Method for carrying out prolonged artificial pulmonary ventilation

FIELD: medicine.

SUBSTANCE: method involves setting respirator operation parameter values taking into account height h, age a and patient body mass m; proper value of thoracic pulmonary extensibility Cprop is determined with patient body mass taken into account. Positive pressure at the end of expiration as forced ventilation characteristic with thoracic pulmonary extensibility taken into account. Then, forced volume-controlled artificial pulmonary ventilation is carried out. Breathing frequency and inhaled volume are adjusted to achieve normal lung ventilation followed by auxiliary lung ventilation.

EFFECT: reduced negative influence upon lungs, systemic and cerebral hemodynamic characteristics; retained pulmonary gas exchange.

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The method relates to the field of medicine and can be used in resuscitation in the treatment of patients with acute respiratory failure requiring prolonged mechanical ventilation (ALV).

Currently the most common method of long-term mechanical ventilation is the ventilation method of injection. The injection apparatus is highly reliable, simple, and easy to work with microprocessors. Medical industry produces a huge variety of respirators injection. Ventilation modern respirators injection, usually set 7-10 parameters. Selecting a subset of them (minute volume ventilation (MOB), tidal volume, breathing frequency (BH)) is described in the literature. The choice of other parameters (speed and shape of the inspiratory flow (F), the ratio of inhalation to exhalation, the duration of the inspiratory pause (Tplateau), the magnitude of positive pressure at the end of the expiratory (peep), inspiratory pressure mode, the regulated pressure (PPC), pressure support (PPS)) in modern literature consecrated extremely insufficient. Currently, doctors do not have the technology to fully customize all the parameters of modern mechanical ventilation. This situation led to the fact that modern respirators use who are not in full.

However, the correct choice of parameters of respiratory support largely determines its effectiveness and results. IVL is designed not only to normalize gas exchange in the lungs, but being a fairly gross interference in the mechanisms of regulation of vital processes, must not damage them. Same, although to a lesser extent, applies to assisted ventilation [Kassil V.L., Lesquin airport G.S., Virigina M.A. Respiratory support. - M., 1997. - S].

In this regard, require revision of the methods of forced and assisted ventilation to reduce their negative impact on the patient.

Used 2 main methods IVL automatic respirators injection: ventilation, controlled (regulated) by volume, and ventilation controlled (adjustable) pressure.

Both methods of ventilation are the pros and cons compared to each other. The main advantage of ventilation, adjustable volume, is guaranteed by the settings of the respirator stability of tidal volume. In the volumetric method of artificial respiration easier to achieve stability in minute volume of ventilation than with ventilation, adjustable pressure. This is true both for forced ventilation and auxiliary. The bulk of pic is baie ventilation is less likely to cause such disorders ventilation, as hyperventilation, hypoventilation is often, volutrauma.

However, ventilation in surround mode does not limit the airway pressure, therefore there is the probability of an uncontrolled growth until the development of barotrauma of the lungs.

In contrast, ventilation, adjustable pressure limiting airway pressure values set inspiratory pressure or pressure support. In this regard, the main advantage of ventilation, adjustable pressure, before volume ventilation is less risk of barotrauma of the lungs. Besides limiting the pressure on the breath helps to reduce the frequency of occurrence of negative hemodynamic effects. Therefore, ventilation, adjustable pressure, is widely used as forced, and during assisted ventilation in situations when you need to decrease intrathoracic pressure and prevention of barotrauma of the lungs (unstable hemodynamics, high intracranial pressure, acute lung injury).

At the moment when conducting ventilation, adjustable volume, the difficulty is:

1) set the optimum flow rate during inhalation;

2) set the optimum level of positive pressure at the end of the expiratory (peep), which would be OK is indicated maximum antiacne, antielectrons action and thus would not cause Baro-, volutrauma and depression hemodynamics;

3) set the optimum duration of the inspiratory pause;

4) set the optimum shape of the curve of the flow velocity on the inhale.

When conducting ventilation, adjustable pressure, the main difficulty is:

1) set the optimum inspiratory pressure and (or) pressure support, which would normogastria and respiratory comfort of the patient;

2) set the optimum level of positive pressure at the end of the expiratory (peep), which would give the maximum antiacne, antielectrons action and thus would not cause Baro-, volutrauma and depression hemodynamics.

Most often the starting method of ventilation is ventilation, adjustable volume. This is to ensure patient safety, as ventilation, adjustable volume, provides the patient is guaranteed the minute volume of ventilation, which is especially important in the near it is recommended to take period after surgery, anaesthesia, resuscitation, damage to organs and body systems as the result of illness or injury).

The configuration of the apparatus in the mode of ventilation, adjustable pressure, is made on the background ventilation, adjustable volume. In this regard, the known methods of holding the owner always contain a description of the configuration of the apparatus in the mode adjustable volume, and not always in the mode, the regulated pressure.

The known method of calculation of parameters of mechanical ventilation [Kassil V.L., Lesquin airport G.S., Virigina M.A. Respiratory support. - M - 1997. - S-204], on which:

a) the patient is weighed, calculated tidal volume (UP) by the formulas:

b) make the found value TO the standard value of the breathing frequency (8-14 min) in the settings menu of the respirator;

C) changing the respiratory rate, choose the minute volume of ventilation (MOB), provide breathing comfort of the patient;

g) calculate the gas flow on the inhale (F, l/min) by the formula:

d) changing the duration of the inspiratory pause, and the shape of the curve of breath, choose the ratio of inspiratory to expiratory (I/E), where RW2/FiO2maximum;

e) set the minimum fraction of oxygen in the inhaled mixture (FiO2), providing RAO2more than 100 mm Hg, SaO2- 95-96%.

The method has drawbacks:

1) do not take into account the growing need and the excess weight of the patient, age, and therefore there is a high likelihood of barotrauma and volutrauma in patients with overweight and older;

2) do not take into account the level of the average airway pressure of the patient, which may lead to it is excessive uncontrolled growth;

3) do not take into account the compliance of the lungs and chest, which can lead to a rise in the average airway pressure and maximum pressure on the inhale;

4) as a criterion oxygenation adopts the definition of PaO2and SaO2invasive and expensive procedure, not giving information in real time (on line), they cannot be repeated as frequently as needed;

5) do not count data pulse oximetry (definition SpO2) as criterion oxygenation;

6) do not count data capnography as a criterion of adequacy of ventilation;

7) the calculated values of the flow velocity on the inhale (F) for patients with high distensibility of the lungs are underestimated, and for patients with low elongation - inflated;

8) the method of calculating inspiratory pressure mode, the regulated pressure (PPC);

9) the method of calculating the magnitude of the positive pressure at the end of the expiratory (peep).

Closest to the claimed method is the determination of parameters of mechanical ventilation [Marino P. Intensive care. - M - 1998. - S-350], on which:

a) the patient is weighed, calculated tidal volume (UP) by the formulas:

b) calculate minute volume of ventilation according to the formula:

C) counting the respiratory rate by the formula:

g) set the calculated parameters in the settings menu of the respirator, conduct mechanical ventilation, adjustable volume.

d) using a gas analyzer, capnograph, pulse oximeter, oxygraph BH correct and UP to achieve normogastria and normoxemia.

e) when switching on the auxiliary ventilation (WL) find the level of inspiratory pressure (pressure support, PPS), in which inspiratory pressure defined by dividing the maximum airway pressure of the patient during inhalation (PMIA) three. This method assumes that the patient is not able to maintain pressure three times higher than the PMIAwithout fatigue.

g) find the optimal positive pressure at the end of the expiratory (peep) by measuring the elasticity of the lungs and oxygen delivery. These figures are measured under different empirically chosen levels of peep. This method of selection called peep ' peep titration”. The best is the level of positive end expiratory pressure, at which the distensibility of the lungs and oxygen delivery to the maximum.

The method has drawbacks

1. When calculating the tidal volume is not taken into account the growing need and the excess weight of the patient, age, and therefore there is a high likelihood of borotra what we volumetry in patients with overweight and older.

2. Ignored the distensibility of the lungs and chest, which can lead to a rise in the average airway pressure and maximum pressure on the breath,

3. The method of determining the level of inspiratory pressure (PPSis intended only for intermittent or auxiliary ventilation and may not be used for forced ventilation.

4. When calculating the inspiratory pressure support (PPS) this method leads to lower values of PPS- 5-10 cm Vogt is often insufficient to achieve the desired tidal volume, especially in patients with restrictive disorders.

5. To calculate the optimal peep on the dynamics of oxygen delivery, you must have information about the content of oxygen in arterial blood and cardiac output. Information about the latest you can get not every ICU intensive care in Russia.

6. The method allows to determine the optimal peep only at the moment of measurement. However, the set of optimal peep can increase the distensibility of the lungs within the first breaths after installation. Then the optimal peep may become sub-optimal (redundant), when the lungs start to swell excessively. In this case, increasing the risk of Baro - and volutrauma. Thus, the optimal peep is optimal is cute for a limited period of time, while the mechanical properties of the lungs does not undergo significant changes.

We believe that the method of matching peep aimed at improving the elasticity of the lungs and oxygen delivery, it is advisable to combine with other methods of increasing the elasticity of the lungs and oxygen delivery that reduce peep during mechanical ventilation (kinetic therapy, inhalation of nitric oxide ventilation with helium). In this case, the risk of undesirable effects of positive end expiratory pressure is reduced.

7. Method of selection peep “titration” is indicated in patients with severe restrictive disorders (acute lung injury) and may not be used for the prevention of restrictive disorders in patients without significant reduction in lung compliance with the safe delivery of oxygen. That is, the method is only suitable for the treatment of advanced severe stages of acute lung injury.

The present invention is to improve the quality of treatment of patients with respiratory failure by optimizing long-term mechanical ventilation based on the anthropometric characteristics of the patient, status, gas exchange and compliance of the lung - thorax when changing modes of artificial ventilation of the lungs.

The task is solved by the fact that when conducting long-term ventilation of the patient is weighed by setting the up the parameters of the respirator: minute volume ventilation (MOB), tidal volume, breathing frequency (BH), are forced ventilation, adjustable volume, and adjust the BH and TO achieve normogastria and normoxemia determine a positive pressure at the end of the expiratory (peep), is transferred to the auxiliary ventilation of the lungs. Additionally take into account the height (h), age (a) of the patient, and taking into account the received data count TO the formula:

where TO tidal volume, ml,

mshouldshould the patient's body mass, kg,

mhouses- overweight patient, kg;

expect initial minute volume ventilation (MOBbeg) by the formula:

where MOUbeg- initial minute volume ventilation, l/min,

K - factor increases metabolism in patients with stress at low stress equal To 1,2; under moderate stress - 1,4; in severe stress - 1,6; when the fever To increase by 0.1 for each degree above 37° C;

mshouldshould the patient's body mass, kg,

mhouses- overweight patient, kg;

determine should thoracopulmonary compliance (Cshould) by the formula:

where Cshouldshould thoracopulmonary compliance, ml/cm Vogt,

mshouldshould body weight, kg

mhousesoverweight, kg

a - age years.

Find the initial velocity of the gas flow on the inhale (Fbeg) by the formula:

where Fbeg- the initial velocity of the gas flow on the inhale, l/min,shouldshould thoracopulmonary compliance, ml/cm Vogt Install received settings BEFORE, BH, FbegEAMbegin the settings menu of the respirator and begin artificial ventilation, adjustable volume, with constant or declining shape of the gas flow on the inhale, choose the shape of the gas flow on the breath, in which the mean airway pressure (Penvironmentsbelow, set the auto gasp.

Set the initial duration of the inspiratory pause (Tplateau)to the initial ratio of inspiratory to expiratory (I/Ebeg) was equal to 1/1,5; with stable hemodynamics set the initial positive pressure of end-expiratory (peepbeg) 5 cm Vogt, unstable hemodynamics, install peepbeg2 cm Vogt

Synchronize patient with respirator, determine the actual thoracopulmonary compliance (C), calculate and determine the level of positive pressure end expiratory forced ventilation (peepprin) by the formula:

where peepprinpositive pressure at the end of videoads forced ventilation, see Vogt,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt Find and set the flow rate on the inhale (F) by the formula:

where F is the flow rate on the inhale, l/min,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt

Calculate and set the ratio of inspiratory to expiratory (I/E) by the formula:

where I/E is the ratio of inhalation to exhalation,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt

In the process of forced ventilation, adjustable volume, determined With at least 1 times in 12 hours and when you change To adjust peep and F correct Tplateauto achieve respiratory comfort of the patient.

Pass to forced ventilation, adjustable pressure, which calculate and set the initial inspiratory pressure for forced ventilation, adjustable pressure (PRsac), by the formula:

where RRsac- initial inspiratory pressure forced ventilation, adjustable pressure,

TO - tidal volume, ml,

The actual the Skye thoracopulmonary compliance, ml/cm Vogt

Set the ratio of inhalation to exhalation, equal to the calculated.

Adjust RRsacto achieve tidal volume mode, the regulated pressure (UP toRS), 10% more than BEFORE and get RRS.

In the process of forced ventilation, adjustable pressure, determined at each change of body position of the patient at least 1 time in 8 hours and when you change To adjust peepprinand RRSregulate the ratio of inspiratory to expiratory (I/E) for respiratory comfort of the patient.

Pass by forced ventilation in the mode of assisted ventilation, calculate and set peep for assisted ventilation (peepsec) by the formula:

where peepsecpositive pressure at the end of exhalation for assisted ventilation, cm Vogt,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt,

Sens - sensitivity trigger respirator, cm Vogt; calculate and set the initial pressure support (PPSfor assisted ventilation, adjustable pressure according to the formula:

where PPS- initial pressure support is the mode of assisted ventilation, adjustable pressure

TO - tidal volume, ml,

With actual thoracopulmonary compliance, ml/cm Vogt

Regulate PPSTo achieve tidal volume in the auxiliary mode, the regulated pressure (UP toPS), 10% more than BEFORE and get PPSregulate the ratio of inspiratory to expiratory (I/E) for respiratory comfort of the patient.

In the process a ventilator, adjustable pressure, determined at each change of body position of the patient at least 1 time in 8 hours and when you change To adjust peepsecand PPS.

The installation of the fraction of oxygen supplied respirator to the breathing circuit (FiO2), produced under the control of the data pulse oximetry or analysis of blood gases to achieve the SpO294-100%, RAO275-200 mm Hg, change MOBbegby changing the BH is produced under the control of the data capnography to achieve Et2from 32 to 45 mm Hg, get MOB.

Determine the type of the Constitution of the patient, are the body mass (mshould) by the formula:

where mshouldshould body weight, kg

h - height, m,

Constitution: asthenic - 1, normostenichesky - 2, giperstenichesky - 3.

When the age of the patient (a) 30 years and older Withshoulddetermined by the formula:

where Cshould- estimated thoracopulmonary compliance, ml/cm Vogt,

mshouldshould body weight, kg

mhousesexcess body weight, kg

Justification of the METHOD, the novelty of the METHOD

The inventive method is based on the elasticity of the lung - thorax and on the principle of minimizing the average pressure in the Airways, which helps to reduce the negative impact of the ALV method of injection on the lungs, systemic and cerebral hemodynamics while maintaining adequate pulmonary gas exchange and respiratory comfort.

In most cases, the indication for prolonged mechanical ventilation are a violation of ventilation-perfusion relationships and decreased lung compliance due to the development of acute lung injury (Ali), which is based on irregular interstitial pulmonary edema. The use of mechanical ventilation method injection in Ali pathogenetically justified, as the positive inside chest pressure has antiacne effect on the lung tissue. To enhance this effect creates a positive pressure at the end of the expiratory (peep), carry out the inversion of inspiration and expiration, and the more pronounced swelling and restriction of the lungs, the large values of peep and the big inversion of breath necessary to apply. It is observed that with increasing peep and the lengthening of the breath produced by the goes improved antitechnology the influence of mechanical ventilation to the lungs, proportional to the average intrathoracic pressure. In terms of mechanical ventilation in patients with Ali, arterial blood oxygenation depends on the generated average pressure in the alveoli. Equivalent average pressure in the alveoli is mean airway pressure measured in the trachea (PsrtrPenvironments). Moreover, the more severe the restriction of the lungs, the large values of Rsrtr(Renvironments) is required. [Vlasenko V., Neverin VK Optimization of parameters of mechanical ventilation with a controlled volume in patients with acute bilateral and unilateral parenchymal lung damage// Manual for doctors. - M - 2002. - 48 S.].

Based on the above we can conclude that the average airway pressure is a valuable diagnostic indicator measurement during mechanical ventilation in patients with STBI allows you to select the optimal mode of ventilation purpose edema interstitial lung edema, increase oxygenation of the arterial blood and the prevention of ventilator-dependent rise in intracranial pressure.

It is known that in the restrictive disorders in the lungs antiacne and antielectrons action ventilation method injection not lung tissue is generated by the average pressure in the alveoli.

This implies that in the three regime IVL value of P srtrcreated by a respirator, should be directly proportional to the degree of restriction. In turn, Rsrtrdepending on the characteristics of the mode of ventilation: tidal volume, breathing frequency, inspiratory flow, duration of inhalation, duration of exhalation, the level of positive pressure at the end of the expiratory (peep), the magnitude of inspiratory pressure inspiratory mode, the regulated pressure. Therefore, in order listed options IVL provided Rsrtradequate restriction, they must also be proportional thoracopulmonary stretch.

Thus, given the elasticity of the lung - thorax allows you to differentiate between the ventilation in patients with restrictive (lower compliance) disorders and unaccented. Therefore, we included indicator thoracopulmonary elasticity formulas for the calculation of flow velocity on the inhale, peep, inspiratory pressure mode, the regulated pressure, pressure support.

The lung distensibility (compliance, non-compliance) is one of the most informative criteria of acute lung injury. In practice a more General definition of compliance decreased lung - thorax, which has age-related changes. The distensibility of the lung - thorax the majority of people beginning to lower the change with age of 30 years [Chic L.L., Kanaev NN. Manual of clinical physiology of respiration. - M., 1980. - 376 S.; Physiological basis of human health. Edited Beatmachine. - Saint-Petersburg. - Arkhangelsk - 2001. - S-328].

The principle of minimizing the negative impact of mechanical ventilation on hemodynamics is achieved by reducing the average airway pressure (Penvironments). Least Penvironmentsoccurs when a full breath (when the beginning of the exhalation breath is over) and out (when the beginning of the inhale exhale ended). This can be achieved correct choice: (a) velocity of the gas stream on the inhale and the form of the curve, b) tidal volume, breathing frequency, g) ratio of inhalation to exhalation.

The described method of calculating the parameters of long-term mechanical ventilation with the purpose of its optimization is most appropriate to use during mechanical ventilation of a modern microprocessor servoventilation (serverusername), because they provided the ability to control all mentioned in method parameters: tidal volume, frequency of breathing, inspiratory flow, duration of inhalation, duration of exhalation, the level of positive pressure at the end of the expiratory (peep), the magnitude of inspiratory pressure inspiratory mode, the regulated pressure, the shape of the curve flow during inhalation. It is preferable to use decelerates (decreasing) the shape of the flow curve on the inhale, because the minimization of the average davleniya airway when declareroles curve inspiratory flow is achieved while maintaining a more physiological relations of inspiration and expiration. It is also possible to use a constant or sinusoidal curves flow during inhalation. Accelera (rising) form of breath with this method is not used.

The novelty of the method lies in the fact that when determining the MOB, BEFORE BHcalctake into account height, age, type of human Constitution.

This allows a calculation of the ventilation parameters taking into account the mechanical properties of the respiratory system associated with morphological and age-related changes, and to reduce the airway pressure during mechanical ventilation, thus reducing the negative impact of ventilation method insufflation on hemodynamics, to achieve its stability.

The proposed formula that provides details MOB, BEFORE, BH, RPCand peep for forced ventilation, PPSand peep for auxiliary ventilation taking into account age, height, type of the Constitution and the masses. After synchronization, the patient's respirator proposed methods of correction of PPCand PPSto achieve calculated BEFORE, the relationship inspiratory to expiratory (I/E) to achieve respiratory comfort, BH and TO use capnography to achieve EtCO230-40 mm Hg, FiO2according to pulse oximetry to achieve the SpO294-100%.

This allows normogastria or moderate hyperventilation, normoxemia, respiratory comfort, to avoid increasing pressure to the I in the respiratory tract and such complications, as barotrauma and volutrauma lungs, restrictive disorders. Capnography and pulse oximetry provide information about gas exchange in real time.

The definition of the elasticity of the lungs is not less than 1 of every 8 hours with subsequent correction peep and F allows to eliminate the inferiority of inhalation and exhalation. As a result, the method allows for the ventilation of the lungs with most physiological ratios of inspiration and expiration (from 1:1 to 1:3), with most physiological forms of the curve of breath (decreasing, constant) with failure, if possible, from prolonged inspiratory pause (more than 0.4 seconds for the declining shape of the inspiratory flow, more than 0.8 seconds for the permanent shape of the inspiratory flow) and high values of positive pressure end expiratory (peep, more than 10 cm Vogt).

The set of essential features “gentle ventilation” prevents auto-peep, to reduce the negative impact of mechanical ventilation on hemodynamics while maintaining adequate pulmonary gas exchange and respiratory comfort.

Thus, the method is designed to optimize traditional long-term mechanical ventilation, which includes changing modes mechanical ventilation to ensure adequate ventilation at all stages of compulsory and supporting ventilation. Achieved all 4 criteria of adequacy artificial lung ventilation (ALV):

- the correspondences of metabolic gas exchange needs of a patient (lack of oxygen debt, normeinrete), which is achieved by taking into account data pulse oximetry, capnography, studies of acid-base status of blood (AAS);

- stability system and organ hemodynamics (no negative influence of mechanical ventilation on heart, brain), which is achieved by using the principle of minimizing the average airway pressure;

- according ventilation mechanical properties of the lung - thorax (no Baro-, volutrauma), which is achieved by taking into account thoracopulmonary compliance (With);

- respiratory patient comfort (no shortness of breath, synchronization patient with respirator), which is a prerequisite for the correction of parameters of mechanical ventilation, especially during assisted ventilation.

How is modern servoventilation in intensive care and intensive therapy in patients with intact gas-transport function of blood (no himicheskoi hypoxia). The method is effective with the regular positioning of the patient (shift body positions, kinetic therapy and rehabilitation of the tracheobronchial tree.

The METHOD IS AS follows

Before IVL determine the weight of the patient (m, kg), measured his height (h, cm), record the age (and years).

Are (m$ what kg) and excess weight (mhouseskg) by the formulas:

where mshould- have patient's weight, kg

mhouses- overweight patient, kg;

m - the actual weight of patient (kg)

Constitution: asthenic - 1, normostenichesky - 2, giperstenichesky - 3,

h - height, m,

If excess weight patient does not have (mhouses0), then the magnitude of excess weight is taken for zero:

mhouses=0.

Determine the initial minute volume ventilation (MOUbegml/min) by the formula:

where MOUbeg- initial minute volume ventilation, l/min,

K - factor increases metabolism in patients with stress at low stress equal To 1,2; under moderate stress - 1,4; in severe stress - 1,6; when the fever To increase by 0.1 for each degree above 37° C.

If stress is not, then the ratio increases metabolism equal to 1(K=1). If excess weight is not, then MOB=× mshould×100.

Find tidal volume (ml)

TO=mshould×7+mhouses×3.

Find the frequency of breaths (BH, 1/min)

BH=DOMbegTO.

Determine the estimated thoracopulmonary compliance (Cshould) according to the formula

for patients older than 30 years with excess weight is s (a> 30, mhouses0).

Withshould=mshould-mhouses/3, for patients 30 years and younger with excess weight (and≤ 30, mhouses0),

Withshould=mshould-(a-30)/3, for patients older than 30 years without excess weight (>30, mhouses<0),

Withshould=mshouldfor patients 30 years and younger without excess weight (and≤ 30, mhouses<0),

where Cshould- estimated distensibility of the lung - thorax, ml/cm Vogt;

mshouldshould body weight, kg

mhousesexcess body weight, kg

a - age years.

Find the initial velocity of the gas flow on the inhale (Fbegl/min) by the formula

The data obtained BEFORE, BH, Fbeg, MOBbegmake in the settings menu of the respirator. Before connecting a patient to a respirator begin forced ventilation, adjustable volume (VCV mode IPPV, CMV), with a constant or with a declining form of the gas flow on the breath, in which the mean airway pressure (Penvironments) below. Connect the auto gasp. Set the duration of the inspiratory pause (plateau)to the initial ratio of inspiratory to expiratory (I/Ebeg) was equal to 1/1,5.

All of the above calculations and adjustment of the respirator it is expedient to do before the patient arrives in the ICU until he located the in the operating room or in the emergency Department (sanitary inspection). For calculations and mode settings IVL anesthesiologist, receiving the patient should inform the resuscitation height, weight, age and body type of the patient.

After setting the mode IVL connect a patient to a respirator.

Here and further on all phases of mechanical ventilation installs fraction of oxygen supplied respirator to the breathing circuit (FiO2), under the control of the data pulse oximeter or the detector to achieve the SpO294-100%, RAO275-200 mm Hg adjust MOUbegby changing the BH to achieve EtCO2or Paco2from 32 to 45 mm Hg according to capnograph or detector, get a MOB.

Synchronize patient with respirator (analgosedation, myorelaxation, temporary hyperventilation) to exclude spontaneous respiratory activity.

With the help of a respirator, spirograph or respiratory monitor to determine the distensibility of the lung-thorax (thoracopulmonary compliance, ml/cm Vogt).

Calculate and determine the level of positive pressure end expiratory forced ventilation (peepprinthe formula

where peepprinpositive pressure at the end of exhalation for forced ventilation of the lungs, cm Vogt,

Withshould- must thoracoport the national compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt;

Find and set the flow rate during inhalation by the formula

where F is the flow rate on the inhale, l/min,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt Calculate and set the ratio of inspiratory to expiratory (I/E) by the formula

where I/E is the ratio of inhalation to exhalation,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt Set the duration of the inspiratory pause (Tplateau)to the ratio of inhalation to exhalation corresponded to the calculated I/E.

If the respirator allows for forced ventilation, adjustable pressure and there are clinical indications for its conduct, then transferred to a ventilator, adjustable pressure, which calculate and set the initial inspiratory pressure (PRsacfor forced ventilation, adjustable pressure according to the formula:

where RRsac- initial inspiratory pressure forced ventilation, adjustable pressure,

TO Yateley volume, ml

With actual thoracopulmonary compliance, ml/cm Vogt Establish the ratio of inspiration and expiration are equal to the calculated I/E.

Adjust RRsacto achieve a tidal volume mode, the regulated pressure (UP toPC), 10% more than BEFORE and get RPC.

When going through clinical indications from forced ventilation mode a ventilator calculate and set peep for assisted ventilation (peepsecthe formula

where peepsecpositive pressure at the end of exhalation for assisted ventilation, cm Vogt,

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt,

Sens - sensitivity trigger respirator, cm vods If the respirator allows auxiliary ventilation, adjustable pressure, and there are clinical indications for its conduct, then calculate and set the initial pressure support (PPSFor assisted ventilation, adjustable pressure, according to the formula

where PPS- initial pressure support mode of assisted ventilation, adjustable pressure,

TO dyatel the school size, ml

With actual thoracopulmonary compliance, ml/cm Vogt

Regulate PPSto achieve tidal volume in the mode of a ventilator, adjustable pressure (UP toPS), 10% more than BEFORE and get PPS.

Push and supporting ventilation, adjustable pressure, determined at each change of body position of the patient at least 1 time in 8 hours and when you change To adjust peepprinand RRS(forced ventilation), MPCwsecand PPS(for auxiliary ventilation), regulate the ratio of inspiratory to expiratory (I/E) for respiratory comfort. Set minimum ratio of inspiratory to expiratory (I/E), which provides respiratory patient comfort. In the case of respiratory comfort is not achieved (the patient is not synchronous with the respirator), conduct other synchronization methods patient with respirator (analgo-sedation, myorelaxation, temporary hyperventilation).

If the respirator does not allow auxiliary ventilation, adjustable pressure, or there are clinical indications for its use, then transferred to a ventilator, adjustable volume.

Push and supporting ventilation, adjustable volume, determined With 1 every 12 hours and when you change With adjustment the comfort peep prin, Peepsecand F, and then adjust the duration of the inspiratory pause to achieve respiratory comfort. Set the minimum duration of the inspiratory pause (Tplateau), which provides respiratory patient comfort. In the case of respiratory comfort is not achieved (the patient is not synchronous with the respirator), conduct other synchronization methods patient with respirator (analgo-sedation, myorelaxation, temporary hyperventilation).

Dynamic correction settings respirator is performed on the background of regular positioning of the patient (shift body positions, kinetic therapy and rehabilitation of the tracheobronchial tree.

EXAMPLE 1

Patient E., 37 years old, diagnosis: knife penetrating thoracoabdominal injury to the left, wound interventricular septum of the heart, not penetrating into the cavity of the heart, a perforating wound of the diaphragm, the left hemothorax, traumatic shock 3 degrees. The condition for admission is extremely heavy due to respiratory insufficiency, traumatic shock. Pronounced cardiac pain. The consciousness of the oppressed to moderate stun. Skin pale cyanotic, covered with cold sweat. The visible mucous anemic, low humidity. Breathing self, auscultatory weakened at the bottom left of the departments, the frequency of water the project for 28 per minute. Rentgenograficheski: left hemothorax. Blood pressure 90/50 mm Hg, heart rate of 120 beats per minute. The abdomen is painful epigastric left. Diuresis reduced. Initiated resuscitation events. The patient is suspended. Weight 88 kg of Defined growth - 185 see the Measured body temperature is 36.8° C. the type of Constitution (Constitution) - normostenichesky. The estimated degree of stress is difficult because the patient was in a state of shock, there was pain. On the basis of the degree of stress ratio increases metabolism -1,6.

As a life-saving surgery: thoracotomy left, suturing wounds of the heart and diaphragm, drainage of pleural cavity for Below left. Pain management: endotracheal anaesthesia, Central analgesia with ketamine. Given that the patient was prescribed long-term mechanical ventilation, anesthesiologist-resuscitator were calculated parameters of artificial ventilation, which were configured respirators RO-6 (operating) and Puritan Bennett 7200 AE (in the ICU). Was carried out the following calculation:

mshould=(22+Constitution)× h2=(22+2)× 1,852=82,14≈ 82 kg

mhouses=m-mshould=88-82=6 kg,

The MOUbeg=To× (mshould×100+mhouses×60)=1,6× (82× 100+6× 60)=13696≈ 13700 ml/min

TO=mshould× 7+mhouses×3=82× 7+6× 3=592≈ 590 ml.

BH=DOMbeg/TO=13700/590=23,22≈ 23 in minutes

The calculated parameters configured respirator RO-6, which allows only forced ventilation, adjustable volume, with the ratio of inhalation to exhalation 1/2. Given the presence of post-hypoxic condition in the breathing circuit was fed pure oxygen (nitrous oxide was not shown). Thus, the ventilation during the operation was conducted with a respiratory volume of 590 ml with a frequency of 23 breaths per minute, with the ratio of inhalation to exhalation 1/2, with the supply of 100% oxygen. In the course of the operation during the audit of the pericardium and the suturing wounds of the heart occurred 3 consecutive cardiac arrest lasting 1 minute each. During stops were conducted direct cardiac massage. Hemodynamics was stable against the background of the introduction vazopressorov, cardiotonic and hormones in figures: pulse 106 min, BP 120/70 mm Hg Total duration of hypotension less than 70 mm Hg was 20 minutes. In subsequent hemodynamics were maintained on normal numbers through the introduction of catecholamines. Until the end of the operation the anesthesiologist-resuscitator were calculated parameters of artificial ventilation, supplementing MOB, BEFORE, BH, planned for prolonged mechanical ventilation in the ICU respirator Puritan nnett 7200 AE. Conducted calculations is oricultural compliance (C) and inspiratory flow (F).

As a patient that is older than 30 years and has excess body weight (>30, mhouses0), it must thoracopulmonary distensibility was calculated by the formula:

Since the true (actual) thoracopulmonary compliance in the operating specified could not be (no respiratory monitor, spirograph), then calculate the initial velocity of flow during inhalation by the formula:

The data obtained BEFORE, BH, FcalcEAMbegmade in the settings menu respirator Puritan Bennett 7200 AE. Establish a permanent shape of the flow curve on the breath, turned on the automatic sigh” (two breath volume 900 ml of 12 times per hour). To achieve the relationship of inspiration and expiration 1/1,5 set inspiratory pause (plateau) with a duration of 0.4 seconds.

Transported the patient from the operating room to intensive care, continued forced ventilation, adjustable volume, with the supply of 80% oxygen (empirically). Identified SpO2- 100%. Identified RAO2- 245 mm Hg Reduced set empirically the value FiO2from 0.8 to 0.6, while Sp2- 99%, RAO; - 198 mm Hg

Since the synchronization of the patient with the respirator in the immediate postoperative period was good, the adaptation of the patient to a respirator is not required. Identified trampolim the national compliance - 46 ml/cm Vogt Calculated the flow rate of inspiratory (F), the magnitude of the positive pressure at the end of exhalation for forced ventilation (peepprin), the ratio of inspiratory to expiratory (I/E). Did the following calculation:

F=(Cshould+2C)/3=(78+2× 46)/3=56,6≈ 57 l/min,

Peepprin=5(Cshould-C)/S+2=5(78-46)/46+2=5,48≈ 5.5 cm Vogt

I/E=(Cshould+C)/3=(78+46)/(3× 46)=0,89=1/1,12≈ 1/1,1

Set the duration of the inspiratory pause (Tplateau) 0,57 to the ratio of inhalation to exhalation corresponded calculated.

Estimated indications for forced ventilation, adjustable pressure. Given the severity and instability of the patient, the absence of conditions for the development of barotrauma of the lungs and to prevent hypoventilation and hypoxemia when possible undetected progression of pulmonary edema resolved, that the indications for transition to presscontrol ventilation in the moment.

Continued ventilation in the prescribed mode, adjustable volume, carried out activities on the normalization of homeostasis, conducted lavage of the tracheobronchial tree, percussion massage of the chest. During this period the patient 8 times turned (positioned), 2 times in 12 hours was determined thoracopulmonary compliance (With). To determine the actual thoracopulmonary stretching is on (C) optionally synchronized patient with respirator with morphine (20 mg), sibazona (10 mg). Further to synchronize the patient from the respirator used morphine 10 mg

During this period thoracopulmonary compliance did not change significantly. The patient's condition remained extremely heavy due postresuscitation disease.

24 hours after surgery thoracopulmonary distensibility decreased to 37 ml/cm Vogt concluded that the increase of interstitial pulmonary edema. Given the progression of pulmonary edema, the emergence of conditions for the development of barotrauma of the lungs exhibited indications for transition to forced ventilation, adjustable pressure. Calculated and set RPS, PeepprinI/E by the formulas:

Adjusted RPSTo achieve UPRS10% more (UP to× 1,1 =0,59× 1,1=0.65) and received RPS=19 cm Vogt

In the future, was determined at each change of body position of the patient 1 every 2 hours. Thoracopulmonary compliance (C) was gradually increased. Twice when changing conducted With the calculation and adjustment of PRsac, PeepprinI/E in the above formula. 2 days after surgery With 57 ml/cm Vogt Calculated and set RRsac, PeepprinI/E:

Correction of PRsacto achieve UPRS10% is more (UP to× 1,1= 0,59× 1,1=0,65) is not needed, as when RRS11 cm Vogt tidal volume was 0,66 L.

When signs of spontaneous respiratory activity adjusted ratio of inspiration and expiration - set I/E, is equal to 1 (1/0,9) - the minimum value that was provided breathing comfort of the patient (no spontaneous breathing).

Continued forced ventilation, adjustable pressure, medication synchronization patient with respirator, refrained from switching to auxiliary ventilation in connection with the existing gross violations on neurodynamics in stem brain structures (the manifestation of post-hypoxic encephalopathy).

In the future, was determined at each change of body position of the patient. Thoracopulmonary compliance gradually increased. Performed the calculation and adjustment of PRsacand peepprinI/E in the above formula. After 8 days after surgery With 70 ml/cm vods By this time the patient has made positive changes in neurological status, the opportunity to transfer the patient to the auxiliary breathing mode SIMV with pressure support. Set the trigger sensitivity (Sens) 3 cm Vogt

Calculated and established PPS, RRsac, PeepsecI/E:

PPS=0,9× UP/C=0,9× 590/70=7,58Ɉ 8 cm Vogt

PRsac=1,1× UP/C=1,1× 590/70=9,27≈ 9 cm Vogt

Peepsec=5(Cshould-C)/S+Sens+2=5(78-70)/70+3+2=5,57≈ 5.6 cm Vogt

I/E=(Cshould+C)/3=(78+70)/(3× 70)=0,7=1/1,4≈ 1/1,4

Adjusted PPSTo achieve UPPS10% more proper (UP to× 1,1=0,59× 1,1=0.65) and got PPS=7 cm Vogt Correction of PRsacto achieve UPPC10% more proper (UP to× 1,1=0,59× 1,1=0.65 l) is not needed, as when RPC9 cm Vogt tidal volume was 0,65 l Adjusted ratio of inspiration and expiration - set I/E, is equal to 1/1,2 is the minimum value that was achieved breathing comfort of the patient.

On the 14th day of treatment the patient has made a significant dynamics on the General status and neurological status. Thoracopulmonary the elongation - 72 ml/cm Vogt it Was decided to transfer the patient to another mode auxiliary ventilation spontaneous breathing under positive airway pressure with pressure support (CPAP+PS). Set the trigger sensitivity (Sens) 1 cm Vogt

Calculated and established PPS, RRsac, Peepsec.

PPS=1,1× UP/C=1,1× 590/72=7,37≈ 7 cm Vogt

Peepsec=5(Cshould-C)/S+Sens+2=5(78-72)/72+1+2=3,42≈ 3.4 cm Vogt

Adjusted PPSto achieve UPPS10%more proper (UP to× 1,1=0,59× 1,1=0.65 l) and received PPS=8 cm Vogt

During long-term mechanical ventilation in the intensive care unit to the breathing circuit filed oxygen (FiO20,6-0,25)that provided normal saturation of hemoglobin with oxygen (SpO294-99% according to pulse oximetry). On the background of infusion-transfusion therapy hemoglobin level did not fall below 90 g/l

On the 22nd day after the operation the patient was successfully transferred to spontaneous breathing and excubitor. 23, the day was transferred to the Department of cardiovascular surgery. Outcome: improvement.

EXAMPLE 2

Patient W., 18 years old, diagnosis: septicopyemia, purulent epidural, hematogenic osteomyelitis, right tibia, drives on the left, infiltrate the middle third of the left shoulder. The condition for admission is extremely heavy due to septic shock, respiratory failure. The consciousness of the oppressed to deep stun. Expressed pain in the thoracic spine. Skin pale cyanotic, warm. The right knee joint is enlarged, hyperemia, painful, impaired his mobility. The visible mucous anemic, low humidity. The independent breathing, respiratory rate 38 / min. Blood pressure is 80/40 mm Hg, heart rate of 120 beats per minute.

Diuresis reduced. Initiated resuscitation event is. The patient is suspended. Weight 49 kg Determined height is 163 see Measured body temperature - 38,0° C. the type of Constitution (Constitution) - asthenic. The estimated degree of stress is difficult because the patient was in a state of shock, there was pain. On the basis of the degree of stress and body temperature coefficient increases metabolism and 1.7.

Indications for urgent surgery: hemilaminectomy6Th1, Th3Th5Th7Th9, Th11the drainage of the epidural space; osteoperforative of the tibia to the right, placing drainage, opening infiltrate the middle third of the left shoulder, left thoracotomy, closure of wounds of the heart and diaphragm, drainage of pleural cavity for Below left. Pain management: endotracheal anaesthesia, Central analgesia with fentanyl and ketamine. Given that the patient was prescribed long-term mechanical ventilation, anesthesiologist-resuscitator were calculated parameters of artificial ventilation, which were configured respirators RO-6 (operating) and Puritan Bennett 7200 AE (in the ICU). Was carried out the following calculation:

mshould=(22+ Constitution)× h2=(22+1)× 1,632=61,1≈ 61 kg

Excess weight is not, i.e. mhouses=0.

The MOUbeg=To× (mshould×100+mhouses×60)=1,7&x000D7; (61× 100+0× 60)=10370≈ 10400 ml/min

TO=mshould×7+mhouses×3=61× 7+0× 3=427≈ 430 ml.

BH=DOMbeg/TO=10400/430=24,19≈ 24 in minutes

The calculated parameters configured respirator RO-6. During anaesthesia in the breathing circuit was fed pure oxygen (nitrous oxide was not shown). Thus, the ventilation during the operation was conducted with a respiratory volume of 430 ml, at a rate of 24 breaths per minute, with the ratio of inhalation to exhalation 1/2, with the supply of 100% oxygen. During the operation, the hemodynamics was stable against the background of the introduction vazopressorov, cardiotonic and hormones in figures: pulse 120 / min, BP 100/60 mm Hg In subsequent hemodynamics were maintained on normal numbers through the introduction of catecholamines. Until the end of the operation the anesthesiologist-resuscitator were calculated parameters of artificial ventilation, supplementing the MOUbegBEFORE , BH, planned for prolonged mechanical ventilation in the ICU respirator Puritan Bennett 7200 AE. Conducted calculations have thoracopulmonary compliance (C) and inspiratory flow (F).

As the patient W. younger than 30 years (and<30), you should thoracopulmonary distensibility was calculated by the formula:

Since the true (actual) thoracopulmonary compliance in the operating specified could not be (from what was wcstoul respiratory monitor, spirograph), then calculate the initial velocity of flow during inhalation by the formula:

The data obtained BEFORE, BH, FcalcEAMbegmade in the settings menu respirator Puritan Bennett 7200 AE. Establish a permanent shape of the flow curve on the breath, turned on the automatic sigh” (two breath volume 700 ml 12 times per hour). To achieve the relationship of inspiration and expiration 1/1,5, set inspiratory pause (Tplateau) with a duration of 0.4 seconds.

Transported the patient from the operating room to intensive care, continued forced ventilation, adjustable volume with the supply of 80% oxygen (empirically). Identified SO2- 100%. Identified RAO2- 288 mm Hg Reduced set empirically the value FiO2from 0.8 to 0.5, while SpO2- 100%, RAO2- 203 mm Hg

Since the synchronization of the patient with the respirator in the immediate postoperative period was good, the adaptation of the patient to a respirator is not required. Identified thoracopulmonary compliance - 35 ml/cm Vogt Calculated the flow rate of inspiratory (F), the magnitude of the positive pressure at the end of exhalation for forced ventilation (peepprin), the ratio of inspiratory to expiratory (I/E). Did the following calculation:

F=(Cshould+2C)/3=(61+2× 35)/3=43,7≈ 44 l/min,

Peepprin=5(Cshould-C)/S+2=5(61-3)/35+2=5,71≈ 5.7cm Vogt

I/E=(Cshould+C)/3=(61+35)/3× 35=0,91=1/1,09≈ 1/1,1

Set the duration of the inspiratory pause (Tplateau) 0.6 so that the ratio of inhalation to exhalation corresponded calculated.

Estimated indications for forced ventilation, adjustable pressure. Given the severity and instability of the patient, the absence of conditions for the development of barotrauma of the lungs and to prevent hypoventilation and hypoxemia when possible undetected progression of pulmonary edema, decided that the evidence for the transition to presscontrol ventilation in the moment.

Continued ventilation in the prescribed mode, adjustable volume, carried out activities on the normalization of homeostasis, conducted lavage of the tracheobronchial tree, percussion massage of the chest. During this period the patient 8 times turned (positioned), 2 times determined thoracopulmonary compliance (With). To determine the actual thoracopulmonary compliance (C) optionally synchronized patient with respirator with morphine (10 mg), sibazona (10 mg). Further to synchronize the patient from the respirator used sibazon 5 mg

24 hours after surgery thoracopulmonary compliance increased to 40 ml/cm Vogt Given the stabilization state hemod the dynamics and gas exchange, exhibited indications for transition to forced ventilation, adjustable pressure. Calculated and set RRsac, PeepprinI/E by the formulas:

Correction of PRsacnot needed, as TOPCwas equal to 0.48 l, that is 10% more than BEFORE(UP to× 1,1=0,43× 1,1=0,47).

In the future, was determined at each change of body position of the patient, 2-3 hours. Thoracopulmonary compliance gradually decreased, due to development of acute lung injury. Twice performed the calculation and adjustment of PRsac, PeepprinI/E in the above formula. In 3 days after surgery With 30 ml/cm Vogt calculated and set RRsac, PeepprinI/E:

Adjusted RRsacto achieve UPPC10% more than BEFORE(UP to × 1,1=0,43× 1,1=0,47), received RPC15 cm Vogt

When signs of spontaneous respiratory activity adjusted ratio of inspiration and expiration - set I/E, is equal to 1(1/0,8) is the minimum value at which ensured breathing comfort of the patient (no spontaneous breathing).

Within 8 days of continued forced ventilation, medication synchronization patient with respirator, refrained from going n the auxiliary ventilation in connection with ongoing acute catabolic, due session.

Was determined at each change of body position of the patient. Thoracopulmonary compliance gradually increased. Performed the calculation and adjustment of PRsac, PeepprinI/E in the above formula. After 9 days after surgery With 41 ml/cm vods By this time the patient made a positive trend began to regress sepsis, there is an opportunity to transfer the patient to the auxiliary breathing mode SIMV with pressure support. Set the trigger sensitivity (Sens) I see Vogt

Calculated and established PPS, RRsac, PeepsecI/E:

PPS=0,9× UP/C=0,9× 430/41=9,44≈ 9 cm Vogt

PRsac=1,1× UP/C=1,1× 430/41=11,54≈ 12 cm Vogt

Peepsec=5(Cshould-C)/S+Sens+2=5(61-41)/41+1+2=5,44≈ 5.4 cm Vogt

I/E=(Cshould+C)/3=(61+41)/(3× 41)=0,83≈ 1/1,2

Adjusted RPSto achieve UP to 10% more proper (UP to× 1,1=0,43× 1,1=0,47) and received PPS=10 cm Vogt Correction of PRsacto achieve UPPS10% more than BEFORE(UP to× 1,1=0,43× 1,1=0,47) is not needed, as when RPC12 cm Vogt tidal volume was 0,49 L. Adjusted ratio of inspiration and expiration - set I/E, is equal to 1/1,1 the minimum value that was achieved breathing comfort of the patient.

On the 12th day of treatment, the Oia patient did considerable dynamics on the General status. Thoracopulmonary compliance - 47 ml/cm Vogt it Was decided to transfer the patient to another mode auxiliary ventilation spontaneous breathing under positive airway pressure with pressure support (CPAP+PS). Set the trigger sensitivity (Sens) 0.5 cm Vogt

Calculated and established PPS, RRsac, Peepsec.

PPS=0,9× UP/C=0,9× 430/47=8,23≈ 8 cm Vogt

Peepsec=5(Cshould-C)/S+Sens+2=5(61-47)/47+0,5+2=3,99≈ 5.4 cm Vogt

Correction of PPSnot needed, as at PPS=8 cm vods TOPSwas equal to 0.47, that is 10% more than BEFORE.

During long-term mechanical ventilation in the intensive care unit to the breathing circuit filed oxygen (FiO20,5-0,25)that provided normal saturation of hemoglobin with oxygen (SO294-99% according to pulse oximetry). On the background of infusion-transfusion therapy hemoglobin level did not fall below 90 g/l

On the 18th day after the operation the patient was successfully transferred to spontaneous breathing and excubitor. 22, the day was transferred to the pediatric emergency surgery. Outcome: improvement.

By the present method were examined 26 patients with trauma, neurotraumatology, neurosurgical profiles, in need of DELL and no source-specific lung damage. Control was the group of 23 patients, comparable in sex, age, pathology, treatment. Mechanical ventilation in both groups spent respirators Puritan-Bennett 7200, Puritan-Bennett 7200ae, Bear 1000. Groups differed in the method of installation options IVL.

In the control group parameters of mechanical ventilation was installed according to traditional methods [Marino Intensywny therapy. - M - 1998. - S-350]: tidal volume, minute volume ventilation (MOB), breathing frequency (BH) was calculated by the formula:

Installed the calculated parameters in the settings menu of the respirator, conducted a ventilator, adjustable volume. Using Eclipse, capnograph, pulse oximeter corrected BH and TO achieve normogastria and normoxemia. Inspiratory pressure-controlled respirator in the mode of forced ventilation, adjustable pressure, selected empirically to achieve the designed TO. When switching on the auxiliary artificial lung ventilation (WILL) found the level of inspiratory pressure (pressure support, PPS), in which inspiratory pressure support was obtained by dividing the maximum airway pressure of the patient during inhalation (PMIA) three. Find the best positive pressure at the end of the expiratory (peep) by measuring the elasticity of the lungs and oxygen delivery. These pokazatel is measured at various empirically chosen, levels of peep. Optimum was considered to be the peep level at which the distensibility of the lungs and oxygen delivery to the maximum.

In the main group settings, mechanical ventilation was established by the proposed method.

The mechanics of respiration was investigated using respirators, respiratory monitor Capnomac Ultima company Datex. Daily compared the following parameters characterizing the effectiveness of respiratory therapy: Paco2, Rpeak, RenvironmentsWith, the level of peep, F, PPCPPSthe duration of the achievements of normogastria, the dose of sedatives, painkillers and muscle relaxants for synchronization of a patient with a respirator.

Statistical data processing was carried out in the program Instat.

The results of the study

In figure 1, 2, 3 shows the dynamics of thoracopulmonary compliance (C), the level of positive pressure end expiratory (peep), level-controlled respirator pressure mode, the regulated pressure (PPCdepending on the method of conducting long-term mechanical ventilation. The results show that using the proposed method for prolonged mechanical ventilation (in the main group) manages earlier to increase thoracopulmonary compliance, reduce peep and the level of PPC. In addition, in the study group received a significantly lower heart rate (p<0.05) and d is C vazopressornye, cardiotonic, sedative, muscle relaxant drugs. Transient differences of the studied parameters in the 6 day study were due to the fact that the majority of patients of the main group was transferred to spontaneous breathing and excluded from the study. In the study group remained the most severe patients with acute lung injury requiring higher peep values and PPC.

Used in method a method of tuning parameters of mechanical ventilation before connecting a patient to a respirator allowed in advance to find adequate parameters of mechanical ventilation in patients with different height, weight, age in 60% of cases versus 33.3% in the control group (stage 1), 2 times accelerated further configuration of the apparatus facilitated the correction of ventilation parameters during the entire period of mechanical ventilation.

The conclusions of the study

1. Accounting anthropometric characteristics of the patients allows the setting of a respirator during long-term mechanical ventilation in 2 times faster than traditionally.

2. The application of the method for prolonged mechanical ventilation based thoracopulmonary compliance and on the principle of minimizing the average airway pressure during prolonged mechanical ventilation helps reduce airway pressure, reduces heart rate, dose of cardiotonics.

3. The application of a CR is Loginova method for prolonged mechanical ventilation promotes growth thoracopulmonary compliance with 3 days.

4. The use of the proposed method for prolonged mechanical ventilation facilitates the synchronization of the patient from the respirator, reduces the dose of sedatives, muscle relaxants.

1. How long artificial lung ventilation (ALV), including the weighing of the patient, the setting operation of the respirator: minute volume ventilation (MOB), tidal volume, breathing frequency (BH), fraction of oxygen supplied respirator to the breathing circuit (FiO2, forced ventilation, adjustable volume, adjusting BH and TO achieve normogastria, the definition of positive pressure at the end of the expiratory (peep), with the transition to auxiliary ventilation of the lungs, characterized in that additionally take into account the height (h), age (a) of the patient and taking into account the received data count TO the formula

TO=7×mshould+mhouses;

where TO tidal volume, ml;

mshouldshould the patient's body mass, kg;

mhouses- overweight patient, kg,

expect initial minute volume ventilation (MOBbegthe formula

MOBbeg=To×(100×mshould+60×mhouses),

where MOUbeg- initial minute volume ventilation, l/min;

K - factor increases metabolism in a patient who s under stress: low stress equal to 1.2; under moderate stress - 1,4; in severe stress - 1,6; when the fever To increase by 0.1 for each degree above 37°C;

mshouldshould the patient's body mass, kg;

mhouses- overweight patient, kg;

determine should thoracopulmonary compliance (Cshouldthe formula

Withshould=mshould-mhouses/3-(a-30)/3;

where Cshouldshould thoracopulmonary compliance, ml/cm Vogt;

mshouldshould the patient's body mass, kg;

mhouses- overweight patient, kg;

a - age years;

find the initial velocity of the gas flow on the inhale ((Fbegthe formula

Fbeg=0,8×Cshould,

where Fbeg- the initial velocity of the gas flow on the inhale, l/min;

Withshouldshould thoracopulmonary compliance, ml/cm Vogt;

install received settings BEFORE, BH, FbegEAMbegin the settings menu of the respirator and begin artificial ventilation, adjustable volume, with constant or declining shape of the gas flow on the inhale, choose the shape of the gas flow on the breath, in which the mean airway pressure (Penvironmentsbelow, install the automatic sigh”; set the initial duration of the inspiratory pause (Tcards the ) to the initial ratio of inspiration and expiration (1/Ebeg) was equal to 1/1,5; with stable hemodynamics set the initial positive pressure of end-expiratory (peepbeg) 5 cm Vogt, unstable hemodynamics, install peepbeg2 cm Vogt; synchronize patient with respirator, determine the actual thoracopulmonary compliance (C), calculate and determine the level of positive pressure end expiratory forced ventilation (peepprinthe formula

Peepprin=5(Cshould-C)/S+2,

where peepprinpositive pressure at the end of exhalation for forced ventilation of the lungs, cm Vogt;

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt,

find and set the flow rate on the inhale (F) by the formula

F=(Cshould+2C)/3,

where F is the flow rate on the inhale, l/min;

Withshouldshould thoracopulmonary compliance, ml/cm Vogt,

With actual thoracopulmonary compliance, ml/cm Vogt;

calculate and set the ratio of inspiratory to expiratory (I/E) by the formula

I/E=(Cshould+C)/3,

where I/E is the ratio of inspiration and expiration;

Withshouldd what should thoracopulmonary compliance, ml/cm Vogt,

in the process of forced ventilation, adjustable volume, determined With at least 1 times in 12 hours and when you change To adjust peep and F correct Tplateauto achieve respiratory comfort of the patient; moving to forced ventilation, adjustable pressure, which calculate and set the initial inspiratory pressure for forced ventilation, adjustable pressure (PRsac), by the formula

PRsac=1,1×UP/C

where RRsac- initial inspiratory pressure forced ventilation, adjustable pressure;

TO - tidal volume, ml;

With actual thoracopulmonary compliance, ml/cm Vogt;

calculate and set the ratio of inhalation to exhalation by the above formula; regulate PRsacto achieve tidal volume mode, the regulated pressure (Dors), 10 % more than BEFORE and get RPCin the process of forced ventilation, adjustable pressure, determined at each change of body position of the patient at least 1 time in 8 hours and when you change To adjust peepprinand RPCregulate the ratio of inspiratory to expiratory (I/E) for respiratory comfort of the patient; moving from forced ventilation mode support is compulsory ventilation, calculate and set peep for assisted ventilation (peepsecthe formula

Peepsec=5(Cshould-C)/S+2+Sens,

where peepsecpositive pressure at the end of exhalation for assisted ventilation, cm Vogt;

Withshouldshould thoracopulmonary compliance, ml/cm Vogt;

With actual thoracopulmonary compliance, ml/cm Vogt;

Sens - sensitivity trigger respirator, cm Vogt,

calculate and set the initial pressure support (PPSfor assisted ventilation, adjustable pressure, according to the formula

PPS=0,9×UP/C

where RPS- initial pressure support mode of assisted ventilation, adjustable pressure;

TO - tidal volume, ml;

With actual thoracopulmonary compliance, ml/cm Vogt,

adjust RPSto achieve tidal volume in the mode of a ventilator, adjustable pressure (UP toPS), 10 % more than BEFORE and get PPSregulate the ratio of inspiratory to expiratory (I/E) for respiratory comfort of the patient; in the process a ventilator, adjustable pressure, determined at each change of body position of the patient is not in d is 1 times in 8 hours and when you change To adjust peep secand PPS.

2. The method according to p. 1, characterized in that the installation of the fraction of oxygen supplied respirator to the breathing circuit (FiO2), produced under the control of the data pulse oximetry or analysis of blood gases to achieve the SpO294-100 %, RAO275-200 mm Hg, changing MOUbegby changing the BH is produced under the control of the data capnography to achieve EtCO2from 32 to 45 mm Hg, get MOB.

3. The method according to p. 1, characterized in that should the body mass (mshoulddetermine the type of the Constitution of the patient by the formula

mshould=(22+Constitution)×h2,

where mshouldshould body weight, kg;

h - height, m;

Constitution: asthenic - 1, normostenichesky - 2, giperstenichesky - 3.

4. The method according to p. 1, characterized in that Withshouldwhen the age of the patient (a) 30 years and younger is determined by the formula

CDol=mshould-mhouses/3,

where CDol- estimated thoracopulmonary compliance, ml/cm Vogt;

mshouldshould body weight, kg;

mhousesexcess body weight, kg



 

Same patents:

FIELD: medicine; artificial respiration apparatuses.

SUBSTANCE: apparatus has support, actuating mechanism and drive. Support is made in form of frame provided with rigid wheels, four bosses provided hole and placed in pairs in opposite and symmetrically to longitudinal axis extendable bed onto solid rollers; bed is provided with head support and lock. Actuating mechanism is mounted onto top part of frame and has four guides having smooth part inserted into hole of bosses, four elastic elements put onto smooth parts of guides, breast cuff placed among guides, arm with ears which has bushings to be housed onto threaded part of guides, working tool placed above breast cuff. Working tool is made of disc provided with axis which has ends to be embedded into rollers of ears of the arm. Apparatus also has aid for influencing breast cuff which aid is fixed onto disc for movement relatively the axis. Breast cuff has elastic sheet made in form of rectangle provided with bushings at the angles, solid plank fastened in the middle of the sheet, two cords which have first ends to fasten to opposite side faces. Drive has electric motor, redactor provided with speed gear-box, coupling and chain gear with bridle. Elastic elements are made in form of coil cylindrical or conical springs. Aid for influencing breast cuff has Π-shaped groove in the middle and slot at side surfaces. Slot has length determined by ratio of Λ=2D, where Λ is length of slot and D is diameter of disc. Width of slot allows moving axes and screws inside it.

EFFECT: simplified kinematical design of apparatus.

11 dwg

FIELD: medicine.

SUBSTANCE: method involves applying dosed load to cardiac respiration system due to compressed gas working pressure being reduced by 0.4 kg/m2 keeping it constant during 5-20 min. Then, the working pressure is reduced depending on patient state starting with a rate of 0.02-0.08 kg/m2/min. Gas exchange and hemodynamic parameters being in norm, the selected rate is increased. The parameters deviating from a norm, the selected rate is adjusted by increasing working pressure to reach their normal values. Optimum gas flow rate is determined and the working pressure is reduced at this rate, continuing to adjust its value under unchanged gas exchange and hemodynamic parameter values or their deviation from norm.

EFFECT: accelerated treatment course.

2 cl

FIELD: medicine.

SUBSTANCE: method involves applying auxiliary non-invasive lung ventilation with air-and-oxygen mixture in PSV mode with supporting pressure being equal to 8-12 cm of water column at inspiration phase, FiO2 0.25-0.3, positive pressure at expiration phase end equal to 2-4 cm of water column being applied. Inspiration trigger sensitivity being equal to 15-2 cm of water column relative to positive pressure at expiration phase end level to reach tidal respiratory volume not less than 6-7 ml/kg under SpO2 and blood gases control.

EFFECT: prevented acute respiratory insufficiency; improved alveolar ventilation; reduced venous bypass.

FIELD: medical engineering.

SUBSTANCE: device has oxygen inhalation sets and artificial lung ventilation means enclosed into dust- and moisture-proof envelopes usable as oxygen-delivery unit. Portable thermochemical oxygen-producing units are connected to the means. Every thermochemical oxygen-producing unit is cylindrical and has casing and cover which flanges are connected to each other via sealing ring by means of removable yoke. The casing has three metal cups inserted one into another and fixed in upper part in the flange. Reactor cartridge provided with hard oxygen-containing composition for setting starter device having striking mechanism is placed in the internal cup. The external cup is perforated and serves as protection casing. Oxygen production unit cover is divided into two parts one of which has safety valve connected to the first output of the reactor cartridge, dust collection filter connected to the second reactor cartridge output on one side and connected to additional cleaning filter via heat exchange unit on the other side, heat exchanger, gas connection nipples, guide member usable in striking mechanism, safety valve and dust collection filter are fixed on cover flange. Additional cleaning filter body is placed on the second part of oxygen production unit cover. Cavity for letting striking mechanism guide pass is arranged along central axis of the additional cleaning filter body. Nipple for releasing oxygen is available on the additional cleaning filter body cover. The nipple has captive nut for making connection to feeding pipe. Starter unit is fixed on the oxygen-producing unit cover and has capsule. The striking mechanism has striker and spring arranged in guiding tube. Air-convection heat exchange unit has coiled pipe manufactured from copper tube. Reflexogenic therapy instrument is available for making anesthesia of wounded person.

EFFECT: enhanced effectiveness of complex treatment with delivering oxygen anesthesia.

2 cl, 4 dwg

FIELD: medical engineering.

SUBSTANCE: device has flow generator, compressed oxygen source, gas distribution device, patient T-branch, control system having microprocessor controller connected to the gas distribution device with all its outlets, flow velocity and upper airway pressure sensors pneumatically connected to the patient T-branch. The device has unit containing arterial blood pressure sensor, heart beat rate sensor, sensor of hemoglobin saturation with oxygen, electric output terminals of which form data bus with those of flow velocity and upper airway pressure sensors. The control system is additionally provided with fuzzy controller and three memory units having their inputs connected via electrical link to fuzzy controller output and their outputs to microprocessor controller input, to data bus output and fuzzy controller input connected to PC with its input.

EFFECT: enhanced effectiveness of treatment; accelerated transition to natural breathing.

2 dwg

The invention relates to medicine, resuscitation, and can be used to assess the effectiveness of assisted ventilation (WL)

The ventilator // 2240767
The invention relates to medical equipment, namely, devices for artificial ventilation of the lungs, and is intended for use in the departments of surgery, anesthesiology and intensive care

The invention relates to medicine, namely to resuscitation, and can be used to assess the adequacy of assisted ventilation

The invention relates to medicine, in particular to methods and means for restoring proper breathing patients after artificial ventilation of the lungs
The invention relates to medicine, namely anesthesiology, and can be used to provide intraoperative monitoring of the spinal cord through the implementation of planned urgent Wake-up the patient on the stage surgical correction of scoliosis or other spinal deformities

FIELD: medicine; artificial respiration apparatuses.

SUBSTANCE: apparatus has support, actuating mechanism and drive. Support is made in form of frame provided with rigid wheels, four bosses provided hole and placed in pairs in opposite and symmetrically to longitudinal axis extendable bed onto solid rollers; bed is provided with head support and lock. Actuating mechanism is mounted onto top part of frame and has four guides having smooth part inserted into hole of bosses, four elastic elements put onto smooth parts of guides, breast cuff placed among guides, arm with ears which has bushings to be housed onto threaded part of guides, working tool placed above breast cuff. Working tool is made of disc provided with axis which has ends to be embedded into rollers of ears of the arm. Apparatus also has aid for influencing breast cuff which aid is fixed onto disc for movement relatively the axis. Breast cuff has elastic sheet made in form of rectangle provided with bushings at the angles, solid plank fastened in the middle of the sheet, two cords which have first ends to fasten to opposite side faces. Drive has electric motor, redactor provided with speed gear-box, coupling and chain gear with bridle. Elastic elements are made in form of coil cylindrical or conical springs. Aid for influencing breast cuff has Π-shaped groove in the middle and slot at side surfaces. Slot has length determined by ratio of Λ=2D, where Λ is length of slot and D is diameter of disc. Width of slot allows moving axes and screws inside it.

EFFECT: simplified kinematical design of apparatus.

11 dwg

FIELD: medicine.

SUBSTANCE: method involves applying dosed load to cardiac respiration system due to compressed gas working pressure being reduced by 0.4 kg/m2 keeping it constant during 5-20 min. Then, the working pressure is reduced depending on patient state starting with a rate of 0.02-0.08 kg/m2/min. Gas exchange and hemodynamic parameters being in norm, the selected rate is increased. The parameters deviating from a norm, the selected rate is adjusted by increasing working pressure to reach their normal values. Optimum gas flow rate is determined and the working pressure is reduced at this rate, continuing to adjust its value under unchanged gas exchange and hemodynamic parameter values or their deviation from norm.

EFFECT: accelerated treatment course.

2 cl

FIELD: medicine.

SUBSTANCE: method involves applying dosed load to cardiac respiration system due to compressed gas working pressure being reduced by 0.4 kg/m2 keeping it constant during 5-20 min. Then, the working pressure is reduced depending on patient state starting with a rate of 0.02-0.08 kg/m2/min. Gas exchange and hemodynamic parameters being in norm, the selected rate is increased. The parameters deviating from a norm, the selected rate is adjusted by increasing working pressure to reach their normal values. Optimum gas flow rate is determined and the working pressure is reduced at this rate, continuing to adjust its value under unchanged gas exchange and hemodynamic parameter values or their deviation from norm.

EFFECT: accelerated treatment course.

2 cl

FIELD: medicine.

SUBSTANCE: method involves applying auxiliary non-invasive lung ventilation with air-and-oxygen mixture in PSV mode with supporting pressure being equal to 8-12 cm of water column at inspiration phase, FiO2 0.25-0.3, positive pressure at expiration phase end equal to 2-4 cm of water column being applied. Inspiration trigger sensitivity being equal to 15-2 cm of water column relative to positive pressure at expiration phase end level to reach tidal respiratory volume not less than 6-7 ml/kg under SpO2 and blood gases control.

EFFECT: prevented acute respiratory insufficiency; improved alveolar ventilation; reduced venous bypass.

FIELD: medicine.

SUBSTANCE: method involves applying auxiliary non-invasive lung ventilation with air-and-oxygen mixture in PSV mode with supporting pressure being equal to 8-12 cm of water column at inspiration phase, FiO2 0.25-0.3, positive pressure at expiration phase end equal to 2-4 cm of water column being applied. Inspiration trigger sensitivity being equal to 15-2 cm of water column relative to positive pressure at expiration phase end level to reach tidal respiratory volume not less than 6-7 ml/kg under SpO2 and blood gases control.

EFFECT: prevented acute respiratory insufficiency; improved alveolar ventilation; reduced venous bypass.

FIELD: medical engineering.

SUBSTANCE: device has oxygen inhalation sets and artificial lung ventilation means enclosed into dust- and moisture-proof envelopes usable as oxygen-delivery unit. Portable thermochemical oxygen-producing units are connected to the means. Every thermochemical oxygen-producing unit is cylindrical and has casing and cover which flanges are connected to each other via sealing ring by means of removable yoke. The casing has three metal cups inserted one into another and fixed in upper part in the flange. Reactor cartridge provided with hard oxygen-containing composition for setting starter device having striking mechanism is placed in the internal cup. The external cup is perforated and serves as protection casing. Oxygen production unit cover is divided into two parts one of which has safety valve connected to the first output of the reactor cartridge, dust collection filter connected to the second reactor cartridge output on one side and connected to additional cleaning filter via heat exchange unit on the other side, heat exchanger, gas connection nipples, guide member usable in striking mechanism, safety valve and dust collection filter are fixed on cover flange. Additional cleaning filter body is placed on the second part of oxygen production unit cover. Cavity for letting striking mechanism guide pass is arranged along central axis of the additional cleaning filter body. Nipple for releasing oxygen is available on the additional cleaning filter body cover. The nipple has captive nut for making connection to feeding pipe. Starter unit is fixed on the oxygen-producing unit cover and has capsule. The striking mechanism has striker and spring arranged in guiding tube. Air-convection heat exchange unit has coiled pipe manufactured from copper tube. Reflexogenic therapy instrument is available for making anesthesia of wounded person.

EFFECT: enhanced effectiveness of complex treatment with delivering oxygen anesthesia.

2 cl, 4 dwg

FIELD: medical engineering.

SUBSTANCE: device has flow generator, compressed oxygen source, gas distribution device, patient T-branch, control system having microprocessor controller connected to the gas distribution device with all its outlets, flow velocity and upper airway pressure sensors pneumatically connected to the patient T-branch. The device has unit containing arterial blood pressure sensor, heart beat rate sensor, sensor of hemoglobin saturation with oxygen, electric output terminals of which form data bus with those of flow velocity and upper airway pressure sensors. The control system is additionally provided with fuzzy controller and three memory units having their inputs connected via electrical link to fuzzy controller output and their outputs to microprocessor controller input, to data bus output and fuzzy controller input connected to PC with its input.

EFFECT: enhanced effectiveness of treatment; accelerated transition to natural breathing.

2 dwg

FIELD: medical engineering.

SUBSTANCE: device has belt manufactured from inextensible flexible material having clamps mounted on one side along its length, with rollers enveloped by cords. Closed chambers built from flexible material, filled with liquid and having pressure gages, are attached to its other side in camp projections. Electromotor is mounted in the middle part of the belt on the same side with the clamps. The electromotor has control system. Drum enveloped with cords is rigidly fixed on the electromotor end part. The middle portion of each cord is rigidly connected to cylindrical drum surface. Free ends of the cords are connected to end clamps.

EFFECT: retained ability of unrestrained patient movements.

2 dwg

The invention relates to medicine, resuscitation, and can be used to assess the effectiveness of assisted ventilation (WL)

The invention relates to medicine, resuscitation, and can be used to assess the effectiveness of assisted ventilation (WL)

FIELD: medical engineering.

SUBSTANCE: device has belt manufactured from inextensible flexible material having clamps mounted on one side along its length, with rollers enveloped by cords. Closed chambers built from flexible material, filled with liquid and having pressure gages, are attached to its other side in camp projections. Electromotor is mounted in the middle part of the belt on the same side with the clamps. The electromotor has control system. Drum enveloped with cords is rigidly fixed on the electromotor end part. The middle portion of each cord is rigidly connected to cylindrical drum surface. Free ends of the cords are connected to end clamps.

EFFECT: retained ability of unrestrained patient movements.

2 dwg

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