งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

Practical Points in NIV นพ. รัฐภูมิ ชามพูนท รพ. พุทธชินราช.

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งานนำเสนอเรื่อง: "Practical Points in NIV นพ. รัฐภูมิ ชามพูนท รพ. พุทธชินราช."— ใบสำเนางานนำเสนอ:

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2 Practical Points in NIV นพ. รัฐภูมิ ชามพูนท รพ. พุทธชินราช

3 ใครในภาพต่อไปนี้ ไม่ได้เป็น พรีเซนเตอร์ต่อต้าน การสูบบุหรี่

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6 What is NIV Mechanical ventilation without using invasive airway When to use NIV Before Intubation Follow Extubation

7 TYPE of NIV 2 Types 1.Negative Pressure 2.Posive Pressure (NIPPV)

8 Normal breathing (Negative pressure breath) pressure

9 0 Mechanical ventilation(positive pressure ventilation)

10 TYPE of NIV 1.Negative Pressure Can be provided without artificial airway  Emerson Iron Lung (Past)  Chest Cuirass  Pneumobelt  Rocking Bed 1.Positive Pressure

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12 Postpolio era

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15 Use in Home mechanical ventilation Communicate more effective Neuromuscular disease X Intrinsic lung disease X Body temp regulation X Not very comfortable

16 2. Positive Pressure(NIPPV) Higher than atmospheric pressure Push air into the lung Can be provided with artificial airway (variety Interface) TYPE of NIV

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19 Mode of NIPPV Volume limited Ventilation –Pressure varied –Discomfort, Gastric distention  Intolerance –Air leakage Pressure limited Ventilation –CPAP –BiPAP –PAV Mixed Volume and Pressure Limited Ventilation

20 Pressure-Limited Ventilation 1.CPAP Simplest Constant pressure provided through inspiration and expiration Decrease WOB, Increase FRC & Gas exchange 2.BiPAP/NPPV IPAP V.S. EPAP Less expiratory resistance Spontaneous, Timed, S/T Mode 3.Proportional Assisted Ventilation (PAV)

21 Interface

22 Nasal Mask Advantages –Less risk of aspiration –Easier secretion clearance –Less claustrophobia –Easier speech –May allow patient to eat –Easy to fit and secure –Less dead space Disadvantages –Mouth leak –Higher resistance through nasal passage –Less effective with nasal obstruction –Nasal irritation and rhinorrhea –Mouth dryness

23 Oronasal Mask(full face) Advantages –Better control of mouth leak –More effective with mouth breathers, particularly during acute application of NIPPV Disadvantages –More dead space –Claustrophobia –More risk of aspiration –More difficulty in eating and speaking –Asphyxiation if ventilator malfunction

24 Circuit Type Single Limb Double Limb

25 Single Limb circuit system

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27 2 Limb circuit system

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29 Leak valve system ไม่มี Leak valve ใน circuit หายใจไม่ ออก !

30 Leak valve system มี Leak valve ใน circuit ค่อยยังชั่ว หน่อย แต่ทำไมลมดัน ไม่หยุด

31 Initial Settings EPAP = CPAP IPAP = Pressure Support (Include PEEP or above PEEP) Back up Rate Pramp(Rising Time) Optional FiO2

32 The faster the initial rise to peak flow level,the sooner the set pressure limit is reached Slow rise to set pressure level is more comfortable for the patient Exessively fast rise to peak flow may cause the ventilator to overshoot the initial pressure limit and create a pressure spike,which can cause discomfort and increase WOB Pressure support ventilation(PS)

33 FAQ 1. อย่างนั้น mode CPAP with PS ใน เครื่อง Invasive Mechanical ventilator ก็คือ NIPPV(Bilevel CPAP) ใช่หรือไม่ ?? เหมือนจะใช่ แต่ไม่ใช่

34 Phase variables 4 phases The change from expiration to inspiration (triggered) Inspiration (limited) The change from inspiration to expiration (cycled) Expiration (baseline,PEEP)

35 inspiration expiration inspiration expiration trigger cycle limit baseline 0 5 pressure time

36 Typically used in the SIMV mode to facilitate weaning in a difficult to wean patient 1.Increase spontaneous Vt (set PS until a desired spontaneous Vt) 2.Decrease spontaneous respiratory rate (set PS until a desired spontaneous RR) 3.Decrease the work of breathing Pressure support ventilation(PS)

37 End flow(resp. cycle off)Rise time

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39 NIV ต้องมี Leak บ้าง ถ้าใช้ CPAP with PS mode แทนจะ เกิด Auto-Triggering Prolong Inspiratory Time Alarm Low MV or Low Vt

40 วิธีแก้ปัญหาเหล่านี้ในเครื่อง (TRUE) NIV Auto-Triggering Trigger Adaptation(Re-adjustment baseflow) Volume trigger eg.6 ml Shape signal

41 Prolong Inspiratory Time Good quality Leak compensation Spontaneous expiratory Threshold (% Peak flow cycle adaptation) Shape signal cycle Safety Feature eg.Flow reversal,max 3 sec inspiratory time วิธีแก้ปัญหาเหล่านี้ในเครื่อง (TRUE) NIV

42 True NIV Adjustable Baseflow PRESSURE Cm H2O EPAP IPAP Variable Cycle Threshold Variable Trigger Threshold

43 2. ใช้แทนกันได้ ไหม ??? ไม่ควร... ไม่ได้ครับ FAQ

44 3. ทำไม NIV ในแต่ละเครื่อง จึงสบายไม่เท่ากัน ? Leakage compensation Trigger Adaptation Inspiration Termination (cycle)

45 NIV made simple ไม่ง่ายนะ จ้ะ

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47 Close monitoring

48 COPD Exacerbation (7.30≤pH<7.35) Interface and type of circuit nasal mask Single limb with leakage valve Initial Settings EPAP 4-8 cmH 2 O IPAP 8-10 (above EPAP 4-6) cmH 2 O titrate until Vt Back up rate 8-10/min FiO2 keep SpO2 >92%

49 Severe COPD Exacerbation(pH< 7.30) Interface and type of circuit Oro-nasal mask Single limb with leakage valve Initial Settings EPAP 4-8 cmH 2 O IPAP 8-10 (above EPAP 4-6) cmH 2 O titrate until Vt Back up rate 8-10/min FiO2 keep SpO2 >92% Close monitoring

50 Cardiogenic Pulmonary edema Interface and type of circuit Oro-nasal mask (High Flow system ) Single limb with leakage valve Initial Settings EPAP 4-8 cmH 2 O titrate until ≈ 8-10 IPAP 8-10 (above EPAP 4-6) cmH 2 O titrate until Vt (OPTIONAL) Back up rate 8-10/min FiO2 keep SpO2 >92%(High FiO2) Close monitoring

51 Hypoxic Respiratory Failure Interface and type of circuit Oro-nasal mask (High Flow system ) Single limb with leakage valve Initial Settings EPAP 4-8 cmH 2 O IPAP (above EPAP 8-20) cmH 2 O titrate until Vt Back up rate /min FiO2 keep SpO2 >92%(High FiO2) Close monitoring

52 How to succeed in NIV Good candidate Good initial settings Good monitoring Good criteria for termination (change to invasive) Not too bad ventilator!!

53 Long-term Mechanical Ventilation Home Mechanical Ventilation Non-invasive Ventilation(NIV)

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ดาวน์โหลด ppt Practical Points in NIV นพ. รัฐภูมิ ชามพูนท รพ. พุทธชินราช.

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