A Dng th v hng (scalars) A1 Cc dng sng c bn

Chng ta thc s ch cn nh 3 dng th c bn sau: dng hnh vung(Square), hnh dc (Ramp), dng hnh sine (Sine). Dng Squares:

Dng sng Square i din cho cc thng s c nh, lin tc, hoc thit lp. V d nh biu din gi tr thit lp p lc trong ch kim sot p lc.
Dng Ramp:

Dng sng biu th cho cc i lng c th thay i c, s khc nhau vi nhng s thay i trong t tnh ca phi, dng sng c th l tng dc hay gim tc. Dng Sine:

Dng sng c biu th trong nhp th t pht ca bnh nhn, nhp th khng c h tr.

A2 Cc kiu dng sng

Trong mi nhp th iu c 3 dng sng c hin th trn my th: p lc, lu dng, Th tch.

p lc Lu lng Th tch

Dng p lc

th p lc hin th lng p lc c to ra trong mi nhp th, t l p lc c t pha bn tri theo thang o cmH20, p lc nh ca nhng hi th l vo khong 22 cmH20. Dng Lu lng

th hin th lu lng, tc dng chy kt hp vi tng nhp th. Dng th tch th biu hin khi lng th tch ht vo v th ra trong tng nhp th. Thang o th tch n v ml c t pha bn tri th. Th tch cung cp trong mt nhp th l vo khong 370ml.

Kiu dng sng vi mode th tch v p lc v cc ch kt hp

Nhp th p lc

Nhp th Th tch

A3 Cc d liu c th thu thp t dng sng quan st c.

1 Dng sng p lc: Kiu nhp th (Pressure vs. Volume) By kh (auto-PEEP) Tt nghn ng kh (Airway Obstruction) p ng gin ph qun (Bronchodilator Response) S tun th, sc cn ng th(Compliance/Raw) Kch th ra PIP, Pplat CPAP, PEEP S mt ng b (Asynchrony) N lc trigger

+ Kiu nhp th Tu vo nhp th l nhp th th tch hay nhp th p lc, th s c cc dng th l Ramp (dc) hay Square (vung).

Mode th tch

Mode p lc

+PIP, Plateau, RAW

Vic thit lp thi gian ngng th ht vo, hoc s dng gi th th vo (insp hold) s to ra mt p lc bnh nguyn (Pplateau) trn dng sng. Vic thit lp Pplateau cho php ta d dng quan st PIP v RAW. Thm thi gian tm ngng th ht vo c th gip ci thin kt qu thng kh. +PEEP

PEEP: p lc dng cui k th ra. Tc dng ca PEEP:

Lm tng trao i kh O2 Hn ch xp ph nang cui k th ra. Lm tng dung tch cn chc nng FRC, tng din tch trao i kh

+ Compliance/Raw

Tng RAW s dn n tng PIP trong khi Pplat khng i. + Auto PEEP

tin hnh o Auto PEEP,ta thc hin gi th th ra Expiratory Hold, v quan st trn dng sng p lc, xy ra hin tng Auto PEEP s lm tng ng p lc so vi ng c bn, mc cho php Auto PEEP <5cmH2O. 2 Dng sng lu dng.

Nu nhp th l th tch, th dng sng lu dng c dng Square (vung). Nu nhp th l p lc, th dng sng lu dng c dng Ramp (dc).

Cc d liu thu thp c t dng sng lu dng: Auto PEEP Tt nghn ng kh iu chnh thi gian i-time p ng gin ph qun Kch th ra Kiu nhp th Dng ht vo S bt ng b N lc trigger

+ Mode th th tch hay p lc.

Mode th tch Mode p lc

+ Tt nghn ng kh

Hin tng tt nghn xut hin khi dng th vo cn nhiu thi gian hn quay v ng c bn. iu ny c th gy ra cc vn i vi mode th chu k lu dng, v d nh h tr p lc gy nn hin tng mt ng b, tng cng th WOB. +Auto PEEP

Khi dng th ra khng quay v ng c bn khi bt u mt nhp th mi, y c th l nguyn nhn ca hin tng Auto PEEP. Cc nguyn nhn gy ra Auto PEEP : trn kh (emphysema), thit lp t l I:E cha ng. + p ng gin ph qun.

nh gi mc p ng vi thuc gin ph qun, ta s thy s ci thin v nh lu dng th th ra cao hn trc khi iu tr. Ngoi ra ng th ra cng sm v ng c bn hn so vi trc iu tr. + iu chnh I-time

B Dng th vng lp trong my th (loop waveform)

B1 Dng th p lc th tch.
Trc Y ca th s biu th thng s th tch, trc x biu th thng s p lc. Biu th cho qu trnh ht vo l ng cong i l, th ra l n cong i xung. im thit lp ban u ca vng lp s bt u ti gi tr PEEP c ci t.

Cdyn

D liu t th vng lp th tch p lc c s dng nh gi nhng g? S cng phng qu mc ca phi ( Lung Overdistention). S tt nghn ng kh ( Airway obstruction) Mc p ng gin ph qun trong iu tr (Bronchodilator Response ) Th my ( C/RAW) S r r (Leaks). S thiu dng (Flow Starvation) Cng th (WOB) N lc trigger.

Hai Dng th th tch p lc Trong mode th th tch (volume mode): th c dng football

Trong mode th p lc (pressure mode): th c dng square

Trong mode th p lc , p lc s c chuyn i vi mt gi tr khng i, do n s to trn th dng sng p lc mt gi tr bnh nguyn (Plateau), iu ny cng to trn th vng lp gi tr bnh nguyn.

plateau

Hin tng cng phng qu mc ca phi (Lung Overdistention) Vic p lc lin tc tng vi mt lng t hoc khng lm thay i th tch s to ra mt bird beak (dng mm chim trn vng lp) v qua gy nn hin tng cng phng qu mc cho phi. khc phc tnh trng ny bng cch gim th tch kh lu thng (tidal volume).

N lc trigger (triggering effort) Nu trong qu trnh th my bnh nhn c du hiu t th, bn s thy trn vng lp mt crossover hay tail im bt u vng lp. Cng nh Cng th cng tng, th ng tail cng di hn.

Tr khng ng th (Airway resistance) Khi tr khng ng kh tng ln. Th b rng ca vng lp cng ln hn. C 2 loi l tng tr khng ng th ra, v tr khng ng ht vo. Tng tr khng ng th ra: nguyn nhn c th do qu trnh bi tit, co tht ph qun, vv. Tng tr khng ng ht vo: nguyn nhn c th do ng t ni kh qun qu nh, ng b tht nt, hay do bnh nhn cn ng, vv.

gin n ca phi (Compliance) Tng gin n

Ly v d: trong trng hp trn kh (Emphysema)

Gim gin n

Hi chng suy h hp cp tin (ARDS), Suy tim xung huyt (CHF), Chng xp phi (Atelectasis), trn mn phi.

S r r kh Hin tng khi dng th vng lp th th ra khng i v ng c bn, cnh bo y l tnh trng r kh.

im un (Inflection points) Mt trong nhng cch bo v phi trong qu trnh iu tr ARDS, l ngh thit lp mc PEEP sao cho lun cao hn im un thp nht, nhm bo m cho ph nng lun m.

B2 Dng th vng lp Lu lng Th tch.

Trc Y ca th s biu th lu lng, trc X biu th th tch. C th c s dng xc nh dng nh lu lng th ht vo, v dng nh lu lng th th ra (PIF, PEF), Th tch kh lu thng Vt. i vi nhp th t pht th dng th vng lp s c dng hnh trn. Phn pha trn th biu th trng thi ht

vo, phn pha di th biu th trng thi th ra.

D liu t th vng lp lu lng th tch c s dng nh gi nhng g?

By kh (auto PEEP). S tt nghn ng kh (Airway obstruction). Tr khng ng kh. Mc p ng gin ph qun trong iu tr (Bronchodilator Response ). Dng ht vo, th ra. R r kh. S t nc. Thiu dng. (Flow strarvation) S mt ng b.

Dng sng ca th ht vo trn th vng lp tng ng vi dng thi lu dng.

S tt nghn ng kh (Airway obstruction). Trong mt vi trng hp s tt nghn ng kh (bnh suyn - asthma), bn c th thy nh lu lng dng th ra thp. Bn cng c th thy hin tng scooping trn ng th ra. scooping cho thy th tch th ra c tc chn li do tt nghn ng th.

By kh (Auto PEEP) hay s r r kh Nu xut hin hin tng by kh hay s r r kh, quan st trn th vng lp im cui th th ra v im u th ht vo s khng gp nhau.

S t nc trong ng th Nu c s t nc trong ng th th trn th vng lp bn s thy xut hin dng sng sawtoothed (dng sng rng ca).

S khng ng b (Asynchrony)
Thiu dng (Flow starvation)

Dng sng p lc th ht vo xut hin dip (ch trng xung) do lu dng khng , bnh nhn cn ht nhiu khong kh hn, do lm gim p lc. Mt bt li chnh ca ch dng lin tc (v d mode kim sot th tich), c th khng p ng c nhu cu ht vo ca bnh nhn. i vi my th servo, my th s t tnh ton tng lu dng cho nhp th k tip, loi b hin tng thiu dng.

Trn dng th vng lp xut hin nhiu v tr trng xung, cho thy du hiu ca s thiu dng.

By kh(Auto PEEP)
Nguyn nhn: Khng thi gian th ra, s xp ph nang sy ra sm, khng n nh/trn th th ra. Lm th no xc nh hin tng Auto PEEP theo dng th: Vi dng sng p lc: Trong qu trnh gi ng th ra , dng sng nm trn n c bn (thng thng >5cmH2O l xy ra auto PEEP). Vi dng sng lu dng: Dng sng dng th ra khng quay v ng c bn khi bt u mt nhp th mi. Vi dng sng th tch: Mt phn ca th th ra khng quay v ng c bn, Vi dng sng vng lp F V, P V: vng lp b gin on.

Khc phc nh th no: S dng liu iu tr gin ph qun (bronchodilator), iu chnihr thi gian th vo (I-time), tng dng v iu chnh PEEP.

Thay i tr khng ng th
Nguyn nhn: Hin tng co tht ph qun (Bronchiospasm). Vn vi ng t ni kh qun. Tc dng cao. Bi tit dch. Van th hay b lc b khoa hay m t. Nc trong HME.

Lm th no xc nh chng trn th: Dng sng p lc: PIP tng nhng p lc lc plateau vn khng i. Dng sng lu dng: Mt nhiu thi gian hn cho th th ra t ti ng c bn. Dng sng th tch: Mt nhiu thi gian ng cong th th ra v v tr ng c bn. Dng vng lp P V: Dng vng lp s rng hn. Dng vng lp F V: Dng th ra gim, trn ng cong th ra xut hin scooping.

Khc phc nh th no: S dng liu php iu tr gin ph qun, ht dch bnh nhn, ng dn lu, thay th HME, thay th ETT, gim lu lng, thay i b lc.

Thay i gin n (compliance)

 gin n ca phi gim. Nguyn nhn: ARDS Xp phi (Atelectasis) u bng trng. CHF Consolidation X ho (Fibrosis) Cng phng qu mc (Overdistention) Trng kh mng phi (Pneumothorax) Trng dch mng phi (Pleural effusion)

Lm th no xc nh chng trn th: Dng sng p lc: PIPv p lc lc plateau iu tng. Dng vng lp P V: Phng trc ngang nhiu.

gin n phi tng Nguyn nhn: Emphysema, tr liu Surfactant Lm th no xc nh chng trn th: Dng sng p lc: PIPv p lc lc plateau iu gim. Dng vng lp P V: Phng trc dc nhiu.

R r kh
Lm th no xc nh chng trn th: Dng sng th tch: Dng sng th th ra khng v ng c bn. Dng sng lu dng: PEF gim. Vng lp P V v F V: ng th ra khng v ng c bn

S mt ng b
Nguyn nhn: lu lng, tc , trigger, thiu dng, tn thng thn kinh, thit lp trigger khng ng Lm th no xc nh chng trn th: Dng sng p lc: Bnh nhn c gng ht/th gia dng sng, gy ra s st gim p lc.

Dng sng lu dng: Bnh nhn c gng ht/th gia dng sng, gy ra s bt thng trogn dng sng lu lng. Vng lp P V, F V: Dng sng p lc th ht vo xut hin dip (ch trng xung) do lu dng khng , bnh nhn cn ht nhiu khong kh hn, do lm gim p lc.

Khc phc nh th no: Th tng tc lu dng, gim thi gian ht vo, hoc tng cc thng s thit lp ph hp vi nhu cu ca bnh nhn hn. Thay i mode th hin ti Nu lin quan n thn kinh c th cn phi s dng ti thuc. iu chnh nhy.

C iu chnh rise time v % insp cycle off

C1 iu chnh rise time (thi gian tng k ht vo)

Thi gian tng k ht vo l thi gian cn t lu lng ht vo hoc p lc ti thi im bt u mt nhp th. Thit lp rise time nhanh

Nu thit lp mt mc rise time qu nhanh, s d dng quan st trn th s tng vt trn th p lc. Nu iu ny xy ra, bn cn phi tng thi gian tng. iu ny lm cho dng chy van m chm hn. V d v iu chnh rise time qu nhanh

Vi thit lp rise time mc 0.05, ta s quan st c trn th p lc im tng vt p lc.

Sau khi iu chnh rise time chm hn , th dng sng quan st tr v bnh thng. Thit lp rise time chm

Nu thit lp rise time qu chm dng sng p lc s nghing hn, iu ny c th nh hng n lng kh lu thng Vt c cung cp khng th p ng nhu cu bnh nhn. Nu iu ny xy ra bn cn phi gim thi gian rise time m van nhanh hn. C2 iu chnh insp cycle off

Trong ch lu lng, nh h tr th tch v h tr p lc, insp cycle off c xc nh ti thi im chuyn i t th th ra v ht vo. Cng c th hiu insp cycle off: Ngng chu k ht vo. Chm dt k ht vo. Expiratory flow sensitivity, Inspiratory flow cycle %, E-cycle, etc

Kt thc k ht vo khi dng lu lng gim n mt gi tr xc nh.

Trong v d trn my th c thit lp kt thc k ht vo v bt u k th ra 30% lu lng nh k ht vo PIF.

iu chnh insp cycle off qu cao hay qu thp

v d trn vic iu chnh insp cycle off qu cao 60% s dn n chu k ht vo kt thc qu sm, v Vt s khng .

 v d trn vic iu chnh insp cycle off qu thp 10%, iu ny s lm cho nhp th ko di. iu ny gy nh hng l n lc th ra ca bnh nhn chng li hi th to ra mt p lc tng vt (tng cng th WOB).