2 - Monitoring

-

. ( ),

auto-PEEP, ,

.

Abstract

The determination or evaluation of the mechanical properties of a patients respiratory system allows the in-

tensive care physician to optimize the conditions of mechanical ventilation while protecting the patient from

problems associated with the use of the ventilator. Airway pressure (maximum dynamic and static), auto-PEEP,

elastance, compliance and resistance are all key measurable characteristics which must be constantly evaluated

in each patient under mechanical ventilation.

.

2.1.

. H

(P),

. , monitoring -

( ) : )

(Pairway, Paw), ) (Pesophageal, Pes), -

(Ppleural, Ppl), ) (V*) .

2.2.

H

. (Palveolar,

Palv) (Ppl), (Ptrans-pulmonary, Ptp), Ptp = Palv Ppl. (Ppl)

(Patm), (Ptrans-thoracic Ptrans chest wall, Pcw),

Pcw = Ppl Patm.

Palv

Patm (Ptrans-respiratory, Prs = Palv Patm), (Ptrans-airway, Pta) ,

(Pairway opening, Pao) (Palv), -

Pta = Pa Palv, ( 2.1) [1, 2].

T

rs

VPaw Rrs V Pex Irs V

C

2.1 : P , PALV

, PPL , PATM , PAB , PTP , PCW -

, PRS , PTA .

, Paw ( , ,

) (Paw Patm) -

: ) ,

(resistive pressure cost), ) (elastic

pressure cost), ) , PEEP auto-PEEP, ) .

.

:

Paw , VT (tidal volume) , Crs (compliance of respiratory

system) , Rrs (resistance of respiratory system)

, (flow) , Pex (end expiratory pressure) , Irs

(inertance f respiratory system) V (acceleration) -

.

, .

, -

, [3].

2.3. (Paw)

, , ,

(Rrs) (Crs) . -

,

. , ,

( 2.2).

, .

. (

1),

.

.

,

.

-

. -

.

(Palv). PD

, Ppeak. T PF PS -

(pause). PZF

. PS -

. -

.

-

.

2.2

.

- ,

. PD , PZF

PS .

Paw, ,

,

(Crs) ( 2.3.).

2.3

. H -

() , () -

() .

H Paw ( 2.3.)

, , -

. Paw

( 2.3.),

. Paw , -

PEEP auto-PEEP /

, [4].

, (triggers)

.

, .

(triggered) , Paw .

(scalloping) , ,

() (VT).

PD Paw

-

( 2.4).

2.4 (assist control) . -

-

.

monitoring

.

, ,

,

-

[5].

2.4. (peak dynamic pressure, Ppeak PD)

, PD

( )

(VT) ( 2.2). PD (Rrs), (Crs) -

,

.

PD.

, cuff PD. H PD

. H

PD. PD ,

,

.

2.5. (S, Pplateau)

H (PS)

(Pex = PEEP + auto-PEEP) -

. (CL),

(Ccw) PS. H PS

(stop-flow), 0,5-1,5 s.

, Paw 0,3-2,0 s PS.

, plateau, : stress

relaxation (gas redistribution). H -

(time-

constant) . ,

, Pplateau

. H Pplateau -

( ). H Pplateau 1-5 cm H2O

(PZF). ,

, PS

(Palv), . (stop-flow no flow conditions)

Palv . H

(Pex). H Pex

PEEP auto-PEEP, PEEP (ZEEP)

auto-PEEP.

PS VT

(Ccw) (CL)

(FRC) auto-PEEP ( 2.5).

2.5 H .

H PS ,

, PD. -

(FRC) PS : ) -

auto-PEP )

(pressurevolume curve) .

, -

. , monitoring

monitoring , , , -

. , -

, ,

strain (strain = / )

. ,

PS (Pplateau). PS

,

auto-PEEP. PS 30 cm H2O

[6].

2.6. (PZF)

,

PD PZF. , Pplateau

( 2.1). H PD PZF (PD PZF)

. H PZF PS (PZF PS)

(pendelluft) /

(viscoelastic phenomena).

2.7. Auto-PEEP

(TE)

, (dynamic hyperinflation). , auto-

P (Palv) Paw. aut-PEEP -

(minute ventilation, VE) , ,

. auto-P -

, , -

[7].

2.6 . ().

auto-P . , auto-P -

, auto-P

, (Ptrans-pulmonary).

H -

auto-P, -

( 2.7) [1, 5].

2.7 3 auto-PEEP. H auto-PEEP

(), . , ,

, auto-PEEP

( ).

H auto-P

,

( auto-P) ( 2.8). H auto-P,

plateau, auto-

P.

2.8 () auto-PEEP (

): auto-PEEP 4 (9-5) cm H2O. () PEEP 5 9 cm H2O

auto-PEEP.

H auto-P , ,

Paw ( ) ( 2.9). ,

auto-P ( auto-P). -

, , auto-P

auto-P. -

.

2.9 (Paw) ,

(CMV), . PD, P PS ,

(Pplateau). (Palv)

. -

auto-PEEP (AP1). , auto-PEEP Paw

(AP2).

T

I

T

TPeepDCBAmPaw

)(

2.8. (mPaw) (mPA)

2.8.1.

, -

(Presistive) ( 2.10, ) (Pelastic). H

(Pelastic) : ) -

(Pend expiratory, Pex = PEEP + auto-PEEP), -

, FRC,

( 2.10, D). )

( 2.10, B). )

(pause) ( 2.10, C). -

, Paw , ,

, . , Paw (mPaw) -

Paw, , -

(TT):

Presistive = RI x VT RI VT ,

Pelastic = VT/Crs Crs (compliance), C

pause = PS x pause time D PEEP x TT.

2.10

. : (frictional). : -

(tidal elastic). C: -

(pause). D: PEEP. auto-PEEP

.

2.8.2.

(mPA)

,

(.., ).

( )T

T

B C D E autoPeep TmP

T

, m mPaw 3 : 1. m

. 2. m

. 3. auto-PEEP mPA

, mPaw . PA (mPA)

PA

(T):

Pelastic = VT/Crs, C pause = PS x pause time, D PEEP x TT RE x VT, RE

.

mPA

Paw (mPaw) :

VE , R R .

H mPA mPaw ,

. , , mPA = mPaw RE =

RI. , , .

, -

, mPA mPaw,

(VE). , mPaw ,

mPA [8].

2.9. (Ppleural, Ppl) (Pesophageal, Pes)

.

Ppl

. Ppl -

. Ppl

Ppl

(deflation recoil) . , Ppl -

( ,

Ptp = Palv Ppl).

(pl). H

(balloon)

, .

,

.

, Pes

. , , , Pes Ppl. ,

Pes Ppl.

H .

,

(sniff maneuver). O

. , 10 cm , ,

. ,

, . 8 ml

( )60

EE I

VmP mPaw R R

, , 6,5-7,5 ml, 0,5-1,5 ml.

(Pes)

(Paw) .

, (transpulmonary)

(Paw Pes) [9, 10].

2.10.

-

, 25 %

. -

,

. 0 cm H2O

6-11 cm H2O .

,

.

2.11. (flow, )

H ( ) . H

, R = P/ .

= x Ve, . (laminar), e 1,

(turbulent), 2 , , .

VT, Crs ,

Paw. , Crs ,

.

. ,

, ( 2.6). ( ) -

(stop flow technique) . -

, ,

(expiratory flow limitation).