Dạng đồ thị trong máy thở (phuong)

5/28/2018 Da ng thi trong my th (phuong)

1/22

A Dng thv hng (scalars)

A1 Cc dng sng c bn

Chng ta thc schcn nh3 dng thc bn sau: dng hnh vung(Square), hnh dc(Ramp), dng hnh sine(Sine).

Dng Squares:

Dng sng Square i din cho cc thng scnh, lin tc, hoc thit lp. V dnh biu din gi trthit lp p lc trong chkim sot p lc.

Dng Ramp:

Dng sng biu thcho cc i lng c ththay i c, skhc nhau vi nhng sthay itrong t tnh ca phi, dng sng c thl tng dc hay gim tc.

Dng Sine:

Dng sng c biu thtrong nhp thtpht ca bnh nhn, nhp thkhng c htr.


2/22

A2 Cc kiu dng sng

Trong mi nhp thiu c 3 dng sng c hin thtrn my th: p lc, lu dng, Thtch.

Dng p lc

thp lc hin thlng p lc c to ra trong mi nhp th, tlp lc c t pha bntri theo thang o cmH20, p lc nh ca nhng hi thl vo khong 22 cmH20.

Dng Lu lng

thhin thlu lng, tc dng chy kt hp vi tng nhp th.

Dng thtch

thbiu hin khi lng thtch ht vo v thra trong tng nhp th. Thang o thtch nvml c t pha bn tri th.

Thtch cung cp trong mt nhp thl vo khong 370ml.

p lc

Thtch

Lu lng


3/22

Kiu dng sng vi mode thtch v p lc v cc chkt hp

A3 Cc dliu c ththu thp tdng sng quan st c.

1 Dng sng p lc:

Kiu nhp th(Pressure vs. Volume) By kh(auto-PEEP) Tt nghn ng kh (Airway Obstruction) p ng gin phqun (Bronchodilator Response) Stun th, sc cn ng th(Compliance/Raw) Kch thra PIP, Pplat CPAP, PEEP Smt ng b(Asynchrony) Nlc trigger

+ Kiu nhp thTuvo nhp thl nhp ththtch hay nhp thp lc, th sc cc dng thl Ramp (dc)hay Square (vung).

Nhp th

p lc

Nhp th

Thtch


4/22

+PIP, Plateau, RAW

Vic thit lp thi gian ngng th ht vo, hoc sdng gith thvo (insp hold) sto ra mtp lc bnh nguyn (Pplateau) trn dng sng. Vic thit lp Pplateau cho php ta ddng quan

st PIP v RAW.

Thm thi gian tm ngng th ht vo c thgip ci thin kt quthng kh.

+PEEP

PEEP: p lc dng cui kthra.

Tc dng ca PEEP:

Mode thtch Mode p lc


5/22

Lm tng trao i kh O2 Hn chxp phnang cui kthra. Lm tng dung tch cn chc nng FRC, tng din tch trao i kh

+ Compliance/Raw

Tng RAW sdn n tng PIP trong khi Pplat khng i.

+ Auto PEEP

tin hnh o Auto PEEP,ta thc hin gith thra Expiratory Hold, v quan st trn dngsng p lc, xy ra hin tng Auto PEEP slm tng ng p lc so vi ng c bn, mccho php Auto PEEP


6/22

Cc dliu thu thp c tdng sng lu dng:

Auto PEEP Tt nghn ng kh iu chnh thi gian i-time p ng gin phqun Kch thra Kiu nhp th Dng ht vo Sbt ng b Nlc trigger

+ Mode ththtch hay p lc.

+ Tt nghn ng kh

Hin tng tt nghn xut hin khi dng thvo cn nhiu thi gian hn quay vng c

bn.

iu ny c thgy ra cc vn i vi mode thchu klu dng, v dnh htrp lcgy nn hin tng mt ng b, tng cng thWOB.

+Auto PEEP

Mode thtch Mode p lc


7/22

Khi dng thra khng quay vng c bn khi bt u mt nhp thmi, y c thl nguynnhn ca hin tng Auto PEEP. Cc nguyn nhn gy ra Auto PEEP : trn kh (emphysema),thit lp tlI:E cha ng.

+ p ng gin phqun.

nh gi mc p ng vi thuc gin phqun, ta sthy sci thin vnh lu dng ththra cao hn trc khi iu tr.

Ngoi ra ng thra cng sm vng c bn hn so vi trc iu tr.

+ iu chnh I-time


8/22

B Dng thvng lp trong my th(loop waveform)

B1 Dng thp lcthtch.

Trc Y ca thsbiu ththng sthtch, trc xbiu ththng sp lc. Biu thcho qu trnh ht vo l ng cong i l, thra l n cong i xung.

im thit lp ban u ca vng lp sbt u ti gitrPEEP c ci t.

Dliu tthvng lp thtch p lc c sdng nh gi nhng g?

Scng phng qu mc ca phi ( Lung Overdistention). Stt nghn ng kh ( Airway obstruction) Mc p ng gin phqun trong iu tr(Bronchodilator Response ) Thmy ( C/RAW) Sr r (Leaks). Sthiu dng(Flow Starvation) Cng th(WOB) Nlc trigger.

Hai Dng ththtch p lc

Trong mode ththtch (volume mode): thc dng football

Trong mode thp lc (pressure mode): thc dng square

Cdyn


9/22

Trong mode thp lc , p lc sc chuyn i vi mt gi trkhng i, do n sto trnthdng sng p lc mt gi trbnh nguyn (Plateau), iu ny cng to trn thvng lpgi trbnh nguyn.

Hin tng cng phng qu mc ca phi (Lung Overdistention)

Vic p lc lin tc tng vi mt lng t hoc khng lm thay i thtch sto ra mt birdbeak(dng mm chim trn vng lp) v qua gy nn hin tng cng phng qu mc chophi. khc phc tnh trng ny bng cch gim thtch kh lu thng (tidal volume).

Nlc trigger (triggering effort)Nu trong qu trnh thmy bnh nhn c du hiu tth, bn sthy trn vng lp mt

crossover hay tail im bt u vng lp.Cng nh Cng thcng tng, th ng tail cng di hn.

plateau


10/22

Trkhng ng th(Airway resistance)

Khi trkhng ng kh tng ln. Th brng ca vng lp cng ln hn.

C 2 loi l tng trkhng ng thra, v trkhng ng ht vo.

Tng trkhng ng thra: nguyn nhn c thdo qu trnh bi tit, co tht phqun,vv.

Tng trkhng ng ht vo: nguyn nhn c thdo ng t ni kh qun qu nh, ngbtht nt, hay do bnh nhn cn ng, vv.

gin nca phi (Compliance)

Tng gin nLy v d: trong trng hp trn kh (Emphysema)

Gim gin n


11/22

Hi chng suy h hp cp tin (ARDS), Suy tim xung huyt (CHF), Chng xp phi(Atelectasis), trn mn phi.

Sr r kh

Hin tng khi dng thvng lp th thra khng i vng c bn, cnh bo y l tnhtrng r kh.

im un (Inflection points)

Mt trong nhng cch bo vphi trong qu trnh iu trARDS, l nghthit lp mcPEEP sao cho lun cao hn im un thp nht, nhm bo m cho phnng lun m.


12/22

B2 Dng thvng lp Lu lngThtch.

Trc Y ca thsbiu thlu lng, trc Xbiu ththtch.

C thc sdng xc nh dng nh lulng th ht vo, v dng nh lu lng th thra(PIF, PEF), Thtch kh lu thng Vt.

i vi nhp thtpht th dng thvnglp sc dng hnh trn.

Phn pha trn thbiu thtrng thi htvo, phn pha di thbiu thtrng thi thra.

Dliu tthvng lp lu lngthtchc sdng nh gi nhng g?

By kh (auto PEEP). Stt nghn ng kh (Airway obstruction). Trkhng ng kh. Mc p ng gin phqun trong iu tr(Bronchodilator Response ). Dng ht vo, thra. R r kh. Stnc. Thiu dng. (Flow strarvation) Smt ng b.

Dng sng ca th ht vo trn thvng lp tng ng vi dng thi lu dng.


13/22

Stt nghn ng kh (Airway obstruction).

Trong mt vi trng hp stt nghn ng kh (bnh suyn - asthma), bn c ththy nhlu lng dng thra thp.

Bn cng c ththy hin tng scooping trnng thra. scooping cho thy thtch thra c tc chn li do tt nghn ng th.


14/22

By kh (Auto PEEP) hay sr r kh

Nu xut hin hin tng by kh hay sr r kh,quan st trn thvng lp im cui th thra v im u th htvo skhng gp nhau.

Stnc trong ng th

Nu c stnc trong ng thth trn thvng lp bn sthy xut hin dng sngsawtoothed (dng sng rng ca).

Skhng ng b(Asynchrony)

Thiu dng (Flow starvation)


15/22

Dng sng p lc th ht vo xut hin dip (chtrng xung) do lu dng khng , bnh nhncn ht nhiu khong kh hn, do lm gim p lc.

Mt bt li chnh ca chdng lin tc (v dmode kim sot thtich), c thkhng p ngc nhu cu ht vo ca bnh nhn.

i vi my thservo, my thsttnh ton tng lu dng cho nhp thktip, loi bhin tng thiu dng.

Trn dng thvng lp xut hin nhiu vtr trng xung, cho thy du hiu ca sthiudng.


16/22

By kh(Auto PEEP)

Nguyn nhn:Khng thi gian thra, sxp phnang sy ra sm, khng n nh/trn ththra.

Lm thno xc nh hin tng Auto PEEP theo dng th:

Vi dng sng p lc: Trong qu trnh ging thra , dng sng nm trn n cbn (thngthng >5cmH2O l xy ra auto PEEP).

Vi dng sng lu dng: Dng sng dng thra khng quay vng c bn khi bt umt nhp thmi.

Vi dng sng thtch: Mt phn ca th thra khng quay vng c bn, Vi dng sng vng lp FV, PV: vng lp bgin on.

Khc phc nh thno:

Sdng liu iu trgin phqun (bronchodilator), iu chnihr thi gian thvo (I-time), tngdng v iu chnh PEEP.

Thay i trkhng ng th

Nguyn nhn:

Hin tng co tht phqun (Bronchiospasm). Vn vi ng t ni kh qun. Tc dng cao. Bi tit dch. Van thhay blc bkhoa hay m t. Nc trong HME.

Lm thno xc nh chng trn th:

Dng sng p lc: PIP tng nhng p lc lc plateau vn khng i. Dng sng lu dng: Mt nhiu thi gian hn cho th thra t ti ng c bn. Dng sng thtch: Mt nhiu thi gian ng cong th thra vvtr ng c bn. Dng vng lp PV: Dng vng lp srng hn. Dng vng lp FV: Dng thra gim, trn ng cong thra xut hin scooping.

Khc phc nh thno:

Sdng liu php iu trgin phqun, ht dch bnh nhn, ng dn lu, thay thHME, thaythETT, gim lu lng, thay i blc.

Thay i gin n(compliance)


17/22

gin nca phi gim.

Nguyn nhn:

ARDS Xp phi (Atelectasis) u bng trng. CHF Consolidation X ho (Fibrosis) Cng phng qu mc (Overdistention) Trng kh mng phi (Pneumothorax) Trng dch mng phi (Pleural effusion)


Dng sng p lc: PIPv p lc lc plateau iu tng. Dng vng lp PV: Phng trc ngang nhiu.

gin nphi tng

Nguyn nhn: Emphysema, trliu Surfactant


Dng sng p lc: PIPv p lc lc plateau iu gim. Dng vng lp PV: Phng trc dc nhiu.

R r kh


Dng sng thtch: Dng sng th thra khng vng c bn. Dng sng lu dng: PEF gim. Vng lp PV v F V: ng thra khng vng c bn

Smt ng b

Nguyn nhn: lu lng, tc , trigger, thiu dng, tn thng thn kinh, thit lp trigger khngng


Dng sng p lc: Bnh nhn cgng ht/thgia dng sng, gy ra sst gim plc.


18/22

Dng sng lu dng: Bnh nhn cgng ht/thgia dng sng, gy ra sbt thngtrogn dng sng lu lng.

Vng lp PV, FV: Dng sng p lc th ht vo xut hin dip (chtrng xung) dolu dng khng , bnh nhn cn ht nhiu khong kh hn, do lm gim plc.

Khc phc nh thno:

Thtng tc lu dng, gim thi gian ht vo, hoc tng cc thng sthit lp phhp vi nhu cu ca bnh nhn hn.

Thay i mode thhin ti Nu lin quan n thn kinh c thcn phi sdng ti thuc. iu chnh nhy.

C iu chnh rise time v % insp cycle offC1 iu chnh rise time (thi gian tng kht vo)

Thi gian tng kht vo l thi gian cn t lu lng ht vo hoc p lc ti thi imbt u mt nhp th.

Thit lp rise time nhanh


19/22

Nu thit lp mt mc rise time qu nhanh, sddng quan st trn thstng vt trn thp lc.

Nu iu nyxy ra, bn cn phi tngthi gian tng. iu nylmcho dng chy van mchmhn.

V dviu chnh rise time qu nhanh

Vi thit lp rise time mc 0.05, ta squan st c trn thp lc im tng vt p lc.

Sau khi iu chnh rise time chm hn , th dng sng quan st trvbnh thng.

Thit lp rise time chm


20/22

Nu thit lp rise time qu chm dng sng p lc snghing hn, iu ny c thnh hngn lng kh lu thng Vt c cung cp khng thp ng nhu cu bnh nhn. Nu iu nyxy ra bn cn phi gim thi gian rise time mvan nhanh hn.

C2 iu chnh insp cycle off

Trong chlu lng, nh htrthtch v htrp lc, insp cycle off c xc nh ti thi

im chuyn i tth thra v ht vo.Cng c thhiu insp cycle off:

Ngng chu kht vo. Chm dt kht vo. Expiratory flow sensitivity, Inspiratory flow cycle %, E-cycle, etc

Kt thc kht vo khi dng lu lng gim n mt gi trxc nh.


21/22

Trong v dtrn my thc thit lp kt thc kht vo v bt u kthra 30% lu lngnh kht vo PIF.

iu chnh insp cycle off qu cao hay qu thp

v dtrn vic iu chnh insp cycle off qu cao 60% sdn n chu kht vo kt thc qusm, v Vt skhng .


22/22

v dtrn vic iu chnh insp cycle off qu thp 10%, iu ny slm cho nhp thko di.iu ny gy nh hng l nlc thra ca bnh nhn chng li hi thto ra mt p lc tngvt (tng cng thWOB).

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Dạng đồ thị trong máy thở (phuong)