ffiltvebis xelovnuri ventilaciis tanamedrove metodebi da rejimebi mmamuka cxaize. 2006 weli. tbilisi

Ffiltvebis xelovnuri Ffiltvebis xelovnuri ventilaciis ventilaciis Tanamedrove Tanamedrove meTodebi da reJimebimeTodebi da reJimebi

Mmamuka CxaiZe. 2006 weli. Mmamuka CxaiZe. 2006 weli. TbilisiTbilisi

“… “… an opening must be attempted in the trunk of the an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again… and will then blow into this, so that the lung may rise again… and

the heart becomes strong…”the heart becomes strong…”

Andreas Vesalius Andreas Vesalius (1555)(1555)

1555 weli - dadebiTi wneviT ventilaciis pirveli koncefcia -–VesaliusVesalius

1955 weli - dadebiTi wneviT pirveli, industriuli ventilatori –- Emerson Company, Emerson Company, Boston, Massachusetts.Boston, Massachusetts.

aqedan daiwyo filtvebis xelovnuri ventilaciis (da intensiuri Terapiis)

era

Mmeqanikuri ventilacia aris intubirebuli pacientis sicocxlis uzrunvelyofis damxmare da ara Terapiuli meTodi

Consensus Conference on Mechanical Ventilation - Consensus Conference on Mechanical Ventilation - January 28-30, 1993, Northbrook, Illinois, USA. January 28-30, 1993, Northbrook, Illinois, USA. Chairman - A . S . Slutsky - Canada. " Intensive Care Chairman - A . S . Slutsky - Canada. " Intensive Care Medicine " - Reports, Guidelines and Recommendations. Medicine " - Reports, Guidelines and Recommendations. 19981998

Kklinikuri situaciebi Kklinikuri situaciebi romlebic moiTxoven f.x.v.-romlebic moiTxoven f.x.v.-

as as sasunTqi sistemis dazianeba –- sasunTqi sistemis dazianeba –- ventilaciuri sunTqvis ukmarisobaventilaciuri sunTqvis ukmarisoba

sunTqvis nervuli regulaciis moSla sunTqvis nervuli regulaciis moSla -–-–centraluri an periferiulicentraluri an periferiuli

qalasSida wnevis regulaciaqalasSida wnevis regulacia K sunTqvaze daxarjuli muSaobis K sunTqvaze daxarjuli muSaobis

Semcireba -Semcireba -kritikul kritikul mdgomareobaSi myofi pacientebimdgomareobaSi myofi pacientebi – –

Qqirurgiuli operaciebi – - Qqirurgiuli operaciebi – - anesTeziis saWiroebaanesTeziis saWiroeba

f.x.v.-is amocanebi f.x.v.-is amocanebi (miznebi)(miznebi)

AA.. Ffiziologiuri amocanebiFfiziologiuri amocanebi

B.B. Kklinikuri amocanebiKklinikuri amocanebi

f.x.v.-is fiziologiuri f.x.v.-is fiziologiuri amocanebi:amocanebi:

1. 1. SevinarCunoT da vmarToT filtvebSi SevinarCunoT da vmarToT filtvebSi gazTa normaluri cvla :gazTa normaluri cvla :

_ alveoluri ventilacia _ alveoluri ventilacia ( PaCO2, pH )( PaCO2, pH ) : : ventilaciuri ventilaciuri daxmarebis mTavari amocana, umetes daxmarebis mTavari amocana, umetes SemTxvevaSi, alveoluri ventilaciis normalizebaa SemTxvevaSi, alveoluri ventilaciis normalizebaa (zog SemTxvevaSi (zog SemTxvevaSi hiperventilaciahiperventilacia an an permisiuli permisiuli hiperkapniahiperkapnia). ).

_ arteriuli oqsigenacia _ arteriuli oqsigenacia (PaO2, SaO2):(PaO2, SaO2): mTavari mTavari amocanaa mivaRwioT da SevinarCunoT arteriuli amocanaa mivaRwioT da SevinarCunoT arteriuli sisxlis oqsigenaciis done mocemuli sisxlis oqsigenaciis done mocemuli klinikuri klinikuri SemTxvevisTvis misaReb cifrebzeSemTxvevisTvis misaReb cifrebze, Jangbadis , Jangbadis dasaSvebi koncentraciis gamoyenebiTdasaSvebi koncentraciis gamoyenebiT (klinikuri (klinikuri SemTxvevebis umetesobisaTvis - es niSnavs SemTxvevebis umetesobisaTvis - es niSnavs SaO2 >SaO2 > 90% an 90% an PaO2 >PaO2 > 60 60mmHgmmHg) )


2. 2. gavzardoT filtvebis moculoba:gavzardoT filtvebis moculoba:_ _ CasunTqvis bolos filtvebis adeqvaturi gaSlaCasunTqvis bolos filtvebis adeqvaturi gaSla : :

mivaRwioT filtvebis sakmaris gaSlas yovel mivaRwioT filtvebis sakmaris gaSlas yovel CasunTqvaze, raTa Tavidan aviciloT CasunTqvaze, raTa Tavidan aviciloT SesaZlo, an vumkurnaloT arsebul SesaZlo, an vumkurnaloT arsebul

ateleqtazebsateleqtazebs _ _ funqciuri rezidualuri funqciuri rezidualuri (FRC)(FRC) tevadobis tevadobis

normalizebanormalizeba : : raTa mivaRwioT f. r. t.- is raTa mivaRwioT f. r. t.- is momatebas ( normalur maCveneblebamde ) an momatebas ( normalur maCveneblebamde ) an SevinarCunoT gazrdili f. r. t.SevinarCunoT gazrdili f. r. t. PEEP- PEEP- is saSualebiT is saSualebiT


3.3. SevamciroT an / da vakontroloT SevamciroT an / da vakontroloT sunTqvaze daxarjuli muSaoba:sunTqvaze daxarjuli muSaoba:

_ _ SevamciroT sasunTqi kunTebis datvirTva:SevamciroT sasunTqi kunTebis datvirTva: rodesac pacients sunTqva gaZnelebuli rodesac pacients sunTqva gaZnelebuli aqvs, sunTqvis procesi Zlier datvirTvas aqvs, sunTqvis procesi Zlier datvirTvas moiTxovs - gazrdili rezistentobis Tu moiTxovs - gazrdili rezistentobis Tu daqveiTebuli komplainsis gamo, Tanac es daqveiTebuli komplainsis gamo, Tanac es datvirTva naklebad efeqturia an saerTo datvirTva naklebad efeqturia an saerTo mdgomareobis simZimis gamo sasurvelia mdgomareobis simZimis gamo sasurvelia

minimaluri energo danaxarjebi.minimaluri energo danaxarjebi.

f.x.v.-is klinikuri f.x.v.-is klinikuri amocanebi:amocanebi:

1. 1. SevamciroT an movxsnaT SevamciroT an movxsnaT hipoqsemia:hipoqsemia: gavzardoTgavzardoT PaOPaO22 anuanu SaOSaO22, , alveoluri ventilaciis gazrdiT, filtvebis moculobis alveoluri ventilaciis gazrdiT, filtvebis moculobis momatebiT, Jangbadis miwodebis gazrdiT an momatebiT, Jangbadis miwodebis gazrdiT an Jangbadis moxmarebis SemcirebiT, am Tu sxva Jangbadis moxmarebis SemcirebiT, am Tu sxva meTodebiT SevamciroT sicocxlisaTvis saSiSi meTodebiT SevamciroT sicocxlisaTvis saSiSi hipoqsiis xarisxi.hipoqsiis xarisxi.

2. 2. SevamciroT an movxsnaT mw. SevamciroT an movxsnaT mw. respiratoruli acidozi:respiratoruli acidozi: SevamciroT SevamciroT ”sicocxlisaTvis saSiSi “' ”sicocxlisaTvis saSiSi “' acidemiaacidemia da swrafad da swrafad daviyvanoTdaviyvanoT PaCO PaCO22 normis farglebSi.normis farglebSi.


3. 3. SevamciroT respiratoruli distresi:SevamciroT respiratoruli distresi: raTa SevamciroT avadmyofisaTvis autaneli raTa SevamciroT avadmyofisaTvis autaneli diskomforti, sanam pirveladi avadmyofoba an diskomforti, sanam pirveladi avadmyofoba an disfunqcia likvidirebuli iqneba.disfunqcia likvidirebuli iqneba.

4. 4. ateleqtazebis reversireba an maTi ateleqtazebis reversireba an maTi prevencia:prevencia: Tavidan aviciloT an Tavidan aviciloT an gamovasworoT filtvebis arasruli gaSlis Sedegad gamovasworoT filtvebis arasruli gaSlis Sedegad ganviTarebuli klinikuri gverdiTi movlenebi.ganviTarebuli klinikuri gverdiTi movlenebi.

5. 5. sasunTqi kunTebis gadaRlis sasunTqi kunTebis gadaRlis Tavidan acileba:Tavidan acileba: umetesoba umetesoba SemTxvevebisa es niSnavs sasunTqi kunTebis SemTxvevebisa es niSnavs sasunTqi kunTebis gadatvirTvis Semcirebas maSin, roca gadatvirTvis Semcirebas maSin, roca datvirTva Zalian didia an roca sasurvelia am datvirTva Zalian didia an roca sasurvelia am datvrTvis minimumade dayvana.datvrTvis minimumade dayvana.


6. 6. mogveces saSualeba sedacia an mogveces saSualeba sedacia an / / da da neirokunTovani blokada neirokunTovani blokada gamoviyenoT:gamoviyenoT: roca saWiroa zogadi roca saWiroa zogadi anesTezia, Rrma sedacia (manipulaciebis dros), anesTezia, Rrma sedacia (manipulaciebis dros), aseve im daavadebebis dros roca saWiroa Rrma aseve im daavadebebis dros roca saWiroa Rrma sedacia, relaqsacia, spontanuri sunTqvis sedacia, relaqsacia, spontanuri sunTqvis daTrgunva.daTrgunva.

7. 7. mTeli organizmis an miokardiumis mTeli organizmis an miokardiumis mier Jangbadis moxmarebis mier Jangbadis moxmarebis Semcireba:Semcireba: SevamciroTSevamciroT Jangbadis Jangbadis moxmareba maSin roca spontanuri sunTqva an moxmareba maSin roca spontanuri sunTqva an sxva kunTovani aqtivoba amcirebs sistemur sxva kunTovani aqtivoba amcirebs sistemur Jangbadis miwodebas an gadatvirTavs isedac Jangbadis miwodebas an gadatvirTavs isedac gadatvirTul guls, mag. : kardiogenuri Soki an gadatvirTul guls, mag. : kardiogenuri Soki an mZime mozrdilTa respiratoruli distres sindromi mZime mozrdilTa respiratoruli distres sindromi (ARDS)(ARDS) . .


8. 8. SevamciroTSevamciroT intrakranialuri intrakranialuri wneva:wneva: gansakuTrebul situaciebSi (mw. gansakuTrebul situaciebSi (mw. daxuruli Tavis travma), SevamciroT daxuruli Tavis travma), SevamciroT momatebuli qalas Sida wneva, momatebuli qalas Sida wneva, kontrolirebadi hiperventilaciiT.kontrolirebadi hiperventilaciiT.

9. 9. davareguliroT gulmkerdis davareguliroT gulmkerdis kedlis moZraoba:kedlis moZraoba: iSviaT iSviaT SemTxvevebSi (gulmkerdis rezeqcia , SemTxvevebSi (gulmkerdis rezeqcia , masiuri umoZrao gulmkerdi) roca gulmkerds masiuri umoZrao gulmkerdi) roca gulmkerds dakarguli aqvs Tavisi ventilaciuri funqcia - dakarguli aqvs Tavisi ventilaciuri funqcia - raTa uzrunvelvyoT adeqvaturi ventilacia da raTa uzrunvelvyoT adeqvaturi ventilacia da

filtvebis gaSla.filtvebis gaSla.

pacientis sunTqvis pacientis sunTqvis parametrebiparametrebi

sunTqvis wuTmoculobasunTqvis wuTmoculoba (Minute (Minute

Volume)Volume) --–– haeris narevi, romelic haeris narevi, romelic CaisunTqeba da amoisunTqeba CaisunTqeba da amoisunTqeba erTi wuTis ganmavlobaSi.erTi wuTis ganmavlobaSi.

sunTqviTi moculobasunTqviTi moculoba (Tidal Volume-(Tidal Volume-

T.V.)T.V.) _ haeris narevi, romelic _ haeris narevi, romelic CaisunTqeba erTjeradi mSvidi CaisunTqeba erTjeradi mSvidi CasunTqvis dros da amoisunTqeba CasunTqvis dros da amoisunTqeba filtvebis mier. filtvebis mier.


sunTqvis sixSire sunTqvis sixSire (frecuency – f – R.R.)(frecuency – f – R.R.) -- wuTis ganmavlobaSi CasunTqva - wuTis ganmavlobaSi CasunTqva - amosunTqvis raodenoba. cxadia, romamosunTqvis raodenoba. cxadia, rom M.V.= T.V. M.V.= T.V. XX f f maSasadame, filtvebis wuT maSasadame, filtvebis wuT ventilacia mniSvnelovnad aris ventilacia mniSvnelovnad aris damokidebuli sunTqvis sixSireze.damokidebuli sunTqvis sixSireze.

wneva sasunTq gzebSiwneva sasunTq gzebSi (Airway (Airway pressure-P)pressure-P)

CasunTqvis pikuri wneva (CasunTqvis pikuri wneva (Peak inspiratory Peak inspiratory pressure - PIP )pressure - PIP )

Pplatos wnevaPplatos wneva (Plateau pressure)(Plateau pressure) saSualo wnevasaSualo wneva (Mean airway pressure - MAP) (Mean airway pressure - MAP)

amosunTqvis bolos dadebiTi wnevaamosunTqvis bolos dadebiTi wneva (Positive (Positive

end expiratory pressure – PEEP)end expiratory pressure – PEEP)


CasunTqvis pikuri wnevaCasunTqvis pikuri wneva ( Peak ( Peak

inspiratory pressure - inspiratory pressure - PIPPIP ) ) – – aris aris maqsimaluri wneva, romelic sasunTq maqsimaluri wneva, romelic sasunTq gzebSi haeris miwodebisas gzebSi haeris miwodebisas viTardeba. viTardeba.

Pplatos wnevaPplatos wneva ( Plateau pressure )( Plateau pressure ) ––ganisazRvreba rogorc CasunTqvis ganisazRvreba rogorc CasunTqvis bolos dadebiTi wneva, romelic bolos dadebiTi wneva, romelic minimum 0,5 wamis ganmavlobaSi minimum 0,5 wamis ganmavlobaSi grZeldeba sasunTq gzebSi nulovani grZeldeba sasunTq gzebSi nulovani nakadis pirobebSi.nakadis pirobebSi.


saSualo wnevasaSualo wneva (Mean airway pressure (Mean airway pressure

MAPMAP)) – – gasaSualoebuli wneva gasaSualoebuli wneva sistemaSi ventilaciis Tanabar periodSi sistemaSi ventilaciis Tanabar periodSi ganisazRvreba, rogorc sahaero ganisazRvreba, rogorc sahaero gzebis saSualo wneva.gzebis saSualo wneva.

amosunTqvis bolos dadebiTi amosunTqvis bolos dadebiTi wnevawneva (Positive end expiratory pressure -(Positive end expiratory pressure -

PEEPPEEP)) – – aris wneva romelic viTardeba aris wneva romelic viTardeba sasunTq gzebSi amosunTqvis fazis sasunTq gzebSi amosunTqvis fazis damTavrebis bolos.damTavrebis bolos.


sasunTq gzebSi haeris nakadisasunTq gzebSi haeris nakadi (Airway (Airway

flow / flow / Peak flowPeak flow) -) - sasunTq gzebSi haeris sasunTq gzebSi haeris gatarebis siCqare. izomeba litrigatarebis siCqare. izomeba litri//wT-Si. wT-Si. realurad izomeba haeris nakadi aparatis realurad izomeba haeris nakadi aparatis konturis distalur nawilSi, rac Seesabameba konturis distalur nawilSi, rac Seesabameba nakads pacientis traqeaSi.nakads pacientis traqeaSi.

CasunTqvis droCasunTqvis dro an CasunTqva/ an CasunTqva/ amosunTqvis SefardebaamosunTqvis Sefardeba (Inspiratory Time / (Inspiratory Time /

I:EI:E ratioratio)) Jangbadis procentoba CasunTqul Jangbadis procentoba CasunTqul

haerSihaerSi ((FiOFiO22)) – – misi SerCeva misi SerCeva damokidebulia mozandasaxul damokidebulia mozandasaxul Jangbadis parcialur wnevaze sisxlSi.Jangbadis parcialur wnevaze sisxlSi.

ventilaciis riTmis ventilaciis riTmis Camoyalibebis reJimebiCamoyalibebis reJimebi

iZulebiTiiZulebiTi damxmare damxmare spontanurispontanuri

{CMV,(s)CMV-PB,Siemens {PS, Flow By, BiPAP,{CMV,(s)CMV-PB,Siemens {PS, Flow By, BiPAP,

A/A/A/C –Bear, IPPV-Drager } CPAP, A/C –Bear, IPPV-Drager } CPAP, AVC, PAVAVC, PAV}}

------------------------------ ------------------------------------------------------ ------------------------

SIMVSIMV

ventilaciis meTodebi:- VCV- PCV

ventilaciis meTodebiventilaciis meTodebimoculobis kontroliT ventilacia - moculobis kontroliT ventilacia -

VCVVCV

ventilaciis meTodebiventilaciis meTodebiwnevis kontroliT ventilacia - wnevis kontroliT ventilacia - PCVPCV

spontanuri sunTqvis ciklispontanuri sunTqvis cikli

damxmare ventilaciis damxmare ventilaciis meTodebimeTodebi

Pressure support ventilation -Pressure support ventilation - – –wneviT damxmare ventilaciawneviT damxmare ventilacia

PSV PSV VSVS PCV PCV

Oopciuri:Oopciuri: Rise Time Factor –Rise Time Factor –dro romelic eZleva ventilators raTa miaRwios dro romelic eZleva ventilators raTa miaRwios

SekveTil wnevas (CasunTqvis fazis drois procentia)SekveTil wnevas (CasunTqvis fazis drois procentia)Exhaled Sensitivity – Exhaled Sensitivity – CasunTqvis nakadis daRmavali fazis dasrulebis CasunTqvis nakadis daRmavali fazis dasrulebis

da amosunTqvis dawyebis SerCeva (CasunTqvis pikuri nakadis da amosunTqvis dawyebis SerCeva (CasunTqvis pikuri nakadis procentia)procentia)

PEEP PEEP PEEP/ CPAPPEEP/ CPAP (Positive End – Expiratory (Positive End – Expiratory

Pressure / Continius Positive Airway Pressure )Pressure / Continius Positive Airway Pressure )–– dadebiTi wneva amosunTqvis dadebiTi wneva amosunTqvis

bolosbolos // mudmivi dadebiTi wnevamudmivi dadebiTi wneva

BiPAP- BiPAP- BiFASIC BiFASIC positive airwaypositive airway pressurepressure mudmivi dadebiTi wnevis or mudmivi dadebiTi wnevis or

doniani ventilaciadoniani ventilacia

mrudi - mrudi - wnevawneva//moculobamoculoba

respiratoruli Terapiis respiratoruli Terapiis mTavari principi:mTavari principi:

ventilatori yovelTvis unda ventilatori yovelTvis unda iyos adaptirebuli pacientis iyos adaptirebuli pacientis moTxovnilebasTan da ara moTxovnilebasTan da ara piriqiT! piriqiT!

meqanikuri ventilmeqanikuri ventilaaciis ciis Sewyveta:Sewyveta:

Kklinkuri situaciidan gamomdinare Kklinkuri situaciidan gamomdinare SeiZleba iyos swrafi (“SeiZleba iyos swrafi (“””SewyvetaSewyveta””) an neli ) an neli ((““gamosvlagamosvla””) procesi ) procesi

Aam dros sxvadasxva teqnika SeiZleba Aam dros sxvadasxva teqnika SeiZleba iyos gamoyenebuli (iyos gamoyenebuli (TT- s magvari miliT - s magvari miliT SPBSPB,, Pdabali donis Pdabali donis PS, CPAP, SIMVPS, CPAP, SIMVanan BiPAP BiPAP Zalian Zalian dabali sunTqvis sixSiriTda a.S.)dabali sunTqvis sixSiriTda a.S.)

Kklinkuri situaciidan gamomdinare Kklinkuri situaciidan gamomdinare eqstubaciis kriteriumebi SeiZleba eqstubaciis kriteriumebi SeiZleba varirebdes.varirebdes.

magrammagramqvemoT mowodebuli rekomendaciebi qvemoT mowodebuli rekomendaciebi

universaluria!universaluria!

EeqimsEeqims unda SeeZlos amoicnos unda SeeZlos amoicnos sunTqvis ukmarisobis da pacientis sunTqvis ukmarisobis da pacientis distresis niSnebi:distresis niSnebi:

- - mzardi taqipnea distresTan kombinaciaSimzardi taqipnea distresTan kombinaciaSi - aJitireba, panika, diaforezi, taqikardia, - aJitireba, panika, diaforezi, taqikardia,

hiper an hipotonia, –romlebic ar moixsneba hiper an hipotonia, –romlebic ar moixsneba ventilatoruli daxmarebis gazrdis Semdegacventilatoruli daxmarebis gazrdis Semdegac

- respiratoruli acidemia - respiratoruli acidemia – pH– pH –is uecari vardna –is uecari vardna <7,25 –is qvemoT<7,25 –is qvemoT

ra teqnikasac unda viyenebdeT, ra teqnikasac unda viyenebdeT, pacienti unda davicvaT sunTqvaze pacienti unda davicvaT sunTqvaze zedmeti muSaobisagan, rasac zedmeti muSaobisagan, rasac ganapirobebs aparatis sarqvelebis da ganapirobebs aparatis sarqvelebis da konturis winaaRmdegobis gadalaxvakonturis winaaRmdegobis gadalaxva

TuTu SIMVSIMV –-is viyenebT, gamosvlis –-is viyenebT, gamosvlis siswrafes da xarisxs unda siswrafes da xarisxs unda ganapirobebdes ganapirobebdes pH, PCO2, pH, PCO2, sunTqvis sunTqvis sixSire,sixSire, HR HR, distresis arseboba, distresis arseboba

TuTu PSV- PSV- –is viyenebT:–is viyenebT:

- - PS –PS –is klebisas unda vixelmZRvaneloT is klebisas unda vixelmZRvaneloT sunTqvis sixSiriT ufro metad, vidre sunTqvis sixSiriT ufro metad, vidre CasunTqvis moculobiTCasunTqvis moculobiT

(rogorc wesi s.s unda iyos(rogorc wesi s.s unda iyos < <<<30)30)

- Tu pacienti inarCunebs normalur arteriul - Tu pacienti inarCunebs normalur arteriul sisxlis gazebs da aris komfortuladsisxlis gazebs da aris komfortulad PS- PS-is is dabal cifrebze (mag.: dabal cifrebze (mag.: 5 cmH5 cmH22O) O) ar aris ar aris aucilebeli CamoviyvanoT es daxmareba aucilebeli CamoviyvanoT es daxmareba nulamde.nulamde.

Tu pacientis apartidan warmatebuli Tu pacientis apartidan warmatebuli moxsna drois mokle periodSi ver moxsna drois mokle periodSi ver moxerxda, saWiroa sistemuri analizi, moxerxda, saWiroa sistemuri analizi, raTa aRmovaCinoT da vumkurnaloT raTa aRmovaCinoT da vumkurnaloT gamomwvev mizezebs, rogoricaa:gamomwvev mizezebs, rogoricaa:

- sunTqvaze zedmeti muSaoba aparatis sunTqvaze zedmeti muSaoba aparatis winaaRmdegobis dasaZlevad (sarqvelebi, winaaRmdegobis dasaZlevad (sarqvelebi, konturi, e.t.mili, filtrebi da sxva)konturi, e.t.mili, filtrebi da sxva)

- respiratoruli faqtorebi (bronqospazmi, respiratoruli faqtorebi (bronqospazmi, bronqorea, sunTqvis centris medikamenturi bronqorea, sunTqvis centris medikamenturi daTrgunva, parenqimuli daavadeba)daTrgunva, parenqimuli daavadeba)

- Aararespiratoruli faqtorebi Aararespiratoruli faqtorebi (gulsisxlZarRvovani disfunqcia, gazrdili (gulsisxlZarRvovani disfunqcia, gazrdili metabolizmi, mGJava-tutovani problemebi, metabolizmi, mGJava-tutovani problemebi, hipofosfatemia, gamofitva, kvebis moSla)hipofosfatemia, gamofitva, kvebis moSla)

Ee.w. “Znelad Ee.w. “Znelad ““mosaxsnel”mosaxsnel”” ” pacientTan, pacientTan, visTanac f.x.v.-dan gamosvla xdeba visTanac f.x.v.-dan gamosvla xdeba ramodenime dRis ganmavlobaSi, ramodenime dRis ganmavlobaSi, sasurvelia RamiT gavzardoT sasurvelia RamiT gavzardoT respiratoruli daxmarebis done, raTa respiratoruli daxmarebis done, raTa mivceT saSualeba efeqturad daisvenos, mivceT saSualeba efeqturad daisvenos, rac gamoixateba ZiliT.rac gamoixateba ZiliT.

warmatebuli eqstubaciisTvis, garda warmatebuli eqstubaciisTvis, garda spontanuri sunTqvis efeqturobisa, spontanuri sunTqvis efeqturobisa, aucilebelia pacients hqondes unari aucilebelia pacients hqondes unari damoukideblad (an minimaluri damoukideblad (an minimaluri daxmarebiT) daicvas zemo sasunTqi daxmarebiT) daicvas zemo sasunTqi gzebi da gaasufTavos isini gzebi da gaasufTavos isini sekretisagan.sekretisagan.

aparitidan gaZnelebuli gamosvlis aparitidan gaZnelebuli gamosvlis SemTxvevaSi rekomendebulia 30-120 SemTxvevaSi rekomendebulia 30-120 wT-iani spontanuri sunTqvis unaris wT-iani spontanuri sunTqvis unaris Semowmeba –Semowmeba – - - spontaneous breathing spontaneous breathing trial (SBT):trial (SBT):

- TT-s magvari miliT -s magvari miliT anan- PS-PS-iT iT (CPAP (CPAP << 5 cmH 5 cmH22O,O, PS -7-8 cmHPS -7-8 cmH22O)O)

mtkicebulebaTa umetesoba gviCvenebs mtkicebulebaTa umetesoba gviCvenebs am meTodebis Tanabar efeqturobas am meTodebis Tanabar efeqturobas warmatebuli eqstubaciisTvis, Tumca aris warmatebuli eqstubaciisTvis, Tumca aris kvlevebi sadac pacientebi, romlebic ver kvlevebi sadac pacientebi, romlebic ver akmayofilebdnen eqstubaciis akmayofilebdnen eqstubaciis kriteriumebs kriteriumebs TT-s magvari miliT -s magvari miliT warmatebulad daeqstubirdnenwarmatebulad daeqstubirdnen PS PS is is saSualebiTsaSualebiT

eqstubaciis Cveneba:eqstubaciis Cveneba: StO2StO2 >> 95% 95% FiO2FiO2 << 0,0,55 PEEPPEEP << 5mmH2O5mmH2O PaCO2 PaCO2 << 45 mmHg 45 mmHg Temp.Temp. << 38,538,5 HbHb >> 8mg/dl8mg/dl C.O. normal (BP; HR;urine output,peripheral microperfusion)C.O. normal (BP; HR;urine output,peripheral microperfusion) MMmmetabolizmietabolizmi (energiis miwodeba) - (energiis miwodeba) -

damakmayofilebeliadamakmayofilebelia Glasgow coma score Glasgow coma score >>1111 VT(spontan.) > 5ml/kg.VT(spontan.) > 5ml/kg. RRRR<< 140% of normal rate140% of normal rate bavSvebSi (anbavSvebSi (an < 35 - < 35 -

didebSididebSi)).. xvelis refleqsi da Zala damakmayofilebelixvelis refleqsi da Zala damakmayofilebeli

zogierT klinikur SemTxvevaSi, zogierTi zogierT klinikur SemTxvevaSi, zogierTi parametri SeiZleba ar iyos mowodebul parametri SeiZleba ar iyos mowodebul zRvrebSi, magram eqstubacia mainc gakeTdes zRvrebSi, magram eqstubacia mainc gakeTdes eqimis dasabuTebuli gadawyvetilebis gamo!eqimis dasabuTebuli gadawyvetilebis gamo!

Kklinikuri Kklinikuri rekomendaciebi:rekomendaciebi:

ARDS –ARDS – mwvave (mozrdilTa) mwvave (mozrdilTa) respiratoruli distres sindromi:respiratoruli distres sindromi:

ARDSNETARDSNET –is SemoTavazebuli ventilaciis marTvis protokoli –e.w.filtvis proteqciuli strategia

SeamcireT sasunTqi moculoba 6 mlSeamcireT sasunTqi moculoba 6 ml//kg-mde sxeulis kg-mde sxeulis savaraudo wonaze gadaTvliTsavaraudo wonaze gadaTvliT

SeinarCuneT SeinarCuneT Pplat <Pplat < 30 30 sm wylis svetism wylis sveti SeamcireT SeamcireT TvTv 4 ml 4 ml//kg-mde sxeulis savaraudo wonaze* kg-mde sxeulis savaraudo wonaze*

gadaTvliT, raTa SeamciroT gadaTvliT, raTa SeamciroT Pplat Pplat Tu es aucilebelia Tu es aucilebelia (permisiuli hiperkapnia)(permisiuli hiperkapnia)

SeinarCuneT SeinarCuneT SaOSaO22/SpO/SpO22 88-95% 88-95% anuanu PaO PaO22 >> 60mmHg.60mmHg. SearCieT SearCieT PEEP FiOPEEP FiO22 –is moTxovnilebis mixedviT –is moTxovnilebis mixedviT

Semdegnairad:Semdegnairad:

FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 20-24

ARDSARDS 1.1. mizani: mizani: SeinarCune/ SeinarCune///gaaumjobese oqsigenacia gaaumjobese oqsigenacia

da ventilacia. Ada ventilacia. AamisTvis gGamoiyene:amisTvis gGamoiyene: ventilaciis is meTodi, romelic SenTvis ventilaciis is meTodi, romelic SenTvis kargadaa cnobili.kargadaa cnobili.

2. dasaSvebi saturacia2. dasaSvebi saturacia >> 90% 90%3. dasaSvebi platos wneva3. dasaSvebi platos wneva << 35 cmH 35 cmH22O.O.

4. filtvis dacvis TvalsazrisiT dasaSvebia e.w. 4. filtvis dacvis TvalsazrisiT dasaSvebia e.w. permisiuli hiperkapniapermisiuli hiperkapnia

5.5. maRalimaRali PEEP- PEEP- zrdiszrdis FRCFRC da aumjobesebs da aumjobesebs oqsigenacias. mMisi SerCeva xdeba empiriulad oqsigenacias. mMisi SerCeva xdeba empiriulad (yovel konkretul SemTxvevaSi individualurad). (yovel konkretul SemTxvevaSi individualurad). Mmisi gamoyenebisas xSirad Seamowme Mmisi gamoyenebisas xSirad Seamowme SesaZlo uaryofiTi gverdiTi movlenebi.SesaZlo uaryofiTi gverdiTi movlenebi.

ARDS ARDS 6. gGamoiyene minimaluri, dasaSvebi6. gGamoiyene minimaluri, dasaSvebi FiOFiO2. 2.

situaciaSi, sadac maRali wneva dasituaciaSi, sadac maRali wneva da FiOFiO22--is maRali is maRali koncentraciaakoncentraciaa aucilebeli, SeiZleba davuSvaTaucilebeli, SeiZleba davuSvaT StO StO22 mciredmcired < 90%. < 90%.

7. Tu7. Tu oqsigenizacia oqsigenizacia rCebarCeba aradeqvaturi aradeqvaturi ––-- gamoiyene gamoiyene Rrma Rrma sedacia, sedacia, relaqsaciarelaqsacia, sxeulis , sxeulis mdebareobis cvlamdebareobis cvla. .

Jangbadis miwodebis sxva faqtorebiJangbadis miwodebis sxva faqtorebi -- gulis wuT gulis wuT moculoba da hemoglobinis moculoba da hemoglobinis Semcveloba sisxlSiSemcveloba sisxlSi aseve aseve gasaTvaliswinebelia.gasaTvaliswinebelia.

bronqoplevraluri fistulabronqoplevraluri fistula 1. Dxeli SevuwyoT defeqtis daxurvas:1. Dxeli SevuwyoT defeqtis daxurvas:- Ggamoiyene minimaluri CasunTqvis moculoba, rac Ggamoiyene minimaluri CasunTqvis moculoba, rac

uzrunvelyofs adeqvatur ventilaciasuzrunvelyofs adeqvatur ventilacias- Ggamoiyene ventilaciis is meTodi, romelic Ggamoiyene ventilaciis is meTodi, romelic

uzrunvelyofs minimalur pikur da plato wnevebs, uzrunvelyofs minimalur pikur da plato wnevebs, adeqvaturo ventilaciisTvisadeqvaturo ventilaciisTvis

- ifiqreifiqre permisiul hiperkapniaze, raTa Seamciro permisiul hiperkapniaze, raTa Seamciro CasunTqvis moculobaCasunTqvis moculoba/ / //wnevawneva

- Mminimumamde SeamcireMminimumamde Seamcire PEEPPEEP PEEPPEEPPEEPPEEP

2. Hhaeris didi Jonvis SemTxvevaSi, Tu 2. Hhaeris didi Jonvis SemTxvevaSi, Tu ver Sli filtvs an oqsigenaciaver Sli filtvs an oqsigenacia//ventilacia ventilacia aradamakmayofilebelia, ifiqre filtvebis aradamakmayofilebelia, ifiqre filtvebis damoukidebel ventilaciaze an damoukidebel ventilaciaze an HFJV. HFJV.

Tavis travmaTavis travma Tu qalasSida wnevTu qalasSida wnevaa momateb momatebuliaulia daiWire daiWire

PPaaCO2 CO2 25-30 25-30 mmHgmmHg an cvale ventilaciis reJimi an cvale ventilaciis reJimi qalas Sida wnevis saWiro cifrebamde. qalas Sida wnevis saWiro cifrebamde. qalasSida wnevis monitoringi qalasSida wnevis monitoringi sasurvesasurvelia.lia.

SeinarCune normokarbia Tavis travmian SeinarCune normokarbia Tavis travmian avadmyofebSi Tu qalasSida wneva avadmyofebSi Tu qalasSida wneva normaluria an Tu misi monitoringi normaluria an Tu misi monitoringi SeuZlebelia.SeuZlebelia.

roca momatebuli qalasSida wnevis gamo roca momatebuli qalasSida wnevis gamo iyenebdi hiperventilacias, normokarbiaze iyenebdi hiperventilacias, normokarbiaze dabruneba unda iyos TandaTanobiTi (24-dabruneba unda iyos TandaTanobiTi (24-48 sT-is ganmavlobaSi).48 sT-is ganmavlobaSi).

mimiokaokardiumis iSemia da rdiumis iSemia da SegubebiTi gulis SegubebiTi gulis ukmarisobaukmarisoba1.1. miokardiumis imiokardiumis iSSemiis dros amoirCie emiis dros amoirCie

meq.vent.-iis iseTi tipimeq.vent.-iis iseTi tipi,, romelic romelic minimumamde daiyvans sunTqvaze minimumamde daiyvans sunTqvaze datvirTvas.datvirTvas.

2.2. roca sicocxlisTvis saSiSi hipoqsemia roca sicocxlisTvis saSiSi hipoqsemia Tan axlavs SegubebiT gulis Tan axlavs SegubebiT gulis ukmarisobas Seafase dadebiTi wneviT ukmarisobas Seafase dadebiTi wneviT ventilaciis potenciuri efeqti, venuri ventilaciis potenciuri efeqti, venuri dabrunebis Semcirebidabrunebis Semcirebiss da da oqsigenizaciis gaumjobesebis oqsigenizaciis gaumjobesebis TvalsazrisiT.TvalsazrisiT.

3.3. unda Sefasdes dadebiTi wneviT unda Sefasdes dadebiTi wneviT ventilaciis ventilaciis gavlenagavlena hemodinamikaze. hemodinamikaze.

nerv-kunTovani nerv-kunTovani daavadebebidaavadebebi

1.1. didi CasunTqvis moculebebi 12-didi CasunTqvis moculebebi 12-15ml/kg SedarebiT maRali PEEP-iT 15ml/kg SedarebiT maRali PEEP-iT (10 cmH2O mde) Tu mis gareSe (10 cmH2O mde) Tu mis gareSe SeiZleba saWiro iyos dispneis SeiZleba saWiro iyos dispneis mosaxsnelad. inspiraciuli mosaxsnelad. inspiraciuli moTxovnilebebis moTxovnilebebis dasakmayofileblad SesaZloa dasakmayofileblad SesaZloa maRali pikuri nakadi maRali pikuri nakadi >> 60 l/wT. iyos 60 l/wT. iyos saWiro.saWiro.

2. sasunTqi kunTebis SesaZleblobis 2. sasunTqi kunTebis SesaZleblobis mixedviT gamoiyene sruli an mixedviT gamoiyene sruli an nawilobrivi meq. ventilacia.nawilobrivi meq. ventilacia.

sahaero gzebis obstruqciuli sahaero gzebis obstruqciuli daavadebadaavadeba

1. 1. ar arsebobs ar arsebobs mtkicebulebamtkicebuleba erTierTi ventilatoruli reJimiventilatoruli reJimiss upiratesobisaupiratesobisa meoresmeoresTanTan SedarebiTSedarebiT. . gamoiyenegamoiyene is reJimi romelic SenTvis yvelaze is reJimi romelic SenTvis yvelaze ufro nacnobia da avadmyofs ufro nacnobia da avadmyofs miscems Svebas.miscems Svebas.

2. cvale CasunTqvis nakadi ise rom 2. cvale CasunTqvis nakadi ise rom maqsimalurad daakmayofilo maqsimalurad daakmayofilo pacientis moTxovnilebebi.pacientis moTxovnilebebi.


3. akontrole da minimumamde 3. akontrole da minimumamde daiyvane filtvebis dinamiuri daiyvane filtvebis dinamiuri gadawelvagadawelva (AutoPEEP):(AutoPEEP):

a) a) misaRebia is minimaluri wuTventilacia, misaRebia is minimaluri wuTventilacia, rac uzrunvelyofs dasaSveb gazTa cvlas rac uzrunvelyofs dasaSveb gazTa cvlas da iZleva maqsimalur amosunTqvis da iZleva maqsimalur amosunTqvis dros. aseTi manevrebia:dros. aseTi manevrebia:

Seamcire wuTventialciaSeamcire wuTventialcia gazarde amosunTqvis drogazarde amosunTqvis dro hiperkapniis daSveba.hiperkapniis daSveba. roca filtvis dinamiuri gadawelvaroca filtvis dinamiuri gadawelvass aqvaqvs s aaddgiligili dada

pacientipacienti imyofeba imyofeba asistirebadasistirebad meq. meq. ventilaciaze mcire odenobis ventilatorventilaciaze mcire odenobis ventilatorulmaulma PEEPPEEP-- mama SeiZleba kargad imoqmedos sunTqvis SeiZleba kargad imoqmedos sunTqvis muSaobis Sesamcireblad. muSaobis Sesamcireblad. TumcaTumca TuTu ventilatorisventilatoris PEEPPEEP aWarbebsaWarbebs autoPEEPautoPEEP--ss eses aucilebladaucileblad gamoiwvevsgamoiwvevs zedmetzedmet gadawelvasgadawelvas dada garTulebebsgarTulebebs..


4. 4. CasunTqvis bolos plato-wneva albaT ar CasunTqvis bolos plato-wneva albaT ar mouxdeba mouxdeba ss..gg..oo..dd--ianian avadmyofs,radgan avadmyofs,radgan plato iwvevs filtvis gadawelvas, Cven plato iwvevs filtvis gadawelvas, Cven gvjera rom didebSi plato gvjera rom didebSi plato wnevawneva<<<35<35cmHcmH22OO usafrTxo iqneba usafrTxo iqneba TumcaTumca misimisi gavlenagavlena gamosavalzegamosavalze ucnobiaucnobia. . platosplatos wneviswnevis gazomvisasgazomvisas pacientipacienti undaunda iyosiyos sedirebulisedirebuli dada paralizebuliparalizebuli..

5. mMoculobis kontroliT asistirebadi 5. mMoculobis kontroliT asistirebadi venetilacia, rogorc sawyisi taqtika, venetilacia, rogorc sawyisi taqtika, fxizlad myof pacietTan, SeiZleba fxizlad myof pacietTan, SeiZleba asocirebuli iyos filtvis gadawelvis asocirebuli iyos filtvis gadawelvis mniSvnelovan riskTan da unda mniSvnelovan riskTan da unda moveridoT.moveridoT.


asTmaasTma(1) (1) sarwmunoa rom maRali plato da sarwmunoa rom maRali plato da

maRali maRali pikuripikuri CasunTqvis wneva CasunTqvis wneva saSiSia asTmian avadmyofebSi saSiSia asTmian avadmyofebSi radganac isini kidev ufro gazrdian radganac isini kidev ufro gazrdian gadawelvas,Cven girCevT gadawelvas,Cven girCevT minimumamdminimumamdee daiyvanoT es wnevebi daiyvanoT es wnevebi asTmis dros, samwuxarod CasunTqvis asTmis dros, samwuxarod CasunTqvis maqsimaluri wneva Zalian aris maqsimaluri wneva Zalian aris damokidebuli e.t milis zomaze da damokidebuli e.t milis zomaze da CasunTqvis nakadis siCqareze.CasunTqvis nakadis siCqareze.


asTmaasTma(2) miuSvi (2) miuSvi PCOPCO22 maRal cifrebze, maRal cifrebze, sanam sanam pH pH

misaRebmisaReb zRvrebSia. zRvrebSia.(3) (3) zogjer sedacia da relaqsacia zogjer sedacia da relaqsacia

aucilebeliaaucilebelia, , radganac pacientradganac pacient / /aparatis aparatis disinqronizacias aqvs adgilidisinqronizacias aqvs adgili, , sedacia/sedacia///paralizis Semdeg Semcirdeba ra paralizis Semdeg Semcirdeba ra aqtiuri eqxpiratoruli Zalisxmeva-SesaZloa aqtiuri eqxpiratoruli Zalisxmeva-SesaZloa Semcirdes sasunTqi gzebis kolafsicSemcirdes sasunTqi gzebis kolafsic. . AasocirebuliAasocirebuli CO CO2 2 –-is produqciis –-is produqciis Semcireba (gansakuTrebiT sasunTqi Semcireba (gansakuTrebiT sasunTqi muskulaturis xarjze) zogjer aseve muskulaturis xarjze) zogjer aseve dadebiTi efeqtia/.dadebiTi efeqtia/.


filtvis qronikuli obstruqciuli daavadebafiltvis qronikuli obstruqciuli daavadeba

aseTiaseTi pacient pacientebis meq. ventilaciis ebis meq. ventilaciis dros (sunTqvis mw. ukmarisobisas) dros (sunTqvis mw. ukmarisobisas) rogorcrogorc wesiwesi ar aris aucilebeli maRali ar aris aucilebeli maRali CasunTqvis wneva da naxSirorJangis CasunTqvis wneva da naxSirorJangis gamodevnacgamodevnac did problem did problemasas arar undaunda warmoadgendeswarmoadgendes. Tu aseTi proble. Tu aseTi problemama gaCnda unda ifiqro Tanaarsebul gaCnda unda ifiqro Tanaarsebul paTologiebze (pnevmoToraqsi, filtvis paTologiebze (pnevmoToraqsi, filtvis SeSupeba, Zlieri bronqospazmi, SeSupeba, Zlieri bronqospazmi, naxvelis sacobebi).naxvelis sacobebi).


filtvis qronikuli obstruqciuli filtvis qronikuli obstruqciuli daavadebadaavadeba

2.2. avadmyofebs qr. respiratoruli avadmyofebs qr. respiratoruli acidoziT alveolacidoziT alveoluri uri ventilacia ventilacia unda SeufasdeT araunda SeufasdeT ara PCO PCO22-- –iT –iT aramedaramed pH pH- - iTiT..

postoperaciuli pacientebipostoperaciuli pacientebi ZiriTadad aseT pacientebs ar ZiriTadad aseT pacientebs ar

esaWiroebaT gaxangrZlivebuli f.x.v.esaWiroebaT gaxangrZlivebuli f.x.v. mTavari yuradReba unda daeTmos mTavari yuradReba unda daeTmos

kardioTorakaluri operaciebis kardioTorakaluri operaciebis Semdeg SesaZlo ateleqtazebis Semdeg SesaZlo ateleqtazebis prevencias.prevencias.

aseTi pacientebi rac SeiZleba aseTi pacientebi rac SeiZleba swrafad unda moixsnan f.x.v.-idan swrafad unda moixsnan f.x.v.-idan raTa Tavidan aviciloT yvela SesaZlo raTa Tavidan aviciloT yvela SesaZlo garTulebebi rac asocirebuli garTulebebi rac asocirebuli gaxangrZlivebul f.x.v. -sTangaxangrZlivebul f.x.v. -sTan

ffiltvebis xelovnuri ventilaciis tanamedrove metodebi da rejimebi mmamuka cxaize. 2006 weli. tbilisi

Documents

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