1
??????? ? ?????? ??????????

• ?????? ?.?. ???????

2
???????

• ??????????
• ???
• ???????

3
???????

• ??????????
• ?????????? ??????? ???????? ????
• ????????????? ??????
• ???????
• ???????
• ?????????????

4
?????????? ??????

• ?????????? ??????????
• ????????? ??????
• ????????????
• ???????????? ?????????? (NIV)
• ??????? ?????
• ??????? ?????

5
NIV
?? Bach J., Gonçalves M. Pulmonary
rehabilitation in neuromuscular disorders and
spinal cord injury, 2006
6
NIV (???????????)
?? Ratzka A. "The Swedish Personal Assistance
Act of 1994, 2004
7
??????? ??????

• ???????
• ???????? ??????????
• ???????? ??????
• ?????????? ???????
• ?????? ???
• ?????????????
• IAPV

?? Scharf T. The Pneumobelt Part of My
Noninvasive Ventilation System, 2004
8
???????

• ????????

9
??? ??? ????
10
???? ?????????? ?????
11
??? ????

• ????????? ??????????????
• ??? ????????? ?????? (?????????, ???, ????)
• ? ?????????? ?????? (?????????, ????)
• ?????????? ??????????????
• ??? ????????? ?????? (??????????????? ?????????)
• ? ?????????? ?????? (????)

12
??? ????

• ????????? ?????????
• ??? ????????? ?????? (????????? ?? ???????????)
• ? ?????????? ?????? (??????????)
• ?????????? ?????????
• ??? ????????? ?????? (??????? ??????? ?????)
• ? ?????????? ?????? (????)

13
??????????? ????????????? ?????????
?????????? ???? ?????????
14
????

• ?????????? ? ??????????? ??????????? ??????????
• ???????? ????? ????????? ???????????
• ???????? ?????? ??????? ????????
• ??????????? ???????? ????????

15
????? ?????????

• ???????? ?????????????? ??????
• ???????? ?????????????? ??
• ??????? ???????? ?????????
• ??????? FiO2

?? Branson R. Toronto Critical Care Symposium,
2002
16
????? ???????
VAPS
CPAP
PAV
SIMV
ATC
BIPAP
APRV
ASB
SPONT
MMV
PLV
PRVC
PS
CMV
PCV
VCV
IPPV
17
?????????? ?? ?????? (V?)

• ?????????? ????? (Flow rate)
• ??????????????? ????? ????? (Vt)
• ????? ????? ?? ??????? ?? CL? Raw
• ???????? ??????????

Pressure
Flow
18
????? ????? X ?????
19
?????????? ?? ???????? (P?)

• ?????????? ?????
• ???????? ?? ??????????
• ????? ????? ??????? ?? CL? Raw
• ????? ????? ?? ????????????

Pressure
Flow
20
VC ??? ??

• Compliance ?
• Pressure Ventilation Volume Ventilation

Volume
Volume
Pressure
Pressure
21
(No Transcript)
22
???????????? Pressure Ventilation

• ????? ??????????????? ? ???????????? ?
  ???????????? ????????
• ??????? ?????? ??????????? ????
• ???????????? ??????? ???????? (PIP)
• ????? ?????????? ????? ????? (Ti)
• ??????? ????????? ???????
• ?????????? ?????????????????, V/Q ???????????? ?
  ???????????

23
?????????? Pressure Ventilation

• ??????????? ????? ???????? ? ??????????? ??
  ???????????? ??????????? ????? ? ?????????
  ???????? ?????????
• Airway resistance (Raw)
• Lung compliance (CL)

24
???????? ?? ???? ?????????

• Assist Control (??????)
• SIMV (?????????)
• CPAP (???????????????)

25
Assist/Control (AC)
26
Assist/Control Ventilation

• ?????????? ? ??????? ????????? ????
• ?????????? ???????????? ???????? ?????????? ?
  ?????????????? ??????????? F ? Vt
• ??????? ????????? ???? ? ?????????????
  ??????????? Vt

27
AC ?????????

• ?????????? ??????????? ????? ??? ????????
  ??????????? ??????????? (? ?.?. ?????
  ?????????)
• ?? ?? ??? ??????????? ?????? ??????? (??????
  ?ompliance ??? RDS)
• ????? ?????????? ????????? ???????? ?????? ? ???
  ??????????? ????????

28
IMV (Intermittent Mandatory Ventilation)
29
IMV
Mechanical Breaths
V
Spontaneous Breaths
P
30
SIMV (Synchronized IMV)

• ? ??????? SIMV, ????????????? ???????? ?????????
  ???????????????? ???????? ?????????????? ??????
  ??
• ??????????
• ????????.

31
SIMV
32
(No Transcript)
33
SIMVPS
34
SIMVPS ?????? A/C
SIMV 5 bpm
?
12 sec
A/C 5 bpm
?
Time
35
SIMV ?????????

• ?????????? ????????????? ????? ??? ??????
  ??????????? ???????????
• ? ?.?. ???????????? ????
• ?????????? ????????????? ????? ? ??????????
  ?????? ???????
• ? ?.?. ??????? ?????? (RDS)
• ??????????? ???????????????? ?????? ????????
• ???????? ?? ???????????

36
Pressure Support (PS)

• ??????? ????????? ??????? (Patient-triggered)
• ???? ????????? ?? ????????
  (Pressure-limited)
• ???? ??????????? ?? ?????? (Flow-cycled)

37
PS
38
CPAP
P

• ??????????????? ??????? ??? ????????? ??????????
  ????????

39
CPAP PS
40
????

• ????
• ????????? ???????? ???????????? ???2
• ?????????? ???, ?.?. ?????????? ???????????.
• ?????????
• ????? ??????? ????????????? ??????????
• ??? ????????, ????????? ? ????????????
  ???????????
• ??????? ????????????? ???? ? ??????
• ????????????? ??????????.
• ? ??????
• ??????? ?????????, ??????????, ???? ??????, ????.

41
BiLevel
?????????? ???????
PH
PL
Pressure Support
P
?????????????????? ????????
T
42
BiLevel PS
PEEPH
PEEPHigh Pressure Support
Pressure Support
P
PEEPL
T
43
BiLevel PS
44
BiLevel / APRV
?????????? ???????
P
T
?????????????????? ????????
45
???????? ???????? ? ??????????? ?????
46
??????? ???
47
????? ?????? ????????????? ?????????
48
???????? ? ??????????? ??????????, ??????????? ??
????????

• ??????? ??????????? ??????????? ??????? ?????
  
• (High Variable Flow)

49
?????????? ?????? ??????? ??? VC
50
??????????Pressure Control

• ??????????? ?? ?? ????????? ???????? ????????
• ?????????? ?? ?????????? ????????? ????????????
• ?????? ????????????? ?? ? ?????
• ?? ????????? PIP ??? PEEP.

51
???????? ???????
Volume control
Pressure support
Pressure control
Dual control
52
?????? ? ??????? ?????????
53
????? ?????
??????? ?????????
??????????? ????????
????? ??????
????? ????? ? ??????????? ????????
54
?????? ? ??????? ?????????

• ???????????? ?? ????? ?????? ???????????? ?????
• VAPS
• PA
• ???????????? ????? ???????
• Volume Support (VS)
• Pressure-Regulated Volume
• Control (PRVC)

55
??????? ???????? ? ??????? ???????????? ?????

• ???????????? ????? PC ? VC
• Volume-Assured Pressure Support
• (VAPS)
• Pressure Augmentation (PA)

56
VAPS

• Bear 1000 (Pressure Augmentation) SIMV, AC, PS
• Bird 8400STi
• VAPS SIMV
• AC
• PS

57
VAPS

• ??????????????? ?????????
• ??????????? ???????? (Plimit)
• ??????? ?? (Minimum TV)
• Respiratory rate
• Peak flow rate (????? TV lt Minimum)
• PEEP
• FiO2
• Trigger sensitivity

58
VAPS
Pressure Support
P
???????? ????????????
F
59
VAPS ???????????

• ???? Pressure limit ??????? ??????? PS
• ???? ??????? ????? ??????? ?????? ????????????
  ? ???????? ?? ????? ???????????
  ????????????? ????? ?????

60
??????? ???????? ????? ???????????? ???????

• ???????????? ????? PS ? PC
• Volume Support (Flow Cycled)
• Pressure-Regulated Volume Control PRVC (Time
  Cycled)

61
??????? ???????? ????? ???????????? ???????

• ??????????? ??????? ????????, ??????????? ???
  ??????????? ??
• ???????????? ?????????? ?? ??? ?????? ?l ? Raw
• ?????????????? ???????? ???????? ? ????????
  ?????? ??? ?????????? ???????? ??????????

62
??????? ???????? ????? ???????????? ???????

• Siemens Servo-300
• Volume Support (VS)
• PRVC
• Hamilton Galileo
• Adaptive Pressure Ventilation
• Drager Evita 4
• Autoflow
• Venturi Cardiopulmonary Corp.
• Variable Pressure Support

63
VS

• Servoventilator - 300A
• Pressure-limited
• Flow cycled
• ?????????????? ???????? ???????? ????????? ???
  ??????????? ?? ? ????????????? ??????????

64
Volume Support

• ??? ?????????? ???? ?????????? ???????? ( R ???
  ?)?
• ?? ????????? ???????? ?????????? ?? ??????,
  ??????? ???????????? ?? ? ??????????????
  ???????????

65
PRVC

• Pressure-Limited
• Time Cycled
• Adaptive Pressure Ventilation (Galileo)
• Autoflow (Drager Evita 4)
• ????????????? ???????????? ??????? ????????
  ????????? ??? ????????? ??????????? ?? ?
  ?????????????? ???????????

66
??????? VS ? PRV? ?? ???????? ????????????
P
67
Automode

• Servoventilator - 300A
• ?????????? VS ? PRVC ? ???? ????? ??????????
• ???????????? ????? Pressure Support ? Pressure
  Control ? ??????????? ?? ????????????????
  ???????????? ?????? ????????

68
Adaptive Support Ventilation

• Hamilton Galileo
• ??????? ???????? ????? ???????. ??????????
  ?????????? ???????? ?????????? ? ???????????
  ??????.
• ???????? ???? ????????? ?? ? ??????
  ?????? ?????????????? ???????????? ? ???????????
  ????????

69
Adaptive Support Ventilation

• ??????????????? ?????????
• ????????? ????? ???? ????????
• Volume Control (20 200)
• PEEP, FiO2, High Pressure alarm
• Flow cycle, Flow acceleration
• ??????? ??????????
• 100 ml/kg/min ??? ????????
• 200 ml/kg/min ??? ?????
• ??? ??????????????? ??????????? (100)

70
ASV
????
MV
????? ????

• Plimit
• PEEP
• FiO2

ASV
71
Adaptive SupportVentilation

• ????? ???????????? ????? ??????????
• ?? ?????? ????? ???????? ?? ???

72
Automatic TubeCompensation (ATC)

• Drager Evita 4
• ???????????? ?????? ???????, ????????????? ???

73
????????????? ??????????????? ??????
?????????? ? ???????? ?????? ?????????
?????? ?????????
6 ETT
P
7 ETT
F
74
Automatic TubeCompensation

• ???????? ?????????????? ???????????????
  ?????????? ???????????? ?????????????
  ??????????????? ??????
• P??. P?????. - ???? flow2
• ?? H2O ?? H2O/?/??? ?/???

75
AT? ??????????? ?????????

• ATC ???????? (?) ?? ??????
• ???? ??? ???????? ????????, ??? ????????? ??
  ??????????????? ??????? ?????????
• ???? ?? ?????????

76
ATC ????????

• ???????? ? PS
• ??? ?????????? ?? ??? ????????? ????????????? ???
  ??? ?????? ??????????
• ????? ???????? ?????????
• ????????? ??????????? ????
• ?? ????????????? ??????????? ????????????????
  ??????? ????? ??????????

77
ATC/ARC
78
??? AT?
??????????????? ???????
?? Fabry B. et al, 1994
AT?
dCPAPinsp -10.4 mbar dCPAPexp 8.8 mbar
dCPAPinsp -2.0 mbar (!) dCPAPexp 1.2 mbar
(!)
Ben Fabry , Josef Guttmann, Luc Eberhard,
Gunther Wolff
Ben Fabry , Josef Guttmann, Luc Eberhard,
Gunther Wolff
79
Proportional Assist Ventilation (FDA )

• Drager Evita 4
• Proportional Pressure Support
• ?????????????? ????? ? ????? ???????????????
  ????????? ? ???????????? ????????
• ???????????? ?????????
• PEEP,FiO2,
• Volume Assist ? Flow Assist.

80
Proportional AssistVentilation

• ????????????? ???????????
• ?????? ???????
• (?Norm x V) (Raw x F)
• ?????????????? ????????
• ?????????? ???????????? ?????????????? ????????

81
The Goldilocks Principle

• Dr. MacIntyre N.,
• (Critical Care Medicine 4/2000)
• ??????? PS ?????? ????
• not too low, not too high, but just right

82
Proportional Assist Ventilation

• ???? ????????? ?????????? ????? ?????? ???????,
  ??????????? ????????????
• ??????
• Volume ? Flow assist 80
• ?????????? ???????? ????????? ??? ??????
  ????????? ??????? ????????

83
??????????

• ??????????? ??????????? ???????????? ????????
  ?????? ???
• ????? ?????? ???????????? ??????????? ???????
• ??????????????? ??????, ??????????? ?? ????????
• ????????????????? ??????? ?????? ?????????? ?
  ????????????? ???????