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Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Which patients with acute exacerbation [r]
(1)(2) Phát triệu chứng đợt cấp
Tổng quan nguyên đợt cấp
Phương pháp điều trị thuốc
Thơng khí hỗ trợ
◦ Thơng khí nhân tạo khơng xâm nhập
(3) Ho tăng
Thay đổi tính chất đờm
◦ Màu sắc
◦ Số lượng
◦ Độ đặc quánh
Khó thở tăng
Thay đổi các triệu chứng so với triệu chứng nền hằng ngày
Điều trị ngoại trú
(4) Chẩn đoán phân biệt
◦ Phù phổi
◦ Tắc mạch phổi
◦ Viêm phổi
Không phải tất cả trường
hợp khó thở và/hoặc thở rít
(5)• Steroids
• Tiêm TM
• Methylprednisolone
• Uống
• Tương đương sinh học
• Prednisone 40 mg
• Kháng sinh
• Methylxanthines
• Khơng khuyến cáo sử dụng giai đoạn cấp
• Oxy
• TRÁNH tăng oxy máu
• Cường beta giao cảm
• Kháng cholinergic
• Corticosteroids phun hít
• Ít liệu
• ? Vai trò bệnh nhân ngoại trú
(6) Khơng xâm nhập
• Mask mũi- miệng
• Mask mũi
• Ống mũi (Pillows)
Xâm nhập
• Qua ống nội khí quản
• [Mở khí quản]
• Bán cấp cai máy kéo dài
Sử dụng cho bệnh nhân ngoại
(7) Thơng khí nhân tạo khơng xâm nhập áp lực dương
• Suy hơ hấp tăng CO2 bù • pH < 7.3
• PaCO2 > 45mmHg
Tỷ lệ tử vong
•11% vs 21%
Tỷ lệ đặt NKQ
•16% vs 33%
Tỷ lệ điều trị thất bại
•20% vs 42%
(8) Thơng khí xâm nhập áp lực dương (IPPV)
• KHI NÀO ?
• Mức độ suy hơ hấp
• Căn nguyên gây đợt cấp • Thở BiPAP thất bại
• Tăng CO2 tiến triển gây biểu thần kinh • Toan hơ hấp nặng
• Khó thở khơng giảm
• Huyết động khơng ổn định
(9) Thơng khí xâm nhập áp lực dương (IPPV)
• Quản lý
1. Lựa chọn bệnh nhân • Triggering Modes
• Hỗ trợ Kiểm sốt (AC)
• Thơng khí ngắt qng theo u cầu /Hỗ trợ áp lực (IMV/PS) • [ Thơng khí hỗ trợ áp lực] (PSV) – Khơng sử dụng giai đoạn cấp • Điều chỉnh FiO2 để đạt PaO2 = 60mmH (SpO2 = 88-92%)
• An thần tối thiểu– Richland Aggitation Scale Score (RASS): zero - neg one
• Phục hồi chức hơ hấp
2. Cơ học phổi Thơng khí khơng đồng bộ
3. Rút nội khí quản sớm
Thường cài đặt
mode
SIMV
(10) Thông khí nhân tạo xâm nhập (IPPV) – Đối tượng
• Hỗ trợ- Kiểm sốt (AC) – Lựa chọn đầu tiên
• BS lâm sàng kiểm sốt thơng khí phút tối thiểu
• BS cài đặt Vt (5-7ml/Kg IBW)
• BS cài đặt tần số thở (4 BPM thấp tần số thở của BN) • Tần số thở BN tần số thở cài đặt BS-Cài đặt Vt • Thơng khí ngắt qng theo yêu cầu với Hỗ trợ áp lực
• BS lâm sàng kiểm sốt thơng khí phút tối thiểu
• BS cài đặt Vt, tần số thở
• Tần số thở BN tần số thở cài đặt BS- Cài đặt Vt dựa vào tốc độ dịng
• Thơng khí hỗ trợ áp lực – KHƠNG khuyến cáo giai đoạn cấp
• Kiểm sốt thơng khí phút bệnh nhân
• Xem xét tần số thở bệnh nhân Vt
• BS: Cài đặt áp lực hỗ trợ để giữ tần số thở < 30 BPM • Associated with Poorer Sleep Architecture than AC
Cấp
Bán cấp
(11) Thơng khí nhân tạo áp lực dương xâm nhập (IPPV) – Khơng đồng thì
• Ngun nhân
A. Auto-PEEP (PEEP nội sinh) B. Trigger Sensitivity
• Tốc độ dịng (1L/Second) • Áp lực (-2cmH2O)
C. Lưu lượng thở (How Quickly the Breath Is Delivered)
(12) Thơng khí nhân tạo áp lực dương xâm nhập (IPPV) – Khơng đồng thì
• Khắc phục cố
• COPD Bệnh lý tắc nghẽn Khí khơng được A. Auto-PEEP (PEEP nội sinh)
• Thêm áp lực cuối thở ra
• Tiến hành giữ áp lực cuối thở ra
• Auto-PEEP = Giữ áp lực cuối thở – Cài đặt PEEP
• Áp dụng PEEP Khắc phục tăng công hô hấp gây bởi Auto-PEEP • Thêm PEEP vào để cài đặt PEEP
• Auto-PEEP (0.80) + Cài đặt PEEP
End-Exp Hold 12 cmH2O Set PEEP 5 cmH2O
Auto-PEEP 7 cmH2O 0.80
Applied PEEP 6 cmH2O
MỨc giá trị gợi ý ban đầu
Ví dụ
(13) Thơng khí nhân tạo áp lực dương xâm nhập (IPPV) – Khơng đồng thì
• Khắc phục cố
B. Trigger Sensitivity
• Tốc độ dịng (2L/min)
• Thể tích đơn vị thời gian (L/phút) bệnh nhân tạo để "nói" rằng máy thở chu kỳ thở mong muốn
• Áp lực (-2cmH2O)
• Áp lực âm bệnh nhân tạo để “nói” máy thở chu kỳ như mong muốn
Suggested Starting Value
(14) Thơng khí nhân tạo áp lực dương xâm nhập (IPPV) – Khơng đồng thì
• Khắc phục cố
C. Lưu lượng thở
• Mặc định 60/phút thường khơng đủ
• Tăng tốc độ dịng = Tăng thời gian hít vào
(15) Thơng khí nhân tạo xâm nhập (IPPV) – Rút nội khí quản
• Rút nội khí quản sớm
• Thử cho BN tự thở (SBT)
• Tiến hành nào?
• Căn nguyên gây suy hơ hấp cịn
• Thơng khí hỗ trợ tối thiểu (FIO2 = 0.4, PEEP = 5cmH2O)
• Thơng khí qua: • Ống chữ T,
• Tối thiểu áp lực hỗ trợ/PEEP (5 cmH2O/5 cmH2O)
• Ống tự động bù trừ (ATC)
• 30phút Chỉ số thở nhanh nông < 104 • Với tinh thần tỉnh táo tiết đờm • Nếu tự thở thất bại Rút NKQ cho thở BiPAP
Giảm:
Tỷ lệ tử vong
Viêm phổi thở máy Thời gian thở máy Mở khí quản
CHỈ ĐỐI VỚI
COPD!
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Organized jointly by the American Thoracic Society, the European Respiratory Society, the EuropeanSociety of Intensive Care Medicine, and the SociÈtÈ
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