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(2006) 65 Practical guidelines for m echan ical ven tilation (2006) S ociety of C ritical Care M ed icine Ch inese M ed ical A ssociation Corresp ond ing au thors: Q IN Y ing 2z h i (D ep artm ent of

1 (2006) 65 Practical guidelines for m echan ical ven tilation (2006) S ociety of C ritical Care M ed icine Ch inese M ed ical A ssociation Corresp ond ing au thors: Q IN Y ing 2z h i (D ep artm ent of Intensive Care U nit the T h ird Central H osp ital T ianj in Ch ina. Em ail: y z y ahoo. com. cn ) and L IU D a2w ei (D ep artm ent of C ritical Care M ed icine P ek ing U nion M ed ical Colleg e H osp ital Ch inese M ed ical S cience A cad em y B eij ing Ch ina. Em ail: dw liu@m edm ail. com. cn or dw liu@p um ch. cn) Abstract W ith the expanding understanding of basic know ledge concern ing resp irato ry function and techno logy of resp irato r m echanical ventilation has becom e an impo rtant interventional arm am entarium to imp rove gas exchange and decrease resp irato ry w o rk. It is one of the impo rtant m eans to enhance oxygen delivery p ro tect the lung and resto re hom eo stasis in the treatm ent of m ultip le o rgan dysfunction syndrom e. T he p rogression in m edical sciences and increasing data pertain ing to evidence - based m edicine have also render the u se of m echan ical ven tilation standardized w ith m o re app rop riate indication. U nder the afo rem entioned conditions it seem s to be essential that the indications and the operation and m anipulation of the soph isticated ven tilato r shou ld be standardized in the care of critically ill patien tṡ A t the sam e tim e accum ulation of clinical experiences in recent years w ith abundant relevant data as a result of m ulti- center studies have furnished h igh ly valuable info rm ation to accomp lish th is effo rṫ Based on evidenced- base data the Ch inese Society of C ritical Care M edicine (Ch inese M edical A ssociation) held a consensus conference to draft a guideline fo r the recomm endation of m echanical ventilation to catego rize all the info rm ation gathered from the literature into five grades from A to E w ith A being the h ighest acco rding to a modified D elph i criteria w h ich w ere adop ted by the In ternational Sep sis Fo rum held in A fter fu rther nationw ide inqu iries and con scien tiou s discu ssion s th is gu ideline has been drafted pending fu rther addition and co rrection. T h is gu ideline ch iefly covers the fo llow ing aspects: the cho ice of m echan ical ven tilation fo r critically ill patien ts the aim and indication of m echan ical ven tilation non - invasive po sitive p ressu re ventilation regulation of modes and settings of the ventilato r etc. W ith imp lem entation of the guideline it is hoped that the clinical use of m echanical ventilation in the critically ill patients w ill be mo re o r less standardized. T he guideline w ill be updated w hen new know ledge is available. : (DO 2) ; (M OD S) ; ; ; : ; ( ) : 2001 ISF D elph i 5 : D elph i A E A : ; ; ; 1 ; : (VA P) : 1. 1 ( ) :

2 66 : 2. 2 : : ( ) ; ; ; VA P ; Ko llef 343 VA P VA P 4: (B ) 1: 2. 3 : (D ) 1. 2 : ( ); ( ) VA P 1989 : % 10 d VA P 21 d d ( ) K irton ( ICU ) VA P (RCT ) VA P 48 h 2 7 d 7 d 21 d 2 : ; 5: (C ) 2. 4 : ; ; ; VA P ; Graven 24 h 48 h ; Ko llef H ess : 7 d : ; 1 VA P ; 7 d 1 d VA P VA P (PCT ) VA P ICU 2: 6: (C ) (B ) : : ; ; ( ) ( Ppeak) (PCV ) (PEEP) (E ILV ) (V T) (EELV ); 2. 1 : cm H 2O (1 cm H 2O = kpa) : (PaCO 2) ph PaCO 2 Granja 95 ph ; 3 (CO PD ) ; Guyton : Ppeak (F io 2) (PaO 2) > 3: (C ) 60 mm H g ( 1 mm H g = kpa )

3 67 (SaO 2) > 0190 (CaO 2 ) PaO 2 (A ECO PD ) (A CPE) (H b) DO 2 CaO 2 (CO ) RCT N PPV DO : (PEEP i) N PPV (A RD S) : ( ) 7: N PPV A ECO PD A CPE : (A ) 8: N PPV (B ) : ( ) 4. 3 : (B ipa P) ( IPA P) cm H 2O (> 100 L gm in) 3. 2 : ; g F io 2 (> 0150) (CO 2) 4. 4 : N PPV : 24 h ; ; > 35 N PPV 40 gm in < 6 8 gm in 4. 5 : (CPA P ) ; : PaO 2< 50 mm H g B ipa P B ipa P < 50 mm H g; PaCO 2 ph : S : (PSV ) + PEEP (T PCV + PEEP) B ipa P IPA P (EPA P) ( ( ) S ; ) S T 4 (NPPV) PCV A CPE CPA P N PPV g B ipa P N PPV B ipa P : IPA PgEPA P ; B ipa P 1 N PPV ( 1 B ipap VA P ) ( ) N PPV ( IM V ) IPA P (V T ) cm H 2O (7 15 m lgkg) EPA P 3 5 cm H 2O (g 4 12 cm H 2O ) IM V ; (T ) gm in s IM V N PPV IM V 4. 6 N PPV : N PPV N PPV N PPV 4. 1 : N PPV : N PPV ( ) : N PPV N PPV : N PPV : g (A PA CH Eg ) N PPV N PPV X : ( ) 9: N PPV 1 2 h ( ) (D ) N PPV : Girault 2 N PPV 5. 1 : 6410% N PPV % N PPV : N PPV CO PD

4 68 - : V T g IM V (S IM V ) S IM V (V PV ) : IM V V T V PV V T V PV ; S IM V ; IM V ; ; ( V T ) : : V T V T V T PEEP : ( ) PCV (P- A CV ) - (PC - S IM V ) PSV (PPV ) CV PPV V T PSV A RD S (V IL I) PEEP V T (CV ) (AV ) CV : ICU V T g PSV : PSV CV V T g (PS) CV PEEP i : CV ; (ESEN S) ; CV : CV ; ; AV 5 8 cm H 2O AV : PSV PSV ( PS ) ( ) V T ; ( ) IPA P ( ) AV CPA P: CPA P ( ) 5. 2 PEEP (assist- contro l ventilation A CV ): : CPA P A CV AV CV : PEEP V T CV ; AV PEEP i PEEP i CPA P A CV P- A CV (V - A CV ) CPA P : A C: V T CPA P g ; A C: PEEP B ipa P: B ipa P : A C ICU (Ph igh) (P low ) V T ( ) (T insp ) Ph igh P low ; CV Ph igh P low PSV S IM V : S IM V CV : Ph igh P low PEEP T insp : B ipa P Ph igh ( S IM V ) ( P low S IM V ) B ipa P (A PRV );

5 69 B ipa P T insp 20 gm in (Pm ean) ; V T (f) B ipa P CV 6. 3 : L gm in Ph igh ; PSV PCV g : g (H FOV ): H FOV H z V T ( s g ; CV ) CO 2 Pm ean g H FOV PEEP i ( 1g15 1g5) 6. 5 : cm H 2O 2 5 L gm in : A RD S : F io 2> 0160 (PaO 2gF io 2) < 200 mm H g > 24 h Pm ean> 20 cm H 2O PEEP > 15 cm H 2O ) PaO 2gF io 2 > ; 20 mm H g (PaO 2gF io 2= Pm ean F io 2 100g ) : Pm ean: PaO F io 2: F io 2 (1100) Pm ean 2 4 cm H 2O PaO 2 PEEP Pm ean 45 cm H 2O F io 2 F io SaO 2 Pm ean F io 2< 0160 ( P): > 0190 PEEP Pm ean PaCO 2 ; PEEP Pm ean SaO 2> cm H 2O PaCO F io 2 : 3 6 H z PaCO PEEP : PEEP ( g ) 33% 50% g Pa2 Pm ean CO 2 (bias flow ): L gm in PEEP i PEEP A RD S : PaCO 2 (RM ): g PEEP PaO 2 DO 2 RM F io 2 V T PEEP : A RD S RCT H FOV - (P - V ) (L IP) L IP 2 cm H 2O PEEP i (52% 37% ) PEEP PEEP PEEP i 80% H FOV PEEP (PAV ): PAV PAV : (FA ) (VA ) CPA P : 7. 1 PAV : - PAV Pm ean ; PAV PS X ; PS FA : VA CPA P PEEP i 6 25 cm H 2O 6. 1 V T : V T : : 5 12 m lgkg cm H 2O PCV V T 6. 2 : : (PaO 2) gm in PaO 2

6 70 A PA CH Eg : (GCS) < 9 VA P : VA P : : F io 2 F io ; ; F io ; F io : : 24 h : : 1% 5% ; ( 24 h : ) CO PD : CV : : h 40% : : : : : : CO : : : : V IL I: : : E ILV ; CO V IL I V IL I : V IL I V T cm H 2O PEEP PEEP VA P: VA P 48 h : 28% VA P VA P VA P 7. 4 : VA P VA P

7 71 CO 33% 11: (A ) 8. 3 (SBT ): 3 m in SBT 3 m in T CPA P 5 cm H 2O gpsv 3 m in SBT SBT : (RV R ) < 105; > 8 gm in < 35 gm in; < 140 gm in < 20% ; V T> 4 m lgkg; SaO 2> m in m in 30 m in 120 m in SBT 8 SBT m in 77% SBT CPA P g ; SBT 2 2 SBT 8. 1 : 24 h : : SBT : (F io 2< 0140 SpO ; ( PaO mm H g; ph 7132; PaCO 2 10 ) mm H g) ; (HR < 120 ( 140 gm in HR < 20% < 180 ); 200 mm H g > 90 mm H g < 20% : ) ; ( gm in ( ) 50% ) ; SBT ( : ) ; ; ( ) : : HR ; SpO 2 12: SBT (A CO 2 ) 8. 4 : ; : : ; ; : : ( ) 10: 24 h ( ) ( ) (B ) 24 h 8. 2 : ( ) 4 : : PaO 2gF io mm H g; PEEP 5 8 cm H 2O ; F io ; ph ( ) 7125; CO PD : ph > 7130 F io 2 < 0135 PaO 2 > : 50 mm H g ( ( > 2 hg < 5 10 Λg kg - 1 m in - 1 ) ) 13: SBT (B ) 5% 15% VA P SBT : SBT 6 12 ICU 4% 23% SBT 1 SBT

8 72 1 d SBT 5 1 d SBT Tobin SBT A CV E steban 2 SBT 1 SBT 15: (A ) SBT 24 h ( 8. 7 (PM V ) : ) ( ) (A SV ) 3 PM V (MM V ) ICU PM V ICU SBT PM V ICU N PPV N PPV PM V SBT N PPV ICU SBT VA P 14: SBT (A ) 16: PM V 8. 6 : 24 h (B ) ( ): - 1 (D IC) (M OD S) 117 D IC D IC D IC D IC D (PA I- 1) D IC D - PA I- 1 D IC PA I- 1 > 90 ΛggL PA I- 1 < 30 ΛggL ; PA I- 1 > 90 ΛggL D IC 28 d PA I- 1 D IC D IC PA I- 1 D IC Int J H em ato l (5): ; SS- 31 (SS- 31) SS- 31 SS- 31 SS- 31 SS ( ) SS- 31 SS- 31 SS J Am Soc N eph ro l (1): ; - Α- - Α- - Α- 266 g 5 d : - Α- ( )m ggl (290 15)m ggl ; 5 d - Α- - 6 ( IL - 6) ; - Α- - Α- C rit Care M ed ( );

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