本文選題：呼吸 + 人工��； 參考：《廣州醫(yī)科大學》2017年碩士論文

【摘要】：研究背景:無創(chuàng)正壓通氣(noninvasive positive pressure ventilation NPPV)是指通過鼻(面)罩、鼻枕或接口器等連接患者的正壓通氣方法。與有創(chuàng)機械通氣比較,NPPV無需建立有創(chuàng)的人工氣道,對患者的創(chuàng)傷更小、并發(fā)癥更少,且經(jīng)濟、方便,容易被患者接受。經(jīng)過二十幾年的發(fā)展,NPPV技術(shù)日趨成熟,已廣泛應(yīng)用于呼吸衰竭和肺康復治療等多個領(lǐng)域。人機同步性(patient-ventilator synchrony PVS)一直是影響NPPV臨床應(yīng)用效果的關(guān)鍵問題。影響人機同步的因素很多,臨床上比較關(guān)注,研究得比較多的有:呼吸機性能、呼吸參數(shù)、通氣模式和漏氣量等。我們在臨床工作中經(jīng)常發(fā)現(xiàn)無創(chuàng)通氣回路測壓管內(nèi)存在冷凝液時人機同步性下降。目前國內(nèi)外尚無測壓管內(nèi)冷凝液影響人機同步的相關(guān)研究。本研究擬探討無創(chuàng)通氣回路測壓管內(nèi)冷凝液對人機同步的影響,并探尋可能的應(yīng)對方法。研究目的:1、研究無創(chuàng)通氣回路測壓管內(nèi)冷凝液對人機同步的影響。2、探討無創(chuàng)通氣回路中測壓管前連接防水閥對人機同步的影響。3、探討無創(chuàng)通氣回路中測壓管前連接氣囊對人機同步的影響,并探索最佳的氣囊大小和充盈狀態(tài)。第一部分:無創(chuàng)通氣中測壓管內(nèi)冷凝液對人機同步的影響對象與方法:對象:11名廣州醫(yī)科大學第一附屬醫(yī)院的志愿者和9名在廣州醫(yī)科大學附屬第一醫(yī)院呼吸內(nèi)科住院需要無創(chuàng)通氣的慢阻肺患者。方法:試驗1.對11例正常健康人,在無創(chuàng)正壓通氣期間,向通氣回路測壓管中段內(nèi)逐漸注入不同容量的蒸餾水直至實驗者不能觸發(fā)呼吸機送氣或注水總量達到1.5 ml,觀察面罩內(nèi)壓力(Pmask)、測壓管近面罩端壓力(Ppro)、測壓管近呼吸機端壓力(Pdis)和呼吸流量(Flow)的動態(tài)變化。試驗2.對9例慢阻肺患者在無創(chuàng)通氣期間,向測壓管內(nèi)注入0.1ml蒸餾水,觀察面罩和測壓管近呼吸機端壓力的變化。結(jié)果:試驗1:在志愿者無創(chuàng)通氣期間往測壓管內(nèi)注水前后比較:(1)經(jīng)Pmask測得的觸發(fā)時間、觸發(fā)壓力和觸發(fā)做功分別從0.09(0.07~0.11)S、0.26(0.15~0.33)cm H2O和0.02(0.01~0.03)cm H2O*S增加到最大時0.31(0.22~0.39)S、2.29(1.76~3.09)cm H2O和0.55(0.41~0.68)cm H2O*S;無效觸發(fā)從0次/min最多增多到9次/min;誤觸發(fā)從0次/min最多增多到33次/min。(2)注水后經(jīng)Pmask和Ppro測得的平臺壓高于預(yù)設(shè)值,分別從注水前(9.74±0.34)和(9.80±0.31)cm H2O增高到最大時(15.79±3.10)和(15.44±3.47)cm H2O,經(jīng)Pdis測得的平臺壓注水前為(9.85±0.29)cm H2O,注水后最高為(12.58±2.64)cm H2O。(3)注水后經(jīng)Pmask和Ppro測得的基線壓分別從(3.67±0.36)和(3.71±0.32)cm H2O增高到最大時(8.40±3.22)和(8.13±3.55)cm H2O,經(jīng)Pdis測得的基線壓從(3.77±0.32)cm H2O增高至(5.36±1.25)cm H2O。(4)注水后送氣壓力波動明顯,經(jīng)Pmask測得的平臺壓波動幅度從注水前0.60(0.48~0.71)cm H2O增大到最大時7.94(7.11~8.63)cm H2O,單個呼吸周期平臺壓波動頻率從0次增加到最多時7次。(5)注水后,吸氣觸發(fā)呼吸機送氣后,Pdis到達平臺壓的時間較Pmask、Ppro延遲,延遲最長為0.11(0.08~0.12)S。試驗2:在慢阻肺患者無創(chuàng)通氣期間往測壓管內(nèi)注水0.1ml后:(1)觸發(fā)時間延長、觸發(fā)壓力增大、觸發(fā)做功增加。(2)測壓管內(nèi)平臺壓低于面罩內(nèi)平臺壓,差值為(1.495±0.301)cm H2O;測壓管內(nèi)基線壓高于面罩內(nèi)基線壓,差值為(0.647±0.756)cm H2O。(3)面罩內(nèi)平臺壓超過預(yù)設(shè)參數(shù),差值為(1.053±0.405)cm H2O;基線壓低于預(yù)設(shè)參數(shù),差值為(0.868±0.638)cm H2O。第二部分:無創(chuàng)通氣中測壓管前連接防水閥對人機同步的影響對象與方法:對象:廣州醫(yī)科大學第一附屬醫(yī)院的志愿者10名和廣州醫(yī)科大學呼吸內(nèi)科住院的需要無創(chuàng)通氣的慢阻肺患者11名。方法:試驗1.測壓管前端連接防水閥,將防水閥置于密閉容器,逐漸改變?nèi)萜鲀?nèi)壓力大小,觀察測壓管相應(yīng)的壓力變化情況。試驗2.對10例志愿者,在無創(chuàng)正壓通氣期間,在測壓管前端連接防水閥,觀察面罩內(nèi)壓力(Pmask)和測壓管內(nèi)壓力(Ptube)的動態(tài)變化。試驗3.對11例慢阻肺患者,在無創(chuàng)正壓通氣期間,在測壓管前端連接防水閥,觀察面罩內(nèi)壓力和測壓管內(nèi)壓力的動態(tài)變化。結(jié)果:試驗1:當容器內(nèi)壓力從0逐漸升至50 cm H2O和從50 cm H2O逐漸降至0的過程中,測壓管內(nèi)壓力隨容器內(nèi)壓力的改變而同步變化,兩者比較無統(tǒng)計學差異,兩者的壓力差為(0.009±0.138)cm H2O;試驗2:志愿者在無創(chuàng)通氣期間:(1)測壓管連接防水閥前后進行比較,經(jīng)Pmask測得的觸發(fā)時間、觸發(fā)壓力和觸發(fā)做功無統(tǒng)計學差異;(2)測壓管連接防水閥前后進行比較,經(jīng)Pmask測得的壓力(包括平臺壓和基線壓)無統(tǒng)計學差異。(3)測壓管連接防水閥后,Pmask和Ptube比較壓力(包括平臺壓和基線壓)無統(tǒng)計學差異。試驗3:慢阻肺患者在無創(chuàng)通氣期間,測壓管前連接防水閥前后比較:(1)觸發(fā)時間、觸發(fā)壓力、觸發(fā)做功無統(tǒng)計學差異。(2)測壓管內(nèi)壓力和面罩內(nèi)壓力保持一致。(3)呼吸機送氣壓力(面罩內(nèi)壓力)和預(yù)設(shè)參數(shù)保持一致。第三部分:無創(chuàng)通氣中測壓管前連接氣囊對人機同步的影響對象與方法:對象:12名廣州醫(yī)科大學第一附屬醫(yī)院的志愿者和6名在廣州醫(yī)科大學呼吸內(nèi)科住院需要無創(chuàng)通氣的慢阻肺患者。方法:試驗1.測壓管前端連接不同大小的氣囊,將氣囊置于密閉容器,調(diào)節(jié)氣囊內(nèi)氣體容量的充盈狀態(tài),逐漸改變?nèi)萜鲀?nèi)壓力大小,觀察測壓管相應(yīng)的壓力變化情況。試驗2.對12例志愿者,在無創(chuàng)正壓通氣期間,在測壓管前端分別連接大中小三種氣囊,調(diào)節(jié)氣囊內(nèi)氣體容量的充盈狀態(tài),觀察面罩內(nèi)壓力(Pmask)和測壓管內(nèi)壓力(Ptube)的動態(tài)變化。試驗3.對6例慢阻肺患者,在無創(chuàng)正壓通氣期間,在測壓管前端連接中氣囊,調(diào)節(jié)氣囊充盈3/5,觀察面罩內(nèi)壓力和測壓管內(nèi)壓力的變化。結(jié)果:試驗1:當容器內(nèi)壓力從0逐漸升至50 cm H2O和從50 cm H2O逐漸降至0的過程中,小氣囊在充盈4/5狀態(tài)下,中氣囊在充盈3/5、4/5和完全充盈狀態(tài)下,大氣囊在充盈1/5,2/5和4/5狀態(tài)下,測壓管內(nèi)壓力和容器內(nèi)壓力無統(tǒng)計學差異(P0.05)。試驗2:(1)測壓管前連接中氣囊在充盈2/5、3/5、4/5狀態(tài)下,大氣囊在充盈1/5、2/5、3/5、4/5狀態(tài)下,呼吸機參數(shù)在10/4 cm H2O-30/14 cm H2O之間,面罩內(nèi)壓力與測壓管內(nèi)壓力差值小于0.5 cm H2O,為臨床可接受范圍。(2)測壓管前連接大氣囊在充盈1/5、2/5、3/5狀態(tài)下,中氣囊在充盈2/5、3/5狀態(tài)下觸發(fā)做功無增加。試驗3:慢阻肺患者在無創(chuàng)通氣期間,測壓管前連接中氣囊,在充盈3/5狀態(tài)下:(1)觸發(fā)壓力無統(tǒng)計學差異,但觸發(fā)時間、觸發(fā)做功與無氣囊時比較稍有增加。(2)面罩內(nèi)的平臺壓稍高于測壓管,基線壓稍低于測壓管,面罩與測壓管內(nèi)壓力差小于0.5 cm H2O。(3)呼吸機送氣壓力(面罩內(nèi)壓力)和預(yù)設(shè)參數(shù)保持一致。研究結(jié)論:1、無創(chuàng)通氣過程中,測壓管內(nèi)冷凝液導致吸氣觸發(fā)時間延長、觸發(fā)壓力增大、觸發(fā)做功增加,無效觸發(fā)和誤觸發(fā)增多;送氣壓力不穩(wěn)定且偏離預(yù)設(shè)參數(shù)值,降低人機同步性。因此我們要加強對測壓管的管理,避免冷凝液的形成。2、測壓管前連接防水閥可阻止面罩內(nèi)冷凝液進入測壓管,防水閥不影響壓力傳導和觸發(fā)做功。3、測壓管前連接氣囊可防止測壓管內(nèi)冷凝液形成,在合適的氣囊大小和充盈狀態(tài)下氣囊對壓力的傳導性好。
[Abstract]:Background: noninvasive positive pressure ventilation (noninvasive positive pressure ventilation NPPV) refers to a positive pressure ventilation method connected to patients through a nasal (face) mask, a nasal pillow or an interfacing device. Compared with invasive mechanical ventilation, NPPV does not need to establish a invasive artificial airway, which is less invasive and less complications for patients and is economical, convenient and easy to be treated by patients. Acceptance. After more than twenty years of development, NPPV technology is becoming more and more mature. It has been widely used in many fields such as respiratory failure and lung rehabilitation. Patient-ventilator synchrony PVS has always been the key problem affecting the clinical application of NPPV. There are many factors affecting the synchronization of human machine. There are the performance of ventilator, respiratory parameters, ventilation mode and air leakage. In clinical work, we often find the decrease of human machine synchronism when the condensate exists in the noninvasive ventilation loop. At present, there is no related research on the influence of man-machine synchronization in the pressure tube condensate at home and abroad. This study is to discuss the internal cooling of the noninvasive ventilation loop. The effect of condensate on man-machine synchronization and the possible coping methods are explored. 1. Study the influence of the condensate in the noninvasive ventilation loop on the human machine synchronization in the non invasive ventilation circuit.2, and discuss the effect of.3 on the man-machine synchronization of the front connection waterproof valve in the noninvasive ventilation loop, and discuss the synchronization of the man-machine with the front connection air bag in the non wound gas loop. The first part: 11 volunteers in the First Affiliated Hospital of Guangzhou Medical University and 9 patients in the respiratory department of the first hospital of Guangzhou Medical University, the First Affiliated Hospital of Medical University, and the chronic obstructive pulmonary disease requiring non-invasive ventilation. Methods: 1. pairs of normal healthy people were tested in 11 cases. During the noninvasive positive pressure ventilation, different volumes of distilled water was gradually injected into the middle section of the ventilatory loop until the experimenter could not trigger the ventilator air delivery or the total amount of water injection to 1.5 ml, the pressure (Pmask) of the mask, the pressure of the pressure tube near the end mask (Ppro), the pressure tube near the end of the ventilator. Dynamic changes in pressure (Pdis) and respiratory flow (Flow). Experiment 2. 9 patients with chronic obstructive pulmonary disease were injected with 0.1ml distilled water into the pressure tube during noninvasive ventilation to observe the changes in the end pressure of the respirator. Results: the test 1: was compared before and after the water injection into the pressure tube during the volunteer's noninvasive ventilation: (1) triggered by Pmask Time, trigger pressure and trigger work are increased from 0.09 (0.07~0.11) S, 0.26 (0.15~0.33) cm H2O and 0.02 (0.01~0.03) cm H2O*S to maximum 0.31 (0.22~0.39) S, 2.29 (1.76~3.09) cm S and 0.55. The invalid trigger is increased from 0 times to 9 times, and the false trigger is from 0 times to 33 times 2. The platform pressure measured by ask and Ppro is higher than the preset value, which is from (9.74 + 0.34) and (9.80 + 0.31) cm H2O to the maximum (15.79 + 3.10) and (15.44 + 3.47) cm H2O respectively, which is (9.85 + 0.29) cm H2O before the platform pressure injected by Pdis, and the highest (12.58 + 2.64) cm H2O. (3) after water injection is from Pmask and baseline pressure, respectively. .67 + 0.36) and (3.71 + 0.32) cm H2O increased to the maximum (8.40 + 3.22) and (8.13 + 3.55) cm H2O. The baseline pressure measured by Pdis increased from (3.77 + 0.32) cm H2O to (5.36 + 1.25) cm H2O. (4), and the pressure fluctuation was obvious after water injection. M H2O, the frequency of pressure fluctuation on a single respiratory cycle platform increased from 0 to 7 times. (5) after water injection, the time of suction triggered by breathing machine was more than Pmask, Ppro delayed, and the longest delay was 0.11 (0.08~0.12) S. test 2: in the non invasive ventilation patients with slow resistance lung after 0.1ml: (1) trigger time was prolonged, touch time was prolonged. (1) touch time prolonged, touch touch The pressure increased and the trigger work increased. (2) the pressure of the inner platform of the pressure measuring tube was lower than that in the mask. The difference was (1.495 + 0.301) cm H2O; the baseline pressure in the piezometric pipe was higher than the baseline pressure in the mask. The difference was (0.647 + 0.756) cm H2O. (3) mask over the presupposed parameters, the difference was (1.053 + 0.405) cm H2O; the baseline pressure was lower than the preset parameter, the difference was 0. .868 + 0.638) cm H2O. second part: the object and method of the influence of the front connection waterproof valve to the man-machine synchronization in the noninvasive ventilation: object: 10 volunteers in the First Affiliated Hospital of Guangzhou Medical University and 11 patients in the respiratory medicine department of the respiratory medicine department of the Medical University of Guangzhou medical University. Water valve, put the water proof valve in the closed vessel, gradually change the pressure in the container, and observe the pressure change of the pressure tube. In test 2., 10 volunteers, during the noninvasive positive pressure ventilation, were connected with the waterproofing valve at the front of the pressure tube, and observed the dynamic changes of the pressure (Pmask) and the pressure in the pressure measuring tube (Ptube). The test 3. pairs of slow resistance. During the noninvasive positive pressure ventilation, during the noninvasive positive pressure ventilation, a waterproof valve was connected to the front end of the piezometer to observe the dynamic changes in the pressure in the mask and the pressure in the pressure measuring tube. Results: in the test 1:, the pressure in the pressure tube varies with the pressure in the container when the pressure in the container rises from 0 to 50 cm H2O and from 50 cm H2O to 0. There was no statistical difference, the pressure difference between the two was (0.009 + 0.138) cm H2O, and the test 2: volunteers were compared before and after the noninvasive ventilation: (1) the pressure tube was connected to the waterproof valve, the trigger time measured by Pmask, the trigger pressure and the trigger work were not statistically different; (2) the pressure of the pressure tube before and after the waterproof valve was compared and the pressure measured by Pmask (package) There was no statistical difference between the platform pressure and the baseline pressure. (3) there was no statistical difference between Pmask and Ptube pressure (including platform pressure and baseline pressure) after the pressure tube was connected to the water proof valve. Test 3: slow resistance lung patients were compared before and after the noninvasive ventilation. (1) trigger time, triggering pressure, and no statistical difference in triggering work. (2) test The pressure inside the tube and the inner pressure of the mask remained consistent. (3) the air pressure of the ventilator (the internal pressure of the mask) was consistent with the presupposed parameters. The third part: the object and method of the influence of the man-machine synchronization by the anterior connection air bag in the noninvasive ventilation: 12 volunteers and 6 at the First Affiliated Hospital of Guangzhou Medical University and 6 at the Medical University of Guangzhou. The patients who are hospitalized in the internal medicine department need slow resistance lung patients with non-invasive ventilation. Methods: Test 1. the front end of the pressure tube to connect the different sizes of air bag, put the air bag in the closed container, adjust the filling state of the gas volume in the air bag, change the pressure in the container and observe the pressure change of the pressure tube. Test 2. pairs of 12 volunteers, in the noninvasive positive pressure During the ventilation, the large and medium air bags were connected to the front of the pressure tube to adjust the filling state of the gas volume in the air bag, and to observe the dynamic changes in the pressure (Pmask) and the pressure (Ptube) in the pressure measuring tube. In test 3., 6 cases of the patients with chronic obstructive pulmonary disease, during the noninvasive positive pressure ventilation, were connected to the air bag in the front of the pressure tube, and the air bag filling 3/5 was observed. Test the change in the pressure inside the mask and the pressure in the pressure measuring tube. Results: when the pressure of the test 1: gradually rises from 0 to 50 cm H2O and from 50 cm H2O to 0, the gasbag is filled with 3/5,4/5 and full filling state under the filling of 3/5,4/5 and full filling state, and the large air bag is filled with 1/5,2/5 and 4/5 under the state of 1/5,2/5 and 4/5. There is no statistical difference in internal pressure (P0.05). Test 2: (1) the air bag in the front connection of the pressure tube in the filling of 2/5,3/5,4/5 state, the large air bag is in the 1/5,2/5,3/5,4/5 state, the ventilator parameters are between 10/4 cm H2O-30/14 cm H2O, the pressure difference between the mask and the pressure measurement tube is less than the 0.5 cm H2O, which is the clinical acceptable range. (2) the pressure tube front connection Under the condition of filling the 1/5,2/5,3/5 state, the balloon in the filling of the 2/5,3/5 state does not increase. Test 3: slow resistance lung patients during the noninvasive ventilation, the air sac in the front of the piezometric connection and the filling 3/5 state: (1) there is no statistical difference in the trigger pressure, but the trigger time is slightly increased when the trigger is doing work and no air bag. (2) mask The internal pressure of the platform is slightly higher than the pressure measuring tube, the baseline pressure is slightly lower than the pressure measuring tube, the pressure difference in the mask and the pressure tube is less than 0.5 cm H2O. (3) and the pressure of the ventilator (the mask pressure) is consistent with the preset parameters. Increase, ineffective trigger and false trigger increase; air pressure is unstable and deviates from presupposed parameter values to reduce human machine synchronization. Therefore, we should strengthen the management of the pressure tube, avoid the formation of.2, the front connection waterproof valve can prevent the condensate into the pressure pipe, the water proof valve does not affect the pressure conduction and the trigger work.3. Connecting the air bag before the pressure tube can prevent the condensate from forming in the piezometric tube, and the air bag has good pressure conductivity under the proper size and filling state of the air bag.
【學位授予單位】：廣州醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R56

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