi).
sahaero gzebis obstruqciuli daavadeba
filtvis qronikuli obstruqciuli daavadeba
2. avadmyofebs qr. respiratoruli acidoziT alveoluri ventilacia unda
SeufasdeT ara PCO2- –iT aramed pH- iT.
postoperaciuli pacientebi
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ZiriTadad aseT pacientebs ar esaWiroebaT gaxangrZlivebuli f.x.v.
mTavari yuradReba unda daeTmos kardioTorakaluri operaciebis
Semdeg SesaZlo ateleqtazebis prevencias.
aseTi pacientebi rac SeiZleba swrafad unda moixsnan f.x.v.-idan
raTa Tavidan aviciloT yvela SesaZlo garTulebebi rac asocirebuli
gaxangrZlivebul f.x.v. -sTan