Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (1)
Prevention and treatment of bronchial - lung infection measures
1. Enhance immunity
(1) strengthen the appropriate nutrition: chronic obstructive pulmonary disease patients often malnourished and appropriately increase nutrition (food increase in nutrients, if necessary, to lose plasma, albumin or compound amino acid) can enhance the body's immunity.
(2) appropriately increase physical activity: According to illness, as can bear the physical activity (such as walking, radio, gymnastics, tai chi move, Ba Duan Jin, and so on) j can enhance physical fitness, improving immunity.
(3)-pui Feishen: the proper use of traditional Chinese medicine Feishen-pui, can prevent chronic obstructive pulmonary disease development. To prevent the occurrence of respiratory failure.
(4) the proper use of gamma globulin: an increase in antibodies, to increase immunity. Usually 6 m1 intramuscular injection, on the 7th time.
(5) regulate immune function: the lower the immune function of patients with chronic obstructive pulmonary disease using levamisole, restore immune function. Friends of Rotary imidazole internal usage is 50 mg, three times a day, the linked 3, then stopping on the 7th.
5/02/2008
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (2)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (2)
Quit
Chronic obstructive pulmonary disease patients quit smoking, avoiding harmful substances in tobacco damage to the body and prevent chronic obstructive pulmonary disease progress, the incidence of respiratory failure, the mechanism is:
1, the alveolar stop-to prevent the destruction of emphysema of the increase;
2, to prevent carbon monoxide and hemoglobin, putting O2 and the proper combination of hemoglobin, oxygen content will not be reduced;
3 prevent harmful substances in tobacco-mediated vascular endothelial cells damage, platelet adhesion, aggregation and the release of the reaction occurred, the slow blood flow, blood coagulation and the stasis of the increase in the formation of micro-thrombosis, pulmonary microcirculation of the obstacles;
4, to prevent harmful substances in tobacco-mediated increased fibrinogen concentration, hematocrit increased blood viscosity of the increased concentration and coagulation of the increase;
5, to prevent harmful substances from tobacco bronchial spasm, airway resistance increased, decreased pulmonary ventilation.
Patients with chronic obstructive pulmonary disease I have to stop smoking, and patients to work together, the lives of people to quit smoking, the only way to truly avoid tobacco for chronic obstructive pulmonary disease, respiratory damage.
Quit
Chronic obstructive pulmonary disease patients quit smoking, avoiding harmful substances in tobacco damage to the body and prevent chronic obstructive pulmonary disease progress, the incidence of respiratory failure, the mechanism is:
1, the alveolar stop-to prevent the destruction of emphysema of the increase;
2, to prevent carbon monoxide and hemoglobin, putting O2 and the proper combination of hemoglobin, oxygen content will not be reduced;
3 prevent harmful substances in tobacco-mediated vascular endothelial cells damage, platelet adhesion, aggregation and the release of the reaction occurred, the slow blood flow, blood coagulation and the stasis of the increase in the formation of micro-thrombosis, pulmonary microcirculation of the obstacles;
4, to prevent harmful substances in tobacco-mediated increased fibrinogen concentration, hematocrit increased blood viscosity of the increased concentration and coagulation of the increase;
5, to prevent harmful substances from tobacco bronchial spasm, airway resistance increased, decreased pulmonary ventilation.
Patients with chronic obstructive pulmonary disease I have to stop smoking, and patients to work together, the lives of people to quit smoking, the only way to truly avoid tobacco for chronic obstructive pulmonary disease, respiratory damage.
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (3)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (3)
Cold summer
1. Cold in the winter or cold temperatures suddenly reduce the time and pay attention to warm to prevent Shouhan, the prevention of chronic obstructive pulmonary disease in respiratory failure is significant, the mechanism is:
1) to avoid the cold caused by bronchial spasms and increased secretions to prevent pulmonary ventilation reduced; ② to avoid the cold-mediated diuretic, to prevent blood viscosity increased, the slow flow stasis, lung blood circulation in particular the microcirculation;
2) to avoid a cold, bronchial reduce - the incidence of lung infection.
Winterization measures:
1) persistent physical activity, enhance physical fitness, enhanced ability to keep out the cold;
2) to increase the living room temperature;
3) the cold, especially when the temperature dropped to appropriately increase warm clothing.
2. Fang Shu in the unusually dry summer, to take measures to reduce the working and living environment of temperature, humidity increased, to prevent chronic obstructive pulmonary disease in respiratory failure who would benefit, the mechanism is:
1) to avoid sweating, a lot of water to prevent the loss, increased blood viscosity, blood stasis slow, lung blood circulation disorders;
2) to avoid excessive sputum Meal Diao, Kechu difficult, hampered alveolar ventilation.
Cold summer
1. Cold in the winter or cold temperatures suddenly reduce the time and pay attention to warm to prevent Shouhan, the prevention of chronic obstructive pulmonary disease in respiratory failure is significant, the mechanism is:
1) to avoid the cold caused by bronchial spasms and increased secretions to prevent pulmonary ventilation reduced; ② to avoid the cold-mediated diuretic, to prevent blood viscosity increased, the slow flow stasis, lung blood circulation in particular the microcirculation;
2) to avoid a cold, bronchial reduce - the incidence of lung infection.
Winterization measures:
1) persistent physical activity, enhance physical fitness, enhanced ability to keep out the cold;
2) to increase the living room temperature;
3) the cold, especially when the temperature dropped to appropriately increase warm clothing.
2. Fang Shu in the unusually dry summer, to take measures to reduce the working and living environment of temperature, humidity increased, to prevent chronic obstructive pulmonary disease in respiratory failure who would benefit, the mechanism is:
1) to avoid sweating, a lot of water to prevent the loss, increased blood viscosity, blood stasis slow, lung blood circulation disorders;
2) to avoid excessive sputum Meal Diao, Kechu difficult, hampered alveolar ventilation.
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (4)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (4)
The prevention of the occurrence of allergic reaction
Allergic reactions useful deterrent to prevent invasion of obstructive pulmonary disease in respiratory failure, is to prevent allergic reactions, inhibit histamine, slow-reactive substances, bradykinin, 5 - HT, eosinophils chemokines, such as platelet activating factor The release of strong material, will prevent bronchospasm, bronchial mucosal edema, secretions increase to prevent the occurrence of pulmonary edema, pulmonary damage to the wall, the broken capillaries, thereby preventing lung ventilation and lung ventilation dysfunction occurred To prevent the formation of respiratory failure.
Effective measures to prevent the allergic reaction is to avoid allergens, desensitization treatment and color celecoxib acid disodium powder inhalation.
1. Avoid contact with allergens in accordance with history, skin tests identify allergens and avoid its contacts. Can prevent allergic reactions.
2. Specific antigen desensitization with the relevant antigen leaching solution to desensitization treatment, a gradual increase of immunoglobulin IgG, the latter with the allergy antigens, thereby preventing IgE and allergic antigen binding, inhibition of allergic reaction occurred. The therapy for more than mixed with the inhaled asthma.
Common mite-specific desensitization therapy is the leaching of desensitization therapy. Leaching is the wave of mites: 1:5000,1:1000,1:100. Paper usage is injected, from the low concentration, the weekly ol ml, case-by-week increase o.1ml, to o.5ml, an increase concentration, still using the injection method. This therapy to the good before the season began three months enough muscle treatment, treatment for l5 Monday, a year can be 1 - 2 courses.
3. Vaccine formulations desensitization vaccine several times after injection, the body produce antibodies specific cycle, and later entered the body of allergic antigen and IgG in combination with the absorption of IgE on the mast cell was the combination of blocking, to prevent Type I allergic The occurrence. This therapy for infected more than the prevention of bronchial asthma.
The prevention of the occurrence of allergic reaction
Allergic reactions useful deterrent to prevent invasion of obstructive pulmonary disease in respiratory failure, is to prevent allergic reactions, inhibit histamine, slow-reactive substances, bradykinin, 5 - HT, eosinophils chemokines, such as platelet activating factor The release of strong material, will prevent bronchospasm, bronchial mucosal edema, secretions increase to prevent the occurrence of pulmonary edema, pulmonary damage to the wall, the broken capillaries, thereby preventing lung ventilation and lung ventilation dysfunction occurred To prevent the formation of respiratory failure.
Effective measures to prevent the allergic reaction is to avoid allergens, desensitization treatment and color celecoxib acid disodium powder inhalation.
1. Avoid contact with allergens in accordance with history, skin tests identify allergens and avoid its contacts. Can prevent allergic reactions.
2. Specific antigen desensitization with the relevant antigen leaching solution to desensitization treatment, a gradual increase of immunoglobulin IgG, the latter with the allergy antigens, thereby preventing IgE and allergic antigen binding, inhibition of allergic reaction occurred. The therapy for more than mixed with the inhaled asthma.
Common mite-specific desensitization therapy is the leaching of desensitization therapy. Leaching is the wave of mites: 1:5000,1:1000,1:100. Paper usage is injected, from the low concentration, the weekly ol ml, case-by-week increase o.1ml, to o.5ml, an increase concentration, still using the injection method. This therapy to the good before the season began three months enough muscle treatment, treatment for l5 Monday, a year can be 1 - 2 courses.
3. Vaccine formulations desensitization vaccine several times after injection, the body produce antibodies specific cycle, and later entered the body of allergic antigen and IgG in combination with the absorption of IgE on the mast cell was the combination of blocking, to prevent Type I allergic The occurrence. This therapy for infected more than the prevention of bronchial asthma.
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (5)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (5)
Avoid inhaling air pollution
Patients with chronic obstructive pulmonary disease inhalation of polluted air can be mediated bronchial spasms, bronchial mucosal edema, bronchial secretions increase in airway resistance increased, decreased pulmonary ventilation, and promote the occurrence of respiratory failure. To prevent the inhalation of air pollution and avoid harmful substances, such as SO2, CL2, No2. NH3, dust and fumes from the bronchial mucosa to stimulate and inhibit bronchial spasms, bronchial mucosal edema, increased bronchial secretions and bronchial epithelial damage cilia loss and is conducive to the maintenance of normal alveolar ventilation to prevent the occurrence of respiratory failure.
To avoid inhalation of air pollution is the main measures:
① mobilize all forces in society deal with emissions, without dealing with the ban, containing harmful substances in exhaust emissions, and maintain human survival space of clean air:
② resettlement air cleaner place to live, work.
Avoid inhaling air pollution
Patients with chronic obstructive pulmonary disease inhalation of polluted air can be mediated bronchial spasms, bronchial mucosal edema, bronchial secretions increase in airway resistance increased, decreased pulmonary ventilation, and promote the occurrence of respiratory failure. To prevent the inhalation of air pollution and avoid harmful substances, such as SO2, CL2, No2. NH3, dust and fumes from the bronchial mucosa to stimulate and inhibit bronchial spasms, bronchial mucosal edema, increased bronchial secretions and bronchial epithelial damage cilia loss and is conducive to the maintenance of normal alveolar ventilation to prevent the occurrence of respiratory failure.
To avoid inhalation of air pollution is the main measures:
① mobilize all forces in society deal with emissions, without dealing with the ban, containing harmful substances in exhaust emissions, and maintain human survival space of clean air:
② resettlement air cleaner place to live, work.
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (6)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (6)
Of dehydration, shock
In patients with chronic obstructive pulmonary disease, prevention and treatment dehydration, shock beneficial to the prevention of the occurrence of respiratory failure, the mechanism is, of dehydration, shock, blood concentration can be avoided, the brain-small gathering, interleukin gathered, platelet adhesion, aggregation and the release of reaction To prevent the increase of blood viscosity, enhanced coagulation, micro-thrombosis to avoid lowering blood volume cycle, in order to maintain normal lung tissue of blood circulation, especially micro-circulation, to maintain the normal function of the lung ventilator.
Of dehydration, shock, major combat is intense vomiting, diarrhea. Sweating a lot, avoid the use of potent diuretics, promptly added liquid, the expansion of blood volume, anti-infection. Correct acid poisoning, use the lining of glucocorticoid, if necessary, the use of vasodilative drugs (654-2) and vasoconstrictor substance.
Of dehydration, shock
In patients with chronic obstructive pulmonary disease, prevention and treatment dehydration, shock beneficial to the prevention of the occurrence of respiratory failure, the mechanism is, of dehydration, shock, blood concentration can be avoided, the brain-small gathering, interleukin gathered, platelet adhesion, aggregation and the release of reaction To prevent the increase of blood viscosity, enhanced coagulation, micro-thrombosis to avoid lowering blood volume cycle, in order to maintain normal lung tissue of blood circulation, especially micro-circulation, to maintain the normal function of the lung ventilator.
Of dehydration, shock, major combat is intense vomiting, diarrhea. Sweating a lot, avoid the use of potent diuretics, promptly added liquid, the expansion of blood volume, anti-infection. Correct acid poisoning, use the lining of glucocorticoid, if necessary, the use of vasodilative drugs (654-2) and vasoconstrictor substance.
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (7)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (7)
Lower blood viscosity and blood coagulation
Chronic obstructive pulmonary disease patients with respiratory failure, and blood viscosity increased coagulation strengthen close ties. Targeted therapy, to reduce blood coagulation and viscosity, improving hemorheology. Lung tissue can improve blood circulation in particular, micro-cycle, improve lung function ventilation to prevent the occurrence of respiratory failure.
Lower blood viscosity and coagulation, in addition to controlling the bronchial - infection control dehydration, shock and acid poisoning, the blood is diluted, inhibiting platelet function, anti-clotting and reduce fibrinogen, dissolved micro-thrombosis, promoting blood circulation Huayu.
Lower blood viscosity and blood coagulation
Chronic obstructive pulmonary disease patients with respiratory failure, and blood viscosity increased coagulation strengthen close ties. Targeted therapy, to reduce blood coagulation and viscosity, improving hemorheology. Lung tissue can improve blood circulation in particular, micro-cycle, improve lung function ventilation to prevent the occurrence of respiratory failure.
Lower blood viscosity and coagulation, in addition to controlling the bronchial - infection control dehydration, shock and acid poisoning, the blood is diluted, inhibiting platelet function, anti-clotting and reduce fibrinogen, dissolved micro-thrombosis, promoting blood circulation Huayu.
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (8)
Chronic obstructive pulmonary disease of the respiratory failure of preventive measures (8)
The prevention of respiratory muscle fatigue
Clinical practice has proved that chronic obstructive pulmonary disease and respiratory failure respiratory muscle fatigue, especially respiratory muscle fatigue is closely related to the prevention of respiratory muscle fatigue, and prevent respiratory driving force behind the movement to reduce and prevent the alveolar ventilation reduced the incidence of respiratory failure. The prevention of respiratory muscle fatigue measures are:
1. Reduce energy consumption to lift bronchial spasms, the elimination of bronchial mucosal edema, reduce bronchial secretions, remove the stubborn phlegm, reduce airway resistance and reduce energy consumption.
2. To improve the nutritional status of strengthening the body improve the nutrition of sugar, protein and vitamin intake all, if necessary, intravenous infusion of amino drums, plasma and albumin.
3. A day for respiratory gymnastics, enhancing the activities of respiratory muscle function.
4. The use of in vitro diaphragm pacemaker respiratory muscle fatigue, you can use in vitro diaphragm pacemaker to improve the alveolar ventilation, exercise the diaphragm, strengthen the activities of the diaphragm.
The prevention of respiratory muscle fatigue
Clinical practice has proved that chronic obstructive pulmonary disease and respiratory failure respiratory muscle fatigue, especially respiratory muscle fatigue is closely related to the prevention of respiratory muscle fatigue, and prevent respiratory driving force behind the movement to reduce and prevent the alveolar ventilation reduced the incidence of respiratory failure. The prevention of respiratory muscle fatigue measures are:
1. Reduce energy consumption to lift bronchial spasms, the elimination of bronchial mucosal edema, reduce bronchial secretions, remove the stubborn phlegm, reduce airway resistance and reduce energy consumption.
2. To improve the nutritional status of strengthening the body improve the nutrition of sugar, protein and vitamin intake all, if necessary, intravenous infusion of amino drums, plasma and albumin.
3. A day for respiratory gymnastics, enhancing the activities of respiratory muscle function.
4. The use of in vitro diaphragm pacemaker respiratory muscle fatigue, you can use in vitro diaphragm pacemaker to improve the alveolar ventilation, exercise the diaphragm, strengthen the activities of the diaphragm.
The clinical symptoms of respiratory failure
The clinical symptoms of respiratory failure
In addition to the respiratory failure symptoms of the disease, mainly carbon dioxide retention and hypoxia caused by multiple organ dysfunction of the performance, such as difficulty in breathing, breathing with intermittent or Chouqi respiration, when a slow and fast deep to shallow breathing, Will have to shoulder nod or breathing. In the case of breathing difficulties, with the lack of oxygen, severe hypoxia, may appear cyanosis, when the shock was not obvious when cyanosis. Severe hypoxia and carbon dioxide retention, skin Hongrun, wet warm sweating, hypertension, cerebrovascular expansion, a pulsating headache. Late due to serious lack of oxygen, acid poisoning caused myocardial damage can occur around the circulatory failure, blood pressure dropped, arrhythmias, heart arrest. Respiratory failure heavier, the liver and kidney functions are affected, there proteinuria, hematuria and upper gastrointestinal bleeding, serum ALT and urea nitrogen increased.
The spirit of acute respiratory failure symptoms markedly slower, there may be suffering from mental disorder, manic, coma, convulsions and other symptoms, chronic hypoxia when there are intellectual or directional dysfunction. When the central nervous system caused by carbon dioxide retention excitement, such as insomnia, irritability, restlessness, Jiyong sedation or sleeping pills, so as not to increase the retention of carbon dioxide, a pulmonary encephalopathy, for the performance of consciousness indifferent, muscle tremors, occasional convulsions, drowsiness and even coma .
In addition to the respiratory failure symptoms of the disease, mainly carbon dioxide retention and hypoxia caused by multiple organ dysfunction of the performance, such as difficulty in breathing, breathing with intermittent or Chouqi respiration, when a slow and fast deep to shallow breathing, Will have to shoulder nod or breathing. In the case of breathing difficulties, with the lack of oxygen, severe hypoxia, may appear cyanosis, when the shock was not obvious when cyanosis. Severe hypoxia and carbon dioxide retention, skin Hongrun, wet warm sweating, hypertension, cerebrovascular expansion, a pulsating headache. Late due to serious lack of oxygen, acid poisoning caused myocardial damage can occur around the circulatory failure, blood pressure dropped, arrhythmias, heart arrest. Respiratory failure heavier, the liver and kidney functions are affected, there proteinuria, hematuria and upper gastrointestinal bleeding, serum ALT and urea nitrogen increased.
The spirit of acute respiratory failure symptoms markedly slower, there may be suffering from mental disorder, manic, coma, convulsions and other symptoms, chronic hypoxia when there are intellectual or directional dysfunction. When the central nervous system caused by carbon dioxide retention excitement, such as insomnia, irritability, restlessness, Jiyong sedation or sleeping pills, so as not to increase the retention of carbon dioxide, a pulmonary encephalopathy, for the performance of consciousness indifferent, muscle tremors, occasional convulsions, drowsiness and even coma .
The incidence of respiratory failure mechanisms and pathophysiology
The incidence of respiratory failure mechanisms and pathophysiology
1 missing O2 and CO2 retention mechanism
(A) lack of ventilation in the resting breathing air, the alveolar ventilation is about 4 L / min, to maintain normal alveolar oxygen and carbon dioxide partial pressure. Reduce alveolar ventilation, alveolar oxygen pressure dropped, carbon dioxide partial pressure increased. Under the conditions of breathing air (oxygen concentration of respirable 20.93 percent, carbon dioxide close to zero).
(B) ventilation / flow ratio imbalance in the ventilation and pulmonary capillary blood perfusion around the ratio must be coordinated to ensure effective gas exchange. Every minute of normal alveolar ventilation (VA) 4L, pulmonary capillary blood flow (Q) 5L, both the ratio of 0.8. Such as pulmonary ventilation in the blood flow rate of greater than (> 0.8). Is a physiological dead space increases, which is invalid cavity effect; alveolar ventilation in the ratio of less than the blood flow (<0.8), so that the mixture of pulmonary blood oxygenation without full access to pulmonary vein, a kind arteriovenous shunt (Figure 2-6-2). Ventilation / flow ratio imbalance, a lack O2, without CO2 retention. The result of blood mixed with the blood of oxygen difference is much greater than CO2 partial pressure, the former for 7.98 kPa, while the latter only 0.79 kPa, difference of 10 times. It may, by the sound of alveolar hyperventilation, emit more CO2, inadequate ventilation to compensate alveolar retention of CO2, or even emit more CO2, a respiratory alkalosis. As hemoglobin oxygen dissociation of the characteristics of normal alveolar capillary blood oxygen saturation already in a flat, the increase even if ventilation, air suction, although the alveolar oxygen, but little increase in blood oxygen saturation, by Sound excessive alveolar ventilation can not compensate the lack of ventilation caused by the perturbation alveolar oxygen shortage and thus a lack O2.
Ventilation> normal blood flow> ventilation
(Dead space effect) (effective ventilation) (static artery diversion effect)
(C) pulmonary artery - because of pulmonary vein-like triage pulmonary diseases such as depression wilt, atelectasis, pneumonia and pulmonary edema and pulmonary real change may cause an increase like triage, so that blood no contact alveolar gas to gas exchange opportunities. Therefore, increasing oxygen concentration and can not be raised PaO2. The greater the flow, increase blood oxygen inhalation after the worse the effect of the partial pressure of oxygen, such as the flow of more than 30 percent of the oxygen partial pressure of oxygen on the limited impact.
(D) diffusion barriers oxygen diffusing capacity of carbon dioxide is only 1 / 20, is in the diffusion barriers, a simple hypoxia.
(5) oxygen consumption increased oxygen consumption is increasing missing one of the reasons for O2, fever, chills, breathing difficulties and convulsions are to increase oxygen consumption. Shivering oxygen consumption up to 500 ml / min, severe asthma, with the increased work of breathing, oxygen consumption for more than 10 times normal. Oxygen consumption increased, decreased alveolar oxygen, help increase the normal ventilation to prevent hypoxia. Figure 2-6-3 that breathing air, oxygen consumption in the partial pressure of oxygen and pulmonary alveolar ventilation of the impact. Map of the curve with the dotted line to the point of intersection of different oxygen consumption, the maintenance of normal alveolar oxygen for pulmonary ventilation, with the increase in oxygen consumption, has also increased significantly, oxygen consumption per minute, respectively For 200 ml, 400ml, 800ml, alveolar ventilation volume of 3 L, 6L, 12l. From the map in each of the earlier steep, after the characteristics of the flat can see that the increase in oxygen consumption dysfunction in patients with ventilation, alveolar oxygen can not be raised, hypoxia hardly eased.
Second, the lack O2, CO2 retention of the impact of the body
(A) the impact of the central nervous brain tissue oxygen consumption accounted for about systemic consumption of 1/5-1/4. Central cortex cells most sensitive to hypoxia, lack O2 and the extent of the central nervous Jihuan the middle of the highest bidders different effects on health. Such as a sudden interruption for O2, purity nitrogen absorption to be 20 seconds in deep coma and body convulsions. Gradually reduce the absorption of O2 concentration, slow onset of symptoms, can cause mild missing O2 attention is not focused, intelligence may be directed obstacles with the increasing lack O2, PaO2 (PaO2) below 6.66 kPa can induce irritability, Trance consciousness, delirium; below 3.99 kPa, would lose consciousness, and even coma; below 2.66 kPa will be irreversible brain damage.
CO2 cerebrospinal fluid retention so that the concentration of hydrogen ions, the impact of brain cell metabolism, reduce excitatory brain cells and inhibit cortex; With the increase in CO2, stimulate the strengthening of the lower cortex, the cortex caused excitement; if CO2 continue to rise, the lower deck of the cortex inhibit So that the central nervous system in a state of anesthesia. In a pre-anesthesia patients often suffer from insomnia, mental excitement, irritability symptoms of the threatened excited.
Missing O2 and CO2 retention will have cerebral vascular expansion, reduced resistance to blood flow, to compensate the血流量增加. O2 will be seriously lacking in brain cells, edema, increased permeability of blood vessels, caused brain interstitial edema, leading to increased intracranial pressure, squeezing brain tissue and oppression of blood vessels, thereby increasing brain missing O2, a vicious cycle.
(B) of the heart, circulation of missing O2 can stimulate the heart to speed up the heart rate and stroke volume increase, high blood pressure. Coronary blood flow in the lack O2, a marked increase in heart blood flow far exceeds the brain and other organs. O2 myocardial lack of sensitivity, early mild O2 that is lacking in the electrocardiogram appeared on the show, a serious lack of O2 can lead to ventricular fibrillation or cardiac arrest. Missing O2 and CO2 retention can cause pulmonary vasoconstriction small increase in pulmonary vascular resistance, leading to increased pulmonary hypertension and right heart burden.
Inhalation of gas in the concentration of CO2, will speed up the heart rate, stroke volume increased, cerebral, coronary vasodilation, subcutaneous superficial capillaries and veins expansion due to the muscles of the spleen and blood vessels to contract, coupled with increased stroke volume, the Blood pressure is still elevated.
(C) lack of respiratory effects of breathing O2 impact than the impact of CO2 retention for small. O2, mainly through lack of carotid sinus and aortic reflection of the role of chemical receptors to stimulate ventilation, such as the slow increase the degree of lack O2, the reflective slow.
CO2 is a strong respiratory center stimulants, inhalation of increased CO2 concentration, ventilation multiplied, the retention of CO2 in deep rapid breathing, but when inhaled超过12% CO2 concentration, ventilation will not increase in the respiratory center Was inhibited. And chronic hypercapnia, there is no corresponding increase in ventilation, but has declined, and respiratory center reaction of the slow, through the kidneys to absorb and bicarbonate from H +, so that no blood pH value decreased, and patients Gas resistance increased, serious lung damage, the thorax movement dysfunction related to ventilation.
(D) of the liver, kidney and blood system of missing O2 can be direct or indirect damage to the liver ALT increased, but with the lack of corrective O2, liver function gradually returned to normal.
Reduce arterial blood oxygen, kidney blood flow, the volume of glomerular filtration, urine output and sodium from the increase of both, but when PaO2 <5.3kPa, reduce kidney blood flow, kidney function was inhibited.
Low oxygen erythropoietin to increase red blood cell proliferation. Kidney and liver produce an enzyme, the blood of the Central African erythropoietin, the predecessor of a generation of active substances to stimulate the bone marrow caused secondary erythrocytosis. To increase the carrying capacity of blood, but also increased blood viscosity, pulmonary circulation and increase the burden on the right heart.
CO2 retention mild renal vascular expansion will increase renal blood flow, increase the amount of urine when PaCO2超过8.64 kPa, blood pH decreased significantly, kidney vasospasm, reduced blood flow, HCO3-and Na + absorption to increase urine output reduction .
(5) of electrolyte and acid-base balance the impact of severe energy shortage O2 cells inhibited the middle of the process and radio, such as三羧酸循环, and the role of oxidative phosphorylation-related activities. This will not only have lower energy efficiency, but also due to produce lactic acid and inorganic phosphorus from metabolic acidosis. As the energy shortage, in-transit damage by the sodium pump, so that cells within the potassium transferred to the blood, and Na + and H + into the cells, causing cells acidosis and hyperkalemia. Metabolic acidosis the fixed buffer acid and bicarbonate in the system work, a carbonate, the organization increased carbon dioxide tension.
PH value of carbonate and bicarbonate depends on the ratio of the former regulation on the kidney (1-3 days), while carbonated regulation on the lung (hours). Healthy people every day from lung carbonate of as many as 15000 mmol, the acute respiratory failure CO2 retention impact on the pH very quickly, often with metabolic acidosis exist, due to acid poisoning caused serious decline in blood pressure, arrhythmia, and even cardiac arrest . And chronic respiratory failure due to the slow development of CO2 retention and kidney from reduced bicarbonate, does not result in significantly lower pH. Because of blood in the main anion HCO3-and CI-in and is a constant, when HCO3-increase, the CI-corresponding lower, a low chlorine hyperlipidemia.
1 missing O2 and CO2 retention mechanism
(A) lack of ventilation in the resting breathing air, the alveolar ventilation is about 4 L / min, to maintain normal alveolar oxygen and carbon dioxide partial pressure. Reduce alveolar ventilation, alveolar oxygen pressure dropped, carbon dioxide partial pressure increased. Under the conditions of breathing air (oxygen concentration of respirable 20.93 percent, carbon dioxide close to zero).
(B) ventilation / flow ratio imbalance in the ventilation and pulmonary capillary blood perfusion around the ratio must be coordinated to ensure effective gas exchange. Every minute of normal alveolar ventilation (VA) 4L, pulmonary capillary blood flow (Q) 5L, both the ratio of 0.8. Such as pulmonary ventilation in the blood flow rate of greater than (> 0.8). Is a physiological dead space increases, which is invalid cavity effect; alveolar ventilation in the ratio of less than the blood flow (<0.8), so that the mixture of pulmonary blood oxygenation without full access to pulmonary vein, a kind arteriovenous shunt (Figure 2-6-2). Ventilation / flow ratio imbalance, a lack O2, without CO2 retention. The result of blood mixed with the blood of oxygen difference is much greater than CO2 partial pressure, the former for 7.98 kPa, while the latter only 0.79 kPa, difference of 10 times. It may, by the sound of alveolar hyperventilation, emit more CO2, inadequate ventilation to compensate alveolar retention of CO2, or even emit more CO2, a respiratory alkalosis. As hemoglobin oxygen dissociation of the characteristics of normal alveolar capillary blood oxygen saturation already in a flat, the increase even if ventilation, air suction, although the alveolar oxygen, but little increase in blood oxygen saturation, by Sound excessive alveolar ventilation can not compensate the lack of ventilation caused by the perturbation alveolar oxygen shortage and thus a lack O2.
Ventilation> normal blood flow> ventilation
(Dead space effect) (effective ventilation) (static artery diversion effect)
(C) pulmonary artery - because of pulmonary vein-like triage pulmonary diseases such as depression wilt, atelectasis, pneumonia and pulmonary edema and pulmonary real change may cause an increase like triage, so that blood no contact alveolar gas to gas exchange opportunities. Therefore, increasing oxygen concentration and can not be raised PaO2. The greater the flow, increase blood oxygen inhalation after the worse the effect of the partial pressure of oxygen, such as the flow of more than 30 percent of the oxygen partial pressure of oxygen on the limited impact.
(D) diffusion barriers oxygen diffusing capacity of carbon dioxide is only 1 / 20, is in the diffusion barriers, a simple hypoxia.
(5) oxygen consumption increased oxygen consumption is increasing missing one of the reasons for O2, fever, chills, breathing difficulties and convulsions are to increase oxygen consumption. Shivering oxygen consumption up to 500 ml / min, severe asthma, with the increased work of breathing, oxygen consumption for more than 10 times normal. Oxygen consumption increased, decreased alveolar oxygen, help increase the normal ventilation to prevent hypoxia. Figure 2-6-3 that breathing air, oxygen consumption in the partial pressure of oxygen and pulmonary alveolar ventilation of the impact. Map of the curve with the dotted line to the point of intersection of different oxygen consumption, the maintenance of normal alveolar oxygen for pulmonary ventilation, with the increase in oxygen consumption, has also increased significantly, oxygen consumption per minute, respectively For 200 ml, 400ml, 800ml, alveolar ventilation volume of 3 L, 6L, 12l. From the map in each of the earlier steep, after the characteristics of the flat can see that the increase in oxygen consumption dysfunction in patients with ventilation, alveolar oxygen can not be raised, hypoxia hardly eased.
Second, the lack O2, CO2 retention of the impact of the body
(A) the impact of the central nervous brain tissue oxygen consumption accounted for about systemic consumption of 1/5-1/4. Central cortex cells most sensitive to hypoxia, lack O2 and the extent of the central nervous Jihuan the middle of the highest bidders different effects on health. Such as a sudden interruption for O2, purity nitrogen absorption to be 20 seconds in deep coma and body convulsions. Gradually reduce the absorption of O2 concentration, slow onset of symptoms, can cause mild missing O2 attention is not focused, intelligence may be directed obstacles with the increasing lack O2, PaO2 (PaO2) below 6.66 kPa can induce irritability, Trance consciousness, delirium; below 3.99 kPa, would lose consciousness, and even coma; below 2.66 kPa will be irreversible brain damage.
CO2 cerebrospinal fluid retention so that the concentration of hydrogen ions, the impact of brain cell metabolism, reduce excitatory brain cells and inhibit cortex; With the increase in CO2, stimulate the strengthening of the lower cortex, the cortex caused excitement; if CO2 continue to rise, the lower deck of the cortex inhibit So that the central nervous system in a state of anesthesia. In a pre-anesthesia patients often suffer from insomnia, mental excitement, irritability symptoms of the threatened excited.
Missing O2 and CO2 retention will have cerebral vascular expansion, reduced resistance to blood flow, to compensate the血流量增加. O2 will be seriously lacking in brain cells, edema, increased permeability of blood vessels, caused brain interstitial edema, leading to increased intracranial pressure, squeezing brain tissue and oppression of blood vessels, thereby increasing brain missing O2, a vicious cycle.
(B) of the heart, circulation of missing O2 can stimulate the heart to speed up the heart rate and stroke volume increase, high blood pressure. Coronary blood flow in the lack O2, a marked increase in heart blood flow far exceeds the brain and other organs. O2 myocardial lack of sensitivity, early mild O2 that is lacking in the electrocardiogram appeared on the show, a serious lack of O2 can lead to ventricular fibrillation or cardiac arrest. Missing O2 and CO2 retention can cause pulmonary vasoconstriction small increase in pulmonary vascular resistance, leading to increased pulmonary hypertension and right heart burden.
Inhalation of gas in the concentration of CO2, will speed up the heart rate, stroke volume increased, cerebral, coronary vasodilation, subcutaneous superficial capillaries and veins expansion due to the muscles of the spleen and blood vessels to contract, coupled with increased stroke volume, the Blood pressure is still elevated.
(C) lack of respiratory effects of breathing O2 impact than the impact of CO2 retention for small. O2, mainly through lack of carotid sinus and aortic reflection of the role of chemical receptors to stimulate ventilation, such as the slow increase the degree of lack O2, the reflective slow.
CO2 is a strong respiratory center stimulants, inhalation of increased CO2 concentration, ventilation multiplied, the retention of CO2 in deep rapid breathing, but when inhaled超过12% CO2 concentration, ventilation will not increase in the respiratory center Was inhibited. And chronic hypercapnia, there is no corresponding increase in ventilation, but has declined, and respiratory center reaction of the slow, through the kidneys to absorb and bicarbonate from H +, so that no blood pH value decreased, and patients Gas resistance increased, serious lung damage, the thorax movement dysfunction related to ventilation.
(D) of the liver, kidney and blood system of missing O2 can be direct or indirect damage to the liver ALT increased, but with the lack of corrective O2, liver function gradually returned to normal.
Reduce arterial blood oxygen, kidney blood flow, the volume of glomerular filtration, urine output and sodium from the increase of both, but when PaO2 <5.3kPa, reduce kidney blood flow, kidney function was inhibited.
Low oxygen erythropoietin to increase red blood cell proliferation. Kidney and liver produce an enzyme, the blood of the Central African erythropoietin, the predecessor of a generation of active substances to stimulate the bone marrow caused secondary erythrocytosis. To increase the carrying capacity of blood, but also increased blood viscosity, pulmonary circulation and increase the burden on the right heart.
CO2 retention mild renal vascular expansion will increase renal blood flow, increase the amount of urine when PaCO2超过8.64 kPa, blood pH decreased significantly, kidney vasospasm, reduced blood flow, HCO3-and Na + absorption to increase urine output reduction .
(5) of electrolyte and acid-base balance the impact of severe energy shortage O2 cells inhibited the middle of the process and radio, such as三羧酸循环, and the role of oxidative phosphorylation-related activities. This will not only have lower energy efficiency, but also due to produce lactic acid and inorganic phosphorus from metabolic acidosis. As the energy shortage, in-transit damage by the sodium pump, so that cells within the potassium transferred to the blood, and Na + and H + into the cells, causing cells acidosis and hyperkalemia. Metabolic acidosis the fixed buffer acid and bicarbonate in the system work, a carbonate, the organization increased carbon dioxide tension.
PH value of carbonate and bicarbonate depends on the ratio of the former regulation on the kidney (1-3 days), while carbonated regulation on the lung (hours). Healthy people every day from lung carbonate of as many as 15000 mmol, the acute respiratory failure CO2 retention impact on the pH very quickly, often with metabolic acidosis exist, due to acid poisoning caused serious decline in blood pressure, arrhythmia, and even cardiac arrest . And chronic respiratory failure due to the slow development of CO2 retention and kidney from reduced bicarbonate, does not result in significantly lower pH. Because of blood in the main anion HCO3-and CI-in and is a constant, when HCO3-increase, the CI-corresponding lower, a low chlorine hyperlipidemia.
Respiratory failure diagnosis and differential diagnosis
Respiratory failure diagnosis and differential diagnosis
Chronic respiratory failure decompensated period, according to patients with chronic respiratory diseases or other respiratory dysfunction leading to the history, missing O2 and (or) CO2 retention of clinical manifestations, with the relevant signs, the diagnosis is not difficult. Arterial blood gas analysis of respiratory failure can objectively reflect the nature and extent of the guidance of oxygen therapy, mechanical ventilation various parameters of the regulation, and correct pH balance and electrolytes are important values.
1. PaO2 (PaO2)
Refers to the physical dissolved in the blood oxygen molecules generated by the pressure. PaO2 healthy growth decreased gradually with age, and physiological effects of receptor. According to partial pressure of oxygen and oxygen saturation of the relationship between oxygenated hemoglobin dissociation curve was S shape, when PaO2> 8kPa (60mmHg) above, the flat of the curve, the oxygen saturation of more than 90%, PaO2 change 5.3 kPa (40mmHg ), But little change in oxygen saturation that much oxygen saturation of oxygen-sensitive, but when PaO2 <8kPa below, the steep curve, the slight decline in oxygen pressure, oxygen saturation sharp decline, the PaO2 Less than 8 kPa (60mmHg) as the diagnosis of respiratory failure indicators.
Second, the arterial blood oxygen saturation (SaO2)
Hemoglobin is the oxygen percentage of units, the normal value is 97 per cent. When PaO2 less than 8 kPa (60mmHg), hemoglobin oxygen dissociation curve in a steep section, the oxygen saturation only reflects the state of hypoxia, the severe respiratory failure in the rescue, with the pulse of oxygen saturation detector to help evaluate missing O2 level, adjust the absorption of O2 concentration SaO2 more than 90%, to reduce the trauma of pumping blood for blood gas analysis, which is a reasonable assessment effect of oxygen therapy and play an active role.
3, arterial blood oxygen content (CaO2)
100 ml of blood is the number of oxygen-ml. Including the combination of hemoglobin and oxygen dissolved oxygen in plasma physics combined. CaO2 = 1.34 × SaO2 × Hb +0.003 × PaO2. Healthy CaO2 reference value of 20 ml%. Mixed blood oxygen saturation (SVO2) to 75 percent, its oxygen content CVO2 for 15 ml%, per 100 ml blood by the organization after about 5 ml of oxygen for the organization to use. Hemoglobin reduction, SaO2 lower than normal, blood oxygen content can still be the normal range.
4. PaCO2 (PaCO2)
Refers to the physical dissolved in the blood of the CO2 produced by the pressure. PaCO2 normal for the 4.6 kPa-6kPa (35-45mmHg), more than 6 kPa for inadequate ventilation, less than 4.6 kPa for ventilation may be excessive. Acute lack of ventilation, PaCO2> 6.6kPa (50mmHg), according to Henderson-Hassellbalch formula, pH below 7.20, it will affect circulation and cell metabolism. Chronic respiratory failure due to the body compensatory mechanisms, PaCO2> 6.65kPa (50mmHg) as an indicator of respiratory failure.
5, pH value
For the hydrogen ion concentration in the blood of a negative value. The normal range of 7.35-7.45, an average of 7.40. Below 7.35 for decompensated acidosis, higher than the 7.45 for decompensated alkalosis, but could not explain what is the nature of the acid-base poisoning. Clinical symptoms and the pH is closely related to migration.
6, base excess (BE)
In 38 ℃, CO2 pressure 5.32 kPa (40mmHg), oxygen saturation measured 100 percent condition, blood titration to the pH of pH7.4. It is human metabolic acid-base balance of quantitative indicators, plus acid to BE positive of the metabolic alkalosis; Canadian base of EB was negative, of metabolic acidosis. The normal range of 0 ± 2.3mmol / L. In the correct metabolism of the acid-base imbalance, it can be used as estimated by acid or Kangjian dose drug reference.
7. Buffer base (BB)
Various buffer in the blood of the total content of alkali, including bicarbonate, phosphate, plasma protein salt, salt and other hemoglobin. It reflects human interference buffer against acid-base capability, and acid-base imbalance in the body of the specific circumstances of compensation. Normal for the 45 mmol / L.
8, the actual bicarbonate (AB)
AB is in the actual partial pressure of carbon dioxide and oxygen saturation of human plasma bicarbonate contained in the content. Normal for the 22-27 mmol / L, an average of 24 mmol / L. HCO3-related content and PaCO2, as PCO2 increased plasma HCO3-content has also increased. On the other hand HCO3-alkali plasma one of the buffer, when too much acid in fixed, by HCO3-buffer and pH stability, and HCO3-content reduction. So AB double by respiratory and metabolic effects.
9, the standard bicarbonate (SB)
Means isolated from the blood samples of air in 38 ℃, PaCO2 to 5.3 kPa, oxygenated hemoglobin 100 percent under the conditions, measured by the plasma bicarbonate (HCO3-) content, for the normal 22 - 27mmol / L, An average of 24 mmol / L. SB from respiratory factors, to reflect the increase or decrease its value in HCO3-the number of reserves, so that metabolic factors and extent of the trend. Metabolic acidosis, SB decreased metabolic alkalosis, SB increased. AB> SB, expressed CO2 retention.
10, the combination of carbon dioxide (CO2CP)
Normal for the 22-29 mmol / L, the main base in the reserves. Metabolic acidosis, or respiratory alkalosis, CO2CP lower metabolic alkalosis or respiratory acidosis, while CO2CP increased. However, respiratory and metabolic acidosis with acid poisoning, CO2CP not necessarily increased, due to respiratory acidosis, kidney or to NH4 + H + form from the H +, to compensate for HCO3-absorption, alkali reserve increase, the increase in the CO2CP Certain extent, respiratory acidosis reflect the seriousness of the blood but can not reflect the dramatic changes in CO2, but also by the metabolism of the base or acid poisoning effect, it has its one-sidedness CO2CP, must be integrated with clinical and electrolyte for full consideration.
These indicators to PaO2, PaCO2 and pH most important, reflecting the lack respiratory failure at the O2, CO2 retention, in an acid-base imbalance, such as adding BE will be able to reflect the body compensatory, or without metabolic acid or alkaline Poisoning, and electrolyte imbalance.
Chronic respiratory failure decompensated period, according to patients with chronic respiratory diseases or other respiratory dysfunction leading to the history, missing O2 and (or) CO2 retention of clinical manifestations, with the relevant signs, the diagnosis is not difficult. Arterial blood gas analysis of respiratory failure can objectively reflect the nature and extent of the guidance of oxygen therapy, mechanical ventilation various parameters of the regulation, and correct pH balance and electrolytes are important values.
1. PaO2 (PaO2)
Refers to the physical dissolved in the blood oxygen molecules generated by the pressure. PaO2 healthy growth decreased gradually with age, and physiological effects of receptor. According to partial pressure of oxygen and oxygen saturation of the relationship between oxygenated hemoglobin dissociation curve was S shape, when PaO2> 8kPa (60mmHg) above, the flat of the curve, the oxygen saturation of more than 90%, PaO2 change 5.3 kPa (40mmHg ), But little change in oxygen saturation that much oxygen saturation of oxygen-sensitive, but when PaO2 <8kPa below, the steep curve, the slight decline in oxygen pressure, oxygen saturation sharp decline, the PaO2 Less than 8 kPa (60mmHg) as the diagnosis of respiratory failure indicators.
Second, the arterial blood oxygen saturation (SaO2)
Hemoglobin is the oxygen percentage of units, the normal value is 97 per cent. When PaO2 less than 8 kPa (60mmHg), hemoglobin oxygen dissociation curve in a steep section, the oxygen saturation only reflects the state of hypoxia, the severe respiratory failure in the rescue, with the pulse of oxygen saturation detector to help evaluate missing O2 level, adjust the absorption of O2 concentration SaO2 more than 90%, to reduce the trauma of pumping blood for blood gas analysis, which is a reasonable assessment effect of oxygen therapy and play an active role.
3, arterial blood oxygen content (CaO2)
100 ml of blood is the number of oxygen-ml. Including the combination of hemoglobin and oxygen dissolved oxygen in plasma physics combined. CaO2 = 1.34 × SaO2 × Hb +0.003 × PaO2. Healthy CaO2 reference value of 20 ml%. Mixed blood oxygen saturation (SVO2) to 75 percent, its oxygen content CVO2 for 15 ml%, per 100 ml blood by the organization after about 5 ml of oxygen for the organization to use. Hemoglobin reduction, SaO2 lower than normal, blood oxygen content can still be the normal range.
4. PaCO2 (PaCO2)
Refers to the physical dissolved in the blood of the CO2 produced by the pressure. PaCO2 normal for the 4.6 kPa-6kPa (35-45mmHg), more than 6 kPa for inadequate ventilation, less than 4.6 kPa for ventilation may be excessive. Acute lack of ventilation, PaCO2> 6.6kPa (50mmHg), according to Henderson-Hassellbalch formula, pH below 7.20, it will affect circulation and cell metabolism. Chronic respiratory failure due to the body compensatory mechanisms, PaCO2> 6.65kPa (50mmHg) as an indicator of respiratory failure.
5, pH value
For the hydrogen ion concentration in the blood of a negative value. The normal range of 7.35-7.45, an average of 7.40. Below 7.35 for decompensated acidosis, higher than the 7.45 for decompensated alkalosis, but could not explain what is the nature of the acid-base poisoning. Clinical symptoms and the pH is closely related to migration.
6, base excess (BE)
In 38 ℃, CO2 pressure 5.32 kPa (40mmHg), oxygen saturation measured 100 percent condition, blood titration to the pH of pH7.4. It is human metabolic acid-base balance of quantitative indicators, plus acid to BE positive of the metabolic alkalosis; Canadian base of EB was negative, of metabolic acidosis. The normal range of 0 ± 2.3mmol / L. In the correct metabolism of the acid-base imbalance, it can be used as estimated by acid or Kangjian dose drug reference.
7. Buffer base (BB)
Various buffer in the blood of the total content of alkali, including bicarbonate, phosphate, plasma protein salt, salt and other hemoglobin. It reflects human interference buffer against acid-base capability, and acid-base imbalance in the body of the specific circumstances of compensation. Normal for the 45 mmol / L.
8, the actual bicarbonate (AB)
AB is in the actual partial pressure of carbon dioxide and oxygen saturation of human plasma bicarbonate contained in the content. Normal for the 22-27 mmol / L, an average of 24 mmol / L. HCO3-related content and PaCO2, as PCO2 increased plasma HCO3-content has also increased. On the other hand HCO3-alkali plasma one of the buffer, when too much acid in fixed, by HCO3-buffer and pH stability, and HCO3-content reduction. So AB double by respiratory and metabolic effects.
9, the standard bicarbonate (SB)
Means isolated from the blood samples of air in 38 ℃, PaCO2 to 5.3 kPa, oxygenated hemoglobin 100 percent under the conditions, measured by the plasma bicarbonate (HCO3-) content, for the normal 22 - 27mmol / L, An average of 24 mmol / L. SB from respiratory factors, to reflect the increase or decrease its value in HCO3-the number of reserves, so that metabolic factors and extent of the trend. Metabolic acidosis, SB decreased metabolic alkalosis, SB increased. AB> SB, expressed CO2 retention.
10, the combination of carbon dioxide (CO2CP)
Normal for the 22-29 mmol / L, the main base in the reserves. Metabolic acidosis, or respiratory alkalosis, CO2CP lower metabolic alkalosis or respiratory acidosis, while CO2CP increased. However, respiratory and metabolic acidosis with acid poisoning, CO2CP not necessarily increased, due to respiratory acidosis, kidney or to NH4 + H + form from the H +, to compensate for HCO3-absorption, alkali reserve increase, the increase in the CO2CP Certain extent, respiratory acidosis reflect the seriousness of the blood but can not reflect the dramatic changes in CO2, but also by the metabolism of the base or acid poisoning effect, it has its one-sidedness CO2CP, must be integrated with clinical and electrolyte for full consideration.
These indicators to PaO2, PaCO2 and pH most important, reflecting the lack respiratory failure at the O2, CO2 retention, in an acid-base imbalance, such as adding BE will be able to reflect the body compensatory, or without metabolic acid or alkaline Poisoning, and electrolyte imbalance.
The treatment of respiratory failure
The treatment of respiratory failure
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.
First, the establishment of the airway patency
In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.
Second, oxygen therapy
By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.
(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.
The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.
(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.
Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).
(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.
Through oxygen masks Venturi principle, the use of oxygen jet produced negative pressure, inhaled air to dilute oxygen, into the air-conditioning control of oxygen concentration in the 25% -50% within the sub-grade structure of regulation 2-6-5, face masks Oxygen concentration in the stable, free from the respiratory rate and tidal volume impact. Is the consumption of its shortcomings, expectoration inconvenience.
Oxygen therapy to the general physical and clinical needs to regulate the concentration of oxygen inhalation, PaO2 of more than 8 kPa, or SaO2 for more than 90 percent. Oxygen consumption increases, such as fever can increase the concentration of oxygen inhalation. Reasonable oxygen therapy increased the effect of respiratory failure, respiratory failure in patients with COPD such as long-term low concentrations of oxygen therapy (especially at night) can reduce pulmonary circulation of resistance and pulmonary artery pressure, increased cardiac contraction, with activities to enhance and extend the survival time of endurance .
Third, increase ventilation and reduce CO2 retention
Alveolar CO2 retention is caused by inadequate ventilation, only to increase alveolar ventilation to effectively discharge CO2. Mechanical ventilation in the treatment of respiratory failure effect has affirmed and the application of respiratory stimulants, because of their different effect, the surviving in the controversy. Profile is as follows:
(A) a reasonable application of respiratory stimulants, respiratory stimulants stimulate the respiratory center or around the chemical receptors, through enhanced respiratory center of excitement, increased respiratory rate and tidal volume to improve ventilation. At the same time, patients with oxygen consumption and CO2 output also increased, and ventilation and a positive correlation. Because of its use of simple, economic, and a certain effect, it was still widely used in clinical, but should have their clinical indications. Patients with low ventilation mainly because of the central inhibition, respiratory stimulant effect of better chronic obstructive pulmonary disease, respiratory failure due to bronchial - lung disease, the response of the central or lower respiratory muscle fatigue caused by low ventilation, at this time of breath Doping should be the pros and cons of the three factors of primary and secondary may be. In nerve conduction system and the respiratory muscle lesions, and pneumonia, pulmonary edema and pulmonary fibrosis of the extensive ventilation dysfunction, respiratory stimulants are no disadvantages benefit and should not be used.
In the application of respiratory stimulants at the same time, should attach importance to reduce the chest, lungs and airway mechanical load, such as the secretion of drainage, the application of bronchial spasm, the elimination of pulmonary edema and other factors affecting the chest compliance. Otherwise, ventilation drive will add to short breath and breathing to increase power, and the need to increase the concentration of oxygen inhalation. In addition, we must make full use of some stimulants respiratory consciousness back to the Soviet Union, to encourage patients to cough, sputum elimination, and maintain the airway open. If necessary, nose or mouth and nose mask with mechanical ventilation support.
Nikethamide is the common respiratory center stimulants, increase ventilation, have a certain role Su-Ti. Patients can sleepiness of the first slow intravenous injection 0.375 g-0.75g, then to 3-3.75 g adding 500 ml of liquid, drop by 25-30 / min infusion. Close observation of patients with the lash response to change consciousness, and respiratory rate, the rate and rhythm, the follow-up of arterial blood gas, in order to regulate dosage. If a skin itching, irritability and other side effects, must be slowed down Disu. If the 4 h-12h did not bear fruit, or a muscle twitch serious reactions, should be suspended, if necessary, a change of mechanical ventilation support.
(B) a reasonable application of mechanical ventilation with respiratory physiology and pathophysiology of the development, nose and mouth masks, artificial airway, breathing and respiratory-care properties of continuous improvement, mechanical ventilation will enable patients with respiratory failure to grow. Practice has proved that mechanical ventilation for the success or failure of respiratory failure, in addition to the breathing machine and related properties, is more important to the medical staff to keep respiratory failure in patients with pathological changes in physiological and reasonable application of mechanical ventilation. By increasing ventilation and provide appropriate oxygen concentration, to a certain extent, improve the ventilation function and reduce the power consumption of breath, respiratory failure in patients with missing O2, CO2 retention and acid-base balance disorders can be different degrees of improvement and corrected, General will not die of respiratory failure. Attention should be paid to prevention and treatment may be lethal infection of the airway, obstructive airway secretions, high-pressure pulmonary complications such as trauma. Even in some serious respiratory failure complicated by multiple organ failure patients, after treatment by mechanical ventilation, because of improved patient heart, brain, kidney, liver and other organs of oxygen the body and internal environment, and then to nasal feeding or intravenous Nutritional support, create the conditions for the resumption of patients, save a lot of dying patient's life.
Shang-qing consciousness of mild to moderate, in line with the patients with respiratory failure, nose or mouth and nose mask for mechanical ventilation; serious condition, although the consciousness-but uncooperative, coma or respiratory secretions of the large number of patients, the timely establishment of gas Road, such as the nose (or mouth) intubation mechanical ventilation, the choice of organizations with good compatibility of high-capacity low-pressure air bags (<3.3 kPa) of PVC or silicone catheter, the catheter can retain more than half a month, to avoid Low capacity use latex rubber high-pressure balloon catheter, because of their reaction, can cause the airway mucosa clear congestion, edema, erosion, and ulcers. In very poor lung function, recurrent respiratory failure, secretions, the body extremely weak, malnutrition, need long-term support of patients with mechanical ventilation, for tracheotomy, the long-term retention of mechanical ventilation trachea casing.
In the use of breathing machine before the medical staff must understand the pathophysiology of patients with respiratory, to suit the tidal volume, respiratory rate and breathing, such as the ratio of various parameters, such as a blockage of the ventilation to be too large tidal volume, frequency slow breath longer Breathing, and restrictive ventilated patients is the opposite. Through simple hand pinch capsule breathing respirator for the transition, followed by a mechanical ventilation and monitoring of patients with clinical manifestations, such as the activities of the thorax, airway pressure and oxygen saturation changes in the general follow-up after 20 min blood gas again Further adjustments breathing machine parameters. In the different periods of mechanical ventilation, ventilation should use different approaches, such as respiratory or manual control capsule ventilation or assisted intermittent positive pressure ventilation (IPPV), PEEP ventilation (PEEP), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV). Ventilation can also be different forms of composition, such as PEEP + PSV for the integration of bi-level positive airway pressure (BiPAP). PEEP improve the ventilation function, SIMV and PSV benefit from the breathing machine, so as to achieve avoid excessive ventilation or inadequate ventilation. Reduce the impact of the heart cycle. During the mechanical ventilation should strengthen management of respiratory and breathing machine. As to the wetlands of the respiratory tract, secretions to attract and maintain respiratory unobstructed; breathing machine disinfection and maintenance of clean, avoid cross-infection. Particularly want to emphasize is the need to strengthen the respiratory and cardiovascular care, early detection of problems, analyse problems and to properly resolve to give full play to mechanical ventilation in the treatment of respiratory failure of the active role so that a reasonable and effective application of mechanical ventilation, improve Its efficacy and reduce complications.
40, to correct acid-base balance disorders and electrolyte imbalance
Diagnosis and treatment of respiratory failure in the process, there are several common types of acid-base balance disorders.
(A) of respiratory acidosis due to lack of pulmonary ventilation, CO2 produced in the body retention hypercapnia, changed the BHCO3/H2CO3 the normal ratio of 1 / 20, acute respiratory acidosis. Patients with chronic respiratory failure, blood-buffer system and the role of the kidney adjustment (secretion of H +, Na + absorption and HCO3-integration into NaHCO3), to near normal pH. Respiratory failure stolen generation acid poisoning can use alkaline agent (5% NaHCO3) temporarily to correct the pH value, but will reduce the ventilation to further increase the CO2 retention, there is no acid poisoning have removed the root causes. Only increase alveolar ventilation can be corrected respiratory acidosis.
(B) respiratory acidosis merger metabolic acidosis due to low O2 levels, insufficient blood volume, cardiac output and reduce cycle around obstacles, such as lactic acid in fixed, such as increased renal damage impact from acid metabolites. Therefore, on the basis of respiratory acid can be complicated with metabolic acidosis. Anions in the fixed acid increased, HCO3-reduction, pH value dropped. Acidosis potassium ions from cell to cell within the transfer of blood K + increase, HCO3-reduced blood CI-expansion of the higher, Na + cells to move. Treatment, in addition to acid poisoning due to serious impact on blood pressure, or pH <7.25 when added alkaline agent, as NaHCO3 will add CO2 retention risk (NaHCO3 + HAC → NaAC + H2O + CO2). At this point should be raised to correct ventilation of CO2 retention and treatment of metabolic acidosis the cause.
(C) respiratory acidosis merger metabolic alkalosis in chronic respiratory acidosis in the course of treatment, often because of mechanical ventilation, so that CO2 emission too fast; added alkaline drug overdose; application of glucocorticoid, diuretics, which Pai increase in potassium, or because the correct acid poisoning, potassium to the cell transfer, have hypokalemia. Vomiting blood or diuretics to reduce the chlorine can produce metabolic alkalosis, pH High, BE is positive. Treatment should be more than a base to prevent the poisoning iatrogenic factors and avoid excessive CO2 emission, and to give adequate chlorination Kushiro, to alleviate the alkali poisoning, the event should be promptly dealt with.
(D) of this respiratory alkalosis for patients with respiratory diseases, respiratory a heartbeat to stop using mechanical ventilation, ventilation because of the excessive emission of CO2 caused by excessive respiratory alkalosis.
(5) respiratory alkalosis metabolic alkalosis merger of chronic respiratory failure in patients with mechanical ventilation, in the short term from too much CO2, and lower than normal, because of compensatory kidney, the body bicarbonate is due to increased volume.
Can also be due to improper handling, respiratory failure in patients with respiratory and metabolic acidosis basis, because of low potassium, low chlorine and alkali from the triple acid-base balance disorders.
5, the rational use of diuretics
Respiratory failure, because of interstitial lung, pulmonary and bronchial mucous membrane thin bronchial pulmonary edema caused wilting depression, atelectasis affect ventilation function, because of respiratory failure at the aldosterone increase in the use of mechanical ventilation and increase the antidiuretic hormone Shuinazhuliu due to the increase. Therefore, in heart failure, respiratory failure, the trial furosemide (furosemide) 10-20mg, if oxygen saturation increased, the use of diuretics proved to be the indication. But we must electrolyte disturbance without the use of the situation, and promptly give added potassium chloride, sodium chloride (mainly gastrointestinal administration) to prevent alkali poisoning.
To sum up, in dealing with respiratory failure, as long as the rational application of mechanical ventilation, oxygen, diuretics and alkaline agent, nasal feeding and intravenous nutritional supplements and electrolyte, particularly in the longer-term COPD pulmonary heart disease rarely eat, the use of diuretics Patients with more attention should be paid. Therefore, respiratory failure of the acid-base balance disorders and electrolyte imbalance is a reason to be investigated, nor is the prevention and treatment.
6, anti-infection treatment
Respiratory infections often induced respiratory failure, because the infected secretions Jizhi increase, particularly in the artificial airway mechanical ventilation and immunocompromised patients can be repeated infections, and difficult to control infection. Therefore, patients with respiratory failure must maintain the smooth drainage of respiratory conditions, according to the sputum culture and sensitivity test, the choice of effective drug control respiratory infections. Must also be pointed out that COPD patients with pulmonary heart disease repeated infection, and often without fever, high blood poisoning symptoms interleukin not only increase the sense of short breath, Weina diminish, if not handled timely, mild infection can also lead to respiratory failure decompensated Occurred.
7, control gastrointestinal bleeding
A serious lack of O2 and CO2 retention patients should be given to conventional oral cimetidine or ranitidine, to prevent gastrointestinal bleeding. If a large number of hematemesis or tar-like stools, should lose new blood, or stomach Guanru norepinephrine ice water. Must vein to the H2 receptor antagonists, or omeprazole. Gastrointestinal bleeding prevention is the key to correct missing O2 and CO2 retention.
8, shock
The shock caused numerous reasons, such as acidosis and electrolyte imbalance, severe infections, gastrointestinal bleeding, the lack of blood volume, heart failure and mechanical ventilation, such as airway pressure too high, should be cause to take corresponding measures. No improvement in the treatment should be given to vasoactive drugs such as dopamine, Ala Ming, and so in order to maintain blood pressure.
9, nutritional support
Patients with respiratory failure due to insufficient calorie intake and increased respiratory Gong, fever and other factors, resulting in increased energy consumption, a negative body metabolism. A long time and will reduce the body's immune function, difficult to control infection, breathing machine fatigue, resulting in respiratory pump failure, or failure to rescue the extension course. Therefore, rescue, to the conventional nasal feeding high-protein, high-fat and low carbohydrate, and a variety of vitamins and trace elements of the diet, when necessary, in a vein of high-nutrition, general daily calories to 14.6 k / kg.
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.
First, the establishment of the airway patency
In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.
Second, oxygen therapy
By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.
(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.
The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.
(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.
Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).
(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.
Through oxygen masks Venturi principle, the use of oxygen jet produced negative pressure, inhaled air to dilute oxygen, into the air-conditioning control of oxygen concentration in the 25% -50% within the sub-grade structure of regulation 2-6-5, face masks Oxygen concentration in the stable, free from the respiratory rate and tidal volume impact. Is the consumption of its shortcomings, expectoration inconvenience.
Oxygen therapy to the general physical and clinical needs to regulate the concentration of oxygen inhalation, PaO2 of more than 8 kPa, or SaO2 for more than 90 percent. Oxygen consumption increases, such as fever can increase the concentration of oxygen inhalation. Reasonable oxygen therapy increased the effect of respiratory failure, respiratory failure in patients with COPD such as long-term low concentrations of oxygen therapy (especially at night) can reduce pulmonary circulation of resistance and pulmonary artery pressure, increased cardiac contraction, with activities to enhance and extend the survival time of endurance .
Third, increase ventilation and reduce CO2 retention
Alveolar CO2 retention is caused by inadequate ventilation, only to increase alveolar ventilation to effectively discharge CO2. Mechanical ventilation in the treatment of respiratory failure effect has affirmed and the application of respiratory stimulants, because of their different effect, the surviving in the controversy. Profile is as follows:
(A) a reasonable application of respiratory stimulants, respiratory stimulants stimulate the respiratory center or around the chemical receptors, through enhanced respiratory center of excitement, increased respiratory rate and tidal volume to improve ventilation. At the same time, patients with oxygen consumption and CO2 output also increased, and ventilation and a positive correlation. Because of its use of simple, economic, and a certain effect, it was still widely used in clinical, but should have their clinical indications. Patients with low ventilation mainly because of the central inhibition, respiratory stimulant effect of better chronic obstructive pulmonary disease, respiratory failure due to bronchial - lung disease, the response of the central or lower respiratory muscle fatigue caused by low ventilation, at this time of breath Doping should be the pros and cons of the three factors of primary and secondary may be. In nerve conduction system and the respiratory muscle lesions, and pneumonia, pulmonary edema and pulmonary fibrosis of the extensive ventilation dysfunction, respiratory stimulants are no disadvantages benefit and should not be used.
In the application of respiratory stimulants at the same time, should attach importance to reduce the chest, lungs and airway mechanical load, such as the secretion of drainage, the application of bronchial spasm, the elimination of pulmonary edema and other factors affecting the chest compliance. Otherwise, ventilation drive will add to short breath and breathing to increase power, and the need to increase the concentration of oxygen inhalation. In addition, we must make full use of some stimulants respiratory consciousness back to the Soviet Union, to encourage patients to cough, sputum elimination, and maintain the airway open. If necessary, nose or mouth and nose mask with mechanical ventilation support.
Nikethamide is the common respiratory center stimulants, increase ventilation, have a certain role Su-Ti. Patients can sleepiness of the first slow intravenous injection 0.375 g-0.75g, then to 3-3.75 g adding 500 ml of liquid, drop by 25-30 / min infusion. Close observation of patients with the lash response to change consciousness, and respiratory rate, the rate and rhythm, the follow-up of arterial blood gas, in order to regulate dosage. If a skin itching, irritability and other side effects, must be slowed down Disu. If the 4 h-12h did not bear fruit, or a muscle twitch serious reactions, should be suspended, if necessary, a change of mechanical ventilation support.
(B) a reasonable application of mechanical ventilation with respiratory physiology and pathophysiology of the development, nose and mouth masks, artificial airway, breathing and respiratory-care properties of continuous improvement, mechanical ventilation will enable patients with respiratory failure to grow. Practice has proved that mechanical ventilation for the success or failure of respiratory failure, in addition to the breathing machine and related properties, is more important to the medical staff to keep respiratory failure in patients with pathological changes in physiological and reasonable application of mechanical ventilation. By increasing ventilation and provide appropriate oxygen concentration, to a certain extent, improve the ventilation function and reduce the power consumption of breath, respiratory failure in patients with missing O2, CO2 retention and acid-base balance disorders can be different degrees of improvement and corrected, General will not die of respiratory failure. Attention should be paid to prevention and treatment may be lethal infection of the airway, obstructive airway secretions, high-pressure pulmonary complications such as trauma. Even in some serious respiratory failure complicated by multiple organ failure patients, after treatment by mechanical ventilation, because of improved patient heart, brain, kidney, liver and other organs of oxygen the body and internal environment, and then to nasal feeding or intravenous Nutritional support, create the conditions for the resumption of patients, save a lot of dying patient's life.
Shang-qing consciousness of mild to moderate, in line with the patients with respiratory failure, nose or mouth and nose mask for mechanical ventilation; serious condition, although the consciousness-but uncooperative, coma or respiratory secretions of the large number of patients, the timely establishment of gas Road, such as the nose (or mouth) intubation mechanical ventilation, the choice of organizations with good compatibility of high-capacity low-pressure air bags (<3.3 kPa) of PVC or silicone catheter, the catheter can retain more than half a month, to avoid Low capacity use latex rubber high-pressure balloon catheter, because of their reaction, can cause the airway mucosa clear congestion, edema, erosion, and ulcers. In very poor lung function, recurrent respiratory failure, secretions, the body extremely weak, malnutrition, need long-term support of patients with mechanical ventilation, for tracheotomy, the long-term retention of mechanical ventilation trachea casing.
In the use of breathing machine before the medical staff must understand the pathophysiology of patients with respiratory, to suit the tidal volume, respiratory rate and breathing, such as the ratio of various parameters, such as a blockage of the ventilation to be too large tidal volume, frequency slow breath longer Breathing, and restrictive ventilated patients is the opposite. Through simple hand pinch capsule breathing respirator for the transition, followed by a mechanical ventilation and monitoring of patients with clinical manifestations, such as the activities of the thorax, airway pressure and oxygen saturation changes in the general follow-up after 20 min blood gas again Further adjustments breathing machine parameters. In the different periods of mechanical ventilation, ventilation should use different approaches, such as respiratory or manual control capsule ventilation or assisted intermittent positive pressure ventilation (IPPV), PEEP ventilation (PEEP), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV). Ventilation can also be different forms of composition, such as PEEP + PSV for the integration of bi-level positive airway pressure (BiPAP). PEEP improve the ventilation function, SIMV and PSV benefit from the breathing machine, so as to achieve avoid excessive ventilation or inadequate ventilation. Reduce the impact of the heart cycle. During the mechanical ventilation should strengthen management of respiratory and breathing machine. As to the wetlands of the respiratory tract, secretions to attract and maintain respiratory unobstructed; breathing machine disinfection and maintenance of clean, avoid cross-infection. Particularly want to emphasize is the need to strengthen the respiratory and cardiovascular care, early detection of problems, analyse problems and to properly resolve to give full play to mechanical ventilation in the treatment of respiratory failure of the active role so that a reasonable and effective application of mechanical ventilation, improve Its efficacy and reduce complications.
40, to correct acid-base balance disorders and electrolyte imbalance
Diagnosis and treatment of respiratory failure in the process, there are several common types of acid-base balance disorders.
(A) of respiratory acidosis due to lack of pulmonary ventilation, CO2 produced in the body retention hypercapnia, changed the BHCO3/H2CO3 the normal ratio of 1 / 20, acute respiratory acidosis. Patients with chronic respiratory failure, blood-buffer system and the role of the kidney adjustment (secretion of H +, Na + absorption and HCO3-integration into NaHCO3), to near normal pH. Respiratory failure stolen generation acid poisoning can use alkaline agent (5% NaHCO3) temporarily to correct the pH value, but will reduce the ventilation to further increase the CO2 retention, there is no acid poisoning have removed the root causes. Only increase alveolar ventilation can be corrected respiratory acidosis.
(B) respiratory acidosis merger metabolic acidosis due to low O2 levels, insufficient blood volume, cardiac output and reduce cycle around obstacles, such as lactic acid in fixed, such as increased renal damage impact from acid metabolites. Therefore, on the basis of respiratory acid can be complicated with metabolic acidosis. Anions in the fixed acid increased, HCO3-reduction, pH value dropped. Acidosis potassium ions from cell to cell within the transfer of blood K + increase, HCO3-reduced blood CI-expansion of the higher, Na + cells to move. Treatment, in addition to acid poisoning due to serious impact on blood pressure, or pH <7.25 when added alkaline agent, as NaHCO3 will add CO2 retention risk (NaHCO3 + HAC → NaAC + H2O + CO2). At this point should be raised to correct ventilation of CO2 retention and treatment of metabolic acidosis the cause.
(C) respiratory acidosis merger metabolic alkalosis in chronic respiratory acidosis in the course of treatment, often because of mechanical ventilation, so that CO2 emission too fast; added alkaline drug overdose; application of glucocorticoid, diuretics, which Pai increase in potassium, or because the correct acid poisoning, potassium to the cell transfer, have hypokalemia. Vomiting blood or diuretics to reduce the chlorine can produce metabolic alkalosis, pH High, BE is positive. Treatment should be more than a base to prevent the poisoning iatrogenic factors and avoid excessive CO2 emission, and to give adequate chlorination Kushiro, to alleviate the alkali poisoning, the event should be promptly dealt with.
(D) of this respiratory alkalosis for patients with respiratory diseases, respiratory a heartbeat to stop using mechanical ventilation, ventilation because of the excessive emission of CO2 caused by excessive respiratory alkalosis.
(5) respiratory alkalosis metabolic alkalosis merger of chronic respiratory failure in patients with mechanical ventilation, in the short term from too much CO2, and lower than normal, because of compensatory kidney, the body bicarbonate is due to increased volume.
Can also be due to improper handling, respiratory failure in patients with respiratory and metabolic acidosis basis, because of low potassium, low chlorine and alkali from the triple acid-base balance disorders.
5, the rational use of diuretics
Respiratory failure, because of interstitial lung, pulmonary and bronchial mucous membrane thin bronchial pulmonary edema caused wilting depression, atelectasis affect ventilation function, because of respiratory failure at the aldosterone increase in the use of mechanical ventilation and increase the antidiuretic hormone Shuinazhuliu due to the increase. Therefore, in heart failure, respiratory failure, the trial furosemide (furosemide) 10-20mg, if oxygen saturation increased, the use of diuretics proved to be the indication. But we must electrolyte disturbance without the use of the situation, and promptly give added potassium chloride, sodium chloride (mainly gastrointestinal administration) to prevent alkali poisoning.
To sum up, in dealing with respiratory failure, as long as the rational application of mechanical ventilation, oxygen, diuretics and alkaline agent, nasal feeding and intravenous nutritional supplements and electrolyte, particularly in the longer-term COPD pulmonary heart disease rarely eat, the use of diuretics Patients with more attention should be paid. Therefore, respiratory failure of the acid-base balance disorders and electrolyte imbalance is a reason to be investigated, nor is the prevention and treatment.
6, anti-infection treatment
Respiratory infections often induced respiratory failure, because the infected secretions Jizhi increase, particularly in the artificial airway mechanical ventilation and immunocompromised patients can be repeated infections, and difficult to control infection. Therefore, patients with respiratory failure must maintain the smooth drainage of respiratory conditions, according to the sputum culture and sensitivity test, the choice of effective drug control respiratory infections. Must also be pointed out that COPD patients with pulmonary heart disease repeated infection, and often without fever, high blood poisoning symptoms interleukin not only increase the sense of short breath, Weina diminish, if not handled timely, mild infection can also lead to respiratory failure decompensated Occurred.
7, control gastrointestinal bleeding
A serious lack of O2 and CO2 retention patients should be given to conventional oral cimetidine or ranitidine, to prevent gastrointestinal bleeding. If a large number of hematemesis or tar-like stools, should lose new blood, or stomach Guanru norepinephrine ice water. Must vein to the H2 receptor antagonists, or omeprazole. Gastrointestinal bleeding prevention is the key to correct missing O2 and CO2 retention.
8, shock
The shock caused numerous reasons, such as acidosis and electrolyte imbalance, severe infections, gastrointestinal bleeding, the lack of blood volume, heart failure and mechanical ventilation, such as airway pressure too high, should be cause to take corresponding measures. No improvement in the treatment should be given to vasoactive drugs such as dopamine, Ala Ming, and so in order to maintain blood pressure.
9, nutritional support
Patients with respiratory failure due to insufficient calorie intake and increased respiratory Gong, fever and other factors, resulting in increased energy consumption, a negative body metabolism. A long time and will reduce the body's immune function, difficult to control infection, breathing machine fatigue, resulting in respiratory pump failure, or failure to rescue the extension course. Therefore, rescue, to the conventional nasal feeding high-protein, high-fat and low carbohydrate, and a variety of vitamins and trace elements of the diet, when necessary, in a vein of high-nutrition, general daily calories to 14.6 k / kg.
Chronic respiratory failure check what needs to be done
Chronic respiratory failure check what needs to be done
Laboratory checks respiratory failure can objectively reflect the nature and extent of the guidance of oxygen therapy, mechanical ventilation various parameters of the regulation, and correct pH balance and electrolytes are important values.
1. PaO2 (PaO2): PaO2 less than 8 kPa (60mmHg) as the diagnosis of respiratory failure indicators.
Second, the arterial blood oxygen saturation (SaO2): severe respiratory failure in the rescue, with the pulse of oxygen saturation detector to help evaluate the degree missing O2.
3, arterial blood oxygen content (CaO2).
4. PaCO2: PaCO2> 6.65kPa (50mmHg) as an indicator of respiratory failure.
5, pH value: less than 7.35 for decompensated acidosis, higher than the 7.45 for decompensated alkalosis,
6, the combination of carbon dioxide (CO2CP).
Laboratory checks respiratory failure can objectively reflect the nature and extent of the guidance of oxygen therapy, mechanical ventilation various parameters of the regulation, and correct pH balance and electrolytes are important values.
1. PaO2 (PaO2): PaO2 less than 8 kPa (60mmHg) as the diagnosis of respiratory failure indicators.
Second, the arterial blood oxygen saturation (SaO2): severe respiratory failure in the rescue, with the pulse of oxygen saturation detector to help evaluate the degree missing O2.
3, arterial blood oxygen content (CaO2).
4. PaCO2: PaCO2> 6.65kPa (50mmHg) as an indicator of respiratory failure.
5, pH value: less than 7.35 for decompensated acidosis, higher than the 7.45 for decompensated alkalosis,
6, the combination of carbon dioxide (CO2CP).
The treatment of acute respiratory failure
The treatment of acute respiratory failure
First, the rescue site: acute respiratory failure and more suddenly, at the scene to take timely rescue measures to prevent and ease the serious lack of oxygen, carbon dioxide retention and acid poisoning, the protection of nerves, circulation, kidney function, and other important organs. General health of human memory oxygen about 1.0 L, calm, oxygen consumption per minute for 200 ml-250ml. Once the sudden cessation of breathing factors should be cleared immediately at the scene of oral secretions in the respiratory tract clear conditions, for intermittent mouth-to the ventilator. However, the operator should pay attention to, to make rapid deep breath to residual gas in, and then quickly suction to total lung, mouth of the forthcoming gas Chuiru, such exhaled gas oxygen concentration higher. If the conditions for balloon catheter with the oral intubation, can breathe easy manual capsule artificial ventilation. In case of cardiac arrest, should also take effective in vitro cardiac massage, and so on cardiopulmonary resuscitation of the rescue measures. Followed by a breathing machine called a reasonable mechanical ventilation.
Second, the high concentration of oxygen: acute respiratory failure, such as respiratory cardiac arrest due to acute pneumonia caused by the lung is changed, and pulmonary edema caused by atelectasis ventilation / flow ratio and lung disorders like triage by the arteriovenous To the lack of oxygen, must be timely use of high concentrations of oxygen, or hypoxia for emergency treatment to alleviate. However, attention should be paid to oxygen concentration and duration, in order to avoid high concentrations of oxygen will cause oxygen poisoning.
First, the rescue site: acute respiratory failure and more suddenly, at the scene to take timely rescue measures to prevent and ease the serious lack of oxygen, carbon dioxide retention and acid poisoning, the protection of nerves, circulation, kidney function, and other important organs. General health of human memory oxygen about 1.0 L, calm, oxygen consumption per minute for 200 ml-250ml. Once the sudden cessation of breathing factors should be cleared immediately at the scene of oral secretions in the respiratory tract clear conditions, for intermittent mouth-to the ventilator. However, the operator should pay attention to, to make rapid deep breath to residual gas in, and then quickly suction to total lung, mouth of the forthcoming gas Chuiru, such exhaled gas oxygen concentration higher. If the conditions for balloon catheter with the oral intubation, can breathe easy manual capsule artificial ventilation. In case of cardiac arrest, should also take effective in vitro cardiac massage, and so on cardiopulmonary resuscitation of the rescue measures. Followed by a breathing machine called a reasonable mechanical ventilation.
Second, the high concentration of oxygen: acute respiratory failure, such as respiratory cardiac arrest due to acute pneumonia caused by the lung is changed, and pulmonary edema caused by atelectasis ventilation / flow ratio and lung disorders like triage by the arteriovenous To the lack of oxygen, must be timely use of high concentrations of oxygen, or hypoxia for emergency treatment to alleviate. However, attention should be paid to oxygen concentration and duration, in order to avoid high concentrations of oxygen will cause oxygen poisoning.
Respiratory failure in patients who do go out
Respiratory failure in patients who do go out
The patients experienced respiratory failure, often using artificial means to carry out the rescue. Aims to use artificial methods of ventilation to supply enough oxygen and emit carbon dioxide. It can make passive expansion of the lung, pulmonary stretch receptors to stimulate expansion, and indirectly stimulate the respiratory center, rehabilitation activities; inhaling the gas contains adequate oxygen to body tissue and the patient respiratory center metabolism; mouth-to go out, respirable Gas was contained in the amount of carbon dioxide, the respiratory center can be exciting, it can often be breathing through mouth-to patients Turning the Tide.
(1) do mouth-to go out, the patient should be supine, the rescue of patients who single-handedly Tuoqi mandibular and head as far as possible, Yang, clear oral secretions to relieve respiratory obstruction; mandibular entrusted with the patient's hand turned lips, To facilitate the inflatable Rufei, I cover a layer of gauze, and the other hand Niejin patients nostrils, so as to avoid blowing the nose when the gas escaped. Shenxi breath to the rescue, at the Ministry of the population forced Chuiru, (If patients can not be closed oral suction, I can do on the nose blowing, that is the primary Tuozhu patients mandible, and pinch Long lips, not from the gas I leakage, forced inflatable at the nostrils.) Until the expansion of the thorax. Children can not be of excessive force, so as to avoid alveolar rupture. Inflatable stopped, who heads the rescue slightly Cezhuan, pinch your nose and immediately relax the hands. As the thorax and lung Danxinghuisu role for gas from the lungs of patients discharged, at this time should monitor the patient's chest to recover the situation, listen to the breathing sound, observe whether respiratory obstruction. On such a rhythm, interrupted to repeatedly blowing. Per minute for 14 to 16 times.
(2) do go out, they should pay attention to ensure smooth respiratory tract. Purposes, should release the patient's neckline, Kudai and thoracoabdominal clothes, the timely removal of patients on the oral and respiratory vomit, secretions and other foreign bodies; patients maintain the correct location of the head, after falling to prevent the tongue and airway obstruction. Implementation of artificial, inflatable to a short time, the period can not be short of breath at the suction period, but can not be too long, so as not to affect ventilation effect. Inflatable should not be too large, swelling from the thorax appropriate suitable. When a patient breathe effectively independent oxygen supply has been restored and has basically met, should be stopped breathing assisted suitable. Regardless of what causes respiratory failure, are in severe danger of the best clock and for emergency treatment, or sent to a nearby hospital for treatment in time.
The patients experienced respiratory failure, often using artificial means to carry out the rescue. Aims to use artificial methods of ventilation to supply enough oxygen and emit carbon dioxide. It can make passive expansion of the lung, pulmonary stretch receptors to stimulate expansion, and indirectly stimulate the respiratory center, rehabilitation activities; inhaling the gas contains adequate oxygen to body tissue and the patient respiratory center metabolism; mouth-to go out, respirable Gas was contained in the amount of carbon dioxide, the respiratory center can be exciting, it can often be breathing through mouth-to patients Turning the Tide.
(1) do mouth-to go out, the patient should be supine, the rescue of patients who single-handedly Tuoqi mandibular and head as far as possible, Yang, clear oral secretions to relieve respiratory obstruction; mandibular entrusted with the patient's hand turned lips, To facilitate the inflatable Rufei, I cover a layer of gauze, and the other hand Niejin patients nostrils, so as to avoid blowing the nose when the gas escaped. Shenxi breath to the rescue, at the Ministry of the population forced Chuiru, (If patients can not be closed oral suction, I can do on the nose blowing, that is the primary Tuozhu patients mandible, and pinch Long lips, not from the gas I leakage, forced inflatable at the nostrils.) Until the expansion of the thorax. Children can not be of excessive force, so as to avoid alveolar rupture. Inflatable stopped, who heads the rescue slightly Cezhuan, pinch your nose and immediately relax the hands. As the thorax and lung Danxinghuisu role for gas from the lungs of patients discharged, at this time should monitor the patient's chest to recover the situation, listen to the breathing sound, observe whether respiratory obstruction. On such a rhythm, interrupted to repeatedly blowing. Per minute for 14 to 16 times.
(2) do go out, they should pay attention to ensure smooth respiratory tract. Purposes, should release the patient's neckline, Kudai and thoracoabdominal clothes, the timely removal of patients on the oral and respiratory vomit, secretions and other foreign bodies; patients maintain the correct location of the head, after falling to prevent the tongue and airway obstruction. Implementation of artificial, inflatable to a short time, the period can not be short of breath at the suction period, but can not be too long, so as not to affect ventilation effect. Inflatable should not be too large, swelling from the thorax appropriate suitable. When a patient breathe effectively independent oxygen supply has been restored and has basically met, should be stopped breathing assisted suitable. Regardless of what causes respiratory failure, are in severe danger of the best clock and for emergency treatment, or sent to a nearby hospital for treatment in time.
Chronic obstructive pulmonary disease with respiratory failure of mechanical ventilation strategy
Chronic obstructive pulmonary disease with respiratory failure of mechanical ventilation strategy
Chronic obstructive pulmonary disease (COPD) with respiratory failure is the Department of Respiratory Medicine of the most common reasons for the use of mechanical ventilation, but there is nothing wrong application of more or unsatisfactory Department. COPD with respiratory failure complicated disease, bronchial - lung infection, airway obstruction, respiratory muscle fatigue, multiple organ dysfunction, such as staggered there. How to become more rational, economic and efficient use of mechanical ventilation, is the need seriously to consider and explore the issue of [1,2]. After years of clinical practice and research, we believe that effective anti-infection treatment, and so on the basis of the following aspects of mechanical ventilation strategy to improve, you can compare large extent on the merger of COPD acute respiratory failure in the treatment of Changed.
1, COPD with respiratory failure on the plane indications
Generally speaking, to the morning, indications of relative relaxation. For COPD with cases of respiratory failure, it is difficult to have a completely standards or "point" to decide whether to use mechanical ventilation. The main decision is based on the condition of dynamic change, that is, patients with ventilation and the recent trend of changes in lung infection. If the general condition is still active after treatment or further ease the increase should be timely applications include mechanical ventilation, an effective means of blocking and correct bad ventilation, respiratory muscle fatigue and poor drainage, such as sputum key link in the pathophysiology , The disease quickly so that the relative ease into the state. If the condition in the stage of development can not be effectively controlled and to be more serious condition, it will significantly increase the complexity of the treatment and prognosis difficult and adverse impact.
For serious infection, airway secretions number of cases to the establishment of the use of artificial airway followed by mechanical ventilation methods, the so-called invasive mechanical ventilation. By the establishment of artificial airway sputum way to ensure the full drainage and ventilation effect. The infection is not very serious, less airway secretions and respiratory muscle fatigue prominent patients, may also consider the use of non-invasive nasal masks or nasal mask mechanical ventilation. Now that the early application of non-invasive ventilation to improve respiratory muscle fatigue, thus facilitating and improving ventilation function Katan ability to have a positive effect.
Second, COPD patients the choice of mode of mechanical ventilation and parameters of the conditioning
COPD patients for the use of mechanical ventilation, a very important principle is to "help rather than replace," that is, as long as the patients have some degree of breathing independently, that is, to use auxiliary ventilation, and improved conditions in the integrated mechanical ventilation after the lower level of support , A gradual increase in patients with breathing independently bear the burden of ventilation. Auxiliary mode from breathing independently trigger some form of mechanical ventilation, patients of respiratory muscles supporting Work, which would enable patients with independent ventilation in the capacity of training and rehabilitation, after an earlier and more successfully weaning prepared. Assist mode include synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), synchronized intermittent mandatory ventilation + pressure support ventilation (SIMV + PSV), two-phase positive airway pressure (Biphasic Positive Airway Pressure, BIPAP), the proportion supporting Ventilation (PAV), and so on. One application SIMV + PSV and PSV models have more practical experience and has been advocating. PSV in particular suction occurred inspiratory flow and objectives of capacity, breath in the three aspects of coordination with the patient, from the perspective of its mechanical ventilation Work more physical, better support for the model, on the plane early to consider the application Or with the use of low frequency SIMV to facilitate the timely mobilization of independent respiratory function. BIPAP and PAV are explored in the model, has a certain According to the preliminary clinical application.
COPD, airway resistance increase compliance and reduce the lung, breath extend the time constant, pervasive breath is not complete, closed gas depression, lung dynamic over-inflated status and endogenous PEEP, the adjustment in the ventilator Attention should be paid as much as possible breath longer time to promote breath, specific measures include increasing the suction flow rate, adjusted suction wave, shortened breath, bronchial expansion, ruled out calls valve dysfunction and, if necessary, sedation patients to choose large-caliber Endotracheal tube (diameter of not less than 7.5 mm); peak in monitoring airway pressure and pressure platform to ensure that it does not increase the premise, plus a certain amount of exogenous PEEP, can help reduce inspiratory Trigger threshold, to reduce endogenous PEEP caused by the suction power consumption to increase and promote breathing independently and mechanical ventilation and coordination between the patient's comfort; To avoid inspiratory lung volume at the end of high tidal volume should not be Too large, should enable the airway platform in the lower 30 cmH2O, best limited to the respiratory rate 20 times / points, as the ventilation when the blood level of carbon dioxide, as long as the maintenance period to ease the level or slightly higher, arterial blood pH value of not less than To 7.30.
COPD patients on the plane after weaning should always consider the possibility of problems and extubation. T-day trip to the PSV or low-level test to detect every possible opportunity. Early extubation of the following methods COPD mechanical ventilation should be regarded as an important strategy to improve.
Third, on a non-invasive mechanical ventilation support COPD patients early extubation weaning strategy:
COPD cases have occurred from severe respiratory failure and requires the use of mechanical ventilation for two main reasons: One is the bronchial - lung infection increase and the other is COPD acute airway obstruction heavier, and had been in a state of fatigue due to respiratory muscle Heavier load, infection poisoning, acid-base balance, electrolyte imbalance, and other functions result of deterioration in-pump failure. COPD is more than two cases on the reasons for the plane, as well as COPD patients weaning the main influence and consideration. COPD in the past on the plane, the short term can often control infection, but because of airway obstruction and respiratory muscle fatigue state and independent ventilation function can not meet the needs of the body, still rely on mechanical ventilation, mechanical ventilation extension of the time, and in the extension of The process of mechanical ventilation, because of the artificial airway, prone to ventilator-associated pneumonia (VAP), the treatment process occurred repeatedly, the weaning process has occurred repeatedly and delay or even ventilator-dependent state.
In fact, the artificial airway in the establishment of effective drainage sputum and reasonable use of antibiotics, bronchial - lung infection can often be more quickly in 3-5 days time under control, clinical performance to reduce the volume of sputum, Viscosity thinning, sputum color to white, the temperature dropped, reduced white blood cell count, on the chest film bronchial - lung infection shadow faded, this stage we can call it "lung infection control window" (Pulmonary Infection Control Window, PIC window). The emergence of infection control window means that patients have been the principal focus on bad ventilation function, airway secretions drainage problem has been relegated to a secondary position, we can take to improve ventilation in patients, especially respiratory muscle fatigue solution to the problem of stability And to further improve conditions. Such a judgement reminds us of the possibility of a lung infection control window of time after the removal of tracheal tube, using nasal masks or nasal mask of non-invasive mechanical ventilation to assist ventilation, and as timely removal of the artificial airway , Is expected to effectively avoid the artificial airway caused by lower respiratory tract infections and ventilator-associated pneumonia.
Based on this consideration, we in Beijing's Chaoyang Hospital respiratory intensive care unit (RICU) on a trial basis in the machine after about five days, once the window of a lung infection control after the removal of endotracheal tube, and then switch to non-invasive mechanical ventilation, to continue To help patients with respiratory muscle fatigue solve, the problem of bad ventilation, and this method before the same conditions but with continued use of the artificial airway mechanical ventilation to the traditional methods of weaning compared. The results showed that using non-invasive ways to help patients with early extubation method can not only significantly reduce the use of invasive mechanical ventilation time, the total of mechanical ventilation, that is invasive and non-invasive ventilation of the time clearly than ever the simple application Invasive mechanical ventilation reduce the time, the incidence of respiratory-related pneumonia was significantly reduced, patients and well tolerated, weaning high success rate. This can also greatly reduce the time and living ICU reduce medical costs.
This is actually bronchial pulmonary infection and ventilation dysfunction / respiratory muscle fatigue on the impact of these two aircraft and weaning the problem in two stages to take a different approach to resolve: the first phase, that is, on the plane early, when Infection and ventilation dysfunction both by the presence of the artificial airway invasive ventilation method is quick to resolve serious infection and bad ventilation problems, and when entering the second phase, that is, when the infection, if effective control, ventilation bad form to use machinery The main reason for ventilation, the timely removal of artificial airway to avoid possible after the relevant infection, use of non-invasive mechanical ventilation to continue to address the failure or respiratory muscle dysfunction problems, after the gradual removal of ventilator.
The lung infection is not obvious but the ventilation serious obstacles to accept the invasive ventilation in patients with COPD, ventilation should be resumed as soon as possible after switching to non-invasive ventilation to prevent ventilator-associated pneumonia occurred improve treatment.
Italy and France the recent two studies showed similar results [3,4], confirmed early extubation sequential use of non-invasive ventilation in the validity and clinical application.
Such invasive and non-invasive mechanical ventilation sequential strategy, the key is to promptly and accurately identify and control invasive and non-invasive mechanical ventilation of the switch points, or lung infection control windows or ventilation function in the non-invasive ventilation The initial tolerance; right to operate non-invasive mechanical ventilation is to guarantee the success of the sequential treatment another important aspect.
Invasive and non-invasive mechanical ventilation of the sequential approach is effective for COPD disease characteristics and laws of mechanical ventilation strategy, can effectively improve treatment and reduce medical costs, a very good clinical practical value, is advocated by weaning strategy. Its application is expected to a greater extent on improving the treatment of COPD with respiratory failure in the face.
Fourth, non-invasive mechanical ventilation in COPD acute respiratory failure of the merger of the status of
Non-invasive mechanical ventilation has the advantage of being free of artificial airway and its related complications, ventilator-associated pneumonia and the incidence of low reservations about the normal swallowing, eating, coughing, speaking function to retain the upper airway physiological temperature, wet and Immune function; need tranquilizers; patients from both physical and psychological make it easier weaning; can be stopped, and long-term or household use. And the artificial airway of invasive mechanical ventilation compared with the primary function can not be for lack of an effective drainage and ventilation effect of instability in the sputum. In addition, non-invasive ventilation mask the shortcomings of other nose / nasal mask discomfort; pressure red facial skin; eye injury; nose masks / nasal mask leakage, such as gastrointestinal Flatulence.
At present, non-invasive ventilation COPD with respiratory failure is an important means of treatment, its main role is supporting-pump feature, ease respiratory muscle fatigue [5,6]. Non-invasive ventilation can be a reasonable application of a considerable part of the successful treatment of COPD acute respiratory failure in patients with the merger, so that from intubation; will have to have a mechanical ventilation of these cases may also play a role in helping early extubation. In principle, for mild cases, the indication of non-invasive ventilation to relax and to help correct when respiratory muscle fatigue, thereby improving the-pump feature and promote Katan. Even for less severe diseases, in the past no indication of mechanical ventilation cases, may also consider more active use of early non-invasive mechanical ventilation to effectively ease the respiratory muscle fatigue, to prevent the condition from deteriorating further. For severe cases, the indication of non-invasive ventilation to strictly, so as not to delay the rescue time. Especially for heavier infection and airway secretions number of cases, although application of non-invasive ventilation was also alleviate the condition, but we should not be reluctant to use non-invasive ventilation, but should be timely adopted by the artificial airway of mechanical ventilation methods More conducive to speedy and effective infection control and correct ventilation failure, in a relatively short period of time to ease the condition, then you can use these to the non-invasive method of mechanical ventilation as soon as possible to help extubation.
Chronic obstructive pulmonary disease (COPD) with respiratory failure is the Department of Respiratory Medicine of the most common reasons for the use of mechanical ventilation, but there is nothing wrong application of more or unsatisfactory Department. COPD with respiratory failure complicated disease, bronchial - lung infection, airway obstruction, respiratory muscle fatigue, multiple organ dysfunction, such as staggered there. How to become more rational, economic and efficient use of mechanical ventilation, is the need seriously to consider and explore the issue of [1,2]. After years of clinical practice and research, we believe that effective anti-infection treatment, and so on the basis of the following aspects of mechanical ventilation strategy to improve, you can compare large extent on the merger of COPD acute respiratory failure in the treatment of Changed.
1, COPD with respiratory failure on the plane indications
Generally speaking, to the morning, indications of relative relaxation. For COPD with cases of respiratory failure, it is difficult to have a completely standards or "point" to decide whether to use mechanical ventilation. The main decision is based on the condition of dynamic change, that is, patients with ventilation and the recent trend of changes in lung infection. If the general condition is still active after treatment or further ease the increase should be timely applications include mechanical ventilation, an effective means of blocking and correct bad ventilation, respiratory muscle fatigue and poor drainage, such as sputum key link in the pathophysiology , The disease quickly so that the relative ease into the state. If the condition in the stage of development can not be effectively controlled and to be more serious condition, it will significantly increase the complexity of the treatment and prognosis difficult and adverse impact.
For serious infection, airway secretions number of cases to the establishment of the use of artificial airway followed by mechanical ventilation methods, the so-called invasive mechanical ventilation. By the establishment of artificial airway sputum way to ensure the full drainage and ventilation effect. The infection is not very serious, less airway secretions and respiratory muscle fatigue prominent patients, may also consider the use of non-invasive nasal masks or nasal mask mechanical ventilation. Now that the early application of non-invasive ventilation to improve respiratory muscle fatigue, thus facilitating and improving ventilation function Katan ability to have a positive effect.
Second, COPD patients the choice of mode of mechanical ventilation and parameters of the conditioning
COPD patients for the use of mechanical ventilation, a very important principle is to "help rather than replace," that is, as long as the patients have some degree of breathing independently, that is, to use auxiliary ventilation, and improved conditions in the integrated mechanical ventilation after the lower level of support , A gradual increase in patients with breathing independently bear the burden of ventilation. Auxiliary mode from breathing independently trigger some form of mechanical ventilation, patients of respiratory muscles supporting Work, which would enable patients with independent ventilation in the capacity of training and rehabilitation, after an earlier and more successfully weaning prepared. Assist mode include synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), synchronized intermittent mandatory ventilation + pressure support ventilation (SIMV + PSV), two-phase positive airway pressure (Biphasic Positive Airway Pressure, BIPAP), the proportion supporting Ventilation (PAV), and so on. One application SIMV + PSV and PSV models have more practical experience and has been advocating. PSV in particular suction occurred inspiratory flow and objectives of capacity, breath in the three aspects of coordination with the patient, from the perspective of its mechanical ventilation Work more physical, better support for the model, on the plane early to consider the application Or with the use of low frequency SIMV to facilitate the timely mobilization of independent respiratory function. BIPAP and PAV are explored in the model, has a certain According to the preliminary clinical application.
COPD, airway resistance increase compliance and reduce the lung, breath extend the time constant, pervasive breath is not complete, closed gas depression, lung dynamic over-inflated status and endogenous PEEP, the adjustment in the ventilator Attention should be paid as much as possible breath longer time to promote breath, specific measures include increasing the suction flow rate, adjusted suction wave, shortened breath, bronchial expansion, ruled out calls valve dysfunction and, if necessary, sedation patients to choose large-caliber Endotracheal tube (diameter of not less than 7.5 mm); peak in monitoring airway pressure and pressure platform to ensure that it does not increase the premise, plus a certain amount of exogenous PEEP, can help reduce inspiratory Trigger threshold, to reduce endogenous PEEP caused by the suction power consumption to increase and promote breathing independently and mechanical ventilation and coordination between the patient's comfort; To avoid inspiratory lung volume at the end of high tidal volume should not be Too large, should enable the airway platform in the lower 30 cmH2O, best limited to the respiratory rate 20 times / points, as the ventilation when the blood level of carbon dioxide, as long as the maintenance period to ease the level or slightly higher, arterial blood pH value of not less than To 7.30.
COPD patients on the plane after weaning should always consider the possibility of problems and extubation. T-day trip to the PSV or low-level test to detect every possible opportunity. Early extubation of the following methods COPD mechanical ventilation should be regarded as an important strategy to improve.
Third, on a non-invasive mechanical ventilation support COPD patients early extubation weaning strategy:
COPD cases have occurred from severe respiratory failure and requires the use of mechanical ventilation for two main reasons: One is the bronchial - lung infection increase and the other is COPD acute airway obstruction heavier, and had been in a state of fatigue due to respiratory muscle Heavier load, infection poisoning, acid-base balance, electrolyte imbalance, and other functions result of deterioration in-pump failure. COPD is more than two cases on the reasons for the plane, as well as COPD patients weaning the main influence and consideration. COPD in the past on the plane, the short term can often control infection, but because of airway obstruction and respiratory muscle fatigue state and independent ventilation function can not meet the needs of the body, still rely on mechanical ventilation, mechanical ventilation extension of the time, and in the extension of The process of mechanical ventilation, because of the artificial airway, prone to ventilator-associated pneumonia (VAP), the treatment process occurred repeatedly, the weaning process has occurred repeatedly and delay or even ventilator-dependent state.
In fact, the artificial airway in the establishment of effective drainage sputum and reasonable use of antibiotics, bronchial - lung infection can often be more quickly in 3-5 days time under control, clinical performance to reduce the volume of sputum, Viscosity thinning, sputum color to white, the temperature dropped, reduced white blood cell count, on the chest film bronchial - lung infection shadow faded, this stage we can call it "lung infection control window" (Pulmonary Infection Control Window, PIC window). The emergence of infection control window means that patients have been the principal focus on bad ventilation function, airway secretions drainage problem has been relegated to a secondary position, we can take to improve ventilation in patients, especially respiratory muscle fatigue solution to the problem of stability And to further improve conditions. Such a judgement reminds us of the possibility of a lung infection control window of time after the removal of tracheal tube, using nasal masks or nasal mask of non-invasive mechanical ventilation to assist ventilation, and as timely removal of the artificial airway , Is expected to effectively avoid the artificial airway caused by lower respiratory tract infections and ventilator-associated pneumonia.
Based on this consideration, we in Beijing's Chaoyang Hospital respiratory intensive care unit (RICU) on a trial basis in the machine after about five days, once the window of a lung infection control after the removal of endotracheal tube, and then switch to non-invasive mechanical ventilation, to continue To help patients with respiratory muscle fatigue solve, the problem of bad ventilation, and this method before the same conditions but with continued use of the artificial airway mechanical ventilation to the traditional methods of weaning compared. The results showed that using non-invasive ways to help patients with early extubation method can not only significantly reduce the use of invasive mechanical ventilation time, the total of mechanical ventilation, that is invasive and non-invasive ventilation of the time clearly than ever the simple application Invasive mechanical ventilation reduce the time, the incidence of respiratory-related pneumonia was significantly reduced, patients and well tolerated, weaning high success rate. This can also greatly reduce the time and living ICU reduce medical costs.
This is actually bronchial pulmonary infection and ventilation dysfunction / respiratory muscle fatigue on the impact of these two aircraft and weaning the problem in two stages to take a different approach to resolve: the first phase, that is, on the plane early, when Infection and ventilation dysfunction both by the presence of the artificial airway invasive ventilation method is quick to resolve serious infection and bad ventilation problems, and when entering the second phase, that is, when the infection, if effective control, ventilation bad form to use machinery The main reason for ventilation, the timely removal of artificial airway to avoid possible after the relevant infection, use of non-invasive mechanical ventilation to continue to address the failure or respiratory muscle dysfunction problems, after the gradual removal of ventilator.
The lung infection is not obvious but the ventilation serious obstacles to accept the invasive ventilation in patients with COPD, ventilation should be resumed as soon as possible after switching to non-invasive ventilation to prevent ventilator-associated pneumonia occurred improve treatment.
Italy and France the recent two studies showed similar results [3,4], confirmed early extubation sequential use of non-invasive ventilation in the validity and clinical application.
Such invasive and non-invasive mechanical ventilation sequential strategy, the key is to promptly and accurately identify and control invasive and non-invasive mechanical ventilation of the switch points, or lung infection control windows or ventilation function in the non-invasive ventilation The initial tolerance; right to operate non-invasive mechanical ventilation is to guarantee the success of the sequential treatment another important aspect.
Invasive and non-invasive mechanical ventilation of the sequential approach is effective for COPD disease characteristics and laws of mechanical ventilation strategy, can effectively improve treatment and reduce medical costs, a very good clinical practical value, is advocated by weaning strategy. Its application is expected to a greater extent on improving the treatment of COPD with respiratory failure in the face.
Fourth, non-invasive mechanical ventilation in COPD acute respiratory failure of the merger of the status of
Non-invasive mechanical ventilation has the advantage of being free of artificial airway and its related complications, ventilator-associated pneumonia and the incidence of low reservations about the normal swallowing, eating, coughing, speaking function to retain the upper airway physiological temperature, wet and Immune function; need tranquilizers; patients from both physical and psychological make it easier weaning; can be stopped, and long-term or household use. And the artificial airway of invasive mechanical ventilation compared with the primary function can not be for lack of an effective drainage and ventilation effect of instability in the sputum. In addition, non-invasive ventilation mask the shortcomings of other nose / nasal mask discomfort; pressure red facial skin; eye injury; nose masks / nasal mask leakage, such as gastrointestinal Flatulence.
At present, non-invasive ventilation COPD with respiratory failure is an important means of treatment, its main role is supporting-pump feature, ease respiratory muscle fatigue [5,6]. Non-invasive ventilation can be a reasonable application of a considerable part of the successful treatment of COPD acute respiratory failure in patients with the merger, so that from intubation; will have to have a mechanical ventilation of these cases may also play a role in helping early extubation. In principle, for mild cases, the indication of non-invasive ventilation to relax and to help correct when respiratory muscle fatigue, thereby improving the-pump feature and promote Katan. Even for less severe diseases, in the past no indication of mechanical ventilation cases, may also consider more active use of early non-invasive mechanical ventilation to effectively ease the respiratory muscle fatigue, to prevent the condition from deteriorating further. For severe cases, the indication of non-invasive ventilation to strictly, so as not to delay the rescue time. Especially for heavier infection and airway secretions number of cases, although application of non-invasive ventilation was also alleviate the condition, but we should not be reluctant to use non-invasive ventilation, but should be timely adopted by the artificial airway of mechanical ventilation methods More conducive to speedy and effective infection control and correct ventilation failure, in a relatively short period of time to ease the condition, then you can use these to the non-invasive method of mechanical ventilation as soon as possible to help extubation.
The symptoms of acute respiratory failure
The symptoms of acute respiratory failure
First, breathing difficulties: the frequency of performance, rhythm and magnitude of the change. Such as the hub of a wave of respiratory failure, intermittent or Chouqi respiration.
Second, cyanosis: O2 is the lack of typical symptoms. When arterial blood oxygen saturation below 85%, the blood flow in the larger lips nail in cyanotic.
Third, the spirit of neurological symptoms: acute respiratory failure symptoms of the spirit of slower to clear, acute shortage of mental disorder can appear O2, manic, coma, convulsions and other symptoms. Acute CO2 retention, pH <7.3, will appear psychiatric symptoms. Serious CO2 retention can occur tendon reflexes weakened or disappeared, pyramidal tract, such as positive sign.
4, symptoms of the circulatory system: a serious lack O2 and CO2 retention caused pulmonary hypertension, heart failure can occur right, with signs of systemic congestion.
5, digestive and urinary symptoms: severe respiratory failure of liver and kidney functions are affected, such as proteinuria, urine and a tube of red blood cells. Gastrointestinal mucosa due to congestion and edema, erosion, bleeding, stress ulcer or upper gastrointestinal bleeding caused.
First, breathing difficulties: the frequency of performance, rhythm and magnitude of the change. Such as the hub of a wave of respiratory failure, intermittent or Chouqi respiration.
Second, cyanosis: O2 is the lack of typical symptoms. When arterial blood oxygen saturation below 85%, the blood flow in the larger lips nail in cyanotic.
Third, the spirit of neurological symptoms: acute respiratory failure symptoms of the spirit of slower to clear, acute shortage of mental disorder can appear O2, manic, coma, convulsions and other symptoms. Acute CO2 retention, pH <7.3, will appear psychiatric symptoms. Serious CO2 retention can occur tendon reflexes weakened or disappeared, pyramidal tract, such as positive sign.
4, symptoms of the circulatory system: a serious lack O2 and CO2 retention caused pulmonary hypertension, heart failure can occur right, with signs of systemic congestion.
5, digestive and urinary symptoms: severe respiratory failure of liver and kidney functions are affected, such as proteinuria, urine and a tube of red blood cells. Gastrointestinal mucosa due to congestion and edema, erosion, bleeding, stress ulcer or upper gastrointestinal bleeding caused.
Common diseases due to respiratory failure
Common diseases due to respiratory failure
Respiratory failure caused by a variety of reasons for pulmonary ventilation and ventilation functions that can not be serious obstacles to the effective exchange of gases, leading to hypoxia and carbon dioxide retention, thus leading to a series of physiological functions and metabolic disorders of SARS.
Damage to the respiratory function of various factors may lead to respiratory failure, respiratory diseases such as: spasm of bronchitis, upper respiratory tract cancer, foreign body airway obstruction caused inadequate ventilation, gas ventilation and lead to uneven distribution of blood disorders, and in hypoxia Carbon dioxide retention.
Lung diseases: pneumonia, severe tuberculosis, emphysema, pulmonary edema, adult respiratory distress syndrome, silicosis, and so on.
Pulmonary vascular disease: lung blood clots, pulmonary infarction, pulmonary capillary hemangioma.
Thoracic diseases: thoracic trauma, deformity and trauma surgery, pneumothorax, such as pleural effusion, the impact of thoracic and lung expansion.
Conduction system and the nervous system and respiratory muscle disorders: cerebrovascular disease, encephalitis, brain trauma, electric shocks, drug poisoning, myasthenia gravis.
The above factors are the common diseases due to respiratory failure.
Respiratory failure caused by a variety of reasons for pulmonary ventilation and ventilation functions that can not be serious obstacles to the effective exchange of gases, leading to hypoxia and carbon dioxide retention, thus leading to a series of physiological functions and metabolic disorders of SARS.
Damage to the respiratory function of various factors may lead to respiratory failure, respiratory diseases such as: spasm of bronchitis, upper respiratory tract cancer, foreign body airway obstruction caused inadequate ventilation, gas ventilation and lead to uneven distribution of blood disorders, and in hypoxia Carbon dioxide retention.
Lung diseases: pneumonia, severe tuberculosis, emphysema, pulmonary edema, adult respiratory distress syndrome, silicosis, and so on.
Pulmonary vascular disease: lung blood clots, pulmonary infarction, pulmonary capillary hemangioma.
Thoracic diseases: thoracic trauma, deformity and trauma surgery, pneumothorax, such as pleural effusion, the impact of thoracic and lung expansion.
Conduction system and the nervous system and respiratory muscle disorders: cerebrovascular disease, encephalitis, brain trauma, electric shocks, drug poisoning, myasthenia gravis.
The above factors are the common diseases due to respiratory failure.
Adult Respiratory Distress Syndrome
Adult Respiratory Distress Syndrome
Adult respiratory distress syndrome (adult respiratory distress syndrome, ARDS) in patients with the heart and lung function is normal, because of the lung or pulmonary diseases in the course of the permeability of secondary acute pulmonary edema and hypoxia of respiratory failure. Although its causes vary, but the lung tissue injury in pathology and function more or less the same, are clinical manifestations of acute respiratory distress, refractory hypoxemia because of a similar levy infant respiratory distress, and their etiology and pathogenesis Different, it then called "adult" to show differences.
As the severe trauma, shock, infection and other diseases rescue raising the level of technology, many patients do not die of disease directly, thereby increasing the incidence of ARDS, ARDS onset Jizhou, rapid development, if not early diagnosis and treatment, died Rate of more than 50 percent (25% -90%), and often died of multiple organ failure.
[Etiology and pathogenesis]
ARDS the cause of many, such as severe shock, severe trauma, fractures, fat embolism, severe infection (particularly gram-negative bacillus sepsis were caused by septic shock), inhalation of irritating gases and stomach contents, oxygen poisoning, drowning, Massive blood transfusion, acute pancreatitis, drugs or narcotics, such as poisoning, which can cause pulmonary - capillary acute injury, however this injury mechanism has not yet been fully clarified, and a variety of factors, and the intricate existence and mutually affected.
At present the majority of scholars believe that many neurotransmitters involved in alveolar - vascular endothelial injury, with neutrophil (PMN) is the activation of endothelial cells capillary permeability increase was mainly due. Interstitial lung health of people, only a small number of PMN, in trauma, acute pancreatitis, physical and chemical stimulation or pump circumstances, as in a variety of chemotactic factor PMN role, to PMN in the pulmonary capillary gathered in a large number, and through the Adhesion of factors, such as the complement system activated the C5a, lipopolysaccharide (LPS), will be PMN adhesion to endothelial cells, PMN activation of endothelial cells to release a series of damaging lung tissue and harmful substances, mainly oxygen free Based, multi-and arachidonic acid metabolite.
If all kinds of protein-dissolving enzyme, elastase, serine protease, collagenase, cathepsin, elastase and collagenase can digest the basement membrane, and pulmonary artery walls elastic organizational structure.
Arachidonic acid metabolite by PMN, macrophages complement activation of phospholipase, from the plasma membrane phospholipids in the release of arachidonic acid, through its lipoxygenase and cyclooxygenase grass two metabolic process, the formation of A series of high-activity products (medium). The blood vessels and bronchial contraction caused pulmonary hypertension and airway resistance increased, to unite platelets, blood clots, and the release of fibrin degradation products, proteolytic enzymes, increased capillary Tong Xing. Because pulmonary capillary membrane damage, permeability increase in permeability of pulmonary edema.
[Pathology]
ARDS was Anhong of the lung or liver-Anzi red changed, visible swelling, bleeding, weight increased significantly. 24h microscopy see in the pulmonary microvascular congestion, hemorrhage, micro-thrombosis, pulmonary alveolar and quality of water within a protein glue and infiltration of inflammatory cells. Nearly 72 h, from plasma protein coagulation, cell Cui films, fibers and residue of the Surfactant a transparent membrane, or large focal alveolar wilt depression. At exudative acute lung cells damaged Ⅰ necrosis, the restoration of lung epithelial cell type Ⅱ. Early fibroblast proliferation and collagen deposition, a week after the alveolar separated, transparent film can be fibrosis, with pulmonary secondary infection.
[Pathophysiology]
Because pulmonary vascular endothelial cells and alveolar type Ⅱ cell damage caused interstitial lung and pulmonary edema, congestion, pulmonary surfactant reduced, leading to closure of small airway depression, depression not alveolar Zhang Wei, lung compliance decreased functional residual Gas reduction. So that ventilation / flow ratio imbalance, pulmonary arteriovenous shunt-like increase and diffusion barriers, causing serious damage to the ventilation function hypoxemia and stimulate the carotid sinus aorta of chemical receptors can stimulate the respiratory center reflection cause excessive ventilation, there Respiratory alkalosis. Late in ARDS, as in critical condition, respiratory muscle fatigue failure, a lack of ventilation, lack O2 more severe, with CO2 retention, a mixed acid poisoning.
In addition to the disease such as trauma, infection, poisoning, and other relevant signs and symptoms, mainly for emergencies, respiratory distress, shortness of breath, cyanosis, often accompanied with irritability, anxiety expressions, sweating, and so on. The characteristics of their respiratory distress usually can not be used so as to improve the therapy, or use other primary cardiovascular diseases (such as pneumothorax, pulmonary emphysema, atelectasis, pneumonia, heart failure) explained. Early signs may be no abnormalities, or only heard Shuangfei stem-La, Asthma Ming Yin, the late and blisters can hear the sound, or breathing tube sound. Early X-ray can be no anomaly, or a slight change in the quality of performance for the fuzzy edge of the Fei Wenli increased, followed by a spot Flake, as well as integration of National Cheng Kung University Flake infiltration shadow visible in the large shadow of bronchial inflatable levy .
[Diagnosis]
The main cause RADS basis for the original cause of morbidity and, in the past without Feibujihuan and exclude left heart failure; sudden sexual respiratory distress, more than 35 per minute, breathing, oxygen commonly used method can not be improved; X - Ray to see first interstitial, after the invasion to diffuse the shadow of the alveolar; blood gas analysis revealed that PaO2 <8 kPa (60mmHg), early PaCO2 <4.6kPa (35mmHg), alveolar gas and blood oxygen difference (PA-aDO2) and the lung-flow (QS / QT) increased oxygenation index (PaO2/FIO2) <300 (PaO2 units mmHg).
[Diagnosis]
With cardiogenic pulmonary edema of identification, cardiogenic pulmonary edema, difficulty breathing and posture-related, bubble-like cough Xue Tan, the strong heart, diuretics, such as better treatment, pulmonary edema and more in the La-lung at the bottom, Pulmonary capillary wedge pressure> 1.58kPa (16cmH2O). ARDS respiratory distress little to do with posture, non-bubble-like Xue Tan Xue Shui-thin, oxygen inhalation conventional circumstances, PaO2 still a decrease, La-wide, often high-pitch "-burst", reduced pulmonary capillary wedge pressure Or normal. ARDS sometimes have to identify with and bronchial pneumonia.
ARDS treatment, including oxygen therapy to improve ventilation function and to correct the lack of oxygen, and causes must be promptly removed so that the primary disease under control, ARDS to heal.
First, adrenal glucocorticoid Application
Glucocorticoid vascular endothelial cells to protect against WBC, platelet aggregation and adhesion wall, a micro-thrombosis; lysosomal membrane stability, reduce complement activity and inhibit cell membrane phospholipid metabolism, reduce the synthesis of arachidonic acid to prevent Prostaglandin and thromboxane A2 production, protection of Ⅱ-cell lung surfactant; with anti-inflammatory and the promotion of interstitial lung fluid absorption; easing bronchial spasms; inhibit the latter part of pulmonary fibrosis. According to the irritation that the current gas inhalation, fractures caused by trauma, such as non-fat embolism caused by infection of ARDS, the use of glucocorticoid sooner the better, the incidence four days after use, less effective. The use of the principle as soon as possible, large and short-range treatment. Such as dexamethasone 20-30 mg, on the 1st, 2-3, the linked two days, if effective, continue to use the few days that is parked. But ARDS with a serious infection or sepsis glucocorticoid should Jiyong or anti.
Second, oxygen therapy
O2 is imperative to correct missing the important measures, such as missing O2 are not corrected, will cause irreversible damage to important organs. General must be a high concentration of oxygen absorption (> 50%), but as far as possible inhalation of low oxygen concentration, as long as the SaO2> 90% to prevent oxygen poisoning occurred.
Third, PEEP ventilation (PEEP)
Breathing machine for a certain volume or delivery of gas flow into the lungs, respiratory and pulmonary inspiratory phase in a positive pressure in the breath of breath until the end of the airway open, mouth, airway and alveolar pressure higher than atmospheric pressure of the type of mechanical ventilation . ARDS PEEP can improve the ventilation function, its principles are as follows: to wilt subsidence of the small airway, alveolar expansion of interstitial lung and pulmonary edema dissipated and improve lung compliance, more functional residual capacity, reduce the physical void cavity, increased alveolar Ventilation, improve the ventilation / flow ratio imbalance, reduced pulmonary arteriovenous shunt-like, lower power and breathe oxygen consumption, thereby enhancing PaO2. The use of PEEP circulating blood volume should be effective enough, PEEP to the pressure from low-level 0.29-0.49 kPa (3-5cmH2O), gradually increasing to 0.98 kPa (10cmH2O), the general should not be超过0.98 kPa, will be affected because of blood from top to bottom cavity The flow of blood back. PEEP pressure> 2.5 kPa, spontaneous pneumothorax rate as high as 14 percent, with mediastinal emphysema. When a stable condition, gradually reduce the value of PEEP, but to maintain SaO2> 90% can be.
4, liquid reasonable input
To ensure adequate blood volume, blood pressure and stability, under the premise of access requirements of a mildly negative balance (-500 ml - 1000ml). For the promotion of tissue fluid dissipated, for furosemide 40-60 mg / d. Damage to the endothelial cells in the vascular permeability increases, colloidal liquid can be infiltrated into mesenchymal, increase pulmonary edema, it should not be completed in early ARDS colloid. Apart from excessive bleeding due to trauma, to blood transfusion, Yi Yi and micro-filter with the new blood transfusion, blood inventory to avoid micro-particles with micro-thrombosis caused pulmonary capillary endothelial cells.
5, nutrition supplies and the incidence of treatment
Patients with ARDS often a lack of nutrition, should be given high nasal feeding and intravenous nutrition, in order to maintain sufficient energy supply, to avoid metabolic functions and dielectric disorder.
Adult respiratory distress syndrome (adult respiratory distress syndrome, ARDS) in patients with the heart and lung function is normal, because of the lung or pulmonary diseases in the course of the permeability of secondary acute pulmonary edema and hypoxia of respiratory failure. Although its causes vary, but the lung tissue injury in pathology and function more or less the same, are clinical manifestations of acute respiratory distress, refractory hypoxemia because of a similar levy infant respiratory distress, and their etiology and pathogenesis Different, it then called "adult" to show differences.
As the severe trauma, shock, infection and other diseases rescue raising the level of technology, many patients do not die of disease directly, thereby increasing the incidence of ARDS, ARDS onset Jizhou, rapid development, if not early diagnosis and treatment, died Rate of more than 50 percent (25% -90%), and often died of multiple organ failure.
[Etiology and pathogenesis]
ARDS the cause of many, such as severe shock, severe trauma, fractures, fat embolism, severe infection (particularly gram-negative bacillus sepsis were caused by septic shock), inhalation of irritating gases and stomach contents, oxygen poisoning, drowning, Massive blood transfusion, acute pancreatitis, drugs or narcotics, such as poisoning, which can cause pulmonary - capillary acute injury, however this injury mechanism has not yet been fully clarified, and a variety of factors, and the intricate existence and mutually affected.
At present the majority of scholars believe that many neurotransmitters involved in alveolar - vascular endothelial injury, with neutrophil (PMN) is the activation of endothelial cells capillary permeability increase was mainly due. Interstitial lung health of people, only a small number of PMN, in trauma, acute pancreatitis, physical and chemical stimulation or pump circumstances, as in a variety of chemotactic factor PMN role, to PMN in the pulmonary capillary gathered in a large number, and through the Adhesion of factors, such as the complement system activated the C5a, lipopolysaccharide (LPS), will be PMN adhesion to endothelial cells, PMN activation of endothelial cells to release a series of damaging lung tissue and harmful substances, mainly oxygen free Based, multi-and arachidonic acid metabolite.
If all kinds of protein-dissolving enzyme, elastase, serine protease, collagenase, cathepsin, elastase and collagenase can digest the basement membrane, and pulmonary artery walls elastic organizational structure.
Arachidonic acid metabolite by PMN, macrophages complement activation of phospholipase, from the plasma membrane phospholipids in the release of arachidonic acid, through its lipoxygenase and cyclooxygenase grass two metabolic process, the formation of A series of high-activity products (medium). The blood vessels and bronchial contraction caused pulmonary hypertension and airway resistance increased, to unite platelets, blood clots, and the release of fibrin degradation products, proteolytic enzymes, increased capillary Tong Xing. Because pulmonary capillary membrane damage, permeability increase in permeability of pulmonary edema.
[Pathology]
ARDS was Anhong of the lung or liver-Anzi red changed, visible swelling, bleeding, weight increased significantly. 24h microscopy see in the pulmonary microvascular congestion, hemorrhage, micro-thrombosis, pulmonary alveolar and quality of water within a protein glue and infiltration of inflammatory cells. Nearly 72 h, from plasma protein coagulation, cell Cui films, fibers and residue of the Surfactant a transparent membrane, or large focal alveolar wilt depression. At exudative acute lung cells damaged Ⅰ necrosis, the restoration of lung epithelial cell type Ⅱ. Early fibroblast proliferation and collagen deposition, a week after the alveolar separated, transparent film can be fibrosis, with pulmonary secondary infection.
[Pathophysiology]
Because pulmonary vascular endothelial cells and alveolar type Ⅱ cell damage caused interstitial lung and pulmonary edema, congestion, pulmonary surfactant reduced, leading to closure of small airway depression, depression not alveolar Zhang Wei, lung compliance decreased functional residual Gas reduction. So that ventilation / flow ratio imbalance, pulmonary arteriovenous shunt-like increase and diffusion barriers, causing serious damage to the ventilation function hypoxemia and stimulate the carotid sinus aorta of chemical receptors can stimulate the respiratory center reflection cause excessive ventilation, there Respiratory alkalosis. Late in ARDS, as in critical condition, respiratory muscle fatigue failure, a lack of ventilation, lack O2 more severe, with CO2 retention, a mixed acid poisoning.
In addition to the disease such as trauma, infection, poisoning, and other relevant signs and symptoms, mainly for emergencies, respiratory distress, shortness of breath, cyanosis, often accompanied with irritability, anxiety expressions, sweating, and so on. The characteristics of their respiratory distress usually can not be used so as to improve the therapy, or use other primary cardiovascular diseases (such as pneumothorax, pulmonary emphysema, atelectasis, pneumonia, heart failure) explained. Early signs may be no abnormalities, or only heard Shuangfei stem-La, Asthma Ming Yin, the late and blisters can hear the sound, or breathing tube sound. Early X-ray can be no anomaly, or a slight change in the quality of performance for the fuzzy edge of the Fei Wenli increased, followed by a spot Flake, as well as integration of National Cheng Kung University Flake infiltration shadow visible in the large shadow of bronchial inflatable levy .
[Diagnosis]
The main cause RADS basis for the original cause of morbidity and, in the past without Feibujihuan and exclude left heart failure; sudden sexual respiratory distress, more than 35 per minute, breathing, oxygen commonly used method can not be improved; X - Ray to see first interstitial, after the invasion to diffuse the shadow of the alveolar; blood gas analysis revealed that PaO2 <8 kPa (60mmHg), early PaCO2 <4.6kPa (35mmHg), alveolar gas and blood oxygen difference (PA-aDO2) and the lung-flow (QS / QT) increased oxygenation index (PaO2/FIO2) <300 (PaO2 units mmHg).
[Diagnosis]
With cardiogenic pulmonary edema of identification, cardiogenic pulmonary edema, difficulty breathing and posture-related, bubble-like cough Xue Tan, the strong heart, diuretics, such as better treatment, pulmonary edema and more in the La-lung at the bottom, Pulmonary capillary wedge pressure> 1.58kPa (16cmH2O). ARDS respiratory distress little to do with posture, non-bubble-like Xue Tan Xue Shui-thin, oxygen inhalation conventional circumstances, PaO2 still a decrease, La-wide, often high-pitch "-burst", reduced pulmonary capillary wedge pressure Or normal. ARDS sometimes have to identify with and bronchial pneumonia.
ARDS treatment, including oxygen therapy to improve ventilation function and to correct the lack of oxygen, and causes must be promptly removed so that the primary disease under control, ARDS to heal.
First, adrenal glucocorticoid Application
Glucocorticoid vascular endothelial cells to protect against WBC, platelet aggregation and adhesion wall, a micro-thrombosis; lysosomal membrane stability, reduce complement activity and inhibit cell membrane phospholipid metabolism, reduce the synthesis of arachidonic acid to prevent Prostaglandin and thromboxane A2 production, protection of Ⅱ-cell lung surfactant; with anti-inflammatory and the promotion of interstitial lung fluid absorption; easing bronchial spasms; inhibit the latter part of pulmonary fibrosis. According to the irritation that the current gas inhalation, fractures caused by trauma, such as non-fat embolism caused by infection of ARDS, the use of glucocorticoid sooner the better, the incidence four days after use, less effective. The use of the principle as soon as possible, large and short-range treatment. Such as dexamethasone 20-30 mg, on the 1st, 2-3, the linked two days, if effective, continue to use the few days that is parked. But ARDS with a serious infection or sepsis glucocorticoid should Jiyong or anti.
Second, oxygen therapy
O2 is imperative to correct missing the important measures, such as missing O2 are not corrected, will cause irreversible damage to important organs. General must be a high concentration of oxygen absorption (> 50%), but as far as possible inhalation of low oxygen concentration, as long as the SaO2> 90% to prevent oxygen poisoning occurred.
Third, PEEP ventilation (PEEP)
Breathing machine for a certain volume or delivery of gas flow into the lungs, respiratory and pulmonary inspiratory phase in a positive pressure in the breath of breath until the end of the airway open, mouth, airway and alveolar pressure higher than atmospheric pressure of the type of mechanical ventilation . ARDS PEEP can improve the ventilation function, its principles are as follows: to wilt subsidence of the small airway, alveolar expansion of interstitial lung and pulmonary edema dissipated and improve lung compliance, more functional residual capacity, reduce the physical void cavity, increased alveolar Ventilation, improve the ventilation / flow ratio imbalance, reduced pulmonary arteriovenous shunt-like, lower power and breathe oxygen consumption, thereby enhancing PaO2. The use of PEEP circulating blood volume should be effective enough, PEEP to the pressure from low-level 0.29-0.49 kPa (3-5cmH2O), gradually increasing to 0.98 kPa (10cmH2O), the general should not be超过0.98 kPa, will be affected because of blood from top to bottom cavity The flow of blood back. PEEP pressure> 2.5 kPa, spontaneous pneumothorax rate as high as 14 percent, with mediastinal emphysema. When a stable condition, gradually reduce the value of PEEP, but to maintain SaO2> 90% can be.
4, liquid reasonable input
To ensure adequate blood volume, blood pressure and stability, under the premise of access requirements of a mildly negative balance (-500 ml - 1000ml). For the promotion of tissue fluid dissipated, for furosemide 40-60 mg / d. Damage to the endothelial cells in the vascular permeability increases, colloidal liquid can be infiltrated into mesenchymal, increase pulmonary edema, it should not be completed in early ARDS colloid. Apart from excessive bleeding due to trauma, to blood transfusion, Yi Yi and micro-filter with the new blood transfusion, blood inventory to avoid micro-particles with micro-thrombosis caused pulmonary capillary endothelial cells.
5, nutrition supplies and the incidence of treatment
Patients with ARDS often a lack of nutrition, should be given high nasal feeding and intravenous nutrition, in order to maintain sufficient energy supply, to avoid metabolic functions and dielectric disorder.
Chronic respiratory failure
Chronic respiratory failure
Chronic respiratory failure often bronchial - pulmonary disease caused by, such as chronic obstructive pulmonary disease, severe tuberculosis, interstitial pulmonary fibrosis, such as pneumoconiosis. Thoracic diseases and thoracic surgery, trauma, extensive pleural thickening, thoracic deformity can lead to chronic respiratory failure.
1 missing O2 and CO2 retention mechanism
(A) lack of ventilation in the resting breathing air, the alveolar ventilation is about 4 L / min, to maintain normal alveolar oxygen and carbon dioxide partial pressure. Reduce alveolar ventilation, alveolar oxygen pressure dropped, carbon dioxide partial pressure increased. Under the conditions of breathing air (oxygen concentration of respirable 20.93 percent, carbon dioxide close to zero).
(B) ventilation / flow ratio imbalance in the ventilation and pulmonary capillary blood perfusion around the ratio must be coordinated to ensure effective gas exchange. Every minute of normal alveolar ventilation (VA) 4L, pulmonary capillary blood flow (Q) 5L, both the ratio of 0.8. Such as pulmonary ventilation in the blood flow rate of greater than (> 0.8). Is a physiological dead space increases, which is invalid cavity effect; alveolar ventilation in the ratio of less than the blood flow (<0.8), so that the mixture of pulmonary blood oxygenation without full access to pulmonary vein, a kind arteriovenous shunt (Figure 2-6-2). Ventilation / flow ratio imbalance, a lack O2, without CO2 retention. The result of blood mixed with the blood of oxygen difference is much greater than CO2 partial pressure, the former for 7.98 kPa, while the latter only 0.79 kPa, difference of 10 times. It may, by the sound of alveolar hyperventilation, emit more CO2, inadequate ventilation to compensate alveolar retention of CO2, or even emit more CO2, a respiratory alkalosis. As hemoglobin oxygen dissociation of the characteristics of normal alveolar capillary blood oxygen saturation already in a flat, the increase even if ventilation, air suction, although the alveolar oxygen, but little increase in blood oxygen saturation, by Sound excessive alveolar ventilation can not compensate the lack of ventilation caused by the perturbation alveolar oxygen shortage and thus a lack O2.
Ventilation> normal blood flow> ventilation
(Dead space effect) (effective ventilation) (static artery diversion effect)
(C) pulmonary artery - because of pulmonary vein-like triage pulmonary diseases such as depression wilt, atelectasis, pneumonia and pulmonary edema and pulmonary real change may cause an increase like triage, so that blood no contact alveolar gas to gas exchange opportunities. Therefore, increasing oxygen concentration and can not be raised PaO2. The greater the flow, increase blood oxygen inhalation after the worse the effect of the partial pressure of oxygen, such as the flow of more than 30 percent of the oxygen partial pressure of oxygen on the limited impact.
(D) diffusion barriers oxygen diffusing capacity of carbon dioxide is only 1 / 20, is in the diffusion barriers, a simple hypoxia.
(5) oxygen consumption increased oxygen consumption is increasing missing one of the reasons for O2, fever, chills, breathing difficulties and convulsions are to increase oxygen consumption. Shivering oxygen consumption up to 500 ml / min, severe asthma, with the increased work of breathing, oxygen consumption for more than 10 times normal. Oxygen consumption increased, decreased alveolar oxygen, help increase the normal ventilation to prevent hypoxia. Breathing air, oxygen consumption in the partial pressure of oxygen and pulmonary alveolar ventilation of the impact. Map of the curve with the dotted line to the point of intersection of different oxygen consumption, the maintenance of normal alveolar oxygen for pulmonary ventilation, with the increase in oxygen consumption, has also increased significantly, oxygen consumption per minute, respectively For 200 ml, 400ml, 800ml, alveolar ventilation volume of 3 L, 6L, 12L.
Second, the lack O2, CO2 retention of the impact of the body
(A) the impact on the central nervous brain tissue oxygen consumption accounted for about systemic consumption of 1/5-1/4. Central cortex cells most sensitive to hypoxia, lack O2 and the extent of the central nervous Jihuan the middle of the highest bidders different effects on health. Such as a sudden interruption for O2, purity nitrogen absorption to be 20 seconds in deep coma and body convulsions. Gradually reduce the absorption of O2 concentration, slow onset of symptoms, can cause mild missing O2 attention is not focused, intelligence may be directed obstacles with the increasing lack O2, PaO2 (PaO2) below 6.66 kPa can induce irritability, Trance consciousness, delirium; below 3.99 kPa, would lose consciousness, and even coma; below 2.66 kPa will be irreversible brain damage.
CO2 cerebrospinal fluid retention so that the concentration of hydrogen ions, the impact of brain cell metabolism, reduce excitatory brain cells and inhibit cortex; With the increase in CO2, stimulate the strengthening of the lower cortex, the cortex caused excitement; if CO2 continue to rise, the lower deck of the cortex inhibit So that the central nervous system in a state of anesthesia. In a pre-anesthesia patients often suffer from insomnia, mental excitement, irritability symptoms of the threatened excited.
Missing O2 and CO2 retention will have cerebral vascular expansion, reduced resistance to blood flow, to compensate the血流量增加. O2 will be seriously lacking in brain cells, edema, increased permeability of blood vessels, caused brain interstitial edema, leading to increased intracranial pressure, squeezing brain tissue and oppression of blood vessels, thereby increasing brain missing O2, a vicious cycle.
(B) of the heart, circulation of missing O2 can stimulate the heart to speed up the heart rate and stroke volume increase, high blood pressure. Coronary blood flow in the lack O2, a marked increase in heart blood flow far exceeds the brain and other organs. O2 myocardial lack of sensitivity, early mild O2 that is lacking in the electrocardiogram appeared on the show, a serious lack of O2 can lead to ventricular fibrillation or cardiac arrest. Missing O2 and CO2 retention can cause pulmonary vasoconstriction small increase in pulmonary vascular resistance, leading to increased pulmonary hypertension and right heart burden.
Inhalation of gas in the concentration of CO2, will speed up the heart rate, stroke volume increased, cerebral, coronary vasodilation, subcutaneous superficial capillaries and veins expansion due to the muscles of the spleen and blood vessels to contract, coupled with increased stroke volume, the Blood pressure is still elevated.
(C) lack of respiratory effects of breathing O2 impact than the impact of CO2 retention for small. O2, mainly through lack of carotid sinus and aortic reflection of the role of chemical receptors to stimulate ventilation, such as the slow increase the degree of lack O2, the reflective slow.
CO2 is a strong respiratory center stimulants, inhalation of increased CO2 concentration, ventilation multiplied, the retention of CO2 in deep rapid breathing, but when inhaled超过12% CO2 concentration, ventilation will not increase in the respiratory center Was inhibited. And chronic hypercapnia, there is no corresponding increase in ventilation, but has declined, and respiratory center reaction of the slow, through the kidneys to absorb and bicarbonate from H +, so that no blood pH value decreased, and patients Gas resistance increased, a serious lung damage, the thorax movement dysfunction related to ventilation.
(D) of the liver, kidney and blood system of missing O2 can be direct or indirect damage to the liver ALT increased, but with the lack of corrective O2, liver function gradually returned to normal.
Reduce arterial blood oxygen, kidney blood flow, the volume of glomerular filtration, urine output and sodium from the increase of both, but when PaO2 <5.3kPa, reduce kidney blood flow, kidney function was inhibited.
Low oxygen erythropoietin to increase red blood cell proliferation. Kidney and liver produce an enzyme, the blood of the Central African erythropoietin, the predecessor of a generation of active substances to stimulate the bone marrow caused secondary erythrocytosis. To increase the carrying capacity of blood, but also increased blood viscosity, pulmonary circulation and increase the burden on the right heart.
CO2 retention mild renal vascular expansion will increase renal blood flow, increase the amount of urine when PaCO2超过8.64 kPa, blood pH decreased significantly, kidney vasospasm, reduced blood flow, HCO3-and Na + absorption to increase urine output reduction .
(5) of electrolyte and acid-base balance the impact of severe energy shortage O2 cells inhibited the middle of the process and radio, such as三羧酸循环, and the role of oxidative phosphorylation-related activities. This will not only have lower energy efficiency, but also due to produce lactic acid and inorganic phosphorus from metabolic acidosis. As the energy shortage, in-transit damage by the sodium pump, so that cells within the potassium transferred to the blood, and Na + and H + into the cells, causing cells acidosis and hyperkalemia. Metabolic acidosis the fixed buffer acid and bicarbonate in the system work, a carbonate, the organization increased carbon dioxide tension.
PH value of carbonate and bicarbonate depends on the ratio of the former regulation on the kidney (1-3 days), while carbonated regulation on the lung (hours). Healthy people every day from lung carbonate of as many as 15000 mmol, the acute respiratory failure CO2 retention impact on the pH very quickly, often with metabolic acidosis exist, due to acid poisoning caused serious decline in blood pressure, arrhythmia, and even cardiac arrest . And chronic respiratory failure due to the slow development of CO2 retention and kidney from reduced bicarbonate, does not result in significantly lower pH. Because of blood in the main anion HCO3-and CI-in and is a constant, when HCO3-increase, the CI-corresponding lower, a low chlorine hyperlipidemia.
In addition to chronic respiratory failure caused the primary symptoms, is missing O2 and CO2 retention caused by multiple organ dysfunction performance.
First, breathing difficulties
Manifested in the frequency and magnitude of changes in rhythm. Such as the hub of a wave of respiratory failure, intermittent or Chouqi respiration; COPD is slow and deep breathing to rapid shallow breathing, auxiliary respiratory muscle strengthening activities, was nodding his head or shoulder to breathe. Central nervous system for the performance of drug poisoning absorbed ease breathing, drowsiness, severe pulmonary heart disease complicated by respiratory failure of carbon dioxide anesthesia, a slow shallow breathing.
Second, cyanosis
O2 is the lack of typical symptoms. When arterial blood oxygen saturation below 85%, the blood flow in the larger lips nail in cyanotic the other should pay attention to red blood cells, increasing cyanosis more obvious, anemia who are not obvious or cyanotic not appear serious shock endings Patients with poor circulation, even if PaO2 is still normal, may also appear cyanotic. Cyanosis also by the skin pigment and cardiac function.
Third, the spirit of neurological symptoms
The spirit of acute respiratory failure symptoms of slower to clear, acute shortage of mental disorder can appear O2, manic, coma, convulsions and other symptoms. O2 has more chronic lack intellectual orientation or dysfunction.
CO2 retention appear before the central curb the excitement of symptoms such as insomnia, irritability, restless, but this must not use sedation or sleeping pills to avoid increasing CO2 retention, a pulmonary encephalopathy, for the performance of consciousness indifferent, muscle tremors, occasional convulsions, drowsiness And even coma. pH compensation, was able to day-to-day life of the individual activities of CO2 retention, pH <7.3, will appear psychiatric symptoms. Serious CO2 retention can occur tendon reflexes weakened or disappeared, pyramidal tract, such as positive sign.
4, symptoms of the circulatory system
A serious lack O2 and CO2 retention caused pulmonary hypertension, heart failure can occur right, with signs of systemic congestion. CO2 retention so that peripheral venous filling surface, skin Hongrun, wet warm sweating, elevated blood pressure, stroke volume increased pulse of Hong Tae result; due to cerebral vascular expansion, a pulsating headache. Late due to serious lack O2, myocardial damage from acid poisoning, a peripheral circulatory failure, blood pressure dropped, arrhythmias, heart arrest.
5, digestive and urinary symptoms
Severe respiratory failure of liver and kidney functions are affected, such as GPT and non-protein nitrogen increased, proteinuria, urine and a tube of red blood cells. Gastrointestinal mucosa due to congestion and edema, erosion, bleeding, stress ulcer or upper gastrointestinal bleeding caused. These symptoms may lack the O2 and CO2 retention corrective disappear.
Chronic respiratory failure decompensated period, according to patients with chronic respiratory diseases or other respiratory dysfunction leading to the history, missing O2 and (or) CO2 retention of clinical manifestations, with the relevant signs, the diagnosis is not difficult. Arterial blood gas analysis of respiratory failure can objectively reflect the nature and extent of the guidance of oxygen therapy, mechanical ventilation various parameters of the regulation, and correct pH balance and electrolytes are important values.
1. PaO2 (PaO2)
Refers to the physical dissolved in the blood oxygen molecules generated by the pressure. PaO2 healthy growth decreased gradually with age, and physiological effects of receptor. According to partial pressure of oxygen and oxygen saturation of the relationship between oxygenated hemoglobin dissociation curve was S shape, when PaO2> 8kPa (60mmHg) above, the flat of the curve, the oxygen saturation of more than 90%, PaO2 change 5.3 kPa (40mmHg ), But little change in oxygen saturation that much oxygen saturation of oxygen-sensitive, but when PaO2 <8kPa below, the steep curve, the slight decline in oxygen pressure, oxygen saturation sharp decline, the PaO2 Less than 8 kPa (60mmHg) as the diagnosis of respiratory failure indicators.
Second, the arterial blood oxygen saturation (SaO2)
Hemoglobin is the oxygen percentage of units, the normal value is 97 per cent. When PaO2 less than 8 kPa (60mmHg), hemoglobin oxygen dissociation curve in a steep section, the oxygen saturation only reflects the state of hypoxia, the severe respiratory failure in the rescue, with the pulse of oxygen saturation detector to help evaluate missing O2 level, adjust the absorption of O2 concentration SaO2 more than 90%, to reduce the trauma of pumping blood for blood gas analysis, which is a reasonable assessment effect of oxygen therapy and play an active role.
3, arterial blood oxygen content (CaO2)
100 ml of blood is the number of oxygen-ml. Including the combination of hemoglobin and oxygen dissolved oxygen in plasma physics combined. CaO2 = 1.34 × SaO2 × Hb +0.003 × PaO2. Healthy CaO2 reference value of 20 ml%. Mixed blood oxygen saturation (SVO2) to 75 percent, its oxygen content CVO2 for 15 ml%, per 100 ml blood by the organization after about 5 ml of oxygen for the organization to use. Hemoglobin reduction, SaO2 lower than normal, blood oxygen content can still be the normal range.
4. PaCO2 (PaCO2)
Refers to the physical dissolved in the blood of the CO2 produced by the pressure. PaCO2 normal for the 4.6 kPa-6kPa (35-45mmHg), more than 6 kPa for inadequate ventilation, less than 4.6 kPa for ventilation may be excessive. Acute lack of ventilation, PaCO2> 6.6kPa (50mmHg), according to Henderson-Hassellbalch formula, pH below 7.20, it will affect circulation and cell metabolism. Chronic respiratory failure due to the body compensatory mechanisms, PaCO2> 6.65kPa (50mmHg) as an indicator of respiratory failure.
5, pH value
For the hydrogen ion concentration in the blood of a negative value. The normal range of 7.35-7.45, an average of 7.40. Below 7.35 for decompensated acidosis, higher than the 7.45 for decompensated alkalosis, but could not explain what is the nature of the acid-base poisoning. Clinical symptoms and the pH is closely related to migration.
6, base excess (BE)
In 38 ℃, CO2 pressure 5.32 kPa (40mmHg), oxygen saturation measured 100 percent condition, blood titration to the pH of pH7.4. It is human metabolic acid-base balance of quantitative indicators, plus acid to BE positive of the metabolic alkalosis; Canadian base of EB was negative, of metabolic acidosis. The normal range of 0 ± 2.3mmol / L. In the correct metabolic acid-base imbalance, it can be used as estimated by acid or Kangjian dose drug reference.
7. Buffer base (BB)
Various buffer in the blood of the total content of alkali, including bicarbonate, phosphate, plasma protein salt, salt and other hemoglobin. It reflects human interference buffer against acid-base capability, and acid-base imbalance in the body of the specific circumstances of compensation. Normal for the 45 mmol / L.
8, the actual bicarbonate (AB)
AB is in the actual partial pressure of carbon dioxide and oxygen saturation of human plasma bicarbonate contained in the content. Normal for the 22-27 mmol / L, an average of 24 mmol / L. HCO3-related content and PaCO2, as PCO2 increased plasma HCO3-content has also increased. On the other hand HCO3-alkali plasma one of the buffer, when too much acid in fixed, by HCO3-buffer and pH stability, and HCO3-content reduction. So AB double by respiratory and metabolic effects.
9, the standard bicarbonate (SB)
Means isolated from the blood samples of air in 38 ℃, PaCO2 to 5.3 kPa, oxygenated hemoglobin 100 percent under the conditions, measured by the plasma bicarbonate (HCO3-) content, for the normal 22 - 27mmol / L, An average of 24 mmol / L. SB from respiratory factors, to reflect the increase or decrease its value in HCO3-the number of reserves, so that metabolic factors and extent of the trend. Metabolic acidosis, SB decreased metabolic alkalosis, SB increased. AB> SB, expressed CO2 retention.
10, the combination of carbon dioxide (CO2CP)
Normal for the 22-29 mmol / L, the main base in the reserves. Metabolic acidosis, or respiratory alkalosis, CO2CP lower metabolic alkalosis or respiratory acidosis, while CO2CP increased. However, respiratory and metabolic acidosis with acid poisoning, CO2CP not necessarily increased, due to respiratory acidosis, kidney or to NH4 + H + form from the H +, to compensate for HCO3-absorption, alkali reserve increase, the increase in the CO2CP Certain extent, respiratory acidosis reflect the seriousness of the blood but can not reflect the dramatic changes in CO2, but also by the metabolism of the base or acid poisoning effect, it has its one-sidedness CO2CP, must be integrated with clinical and electrolyte for full consideration.
These indicators to PaO2, PaCO2 and pH most important, reflecting the lack respiratory failure at the O2, CO2 retention, in an acid-base imbalance, such as adding BE will be able to reflect the body compensatory, or without metabolic acid or alkaline Poisoning, and electrolyte imbalance.
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.
First, the establishment of the airway patency
In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.
Second, oxygen therapy
By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.
(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.
The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.
(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.
Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).
(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.
First, the establishment of the airway patency
In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.
Second, oxygen therapy
By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.
(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.
The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.
(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.
Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).
(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.
Through oxygen masks Venturi principle, the use of oxygen jet produced negative pressure, inhaled air to dilute oxygen, into the air-conditioning control of oxygen concentration in 25 to 50 percent range, face masks, oxygen concentration and stability, free from the respiratory rate and tidal Of the impact. Is the consumption of its shortcomings, expectoration inconvenience.
Oxygen therapy to the general physical and clinical needs to regulate the concentration of oxygen inhalation, PaO2 of more than 8 kPa, or SaO2 for more than 90 percent. Oxygen consumption increases, such as fever can increase the concentration of oxygen inhalation. Reasonable oxygen therapy increased the effect of respiratory failure, respiratory failure in patients with COPD such as long-term low concentrations of oxygen therapy (especially at night) can reduce pulmonary circulation of resistance and pulmonary artery pressure, increased cardiac contraction, with activities to enhance and extend the survival time of endurance .
Third, increase ventilation and reduce CO2 retention
Alveolar CO2 retention is caused by inadequate ventilation, only to increase alveolar ventilation to effectively discharge CO2. Mechanical ventilation in the treatment of respiratory failure effect has affirmed and the application of respiratory stimulants, because of their different effect, the surviving in the controversy. Profile is as follows:
(A) a reasonable application of respiratory stimulants, respiratory stimulants stimulate the respiratory center or around the chemical receptors, through enhanced respiratory center of excitement, increased respiratory rate and tidal volume to improve ventilation. At the same time, patients with oxygen consumption and CO2 output also increased, and ventilation and a positive correlation. Because of its use of simple, economic, and a certain effect, it was still widely used in clinical, but should have their clinical indications. Patients with low ventilation mainly because of the central inhibition, respiratory stimulant effect of better chronic obstructive pulmonary disease, respiratory failure due to bronchial - lung disease, the response of the central or lower respiratory muscle fatigue caused by low ventilation, at this time of breath Doping should be the pros and cons of the three factors of primary and secondary may be. In nerve conduction system and the respiratory muscle lesions, and pneumonia, pulmonary edema and pulmonary fibrosis of the extensive ventilation dysfunction, respiratory stimulants are no disadvantages benefit and should not be used.
In the application of respiratory stimulants at the same time, should attach importance to reduce the chest, lungs and airway mechanical load, such as the secretion of drainage, the application of bronchial spasm, the elimination of pulmonary edema and other factors affecting the chest compliance. Otherwise, ventilation drive will add to short breath and breathing to increase power, and the need to increase the concentration of oxygen inhalation. In addition, we must make full use of some stimulants respiratory consciousness back to the Soviet Union, to encourage patients to cough, sputum elimination, and maintain the airway open. If necessary, nose or mouth and nose mask with mechanical ventilation support.
Nikethamide is the common respiratory center stimulants, increase ventilation, have a certain role Su-Ti. Patients can sleepiness of the first slow intravenous injection 0.375 g-0.75g, then to 3-3.75 g adding 500 ml of liquid, drop by 25-30 / min infusion. Close observation of patients lashes response to change consciousness, and respiratory rate, the rate and rhythm, the follow-up of arterial blood gas, in order to regulate dosage. If a skin itching, irritability and other side effects, must be slowed down Disu. If the 4 h-12h did not bear fruit, or a muscle twitch serious reactions, should be suspended, if necessary, a change of mechanical ventilation support.
(B) a reasonable application of mechanical ventilation with respiratory physiology and pathophysiology of the development, nose and mouth masks, artificial airway, breathing and respiratory-care properties of continuous improvement, mechanical ventilation will enable patients with respiratory failure to grow. Practice has proved that mechanical ventilation for the success or failure of respiratory failure, in addition to the breathing machine and related properties, is more important to the medical staff to keep respiratory failure in patients with pathological changes in physiological and reasonable application of mechanical ventilation. By increasing ventilation and provide appropriate oxygen concentration, to a certain extent, improve the ventilation function and reduce the power consumption of breath, respiratory failure in patients with missing O2, CO2 retention and acid-base balance disorders can be different degrees of improvement and corrected, General will not die of respiratory failure. Attention should be paid to prevention and treatment may be lethal infection of the airway, obstructive airway secretions, high-pressure pulmonary complications such as trauma. Even in some serious respiratory failure complicated by multiple organ failure patients, after treatment by mechanical ventilation, because of improved patient heart, brain, kidney, liver and other organs of oxygen the body and internal environment, and then to nasal feeding or intravenous Nutritional support, create the conditions for the resumption of patients, save a lot of dying patient's life.
Shang-qing consciousness of mild to moderate, in line with the patients with respiratory failure, nose or mouth and nose mask for mechanical ventilation; serious condition, although the consciousness-but uncooperative, coma or respiratory secretions of the large number of patients, the timely establishment of gas Road, such as the nose (or mouth) intubation mechanical ventilation, the choice of organizations with good compatibility of high-capacity low-pressure air bags (<3.3 kPa) of PVC or silicone catheter, the catheter can retain more than half a month, to avoid Low capacity use latex rubber high-pressure balloon catheter, because of their reaction, can cause the airway mucosa clear congestion, edema, erosion, and ulcers. In very poor lung function, recurrent respiratory failure, secretions, the body extremely weak, malnutrition, need long-term support of patients with mechanical ventilation, for tracheotomy, the long-term retention of mechanical ventilation trachea casing.
In the use of breathing machine before the medical staff must understand the pathophysiology of patients with respiratory, to suit the tidal volume, respiratory rate and breathing, such as the ratio of various parameters, such as a blockage of the ventilation to be too large tidal volume, frequency slow breath longer Breathing, and restrictive ventilated patients is the opposite. Through simple hand pinch capsule breathing respirator for the transition, followed by a mechanical ventilation and monitoring of patients with clinical manifestations, such as the activities of the thorax, airway pressure and oxygen saturation changes in the general follow-up after 20 min blood gas again Further adjustments breathing machine parameters. In the different periods of mechanical ventilation, ventilation should use different approaches, such as respiratory or manual control capsule ventilation or assisted intermittent positive pressure ventilation (IPPV), PEEP ventilation (PEEP), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV). Ventilation can also be different forms of composition, such as PEEP + PSV for the integration of bi-level positive airway pressure (BiPAP). PEEP improve the ventilation function, SIMV and PSV benefit from the breathing machine, so as to achieve avoid excessive ventilation or inadequate ventilation. Reduce the impact of the heart cycle. During the mechanical ventilation should strengthen management of respiratory and breathing machine. As to the wetlands of the respiratory tract, secretions to attract and maintain respiratory unobstructed; breathing machine disinfection and maintenance of clean, avoid cross-infection. Particularly want to emphasize is the need to strengthen the respiratory and cardiovascular care, early detection of problems, analyse problems and to properly resolve to give full play to mechanical ventilation in the treatment of respiratory failure of the active role so that a reasonable and effective application of mechanical ventilation, improve Its efficacy and reduce complications.
40, to correct acid-base balance disorders and electrolyte imbalance
Diagnosis and treatment of respiratory failure in the process, there are several common types of acid-base balance disorders.
(A) of respiratory acidosis due to lack of pulmonary ventilation, CO2 produced in the body retention hypercapnia, changed the BHCO3/H2CO3 the normal ratio of 1 / 20, acute respiratory acidosis. Patients with chronic respiratory failure, blood-buffer system and the role of the kidney adjustment (secretion of H +, Na + absorption and HCO3-integration into NaHCO3), to near normal pH. Respiratory failure stolen generation acid poisoning can use alkaline agent (5% NaHCO3) temporarily to correct the pH value, but will reduce the ventilation to further increase the CO2 retention, there is no acid poisoning have removed the root causes. Only increase alveolar ventilation can be corrected respiratory acidosis.
(B) respiratory acidosis merger metabolic acidosis due to low O2 levels, insufficient blood volume, cardiac output and reduce cycle around obstacles, such as lactic acid in fixed, such as increased renal damage impact from acid metabolites. Therefore, on the basis of respiratory acid can be complicated with metabolic acidosis.
Chronic respiratory failure often bronchial - pulmonary disease caused by, such as chronic obstructive pulmonary disease, severe tuberculosis, interstitial pulmonary fibrosis, such as pneumoconiosis. Thoracic diseases and thoracic surgery, trauma, extensive pleural thickening, thoracic deformity can lead to chronic respiratory failure.
1 missing O2 and CO2 retention mechanism
(A) lack of ventilation in the resting breathing air, the alveolar ventilation is about 4 L / min, to maintain normal alveolar oxygen and carbon dioxide partial pressure. Reduce alveolar ventilation, alveolar oxygen pressure dropped, carbon dioxide partial pressure increased. Under the conditions of breathing air (oxygen concentration of respirable 20.93 percent, carbon dioxide close to zero).
(B) ventilation / flow ratio imbalance in the ventilation and pulmonary capillary blood perfusion around the ratio must be coordinated to ensure effective gas exchange. Every minute of normal alveolar ventilation (VA) 4L, pulmonary capillary blood flow (Q) 5L, both the ratio of 0.8. Such as pulmonary ventilation in the blood flow rate of greater than (> 0.8). Is a physiological dead space increases, which is invalid cavity effect; alveolar ventilation in the ratio of less than the blood flow (<0.8), so that the mixture of pulmonary blood oxygenation without full access to pulmonary vein, a kind arteriovenous shunt (Figure 2-6-2). Ventilation / flow ratio imbalance, a lack O2, without CO2 retention. The result of blood mixed with the blood of oxygen difference is much greater than CO2 partial pressure, the former for 7.98 kPa, while the latter only 0.79 kPa, difference of 10 times. It may, by the sound of alveolar hyperventilation, emit more CO2, inadequate ventilation to compensate alveolar retention of CO2, or even emit more CO2, a respiratory alkalosis. As hemoglobin oxygen dissociation of the characteristics of normal alveolar capillary blood oxygen saturation already in a flat, the increase even if ventilation, air suction, although the alveolar oxygen, but little increase in blood oxygen saturation, by Sound excessive alveolar ventilation can not compensate the lack of ventilation caused by the perturbation alveolar oxygen shortage and thus a lack O2.
Ventilation> normal blood flow> ventilation
(Dead space effect) (effective ventilation) (static artery diversion effect)
(C) pulmonary artery - because of pulmonary vein-like triage pulmonary diseases such as depression wilt, atelectasis, pneumonia and pulmonary edema and pulmonary real change may cause an increase like triage, so that blood no contact alveolar gas to gas exchange opportunities. Therefore, increasing oxygen concentration and can not be raised PaO2. The greater the flow, increase blood oxygen inhalation after the worse the effect of the partial pressure of oxygen, such as the flow of more than 30 percent of the oxygen partial pressure of oxygen on the limited impact.
(D) diffusion barriers oxygen diffusing capacity of carbon dioxide is only 1 / 20, is in the diffusion barriers, a simple hypoxia.
(5) oxygen consumption increased oxygen consumption is increasing missing one of the reasons for O2, fever, chills, breathing difficulties and convulsions are to increase oxygen consumption. Shivering oxygen consumption up to 500 ml / min, severe asthma, with the increased work of breathing, oxygen consumption for more than 10 times normal. Oxygen consumption increased, decreased alveolar oxygen, help increase the normal ventilation to prevent hypoxia. Breathing air, oxygen consumption in the partial pressure of oxygen and pulmonary alveolar ventilation of the impact. Map of the curve with the dotted line to the point of intersection of different oxygen consumption, the maintenance of normal alveolar oxygen for pulmonary ventilation, with the increase in oxygen consumption, has also increased significantly, oxygen consumption per minute, respectively For 200 ml, 400ml, 800ml, alveolar ventilation volume of 3 L, 6L, 12L.
Second, the lack O2, CO2 retention of the impact of the body
(A) the impact on the central nervous brain tissue oxygen consumption accounted for about systemic consumption of 1/5-1/4. Central cortex cells most sensitive to hypoxia, lack O2 and the extent of the central nervous Jihuan the middle of the highest bidders different effects on health. Such as a sudden interruption for O2, purity nitrogen absorption to be 20 seconds in deep coma and body convulsions. Gradually reduce the absorption of O2 concentration, slow onset of symptoms, can cause mild missing O2 attention is not focused, intelligence may be directed obstacles with the increasing lack O2, PaO2 (PaO2) below 6.66 kPa can induce irritability, Trance consciousness, delirium; below 3.99 kPa, would lose consciousness, and even coma; below 2.66 kPa will be irreversible brain damage.
CO2 cerebrospinal fluid retention so that the concentration of hydrogen ions, the impact of brain cell metabolism, reduce excitatory brain cells and inhibit cortex; With the increase in CO2, stimulate the strengthening of the lower cortex, the cortex caused excitement; if CO2 continue to rise, the lower deck of the cortex inhibit So that the central nervous system in a state of anesthesia. In a pre-anesthesia patients often suffer from insomnia, mental excitement, irritability symptoms of the threatened excited.
Missing O2 and CO2 retention will have cerebral vascular expansion, reduced resistance to blood flow, to compensate the血流量增加. O2 will be seriously lacking in brain cells, edema, increased permeability of blood vessels, caused brain interstitial edema, leading to increased intracranial pressure, squeezing brain tissue and oppression of blood vessels, thereby increasing brain missing O2, a vicious cycle.
(B) of the heart, circulation of missing O2 can stimulate the heart to speed up the heart rate and stroke volume increase, high blood pressure. Coronary blood flow in the lack O2, a marked increase in heart blood flow far exceeds the brain and other organs. O2 myocardial lack of sensitivity, early mild O2 that is lacking in the electrocardiogram appeared on the show, a serious lack of O2 can lead to ventricular fibrillation or cardiac arrest. Missing O2 and CO2 retention can cause pulmonary vasoconstriction small increase in pulmonary vascular resistance, leading to increased pulmonary hypertension and right heart burden.
Inhalation of gas in the concentration of CO2, will speed up the heart rate, stroke volume increased, cerebral, coronary vasodilation, subcutaneous superficial capillaries and veins expansion due to the muscles of the spleen and blood vessels to contract, coupled with increased stroke volume, the Blood pressure is still elevated.
(C) lack of respiratory effects of breathing O2 impact than the impact of CO2 retention for small. O2, mainly through lack of carotid sinus and aortic reflection of the role of chemical receptors to stimulate ventilation, such as the slow increase the degree of lack O2, the reflective slow.
CO2 is a strong respiratory center stimulants, inhalation of increased CO2 concentration, ventilation multiplied, the retention of CO2 in deep rapid breathing, but when inhaled超过12% CO2 concentration, ventilation will not increase in the respiratory center Was inhibited. And chronic hypercapnia, there is no corresponding increase in ventilation, but has declined, and respiratory center reaction of the slow, through the kidneys to absorb and bicarbonate from H +, so that no blood pH value decreased, and patients Gas resistance increased, a serious lung damage, the thorax movement dysfunction related to ventilation.
(D) of the liver, kidney and blood system of missing O2 can be direct or indirect damage to the liver ALT increased, but with the lack of corrective O2, liver function gradually returned to normal.
Reduce arterial blood oxygen, kidney blood flow, the volume of glomerular filtration, urine output and sodium from the increase of both, but when PaO2 <5.3kPa, reduce kidney blood flow, kidney function was inhibited.
Low oxygen erythropoietin to increase red blood cell proliferation. Kidney and liver produce an enzyme, the blood of the Central African erythropoietin, the predecessor of a generation of active substances to stimulate the bone marrow caused secondary erythrocytosis. To increase the carrying capacity of blood, but also increased blood viscosity, pulmonary circulation and increase the burden on the right heart.
CO2 retention mild renal vascular expansion will increase renal blood flow, increase the amount of urine when PaCO2超过8.64 kPa, blood pH decreased significantly, kidney vasospasm, reduced blood flow, HCO3-and Na + absorption to increase urine output reduction .
(5) of electrolyte and acid-base balance the impact of severe energy shortage O2 cells inhibited the middle of the process and radio, such as三羧酸循环, and the role of oxidative phosphorylation-related activities. This will not only have lower energy efficiency, but also due to produce lactic acid and inorganic phosphorus from metabolic acidosis. As the energy shortage, in-transit damage by the sodium pump, so that cells within the potassium transferred to the blood, and Na + and H + into the cells, causing cells acidosis and hyperkalemia. Metabolic acidosis the fixed buffer acid and bicarbonate in the system work, a carbonate, the organization increased carbon dioxide tension.
PH value of carbonate and bicarbonate depends on the ratio of the former regulation on the kidney (1-3 days), while carbonated regulation on the lung (hours). Healthy people every day from lung carbonate of as many as 15000 mmol, the acute respiratory failure CO2 retention impact on the pH very quickly, often with metabolic acidosis exist, due to acid poisoning caused serious decline in blood pressure, arrhythmia, and even cardiac arrest . And chronic respiratory failure due to the slow development of CO2 retention and kidney from reduced bicarbonate, does not result in significantly lower pH. Because of blood in the main anion HCO3-and CI-in and is a constant, when HCO3-increase, the CI-corresponding lower, a low chlorine hyperlipidemia.
In addition to chronic respiratory failure caused the primary symptoms, is missing O2 and CO2 retention caused by multiple organ dysfunction performance.
First, breathing difficulties
Manifested in the frequency and magnitude of changes in rhythm. Such as the hub of a wave of respiratory failure, intermittent or Chouqi respiration; COPD is slow and deep breathing to rapid shallow breathing, auxiliary respiratory muscle strengthening activities, was nodding his head or shoulder to breathe. Central nervous system for the performance of drug poisoning absorbed ease breathing, drowsiness, severe pulmonary heart disease complicated by respiratory failure of carbon dioxide anesthesia, a slow shallow breathing.
Second, cyanosis
O2 is the lack of typical symptoms. When arterial blood oxygen saturation below 85%, the blood flow in the larger lips nail in cyanotic the other should pay attention to red blood cells, increasing cyanosis more obvious, anemia who are not obvious or cyanotic not appear serious shock endings Patients with poor circulation, even if PaO2 is still normal, may also appear cyanotic. Cyanosis also by the skin pigment and cardiac function.
Third, the spirit of neurological symptoms
The spirit of acute respiratory failure symptoms of slower to clear, acute shortage of mental disorder can appear O2, manic, coma, convulsions and other symptoms. O2 has more chronic lack intellectual orientation or dysfunction.
CO2 retention appear before the central curb the excitement of symptoms such as insomnia, irritability, restless, but this must not use sedation or sleeping pills to avoid increasing CO2 retention, a pulmonary encephalopathy, for the performance of consciousness indifferent, muscle tremors, occasional convulsions, drowsiness And even coma. pH compensation, was able to day-to-day life of the individual activities of CO2 retention, pH <7.3, will appear psychiatric symptoms. Serious CO2 retention can occur tendon reflexes weakened or disappeared, pyramidal tract, such as positive sign.
4, symptoms of the circulatory system
A serious lack O2 and CO2 retention caused pulmonary hypertension, heart failure can occur right, with signs of systemic congestion. CO2 retention so that peripheral venous filling surface, skin Hongrun, wet warm sweating, elevated blood pressure, stroke volume increased pulse of Hong Tae result; due to cerebral vascular expansion, a pulsating headache. Late due to serious lack O2, myocardial damage from acid poisoning, a peripheral circulatory failure, blood pressure dropped, arrhythmias, heart arrest.
5, digestive and urinary symptoms
Severe respiratory failure of liver and kidney functions are affected, such as GPT and non-protein nitrogen increased, proteinuria, urine and a tube of red blood cells. Gastrointestinal mucosa due to congestion and edema, erosion, bleeding, stress ulcer or upper gastrointestinal bleeding caused. These symptoms may lack the O2 and CO2 retention corrective disappear.
Chronic respiratory failure decompensated period, according to patients with chronic respiratory diseases or other respiratory dysfunction leading to the history, missing O2 and (or) CO2 retention of clinical manifestations, with the relevant signs, the diagnosis is not difficult. Arterial blood gas analysis of respiratory failure can objectively reflect the nature and extent of the guidance of oxygen therapy, mechanical ventilation various parameters of the regulation, and correct pH balance and electrolytes are important values.
1. PaO2 (PaO2)
Refers to the physical dissolved in the blood oxygen molecules generated by the pressure. PaO2 healthy growth decreased gradually with age, and physiological effects of receptor. According to partial pressure of oxygen and oxygen saturation of the relationship between oxygenated hemoglobin dissociation curve was S shape, when PaO2> 8kPa (60mmHg) above, the flat of the curve, the oxygen saturation of more than 90%, PaO2 change 5.3 kPa (40mmHg ), But little change in oxygen saturation that much oxygen saturation of oxygen-sensitive, but when PaO2 <8kPa below, the steep curve, the slight decline in oxygen pressure, oxygen saturation sharp decline, the PaO2 Less than 8 kPa (60mmHg) as the diagnosis of respiratory failure indicators.
Second, the arterial blood oxygen saturation (SaO2)
Hemoglobin is the oxygen percentage of units, the normal value is 97 per cent. When PaO2 less than 8 kPa (60mmHg), hemoglobin oxygen dissociation curve in a steep section, the oxygen saturation only reflects the state of hypoxia, the severe respiratory failure in the rescue, with the pulse of oxygen saturation detector to help evaluate missing O2 level, adjust the absorption of O2 concentration SaO2 more than 90%, to reduce the trauma of pumping blood for blood gas analysis, which is a reasonable assessment effect of oxygen therapy and play an active role.
3, arterial blood oxygen content (CaO2)
100 ml of blood is the number of oxygen-ml. Including the combination of hemoglobin and oxygen dissolved oxygen in plasma physics combined. CaO2 = 1.34 × SaO2 × Hb +0.003 × PaO2. Healthy CaO2 reference value of 20 ml%. Mixed blood oxygen saturation (SVO2) to 75 percent, its oxygen content CVO2 for 15 ml%, per 100 ml blood by the organization after about 5 ml of oxygen for the organization to use. Hemoglobin reduction, SaO2 lower than normal, blood oxygen content can still be the normal range.
4. PaCO2 (PaCO2)
Refers to the physical dissolved in the blood of the CO2 produced by the pressure. PaCO2 normal for the 4.6 kPa-6kPa (35-45mmHg), more than 6 kPa for inadequate ventilation, less than 4.6 kPa for ventilation may be excessive. Acute lack of ventilation, PaCO2> 6.6kPa (50mmHg), according to Henderson-Hassellbalch formula, pH below 7.20, it will affect circulation and cell metabolism. Chronic respiratory failure due to the body compensatory mechanisms, PaCO2> 6.65kPa (50mmHg) as an indicator of respiratory failure.
5, pH value
For the hydrogen ion concentration in the blood of a negative value. The normal range of 7.35-7.45, an average of 7.40. Below 7.35 for decompensated acidosis, higher than the 7.45 for decompensated alkalosis, but could not explain what is the nature of the acid-base poisoning. Clinical symptoms and the pH is closely related to migration.
6, base excess (BE)
In 38 ℃, CO2 pressure 5.32 kPa (40mmHg), oxygen saturation measured 100 percent condition, blood titration to the pH of pH7.4. It is human metabolic acid-base balance of quantitative indicators, plus acid to BE positive of the metabolic alkalosis; Canadian base of EB was negative, of metabolic acidosis. The normal range of 0 ± 2.3mmol / L. In the correct metabolic acid-base imbalance, it can be used as estimated by acid or Kangjian dose drug reference.
7. Buffer base (BB)
Various buffer in the blood of the total content of alkali, including bicarbonate, phosphate, plasma protein salt, salt and other hemoglobin. It reflects human interference buffer against acid-base capability, and acid-base imbalance in the body of the specific circumstances of compensation. Normal for the 45 mmol / L.
8, the actual bicarbonate (AB)
AB is in the actual partial pressure of carbon dioxide and oxygen saturation of human plasma bicarbonate contained in the content. Normal for the 22-27 mmol / L, an average of 24 mmol / L. HCO3-related content and PaCO2, as PCO2 increased plasma HCO3-content has also increased. On the other hand HCO3-alkali plasma one of the buffer, when too much acid in fixed, by HCO3-buffer and pH stability, and HCO3-content reduction. So AB double by respiratory and metabolic effects.
9, the standard bicarbonate (SB)
Means isolated from the blood samples of air in 38 ℃, PaCO2 to 5.3 kPa, oxygenated hemoglobin 100 percent under the conditions, measured by the plasma bicarbonate (HCO3-) content, for the normal 22 - 27mmol / L, An average of 24 mmol / L. SB from respiratory factors, to reflect the increase or decrease its value in HCO3-the number of reserves, so that metabolic factors and extent of the trend. Metabolic acidosis, SB decreased metabolic alkalosis, SB increased. AB> SB, expressed CO2 retention.
10, the combination of carbon dioxide (CO2CP)
Normal for the 22-29 mmol / L, the main base in the reserves. Metabolic acidosis, or respiratory alkalosis, CO2CP lower metabolic alkalosis or respiratory acidosis, while CO2CP increased. However, respiratory and metabolic acidosis with acid poisoning, CO2CP not necessarily increased, due to respiratory acidosis, kidney or to NH4 + H + form from the H +, to compensate for HCO3-absorption, alkali reserve increase, the increase in the CO2CP Certain extent, respiratory acidosis reflect the seriousness of the blood but can not reflect the dramatic changes in CO2, but also by the metabolism of the base or acid poisoning effect, it has its one-sidedness CO2CP, must be integrated with clinical and electrolyte for full consideration.
These indicators to PaO2, PaCO2 and pH most important, reflecting the lack respiratory failure at the O2, CO2 retention, in an acid-base imbalance, such as adding BE will be able to reflect the body compensatory, or without metabolic acid or alkaline Poisoning, and electrolyte imbalance.
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.
First, the establishment of the airway patency
In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.
Second, oxygen therapy
By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.
(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.
The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.
(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.
Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).
(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.
Chronic respiratory failure more than a certain diseases, but in acute decompensated respiratory failure, can be directly life threatening, must take timely and effective rescue. Respiratory failure is to maintain the principle of respiratory smooth conditions, improve and rectify O2 missing CO2 retention, and metabolic dysfunction, which is based on disease and treatment-induced factors for time and create the conditions, but the specific measures should be combined with the actual situation Set.
First, the establishment of the airway patency
In improving the ventilation and oxygen therapy before, we must take various measures to maintain smooth enable respiratory tract. Such as porous catheter through the mouth, throat, or secretion of gastric reflux aspiration. Kechu viscous phlegm difficult, the new spray of bromine has been inhaled, can also retain a ring of plastic membrane puncture, the injection of saline diluted secretions, or bronchial spasm of bronchial β2 doping expansion, if necessary, to adrenal cortex Inhaled steroid ease bronchospasm; bronchoscopy can be used to suction secretions. If the effect of the poor, the use of nasal intubation or tracheotomy, the establishment of artificial airway.
Second, oxygen therapy
By enhancing alveolar oxygen (PaO2), an increase O2 diffusing capacity, improve PaO2 and oxygen saturation, increasing the use of oxygen.
(A) hypoxia without carbon dioxide retention of the low-oxygen therapy oxygen therapy alveolar ventilation, oxygen consumption increased, and the diffusion of dysfunction can be better to correct missing O2; ventilation / imbalance in the ratio of blood flow in patients with increased concentration of oxygen after inhaling , To increase ventilation alveolar oxygen shortage, improve its surrounding capillary blood oxygen intake so that the PaO2 increased. The site of chronic pulmonary interstitial pneumonia, interstitial pulmonary fibrosis, pulmonary edema, alveolar cell carcinoma of the lymphatic cancer and inflammation of the patients, mainly for the diffusion damage, ventilation / flow ratio imbalance caused by hypoxia And stimulate the carotid sinus, the aorta of chemical receptors cause excessive ventilation, PaCO2 low absorption can be given a higher oxygen concentration (35% -45%), to correct missing O2, then improve ventilation. But late in patients with high concentrations of oxygen absorption less effective.
The pneumonia is caused by the change, pulmonary edema and atelectasis caused by ventilation / flow ratio imbalance and lack of pulmonary artery shunt O2, and can not increase due to oxygen therapy diversion of blood oxygenation, such as the flow is less than 20 hours %, Inhaled high concentrations of oxygen (> 50%) corrected missing O2; if more than 30 percent of its bad effects, such as long-term inhalation of high concentrations of oxygen will cause oxygen poisoning.
(B) hypoxia with the obvious carbon dioxide retention of its oxygen therapy oxygen therapy should be given to the principle of low concentration (<35%) continued to oxygen, its principles are as follows.
Decompensated chronic respiratory failure, lack O2 with CO2 retention is the consequences of inadequate ventilation, because of hypercapnia of patients with chronic respiratory failure, the respiratory center of chemical receptors on the CO2 response of the poor, relying mainly on the maintenance of respiratory O2 hyperlipidemia on the low-neck Sinus artery, the aorta of chemical receptors in the driving role. If inhaled high concentrations of oxygen, PaO2 rising rapidly, so that the loss of peripheral chemical receptors to stimulate low O2 hyperlipidemia, patients with the slow and shallow breathing, PaCO2 go up, when a serious CO2 anesthesia, which often change consciousness and PaCO2 Increase the speed; inhaled high concentrations of low-O2 lifting O2 pulmonary vasoconstriction, allowing high pulmonary ventilation and blood flow than the (VA / QA) units in the lung blood flow to the low-VA / QA than lung units, increase ventilation and blood Flow ratio imbalance caused physiological dead space and tidal volume ratio (VD / VT) increase, thereby reducing alveolar ventilation, PaCO2 further increased in accordance with hemoglobin oxygen dissociation of the characteristics of the serious shortage O2 when, PaO2 and SaO2 The relationship between oxygen in the dissociation of the steepness of the curve, PaO2 slightly higher, SaO2 will be more, but there are still missing O2, can stimulate the chemical receptors, the ventilation to reduce the impact of low concentration of O2 therapy to correct low alveolar Ventilation (VA) of the alveolar oxygen tension (PaO2), and this inhaled oxygen concentration at different alveolar oxygen and alveolar ventilation of the curve, has earlier steep, after the characteristics of the flat, see Figure 2-6 -4. When inhaled oxygen concentration in more than 30 percent, although the alveolar ventilation is less than 1.5 L / min, alveolar oxygen maintained at 10.67 kPa (80mmHg), and alveolar partial pressure of carbon dioxide (PaCO2) will exceed 13.3 kPa (100mmHg). Generally low concentration of respirable O2, PaCO2 rise no more than 17/21, PaO2 rose 2.8 kPa (21mmHg), while PaCO2 rise no more than 2.26 kPa (17mmHg).
(C) the method commonly used oxygen therapy oxygen therapy for nasal catheter or nasal oxygen, the oxygen concentration of respirable (F1O2) and the inhaled oxygen flow was broadly following relations: F1O2 = 21 +4 × inhaled oxygen flow (L / min). It should be noted the same flow, with nasal inhalation of oxygen concentration of respirable per minute ventilation volume changes and changes. As to the low ventilation inhalation, the actual oxygen concentration higher than the calculation of the value of the high ventilation when inhaled oxygen concentration than the calculated values to lower.
Through oxygen masks Venturi principle, the use of oxygen jet produced negative pressure, inhaled air to dilute oxygen, into the air-conditioning control of oxygen concentration in 25 to 50 percent range, face masks, oxygen concentration and stability, free from the respiratory rate and tidal Of the impact. Is the consumption of its shortcomings, expectoration inconvenience.
Oxygen therapy to the general physical and clinical needs to regulate the concentration of oxygen inhalation, PaO2 of more than 8 kPa, or SaO2 for more than 90 percent. Oxygen consumption increases, such as fever can increase the concentration of oxygen inhalation. Reasonable oxygen therapy increased the effect of respiratory failure, respiratory failure in patients with COPD such as long-term low concentrations of oxygen therapy (especially at night) can reduce pulmonary circulation of resistance and pulmonary artery pressure, increased cardiac contraction, with activities to enhance and extend the survival time of endurance .
Third, increase ventilation and reduce CO2 retention
Alveolar CO2 retention is caused by inadequate ventilation, only to increase alveolar ventilation to effectively discharge CO2. Mechanical ventilation in the treatment of respiratory failure effect has affirmed and the application of respiratory stimulants, because of their different effect, the surviving in the controversy. Profile is as follows:
(A) a reasonable application of respiratory stimulants, respiratory stimulants stimulate the respiratory center or around the chemical receptors, through enhanced respiratory center of excitement, increased respiratory rate and tidal volume to improve ventilation. At the same time, patients with oxygen consumption and CO2 output also increased, and ventilation and a positive correlation. Because of its use of simple, economic, and a certain effect, it was still widely used in clinical, but should have their clinical indications. Patients with low ventilation mainly because of the central inhibition, respiratory stimulant effect of better chronic obstructive pulmonary disease, respiratory failure due to bronchial - lung disease, the response of the central or lower respiratory muscle fatigue caused by low ventilation, at this time of breath Doping should be the pros and cons of the three factors of primary and secondary may be. In nerve conduction system and the respiratory muscle lesions, and pneumonia, pulmonary edema and pulmonary fibrosis of the extensive ventilation dysfunction, respiratory stimulants are no disadvantages benefit and should not be used.
In the application of respiratory stimulants at the same time, should attach importance to reduce the chest, lungs and airway mechanical load, such as the secretion of drainage, the application of bronchial spasm, the elimination of pulmonary edema and other factors affecting the chest compliance. Otherwise, ventilation drive will add to short breath and breathing to increase power, and the need to increase the concentration of oxygen inhalation. In addition, we must make full use of some stimulants respiratory consciousness back to the Soviet Union, to encourage patients to cough, sputum elimination, and maintain the airway open. If necessary, nose or mouth and nose mask with mechanical ventilation support.
Nikethamide is the common respiratory center stimulants, increase ventilation, have a certain role Su-Ti. Patients can sleepiness of the first slow intravenous injection 0.375 g-0.75g, then to 3-3.75 g adding 500 ml of liquid, drop by 25-30 / min infusion. Close observation of patients lashes response to change consciousness, and respiratory rate, the rate and rhythm, the follow-up of arterial blood gas, in order to regulate dosage. If a skin itching, irritability and other side effects, must be slowed down Disu. If the 4 h-12h did not bear fruit, or a muscle twitch serious reactions, should be suspended, if necessary, a change of mechanical ventilation support.
(B) a reasonable application of mechanical ventilation with respiratory physiology and pathophysiology of the development, nose and mouth masks, artificial airway, breathing and respiratory-care properties of continuous improvement, mechanical ventilation will enable patients with respiratory failure to grow. Practice has proved that mechanical ventilation for the success or failure of respiratory failure, in addition to the breathing machine and related properties, is more important to the medical staff to keep respiratory failure in patients with pathological changes in physiological and reasonable application of mechanical ventilation. By increasing ventilation and provide appropriate oxygen concentration, to a certain extent, improve the ventilation function and reduce the power consumption of breath, respiratory failure in patients with missing O2, CO2 retention and acid-base balance disorders can be different degrees of improvement and corrected, General will not die of respiratory failure. Attention should be paid to prevention and treatment may be lethal infection of the airway, obstructive airway secretions, high-pressure pulmonary complications such as trauma. Even in some serious respiratory failure complicated by multiple organ failure patients, after treatment by mechanical ventilation, because of improved patient heart, brain, kidney, liver and other organs of oxygen the body and internal environment, and then to nasal feeding or intravenous Nutritional support, create the conditions for the resumption of patients, save a lot of dying patient's life.
Shang-qing consciousness of mild to moderate, in line with the patients with respiratory failure, nose or mouth and nose mask for mechanical ventilation; serious condition, although the consciousness-but uncooperative, coma or respiratory secretions of the large number of patients, the timely establishment of gas Road, such as the nose (or mouth) intubation mechanical ventilation, the choice of organizations with good compatibility of high-capacity low-pressure air bags (<3.3 kPa) of PVC or silicone catheter, the catheter can retain more than half a month, to avoid Low capacity use latex rubber high-pressure balloon catheter, because of their reaction, can cause the airway mucosa clear congestion, edema, erosion, and ulcers. In very poor lung function, recurrent respiratory failure, secretions, the body extremely weak, malnutrition, need long-term support of patients with mechanical ventilation, for tracheotomy, the long-term retention of mechanical ventilation trachea casing.
In the use of breathing machine before the medical staff must understand the pathophysiology of patients with respiratory, to suit the tidal volume, respiratory rate and breathing, such as the ratio of various parameters, such as a blockage of the ventilation to be too large tidal volume, frequency slow breath longer Breathing, and restrictive ventilated patients is the opposite. Through simple hand pinch capsule breathing respirator for the transition, followed by a mechanical ventilation and monitoring of patients with clinical manifestations, such as the activities of the thorax, airway pressure and oxygen saturation changes in the general follow-up after 20 min blood gas again Further adjustments breathing machine parameters. In the different periods of mechanical ventilation, ventilation should use different approaches, such as respiratory or manual control capsule ventilation or assisted intermittent positive pressure ventilation (IPPV), PEEP ventilation (PEEP), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV). Ventilation can also be different forms of composition, such as PEEP + PSV for the integration of bi-level positive airway pressure (BiPAP). PEEP improve the ventilation function, SIMV and PSV benefit from the breathing machine, so as to achieve avoid excessive ventilation or inadequate ventilation. Reduce the impact of the heart cycle. During the mechanical ventilation should strengthen management of respiratory and breathing machine. As to the wetlands of the respiratory tract, secretions to attract and maintain respiratory unobstructed; breathing machine disinfection and maintenance of clean, avoid cross-infection. Particularly want to emphasize is the need to strengthen the respiratory and cardiovascular care, early detection of problems, analyse problems and to properly resolve to give full play to mechanical ventilation in the treatment of respiratory failure of the active role so that a reasonable and effective application of mechanical ventilation, improve Its efficacy and reduce complications.
40, to correct acid-base balance disorders and electrolyte imbalance
Diagnosis and treatment of respiratory failure in the process, there are several common types of acid-base balance disorders.
(A) of respiratory acidosis due to lack of pulmonary ventilation, CO2 produced in the body retention hypercapnia, changed the BHCO3/H2CO3 the normal ratio of 1 / 20, acute respiratory acidosis. Patients with chronic respiratory failure, blood-buffer system and the role of the kidney adjustment (secretion of H +, Na + absorption and HCO3-integration into NaHCO3), to near normal pH. Respiratory failure stolen generation acid poisoning can use alkaline agent (5% NaHCO3) temporarily to correct the pH value, but will reduce the ventilation to further increase the CO2 retention, there is no acid poisoning have removed the root causes. Only increase alveolar ventilation can be corrected respiratory acidosis.
(B) respiratory acidosis merger metabolic acidosis due to low O2 levels, insufficient blood volume, cardiac output and reduce cycle around obstacles, such as lactic acid in fixed, such as increased renal damage impact from acid metabolites. Therefore, on the basis of respiratory acid can be complicated with metabolic acidosis.
Subscribe to:
Posts (Atom)
