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1、机械通气的历史与变化 Epidemiology of MV,首都医科大学附属复兴医院 席修明,讨论的问题,历史回顾 机械通气的流行病学调查 循证医学与机械通气的变化 总结,人工呼吸器的历史,Artificial Respiration in Pre-Physiology 最古老的人工呼吸器的描述来自古埃及神话，Isis 用呼吸拯救Osiris的生命 圣经-创世纪(Genesis)和国王(Kings) 中的描写;,历史回顾-Negative Pressure Ventilation (Iron Lung) that was wildly used during the polio epidemi
2、cs,历史回顾-The first ICU in the world,Kommunehospitalet in Copenhagen. The hospital was inaugurated in 1863. The student nurses Turned into the worlds first ICU was on the first floor,Acta Anaesthesiol Scand 2003;47:1190-1195,历史回顾-The first ICU in the world,Bjorn Ibsen (1915-). Initiator Of the first m
3、ultidisciplinary ICU In 1951 he receivede his specialist diploma In anesthesiology. The turning Point in his career came when He became involved in the treatment Of the most severely ill victims Of the 1952 poliomyelitis outbreak In Denmark,Acta Anaesthesiol Scand 2003;47:1190-1195,Patient no. 1 Dec
4、ember 21st,1953 6.00 p.m: A 43 year-old-man was admitted from the medical ward to the Observation Room, three days after he had attempted to hang himself. He was agitated, confused and cyanotic with laboured respiration. T 38.6C, pulse 136. An X-ray showed bilateral infiltrated and oedema of the lun
5、g. Oxygen via facemask and when the SaO2 decreased, with positive pressure ventilation from bag and mask, was started.,历史回顾,Acta Anaesthesiol Scand 2003;47:1190-1195,December 22nd 7.15 a.m: The condition of the patient had deteriorated. A tube with cuff was passed into his trachea and manual positiv
6、e ventilation with 60% oxygen in N2O was started. 00.45 p.m: SaO2 80%, Increases to 86% when 100% oxygen was used instead of the O2/N2O mixture 3.00 p.m: ABG pH 7.51, pCO2 31mmHg, SaO2100%. Clinically the patient was much improved. The respiration was sufficient and he was extubated.,历史回顾,Acta Anaes
7、thesiol Scand 2003;47:1190-1195,历史回顾,Bjorn Ibsen第一次使用正压通气治疗呼吸衰竭的医生 （In the first ICU in the world） 这项新技术的应用使脊髓灰质炎的病死率从1952.7的87%下降到1953.3的15% 因此1953年3月是机械通气的生日,Acta Anaesthesiol Scand 2003;47:1190-1195,历史回顾,机械通的流行病学,第一个机械通气流行病学的报告是Rogers 1972 发表的,Chest 1972；62：94-97,Impact of the Respiratory Intensi
8、ve Care Unit on Survival of Patients with Acute Respiratory Failure,持续机械通气患者病死率的比较（1965-1968 普通病房 vs 1969 on RICU),Chest 1972；62：94-97,Conclusion A dramatic reduction in mortality from ARF has been achieved when these patients were treated in a unit with specially trained physicians, nurses and auxi
9、liary personnel Availability of accurate monitoring, inhalation and physical therapy on the unit Interaction of the physicians, nurses and technicians from the unit with other members of hospital staff has raised the level of respiratory care for the entire institution,Impact of the Respiratory Inte
10、nsive Care Unit on Survival of Patients with Acute Respiratory Failure,Chest 1972；62：94-97,Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital,1992.1 Esdeban 对西班牙47个ICU机械通气模式和脱机方法进行了调查，290名病人机械通气时间大于24小时,Chest 1994;106:1188-1193,Modes of Mechanical Ventilation and Wea
11、ning - A National Survey of Spanish Hospital,Chest 1994;106:1188-1193,呼吸机可提供的模式,病人应用的模式,Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital,病人机械通气的天数,Chest 1994;106:1188-1193,Modes of Mechanical Ventilation and Weaning - A National Survey of Spanish Hospital,脱机模式与成功率
12、T-piece 最好 SIMV PS SIMV+PS,Chest 1994;106:1188-1193,How is the Mechanical Ventilation Employed in ICU ？,1996.11-1997.1 Esteban 主持8个国家412个ICU参加的机械通气流行病学调查 共有4153住ICU病人，其中1638名机械通气（39%）,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？,人工气道的选择（8个国家）,Am J
13、Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？,机械通气选择的模式,脱机选择的模式,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？,A/C 和 PSV 时呼吸机参数的设定,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventil
14、ation Employed in ICU ？,PEEP 的设定,Am J Respir Crit Care Med 2000;106:1450-1458,How is the Mechanical Ventilation Employed in ICU ？,In summary: 机械通气模式多种多样，90%机械通气病人使用A/C or PS or PS+SIMV Vt 的选择通常是7-10ml/kg PEEP 的选择多为5cmH2O SIMV和某些新的通气模式很少使用（ 允许性高碳酸症通气，无创通气） 脱机的方式多种多样，使用SBT的不多,Am J Respir Crit Care Med
15、 2000;106:1450-1458,Mechanical Ventilation in Ontaroio; 1992-2000,回顾性，队列调查研究 1992-2000 Ontario 州住院病人资料库 150755名非心脏手术病人，接受机械通气 Crit Care Med 2004；32：1504-1509,Mechanical Ventilation in Ontaroio; 1992-2000,92 93 94 95 96 97 98 99 2000 Change % MV Patient 15989 16108 16964 17303 17686 18017 18785 19609
16、 19388 20 MV per 10,0000 population 200 199 207 208 210 211 217 223 217 12 Inpatient Bed day 8394 7975 7452 7138 6713 6239 6209 6158 6199 -26 MV days Per 10,0000 Population 86827 81701 90392 96434 95518 101724 107394 111573 109030 26 Mortality 30 day 27 28 29 30 31 31 33 33 32 p0.001,Characteristics
17、 and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,多中心、前瞻性的队列研究 20个国家，361个ICU，98.3.1-98.3.31 共15757病人收入ICU，5183病人机械通气12小时，观察28天 平均机械通气时间5.9天 平均ICU住院11.2天 JAMA，2002；287：345-355,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A
18、 28-Day international Study,COPD & ARDS 机械通气的模式（1.3.7天） COPD ARDS day 1 day 3 day7 day1 day 3 day 7 (n=522) (n=283) (n=85) (n=231) (n=174) (n=82) MV Modes No(%) A/C 344(65.9) 180(63.6) 57(67.1) 165(67) 111(63.8) 50(61) SIMV/PS 50(9.6) 32(11.3) 9(10.6) 24(10.4) 20(11.5) 8(9.8) PS 40(7.6) 24(8.5) 10(1
19、1.8) 3(1.4) 6(3.4) 3(3.7) PCV 20(3.9) 11(3.9) 2(2.4) 24(10.4) 23(13.2) 13(15.9) SIMV 24(4.6) 10(3.5) 2(2.4) 10(4.2) 4(2.3) 2(2.4),JAMA，2002；287：345-355,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,COPD,ARDS,JAMA，2002；287：345-355,Charact
20、eristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,JAMA，2002；287：345-355,机械通气时间与存活率的关系,Characteristics and Outcomes in Adult Patients Receiving Mechanical Ventilation-A 28-Day international Study,每日机械通气模式的变化,JAMA，2002；287：345-355,The Changing Epidem
21、iology of Mechanical Ventilation: A Population-based Study Journal of Intensive Care Med 200621(3):173-182,1996-2002 回顾性调查研究，北卡罗来那州出院病人资料库，ICD-9修订版的诊断标准 1996年机械通气病人285/10万，2002增加为314/10万，增加11%（p0.05),The Changing Epidemiology of Mechanical Ventilation: A Population-based Study Journal of Intensive C
22、are Med 200621(3):173-182,机械通气病人合并肾脏病明显增加（96年17% vs 02年 24%）,肾病,The Changing Epidemiology of Mechanical Ventilation: A Population-based Study Journal of Intensive Care Med 200621(3):173-182,机械通气病人医疗消费指数（C P I）增长12%,The Changing Epidemiology of Mechanical Ventilation: A Population-based Study Journal
23、 of Intensive Care Med 200621(3):173-182,出院病人回家45.5%下降到34.4%, 回到Nursing Home 从7.3% 增加到 10.7%，回家的人越来越少,Evolution of Mechanical Ventilation in Response to Clinical Research,多中心、前瞻性、队列研究 23个国家，349个ICU 4968名机械通气的病人入选 对107个ICU中1675名病人与1998年1383名病人临床资料进行比较 2004与1998临床使用机械通的变化 Am J Respir Crit Care Med 200
24、8;177:170-177,Evolution of Mechanical Ventilation in Response to Clinical Research,2004 vs 1998 推测发生的变化 ？,Noninvasive positive-pressure ventilation Increased use of NPPV for COPD Increased use of NPPV for Acute hypoxemic respiratory failure ARDS Decreased tidal volumes Minimal increase in levels of
25、PEEP No change in the use of pressure-control modes No change in the use of prone position Weaning from mechanical ventilation Increased use of PS versus T-piece in spontaneous breathing trials Increased use of spontaneous breathing trials to assess extubation readiness Decreased use of SIMV as a me
26、thod for gradually reducing ventilation support Increased use of PS as a method for gradually reducing ventilation support No significant change in tracheostomy uuse or timing,Evolution of Mechanical Ventilation in Response to Clinical Research,NPPV 病人 2004与1998的比较,Am J Respir Crit Care Med 2008;177
27、:170-177,NPPV NPPV的临床应用 2004明显增加，包括COPD和ARF NPPV的时间增加（2 vs 3 d, p=0.03) 气管插管率和无明显变化。但NPPV成功的病人病死率有下降（20% vs 10%，p=0.08),Evolution of Mechanical Ventilation in Response to Clinical Research,Am J Respir Crit Care Med 2008;177:170-177,Evolution of Mechanical Ventilation in Response to Clinical Research
28、,ARDS 病人的特点 2004与1998的比较,Am J Respir Crit Care Med 2008;177:170-177,ARDS Vt的临床使用明显减少（2004年Vt超过10ml/kg 7.5 vs29.6%.p10cmH2O 40% vs 20%) Volume assist-control 仍是ARDS 患者最常用机械通气模式，每1000个ARDS日，1998年A/C 占548天，2004年占504天 PCV模式，每1000个ARDS日，1998年占244天，2004年占202天 俯卧位通气减少（2004，7%。1998，13%） 病死率无变化,Evolution of
29、Mechanical Ventilation in Response to Clinical Research,脱机 共有1649名计划性脱机的患者，拔管前做SBT 1998年58%，2004年62% p=0.09，SBT有增加的趋势 SBT成功后拔管的比列明显增加（62% vs 77% p0.001) T-piece 是最常用SBT（1998年76%，2004年71%，p=0.07) 但低水平PS用于SBT有增加的趋势（10 vs 14% p=0.06) 第一次SBT后未能拔管的病人中使用SIMV和SIMV+PS明显减少(11 vs 1.6% p0.001)和(26% vs 15%,p0.0
30、01)，使用PSV明显增加（19 vs 55%,p0.001),Evolution of Mechanical Ventilation in Response to Clinical Research,Evolution of Mechanical Ventilation in Response to Clinical Research,In summary: 本研究描述了机械通气的现状、变化和病人的预后 研究表明临床机械通气的行为已经发生了变化（ARDS、NPPV、Weaning） 机械通气的病死率变化不大 Am J Respir Crit Care Med 2008;177:170-177
31、,Prolonged Acute Mechanical Ventilation, hospital resource utilization, and mortality in United States,多中心、横断面调查 2003年美国出院的成年患者。机械通气96小时为长期急性机械通气（Prolonged Acute MV,PAMV), 按ICD-9 96.70-96.72 Crit Care Med 2008；36：724-730,Prolonged Acute Mechanical Ventilation, hospital resource utilization, and mort
32、ality in United States,31340578 出院患者,2.4% on MV,469168(61%) MV96 day,294333(39%) PAMV,Crit Care Med 2008；36：724-730,Prolonged Acute Mechanical Ventilation, hospital resource utilization, and mortality in United States,Crit Care Med 2008；36：724-730,Prolonged Acute Mechanical Ventilation, hospital res
33、ource utilization, and mortality in United States,结论 2003年美国有近30万PAMV 患者 每年消耗160亿美金 占全部机械通气的2/3,Crit Care Med 2008；36：724-730,小结,机械通气的变化 1. ARDS Vt 减小、PEEP 增加、HFPV增加, NPPV增加 2. COPD NPPV增加 3. Weaning SBT 增加，SIMV减少 机械通气的模式无变化，最常用的仍为A/C，SIMV，PS 机械通气的改变改善了病人的预后，但PAMV的病人明显增多，消耗大量资源，如何应对？,总结,由于多个RCT研究的不断发表，我们看到机械通气发生悄悄的变化 这些变化也反映了机械通气的发展趋势 这些变化改变了病人的预后，缩短了机械通的时间 机械通气的病人明显增加，长时间依赖MV增多，这些病人如何管理？,