呼吸机波形分析简介（压力-时间曲线）

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                    <section><section powered-by="gulangu"><section><section><p><img src="image/20201019/39acfa30cf2479f2f48202d4ddcddb42_1.gif" /></p></section></section></section><section powered-by="gulangu"><section><section><p>压力-时间曲线</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/79d4117561925ea1ad47d6261c86a8de_3.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>AB：吸气相（绿色线）：<br  /></p><p>BC：呼气相（黄色线）</p><p>Ppeak：气道峰压</p><p>Baseline：基线</p><p>Mean Airway Pressure：平均气道压</p><p>注：绿色代表指令吸气，红色代表自主吸气，黄色代表呼气。</p></section></section></section><section powered-by="gulangu"><section><section><p>机器触发的指令呼吸（VIM）</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/6631fd82fcdaf4f558fe22fb32c52a90_5.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;在A点出压力上升，之前没有病人吸气造成的压力下降，说明为机器触发的呼吸。</p></section></section></section><section powered-by="gulangu"><section><section><p>病人触发的指令呼吸（PIM）</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/ad1b79d7451dd5a71f311f88a7d0ffe1_7.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;压力上升前有低于基线的压力下降（A点处），说明病人的吸气努力导致一次指令呼吸。</p></section></section></section><section powered-by="gulangu"><section><section><p>自主呼吸</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/5becacb88601bbbbdd67b2d090a07681_9.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;自主呼吸（没有压力支持）在压力上的变化比较小，表现为病人在基线上呼吸。在基线上的压力代表吸气，在基线以下的压力代表呼气。</p></section></section></section><section powered-by="gulangu"><section><section><p>压力支持通气</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/b2f5059f4f42e9dbe7c33e8e0c2db6ee_11.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;压力上升至一个平台，并且显示有不同的吸气时间，说明为压力支持呼吸。</p></section></section></section><section powered-by="gulangu"><section><section><p>压力控制通气</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/2d4ce14292eda1af470276c7ceb5074f_13.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;压力上升至一个平台，并且显示有不同的吸气时间，说明为压力支持呼吸。</p></section></section></section><section powered-by="gulangu"><section><section><p>伴主动呼气阀的压力控制呼吸</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/82c3e1e67c21d4bd86da5f4137ac2d96_15.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;图中显示压力控制通气，在平台期峰压时发生自主呼吸（A），这种方式通常见于使用主动呼气阀的呼吸机。</p></section></section></section><section powered-by="gulangu"><section><section><p>双水平通气</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/bba35f7c0ed5d9760b8c8cbfaade1210_17.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 图中为双水平通气伴在高PEEP（A）和低PEEP（B）发生的自主呼吸。注意：双水平模式使PEEP<span>N</span>向PEEP<span>L</span>转换时与病人自主呼吸的呼气同步。</p></section></section></section><section powered-by="gulangu"><section><section><p>气道压力释放通气（APRV）</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/bd89256af3ca78ede4cdd331fa94ab1e_19.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;APRV模式的特征为长吸气时间（TIME<span>H</span>）（A）和短的“释放”时间（TIME<span>L</span>）（B）。注意所有的自主呼吸都发生在PEEP<span>N</span>。 &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</p></section></section></section><section powered-by="gulangu"><section><section><p>评估平台压</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/709d7d4b58144b0fb6f0e21c4c4ae92e_21.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;图中表示压力控制或压力支持通气，不能获得平台压（A）说明存在泄漏或不能满足病人的流速需求。</p></section></section></section><section powered-by="gulangu"><section><section><p>评估触发功</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/decf583972367d56f7dea837e5ca6c11_23.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 压力下降的深度（P<span>r</span>）和压力在基线下持续的时间（D<span>TOT</span>）说明病人触发呼吸的努力。较大的触发压力（P<span>T</span>）或较长的触发延迟时间（D<span>T</span>）也可以说明呼吸机设置的触发灵敏度较低或呼吸机反映时间较慢。</p></section></section></section><section powered-by="gulangu"><section><section><p>评估呼吸事件</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/40a5a6d444109b7f74b872edbaf0dd63_25.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; A到B说明吸气时间；B到C说明呼气时间；如果在下一次吸气输送之前呼气没有返回到基线（D），说明呼气时间过短。</p></section></section></section><section powered-by="gulangu"><section><section><p>调整峰流速</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/5d6f59079099ff6f2c6227281095876c_27.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;图中表示容量通气时，压力上升速率与峰流速的设置相关，到达峰流速缓慢或延迟，说明流速设置过低。压力上升很快，常常伴有峰压的增加，能说明峰流速设置过高。在压力通气时，压力上升的这种变化也说明需要调整呼吸机的压力上升时间。</p></section></section></section><section powered-by="gulangu"><section><section><p>测量静态力学</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/5cab3e548d80d344b4b51458a7e78bba_29.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;A代表峰压。</p><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;B代表静态压力，或输送容量后肺内的压力。</p><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;C代表不稳定的压力平台，可能是因为泄漏或病人的吸气努力所致。用此平台压计算顺应应性或阻力，可导致错误的呼吸力学数值。（也可能是肺泡的时间常数不匀一）</p><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 图中显示稳定的静态压力平台测量，可以区分气流通过呼吸回路时产生的压力和使肺充气所需要的压力。当测量静态顺应性和气道阻力时，压力-时间曲线可以用于检验平台的稳定性。</p></section></section></section><section powered-by="gulangu"><section><section><p>评估压力上升时间</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/24a3935cf31073126b5f2bf9b293ff0a_31.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;压力通气时达到目标压力的上升速度 常常因病人的肺阻抗或病人的需求不同而变化。在呼吸输送期间，这些变量可以导致不合理的压力波形。很多临床医生相信在压力通气时理想的波形应该快速地达到目标压力，近似方波。这样可以在吸气相尽早达到目标压力并保持压力。这种送气方式可以使病人的流速需要得到满足，但可引起较高的平均气道压。 &nbsp; &nbsp; &nbsp; &nbsp;</p></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/ed95cbde6a8619c04a8e21e633f2d4fa_32.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 当顺应性或流速需求不经典的升高，压力上升可能太慢，结果在吸气相目标压力较晚达到，因而导致平均气道压力下降（A）。压力上升时间太慢也可影响病人的舒适度和同步性。<br  /></p><p>&nbsp; &nbsp; &nbsp; &nbsp; 太快的压力上升时间可以导致输送的压力超过设置的目标压力，并潜在的使病人受到“高过可接受的压力”（C）。压力通气的“超射”现象常见于顺应性低或阻力增高。</p></section></section></section><section powered-by="gulangu"><section><section><p>设置压力上升时间</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/09de7817c55f5f2831332ff96b917ded_34.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;可调整的压力上升时间设置可以允许临床临床医生调整压力控制通气的呼吸输送。使之更接近满足病人的需要和临床情况。如果病人的需要增加或顺应性很高，导致慢的压力上升（A），设置压力上升时间来增加流速输出可导致更理想的“方形”压力波形（B）。</p><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;如果病人的顺应性很低或阻力很高，压力的快速上升可导致不恰当的压力超射（C）。较慢的压力上升时间可减少或消除超射（B）。 &nbsp; &nbsp; &nbsp;</p></section></section></section><section powered-by="gulangu"><section><section><p>评估自动PEEP操作</p></section><p><img src="image/20201019/a0a2ce95ecae97f1f39cb465ea1a1e77_2.png" /></p> <section></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/f7fbd89a1854bcb1d7f75017363fb7ef_36.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 图中显示为一个成功的确定自动呼气末正压（auto-PEEP）或内源性呼气末正压（PEEP）呼气暂停操作。呼气暂停允许肺内压与回路内的压力平衡，该压力测值即为总PEEP。然后PEEP<span>tot</span>减去设置的PEEP，其差值即为auto-PEEP。</p></section></section></section><section powered-by="gulangu"><section><section><p><img src="image/20201019/dc9a5ac68b1dde01aa10495af24f7560_37.jpg" /></p></section></section></section><section powered-by="gulangu"><section><section><p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 一个成功的呼气暂停操作要求足够的暂停时间使肺与回路的压力达到平衡（A）。该图显示了平衡点和呼气暂停的最小时间。较短的暂停时间不能允许压力平衡，可能导致PEEPtot被低估。因此病人的自动PEEP就会被低估。在自动PEEP操作时观察压力-时间曲线可使医生评估操作的质量和PEEP值的准确性。</p></section></section></section><section powered-by="gulangu"><section><section><p><br  /></p></section></section></section><section powered-by="gulangu"><section><section><section powered-by="gulangu"><section><section><p>欢</p></section></section></section></section><section><section powered-by="gulangu"><section><section><p>迎</p></section></section></section></section><section><section powered-by="gulangu"><section><section><p>关</p></section></section></section></section><section><section powered-by="gulangu"><section><section><p>注</p></section></section></section></section></section></section><section powered-by="gulangu"><section><section><p><br  /></p></section></section></section><section powered-by="gulangu"><section><section><section powered-by="gulangu"><section><section><p><img src="image/20201019/478db12e740e1f1a55dc01b9d964f330_38.jpg" /></p></section></section></section></section><section><section powered-by="gulangu"><section><section></section></section></section></section><section><section powered-by="gulangu"><section><section><p>关注我们</p><p>一起涨姿势！</p></section></section></section></section></section></section></section>