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瑞思迈通气解决方案…创造更高品质的医疗服务无创通气的临床应用神经内科1VPAPIIIEnhanced©ResMed2005September无创通气的临床应用神经内科1VPAPIEnha2VentilatorTraining:I

ntroduction©ResMed2010无创机械通气（NoninvasiveVentilation）:是指无需建立人工气道(气管插管、气管切开）所进行的机械通气，目前无创通气主要是指经口鼻罩/鼻罩/鼻枕实施的无创正压机械通气。2VPAPIII

Enhanced©ResMed2005September无创机械通气（NoninvasiveVentilation3VentilatorTraining:Introduction©ResMed2010与有创通气的区别、联系无创通气有创通气与有创通气的区别、联系无创通气有创通气4Ventilat

orTraining:Introduction©ResMed2010有创通气、无创通气的连接方法气管插管鼻罩面罩气管切开有创通气、无创通气的连接方法气管插管鼻罩面罩气管切开5VentilatorTraining:Introductio

n©ResMed2010无创通气与有创通气的关系：并非替代，而是相互补充1、插管前的尝试；2、脱机后的序贯；3、某些疾病的首选治疗无创通气与有创通气的关系：并非替代，而是相互补充6VentilatorTraining:Introd

uction©ResMed2010无创通气明显益处非创伤性感染率低，几乎没有VAP（呼吸机相关肺炎）发生保留患者的正常功能（说话、进食、咳嗽）提早使用，将明显减少患者插管几率治疗时痛苦小，患者及家属易于接受

使用方便，可以随时上机，随时撤机辅助呼吸机依赖患者脱机训练，缩短插管时间无创通气明显益处非创伤性7VentilatorTraining:Introduction©ResMed2010现代无创正压通气的发展•1981年瑞思迈公司创始人之一，世界著名呼吸病学家科林.

沙利文教授发明了现代无创正压呼吸机，成为无创通气发展史上的里程碑•1989年研制出Bipap呼吸机（双水平气道正压通气）•1989年Meudri应用无创通气治疗急性呼吸衰竭•我国的无创通气技术从90年代末逐步发展起来CollinSullivan现代无创正压通气的发展1981年瑞思迈公司创始人

之一，世界著8VentilatorTraining:Introduction©ResMed2010无创呼吸机的分类：单水平无创呼吸机：CPAP呼吸机/睡眠呼吸机（ContinousPositiveAirwayPressure）双水平无创呼吸机：Bipap呼吸机/医用无创呼

吸机（BilevelPositiveAirwayPressure）无创呼吸机的分类：单水平无创呼吸机：CPAP呼吸机/9VentilatorTraining:Introduction©ResMed2010无创通气的适用疾病➢COPD急性加重（AECOPD)➢急性心源性肺水肿➢胸廓、脊柱

疾病、肺纤维化➢神经-肌肉疾病➢有创通气辅助脱机➢低氧呼吸衰竭、ARDS早期➢手术后呼吸衰竭➢慢性终末期疾病伴呼吸衰竭➢哮喘急性发作参见《无创通气专家共识》NewVersion无创通气的适用疾病COPD急性加重（AECOPD)10VentilatorTraining:Introd

uction©ResMed2010成人呼吸窘迫综合征（ARDS）为代表－吸气受限性胸壁限制性疾病（如脊柱侧弯、外科胸壁成形术后等）；神经肌肉系统疾病胸廓畸形、肺叶切除、结核后遗症高度肥胖（肥胖低通气综合症）成人呼吸窘迫综合征（ARDS）为代表－吸气受限性胸壁限制性疾11Ventilato

rTraining:Introduction©ResMed201011VPAPIIIEnhanced©ResMed2005September以COPD慢性阻塞性肺病为代表的－呼气受限性➢慢性阻塞性肺病(ChronicObstructivePulmonaryDisease)是以不完全可逆性气

流受限为特征的疾病。➢气流受限通常是渐进性的，并且伴有肺部对有毒颗粒或气体的异常的炎症反应,可引起全身性损害。➢是全球导致慢性发病及慢性死亡的主要病因，估计在未来的几十年中其发病率及死亡率将会继续增加。机械通气挽救不少COPD患者的生命或延长COPD患者生命。1VPA

PIEnhanced©ResM12VentilatorTraining:Introduction©ResMed201012VPAPIIIEnhanced©ResMed2005September哪些情况不能用（绝对禁忌症的患者）➢拒绝插管➢气道分泌物多选择性使用➢心跳呼吸停止➢自主呼吸微

弱、昏迷➢误吸可能性高➢合并其他器官功能衰竭➢面部创伤/术后/畸形➢不合作12VPAPIEnhanced©ResM13VentilatorTraining:Introduction©ResMed2010无创通气的模式与参数无创通气的模式与参数1

4VentilatorTraining:Introduction©ResMed2010常见的通气模式•S：自主呼吸模式•T：时间控制模式（机控模式）•ST：带后备通气频率的自主呼吸模式•CPAP:持续气道正压通气模式（单水平通气）病人呼吸机S模式、CPAP模式ST模式T模式常见的通气模式

S：自主呼吸模式病人呼吸机S模式、CP15VentilatorTraining:Introduction©ResMed2010S(自主呼吸模式):压力时间患者吸气触发S模式S模式S(自主呼吸模式):压力时间患者吸气

触发S模式S模式16VentilatorTraining:Introduction©ResMed2010T(时间控制通气)：•到达机器设定的时间由机器来切换•使用的几率很小TTT(时间控制通气)：到达机器设定的时间由机器来切换TT17VentilatorTr

aining:Introduction©ResMed2010ST(带后备通气频率的自主模式)•该模式是以病人自主触发呼吸为主，后备时间控制为辅。•医院中最为常用的无创模式，也成为安全模式STT患者吸气触发患者呼气触发取决于呼吸频率ST(带后备通气频率的自主模式)

该模式是以病人自主触发呼吸为18VentilatorTraining:Introduction©ResMed2010CPAP:持续气道正压通气模式•CPAP有创呼吸机的PEEP•整个通气过程按照设定的目标压力水平工作•主要应用：

睡眠呼吸暂停、肺水肿恒定目标治疗压力病人吸气CPAP:持续气道正压通气模式CPAP有创呼吸19VentilatorTraining:Introduction©ResMed2010IPAP•吸气压（高压）•作用：

大小和潮气量相关，合适潮气量的最小压力•初始8-12cmH2O，5-20分钟后增加至目标压力（评估目标压力），一般不超过25cmH2OTTIPAP大小IPAP吸气压（高压）TIPAP大小20VentilatorTraining:Int

roduction©ResMed2010EPAP•呼气压（低压）•作用：EPAP相当于PEEP。具有增加功能残气量、复张肺泡、改善V/Q失调，增加氧合的作用（低氧性呼吸衰竭，Ⅰ型呼衰）；•恰当的EPAP可正确影响血液动力学（急性心源性肺水肿）或过高的EPAP抑制心血管系统（心率加快

，血压下降）；采用PEEPi的80%值的EPAP可以对抗内源性PEEP(COPD和哮喘患者）。–初始4-8cmH2o，Ⅰ型呼衰时可适当上调至8-12cmH2OTTEPAP大小EPAP呼气压（低压）TEPAP大小21Ventilato

rTraining:Introduction©ResMed201021VPAPIIIEnhanced©ResMed2005SeptemberRespRate后备通气频率➢在病人自主呼吸停止时，按设定频率给病人送气，防止窒息➢

常用10-20次（浅快呼吸患者的调整与修改、夜间入睡后的调整）➢后备通气的起始时间计算节点：从吸气触发开始计算21VPAPIEnhanced©ResM22VentilatorTraining:Intro

duction©ResMed201022VPAPIIIEnhanced©ResMed2005SeptemberRiseTime压力上升时间➢常用100-400ms➢数值越低，送气气流越快，数值越高，送气气流越缓

和（气流冲不冲）➢100ms从EPAP上升到IPAP➢400ms从EPAP上升到IPAP2VPAPIEnhanced©ResM23VentilatorTraining:Introduction©ResMed201023XXXXXXX©ResMedYRMONTH✓正常人Ti0.8-1.2S，COPD

患者适当限时Ti✓无创通气主流吸气时间设定✓Timin（最小吸气时间）：0.5S✓Timax（最大吸气时间）：1.6S，（COPD设定1.0S）✓0.5-1.6S范围内自由呼吸，时间长短由病人决定，同步性好✓（高速公路

限速60-120km/h）Ti吸气时间23X©ResMedYRMONT24VentilatorTraining:Introduction©ResMed2010Trigger（吸气触发灵敏度）原则：在不要出现误触发的前提下，吸气触发敏感度(TRIGGER)越

高越好，患者的触发功做功少、同步性好High:VerysensitiveMed:DefaultLow:LesssensitiveHigh:2.5L/minMed:4.5L/minLow:7.5L/min(±0.5L/min)注意：设定时应考虑到是否连接使用了氧气输入LowMediumHighT

riger（吸气触发灵敏度）原则：在不要出现误触发的前25VentilatorTraining:Introduction©ResMed201025VPAPIIIEnhanced©ResMed2005September吸气灵敏度调整不合适导致的问题➢无法触发，增加患者做功➢双触发➢自动触发，

送气频率加快25VPAPIEnhanced©ResM26VentilatorTraining:Introduction©ResMed2010Cycle（呼气触发灵敏度）•COPD患者需要设定高的呼气灵敏度HIGH；•正常肺力学（顺应性、阻力差异）的患者设定为中等值MED;•

ARDS/肺纤维化患者需要较低的呼气灵敏度LOW。•High:33%ofpeakinspiratoryflow•Med:25%•Low:18%LowMediumHighCycle（呼气触发灵敏度）COPD患者需要设定高的呼气灵27VentilatorTrainin

g:Introduction©ResMed2010面罩数据库、管路数据库等配件的选择不同型号的面罩或即使同一面罩，在不同压力状态下的漏气量也是不同的。选择相应的面罩类型后，呼吸机自动调用面罩漏气基础数据进行自动调节选择瑞思迈品牌面罩，排二氧化碳能力是其它面罩的20倍面罩数据库、管

路数据库等配件的选择不同型号的面罩或即使同一28VentilatorTraining:Introduction©ResMed201028VPAPIIIEnhanced©ResMed2005September上机步骤➢患者沟通（紧急情况处理、停机情况处

理、不配合）➢调参数➢选择配件（鼻罩、面罩），处理面部（假牙、鼻贴）➢接氧管（氧管接法），调氧流量，佩戴面罩、管路➢送气➢监测（潮气量、血氧、呼吸频率、主观指证）➢调整、再观察（重度患者的严密监测）➢

停止送气、撤机无创通气是个轻松活28VPAPIEnhanced©ResM29VentilatorTraining:Introduction©ResMed201029VPAPIIIEnhanced©ResMed2005September不良反应➢胀

气（压力、说话）➢口干➢不配合，不坚持（家属工作）29VPAPIEnhanced©ResM30VentilatorTraining:Introduction©ResMed2010S9VPAPST物超所值的双水平无创呼吸机S9VPAPST物超所值的双水平无创呼吸机31Ven

tilatorTraining:Introduction©ResMed2010XXXXXXX©ResMedYRMONTH31齐全的模式与参数•模式：S、T、ST、CPAP•参数：IPAP：2-25cmH2O；EPAP：4-20cmH2O；RespR

ate：5-50BPM；Timax：0.2-4.0s;Timin：0.1-Timax；Triger：5级可调；Cycle：5级可调；峰流速：200L/Min。XXXXXXX©ResMedYRMONTH31齐全的32Vent

ilatorTraining:Introduction©ResMed2010最简单的操作一键操作中文显示界面最简单的操作一键操作33VentilatorTraining:Introduction©ResMed

2010完善的监测呼气压吸气压完善的监测呼气压吸气压34VentilatorTraining:Introduction©ResMed2010使用情况管理•信息菜单查看睡眠质量、睡眠报告•SD卡可在电脑上读取、分析病人一年数据睡眠质量睡眠报告SD卡读取信息Flow,1,0.3

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66Flow,327,0.269999Flow,328,0.230557Flow,329,0.220009Flow,330,0.133093Flow,331,-0.09Flow,332,-0.248581Flow,333,-0.286021Flo

w,334,-0.271823Flow,335,-0.258005Flow,336,-0.241887Flow,337,-0.229989Flow,338,-0.2016Flow,339,-0.182013Flow

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low,346,-0.122292Flow,347,-0.106022Flow,348,-0.093845Flow,349,-0.045961Flow,350,0.109855Flow,351,0.194007Flow,352,0.215729

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.198036Flow,362,0.190664Flow,363,0.222023Flow,364,0.227421Flow,365,0.118016Flow,366,-0.075248Flow,367,-0.251962Flow,368,-0.294235Flow,369,-0.284007

Flow,370,-0.26456Flow,371,-0.260019Flow,372,-0.271868Flow,373,-0.239968Flow,374,-0.189185Flow,375,-0.189979Flow,376,-0.179443Flow

,377,-0.163977Flow,378,-0.163216Flow,379,-0.215981Flow,380,-0.161749Flow,381,-0.056032Flow,382,0.058618Flow,383,0.24601

1Flow,384,0.348662Flow,385,0.418045Flow,386,0.469205Flow,387,0.535969Flow,388,0.545675Flow,389,0.570028Flow,390,0.609954Flow,391,0.601981Flow

,392,0.621605Flow,393,0.601981Flow,394,0.526361Flow,395,0.388014Flow,396,0.20985Flow,397,-0.068026Flow,398,-0.333775Flow,399,-0.40000

8Flow,400,-0.430935Flow,401,-0.45604Flow,402,-0.428706Flow,403,-0.402022Flow,404,-0.375467Flow,405,-0.350019Flow,406,-0.320093Flow,407,-0.2

91972Flow,408,-0.271915Flow,409,-0.258005Flow,410,-0.230167Flow,411,-0.217995Flow,412,-0.206847Flow,413,-0.208015Flow,414,-0.185437Flow,415,-0.175

971Flow,416,-0.149447Flow,417,-0.068026Flow,418,0.048596Flow,419,0.146032Flow,420,0.224194Flow,421,0.291972Flow,

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430,-0.024566Flow,431,-0.390029Flow,432,-0.503261Flow,433,-0.482042Flow,434,-0.43737Flow,435,-0.386Flow,436,-0.35823Flow,4

37,-0.341962Flow,438,-0.311845Flow,439,-0.277964Flow,440,-0.271535Flow,441,-0.253976Flow,442,-0.232093Flow,443,-0.212044Flow,444,-0.19

0666Flow,445,-0.179999Flow,446,-0.168754Flow,447,-0.170019Flow,448,-0.135075Flow,449,-0.094028Flow,450,-0.04249Fl

ow,451,-0.016022Flow,452,-0.012863Flow,453,-0.026002Flow,454,0.035355Flow,455,0.109959Flow,456,0.14128Flow,457,0.2

20009Flow,458,0.256725Flow,459,0.328045Flow,460,0.356073Flow,461,0.293986Flow,462,0.273057Flow,463,0.201973Flow,464,

0.18555Flow,465,0.146032Flow,466,0.168573Flow,467,0.068026Flow,468,-0.173643Flow,469,-0.298015Flow,470,-0

.285382Flow,471,-0.253976Flow,472,-0.230651Flow,473,-0.215981Flow,474,-0.204901Flow,475,-0.194007Flow,476,-0.174015Flow,477,-0.165991F

low,478,-0.159052Flow,479,-0.156011Flow,480,-0.144516Flow,481,-0.113987Flow,482,-0.102004Flow,483,-0.101993Flow,484,-0.0940

95Flow,485,-0.096042Flow,486,-0.099994Flow,487,-0.071963Flow,488,0.041738Flow,489,0.113987Flow,490,0.139033Flow,491,0.173956Flo

w,492,0.17796Flow,493,0.161963Flow,494,0.138981Flow,495,0.151983Flow,496,0.110827Flow,497,0.078006Flow,498,0.111755Flow,499

,0.082034Flow,500,0.075288Flow,501,-0.019959Flow使用情况管理信息菜单查看睡眠质量、睡眠报告睡眠质量睡眠报告S35VentilatorTraining:Introduction©ResMed2010Stellar100/150在所有科室表现出色

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，拥有它，物超所值39Stelar是呼吸界的瑞士军刀，拥有它，物超所值3940VentilatorTraining:Introduction©ResMed2010Thankyou!