Umelá ventilácia detí
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1 Umelá ventilácia detí Milan Kurák III. KPAIM SZU Bratislava a DFN Košice; kurakm@zoznam.sk CEEA 2012 Košice
2
3 UPV u detí Ako dopadne? Budú ho ventilovať na OAIM?
4 UPV u detí sebadôvera 50% úspechu Vt 6ml/kg Ti 30% - 1:2 F PEEP 5
5 Východisko The Acute Respiratory Distress Syndrome Network...protective low VT strategy of 6 ml/kg plateau pressure less than 30 cm H2O, versus 12 ml/kg with a plateau pressure less than 50 cm H2O. They found a statistically significant reduction in mortality from 39.8% to 31% in the lower VT group [11]. current guidelines recommend VTs of 6 ml/kg of PBW for the management of patients with ALI or ARDS [33]. R. G. Brower, M. A. Matthay, A. Morris, D. Schoenfeld, B. T. Thompson, and A. Wheeler, Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome, New England Journal of Medicine, vol. 342, no. 18, pp , 2000
6 UPV u detí Deti Normálny dychový objem 6-8ml/kg Vitálna kapacita 30-40ml/kg Dojč ml/kg Dieťa nie je malý dospelý
7 Je to dôležité? Spotreba kyslíka Dojča 8-10 ml/kg/min Dosp ml/min BMR 55 kcal/kg/deň 25 kcal/kg/deň
8 Je to dôležité? Najužšia časť subglotický priestor Zúženie o 1 mm vzostup rezist o 33% Mäkké chrupky Trachea ( jej priemer) široká od 3-4 mm u detí, cca mm u dospelých Raw Novorodenci 3-4 kpa* l-1*s-1 Batoľatá 2-3 kpa* l-1*s-1 Malé deti 1-2 kpa* l-1*s-1 Dospelí 0,2-0,4 kpa* l-1*s-1
9 Je to dôležité? Dojča perif dych cesty < 2mm 50% rezist. Dosp 20% Kolaterálna ventilácia Interalveolárne a bronchoalveolárne kanáliky Počet alveolov 20 mil...dosp 300mil. Vo veku 5-8 rokov
10 Etiológia respiračného zlyhania Dýchacie cesty Epiglotitída, Laryngitída, Aspirácia cudzieho telesa, Astma Pľúcny parenchym Bronchiolitída, ARDS, Pneumónia, Edém pľúc CNS Kraniocerebrálna trauma, Intrakraniálne krvácanie, Intoxikácie Periférny nervový systém Poranenie miechy, Guillan-Barrého syndróm Dýchacie svaly Svalové dystrofie, Kachexia, Myasténia gravis Hrudník Hemothorax Chylothorax Deformity hrudníka Pneumothorax Pľúcne cievne riečište Embólia do pľucnice Perzistujúca pľúcna cirkulácia
11 Anamnéza 50% diagnózy Novorodenecké obdobie UPV intubačná stenóza BPD Inspiračný stridor
12 Fyzikálne vyšetrenie Tachypnoe Charakter kompenzácie Vťahovanie mäkkých štruktúr Interkostálne priestory, jugulum, epigastrium Nazálne súhyby Postonkávanie Psychomotorický nekľud
13 Fyzikálne vyšetrenie Inspiračný stridor Okolnosti vzniku Teplota, slinenie, hlas, poloha Kongenitálne anomálie manifestácia pri respiračnom infekte
14 Fyzikálne vyšetrenie Kardiovaskulárny systém Akcia srdca Indikátor stavu dieťaťa Nekoreluje s PSM kľudom? bradykardia Adekvátny artériový tlak najmä periférna perfúzia snímanie saturácie kyslíka novorodenec dojča batoľa školák adolescent 60 90
15 Indikácia UPV u detí Laboratórne PaCO 2 > 8-9k Pa Pa O 2 < 8kPa pri liečbe kyslíkom Klinické Apnoe Cyanóza pri liečbe kyslíkom Tichý hrudník nadmerná dychová práca Alterovaná cirkulácia
16 Intubácia midazolam, propofol, thiopental Pomôcky na obtiažnu intubáciu ET kanyly Termin. nov.» U/3,5 - Kojenec» U/3,5 4,0 C/3,0 3,5 Dieťa 1 2 roky» U/4,0 4,5 - C/3,5 4,0 > 2 roky» vek/ vek/4 + 3,5 Resusc. 2010
17 RTG Hrudníka Pozorovať symetr. snímky klavikuly Správna poloha ET kanyly Nad karinou Na úrovni tela stavca Th 2 3
18 Úvodné nastavenie Tlaková ventilácia Objemová ventilácia Konštantná minútová ventilácia Tlaková podpora min cmh 2 O Požadovaný objem 6 8 ml/kg
19 Inspiračný tlak Optimálny inspiračný tlak Vt 4-8 ml/kg 30 cmh 2 O < 35 cmh2o
20 Inspiračný čas Časová konštanta Nov. 0,12 s Dojča 0,3 s Dosp. 0,5 s 3-5 konšt.
21 Inspiračný čas Vek Sekundy Novorodenec 0,25 0,5 Dojča 0,5 0,6 Batoľa 0,5 0,75 Školáci 1,0 1,5 Adolecsenti 1,0 2,0
22 Frekvencia Vek Počet dychov/minútu Novorodenec 30 Dojča rokov 20 Viac ako 5 rokov 16 et CO 2
23 PEEP Zabraňuje kolapsu alveolov Optimalizácia FRC Zlepšenie oxygenácie Redukcia dychovej práce Distribučná homogenizácia V/P
24 Analgosedácia Adekvátna synchronizácia s ventilátorom benzodiazepíny midazolam opiody morfín, sufentanyl, fentanyl ketamin propofol relaxácia Optimálna hĺbká sedácie
25 Pozeraj na pacienta Počúvaj pacienta Saturácia O2... etco2 RTG hrudníka Ventilátor krivky D isplacement O bstruction P neumothorax E quipment S tomach Problémy
26 Komplikácie iritácia kože po fixácii ET kanyly leukoplastom poranenie sliznice trachey opakovaným odsávaním, opuch dýchacích ciest, barotrauma cirkulačná instabilita nozokomiálne infekcie chronické poškodenie pľúc
27 Extubácia postupné odpájanie dostatočné vedomie, fungujúce reflexy dýchacích ciest min. spotreba kyslíka FiO2<0,3 so saturáciou SpO2 >94% min. frekv. podporného režimu 5 dychov/min min. tlaková podpora 5-10 cmh2o nad PEEP
28 Akútna bronchiolitída vírusová etiológia zápal - dolné úseky dýchacích ciest, najmä bronchioly zásady protektívnej UPV neočakávane agresívna ventilácia
29 Bronchiálna astma bronchospazmus a zápal dynamická hyperinflácia - auto-peep Indikácia na UPV (vysoká mortalita) Progresívne zhoršovanie tichý hrudník kauzálna liečba optimálne I<<E permisívna hyperkapnia - TGI
30 ALI/ARDS multifaktoriálna etiológia Vt 5-7 ml/kg, dostatočný PEEP cm H2O min. FiO 2 ( menej ako 0,6) permisívna hyperkapnia pco 2 < 12 kpa (ph >7,25) nižšie hodnoty saturácie kyslíka (sato 2 >88%) optimalizovaná dodávka kyslíka hemoglobínu (Hb>100 g/l ) optimálny srdcový výdaj pronačná poloha, inverzný režim Mimoventilačná starostlivosť
31 TBI TBI objemový režim stabilná minutová ventilácia etco2 Nízky PEEP
32 Chronická UPV u detí Stabilný ventilačný režim Rodina Neurologické postihnutia Centrálny hypoventilačný syndróm Svalové ochorenia Chronické poškodenia pľúc Prekvapujúco dobré výsledky
33 Prečo? Regionalizácia pre dobro pacienta KPAIM Sek. transport DO Primárny transport
34 Transport pacienta Stanovenie priorít napr. ARDS Rýchlosť Odosielateľ KOMUNIKÁCIA (Dôvera) Osobné mobilné telefóny (Záznam) Príjemca Transp. tím Stabilizácia
35 UPV dieťaťa O kvalite starostlivosti rozhoduje najslabšie ohnivko reťaze
36 Záver Vt 6ml/kg Ti 30% - 1:2 F PEEP 5
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