无创通气中测压管内冷凝液对人机同步的影响及其应对方法的探讨

发布时间：2018-05-18 04:38

本文选题：呼吸 + 人工　；参考：《广州医科大学》2017年硕士论文

【摘要】：研究背景:无创正压通气(noninvasive positive pressure ventilation NPPV)是指通过鼻(面)罩、鼻枕或接口器等连接患者的正压通气方法。与有创机械通气比较,NPPV无需建立有创的人工气道,对患者的创伤更小、并发症更少,且经济、方便,容易被患者接受。经过二十几年的发展,NPPV技术日趋成熟,已广泛应用于呼吸衰竭和肺康复治疗等多个领域。人机同步性(patient-ventilator synchrony PVS)一直是影响NPPV临床应用效果的关键问题。影响人机同步的因素很多,临床上比较关注,研究得比较多的有:呼吸机性能、呼吸参数、通气模式和漏气量等。我们在临床工作中经常发现无创通气回路测压管内存在冷凝液时人机同步性下降。目前国内外尚无测压管内冷凝液影响人机同步的相关研究。本研究拟探讨无创通气回路测压管内冷凝液对人机同步的影响,并探寻可能的应对方法。研究目的:1、研究无创通气回路测压管内冷凝液对人机同步的影响。2、探讨无创通气回路中测压管前连接防水阀对人机同步的影响。3、探讨无创通气回路中测压管前连接气囊对人机同步的影响,并探索最佳的气囊大小和充盈状态。第一部分:无创通气中测压管内冷凝液对人机同步的影响对象与方法:对象:11名广州医科大学第一附属医院的志愿者和9名在广州医科大学附属第一医院呼吸内科住院需要无创通气的慢阻肺患者。方法:试验1.对11例正常健康人,在无创正压通气期间,向通气回路测压管中段内逐渐注入不同容量的蒸馏水直至实验者不能触发呼吸机送气或注水总量达到1.5 ml,观察面罩内压力(Pmask)、测压管近面罩端压力(Ppro)、测压管近呼吸机端压力(Pdis)和呼吸流量(Flow)的动态变化。试验2.对9例慢阻肺患者在无创通气期间,向测压管内注入0.1ml蒸馏水,观察面罩和测压管近呼吸机端压力的变化。结果:试验1:在志愿者无创通气期间往测压管内注水前后比较:(1)经Pmask测得的触发时间、触发压力和触发做功分别从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增加到最大时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;无效触发从0次/min最多增多到9次/min;误触发从0次/min最多增多到33次/min。(2)注水后经Pmask和Ppro测得的平台压高于预设值,分别从注水前(9.74±0.34)和(9.80±0.31)cm H2O增高到最大时(15.79±3.10)和(15.44±3.47)cm H2O,经Pdis测得的平台压注水前为(9.85±0.29)cm H2O,注水后最高为(12.58±2.64)cm H2O。(3)注水后经Pmask和Ppro测得的基线压分别从(3.67±0.36)和(3.71±0.32)cm H2O增高到最大时(8.40±3.22)和(8.13±3.55)cm H2O,经Pdis测得的基线压从(3.77±0.32)cm H2O增高至(5.36±1.25)cm H2O。(4)注水后送气压力波动明显,经Pmask测得的平台压波动幅度从注水前0.60(0.48~0.71)cm H2O增大到最大时7.94(7.11~8.63)cm H2O,单个呼吸周期平台压波动频率从0次增加到最多时7次。(5)注水后,吸气触发呼吸机送气后,Pdis到达平台压的时间较Pmask、Ppro延迟,延迟最长为0.11(0.08~0.12)S。试验2:在慢阻肺患者无创通气期间往测压管内注水0.1ml后:(1)触发时间延长、触发压力增大、触发做功增加。(2)测压管内平台压低于面罩内平台压,差值为(1.495±0.301)cm H2O;测压管内基线压高于面罩内基线压,差值为(0.647±0.756)cm H2O。(3)面罩内平台压超过预设参数,差值为(1.053±0.405)cm H2O;基线压低于预设参数,差值为(0.868±0.638)cm H2O。第二部分:无创通气中测压管前连接防水阀对人机同步的影响对象与方法:对象:广州医科大学第一附属医院的志愿者10名和广州医科大学呼吸内科住院的需要无创通气的慢阻肺患者11名。方法:试验1.测压管前端连接防水阀,将防水阀置于密闭容器,逐渐改变容器内压力大小,观察测压管相应的压力变化情况。试验2.对10例志愿者,在无创正压通气期间,在测压管前端连接防水阀,观察面罩内压力(Pmask)和测压管内压力(Ptube)的动态变化。试验3.对11例慢阻肺患者,在无创正压通气期间,在测压管前端连接防水阀,观察面罩内压力和测压管内压力的动态变化。结果:试验1:当容器内压力从0逐渐升至50 cm H2O和从50 cm H2O逐渐降至0的过程中,测压管内压力随容器内压力的改变而同步变化,两者比较无统计学差异,两者的压力差为(0.009±0.138)cm H2O;试验2:志愿者在无创通气期间:(1)测压管连接防水阀前后进行比较,经Pmask测得的触发时间、触发压力和触发做功无统计学差异;(2)测压管连接防水阀前后进行比较,经Pmask测得的压力(包括平台压和基线压)无统计学差异。(3)测压管连接防水阀后,Pmask和Ptube比较压力(包括平台压和基线压)无统计学差异。试验3:慢阻肺患者在无创通气期间,测压管前连接防水阀前后比较:(1)触发时间、触发压力、触发做功无统计学差异。(2)测压管内压力和面罩内压力保持一致。(3)呼吸机送气压力(面罩内压力)和预设参数保持一致。第三部分:无创通气中测压管前连接气囊对人机同步的影响对象与方法:对象:12名广州医科大学第一附属医院的志愿者和6名在广州医科大学呼吸内科住院需要无创通气的慢阻肺患者。方法:试验1.测压管前端连接不同大小的气囊,将气囊置于密闭容器,调节气囊内气体容量的充盈状态,逐渐改变容器内压力大小,观察测压管相应的压力变化情况。试验2.对12例志愿者,在无创正压通气期间,在测压管前端分别连接大中小三种气囊,调节气囊内气体容量的充盈状态,观察面罩内压力(Pmask)和测压管内压力(Ptube)的动态变化。试验3.对6例慢阻肺患者,在无创正压通气期间,在测压管前端连接中气囊,调节气囊充盈3/5,观察面罩内压力和测压管内压力的变化。结果:试验1:当容器内压力从0逐渐升至50 cm H2O和从50 cm H2O逐渐降至0的过程中,小气囊在充盈4/5状态下,中气囊在充盈3/5、4/5和完全充盈状态下,大气囊在充盈1/5,2/5和4/5状态下,测压管内压力和容器内压力无统计学差异(P0.05)。试验2:(1)测压管前连接中气囊在充盈2/5、3/5、4/5状态下,大气囊在充盈1/5、2/5、3/5、4/5状态下,呼吸机参数在10/4 cm H2O-30/14 cm H2O之间,面罩内压力与测压管内压力差值小于0.5 cm H2O,为临床可接受范围。(2)测压管前连接大气囊在充盈1/5、2/5、3/5状态下,中气囊在充盈2/5、3/5状态下触发做功无增加。试验3:慢阻肺患者在无创通气期间,测压管前连接中气囊,在充盈3/5状态下:(1)触发压力无统计学差异,但触发时间、触发做功与无气囊时比较稍有增加。(2)面罩内的平台压稍高于测压管,基线压稍低于测压管,面罩与测压管内压力差小于0.5 cm H2O。(3)呼吸机送气压力(面罩内压力)和预设参数保持一致。研究结论:1、无创通气过程中,测压管内冷凝液导致吸气触发时间延长、触发压力增大、触发做功增加,无效触发和误触发增多;送气压力不稳定且偏离预设参数值,降低人机同步性。因此我们要加强对测压管的管理,避免冷凝液的形成。2、测压管前连接防水阀可阻止面罩内冷凝液进入测压管,防水阀不影响压力传导和触发做功。3、测压管前连接气囊可防止测压管内冷凝液形成,在合适的气囊大小和充盈状态下气囊对压力的传导性好。
[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.
【学位授予单位】：广州医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R56

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