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n Tt Nghip

TM TT N

cac nc phat trin trn th gii noi chung va Vit Nam noi ring, trang
thit bi trong nganh y t ong vai tro ht sc quan trong, quyt inh n s ln
manh va phat cua mi trung tm y t va cac bnh vin, trong s cac trang thit bi y
t, may th la thit bi khng th thiu trong hi sc cp cu va h tr iu tri cho
bnh nhn.

May th lam nhim vu cung cp mt phn hay toan b cng vic ma c th


tao ra a khi vao va ra khoi phi. No ong vai tro quan trong trong vic duy tri
s sng cho bnh nhn, ma kha nng t th cua ho bi han ch hoc kha nng t
th tam thi bi mt i. y la iu kin tin quyt cu sng va phuc hi sc
khoe cho ngi bnh.

Vn t ra y la lam sao va giup cha tri cac bnh ly nhim v


h hp, hng dn ti cai th va thi th may, va am bao lam sach mi trng
bn ngoai. tai nay nhm gii thiu mt loai may th hin ang c s dung
rt rng rai tai cac trung tm y t va bnh vin ln, o la may th Esprit.

Esprit la may th ki thut cao, a tinh nng thich hp cho hi sc cp cu


hin nay. Vi cu truc 5 b vi x ly tinh t, Esprit h tr ca hai ch thng khi
xm nhp va khng xm nhp, hai kiu th ap lc va th tich. c B Y T chon
cung cp trong chng trinh phong chng Cum A/H5N1 trn toan quc

an se bao gm nhng ni dung sau:

Chng 1: Sinh ly h hp

Chng 2: Tng quan v may th

Chng 3: Cu tao va nguyn ly hoat ng

Chng 4: Cac thng s ki thut cua may

Chng 5: Bao tri sa cha

Chng 6: Giao tip may th

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MC LC

TM TT N......................................................................................................................1

CHNG 1. SINH LY H HP...............................................................................................7

1.1 Cu tao cua h h hp...................................................................................................7

1.1.1 ng dn khi......................................................................................................7

1.1.2 Lng ngc...........................................................................................................10

1.1.3 Phi va mang phi..............................................................................................10

1.2.1 Thng khi t nhin.............................................................................................10

1.2.2 Thng khi nhn tao............................................................................................11

1.3 Cac tham s trong qua trinh thng khi........................................................................11

1.3.1 Ap sut phi........................................................................................................11

1.3.2 Th tich phi.......................................................................................................14

1.3.3 Dung tich phi....................................................................................................14

1.4 Phng phap Nitrogen-Washout o dung tich cn chc nng FRC...........................15

1.5 Cng h hp................................................................................................................16

CHNG 2. TNG QUAN V MY TH............................................................................18

2.1 Gii thiu chung..........................................................................................................18

2.1.1 Vai tro cua may th va chi inh thng khi nhn tao.........................................18

2.1.2 Tin trinh phat trin cua may th hin ai.......................................................20

2.2 Phn loai may th........................................................................................................21

2.2.1 Phn loai theo chc nng s dung....................................................................21

2.2.2 Phn loai theo chc nng iu khin................................................................22

2.3 Cac phng thc thng khi nhn tao..........................................................................23

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2.3.1 Thng khi nhn tao iu khin CMV................................................................23

2.3.2 Thng khi nhn tao vi ap lc dng tinh ngt qung IPPV.........................23

2.3.3 Thng khi nhn tao h tr iu khin A/CMV.................................................24

2.3.4 Thng khi nhn tao ngt qung IMV...............................................................25

2.3.5 Thng khi iu khin vi ap lc dng ngt qung ng thi SIMV...............26

2.3.6 Thng khi nhn tao h tr ap lc PSV.............................................................27

2.3.7 Thng khi nhn tao vi ap lc giam theo chu ky APRV..................................29

2.3.8 Thng khi nhn tao ap lc ng dn khi dng tinh hai pha BIPAP..........30

2.3.9 Thng khi nhn tao ap lc dng lin tuc CPPV............................................30

2.3.10 Thng khi nhn tao vi dong chay lin tuc CFV..............................................32

2.3.11 Thng khi t nhin vi ap lc dng lin tuc CPAP.......................................32

2.3.12 Thng khi nhn tao vi th tich phut bt buc MMV......................................33

2.3.13 Th t nhin SPONT.........................................................................................34

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Danh sch cc t vit tt


Vt Tidal Volume
IRV Inspiratory Reserve Volume
ERV Expiratory Reserve Volume
RV Residual Volume
FRC Functinal Residual Capacity
IC Inspiratory Capacity
VC Vital Capacity
TLC Total Lung Capacity
ARDS Adult Respiratory Distress Syndrome
COPD Chronic Obstructive Pulmonary Disease
NEEP Negative End Expiratory Pressure
MAP Mean Airway Pressure
PEEP Positive End Expiratory Pressure
PIP Peak Inspiratory Pressure
CMV Controlled Mandatory Ventilation
A/CMV Assist/Controll Mandatory Ventilation
IMV Intermittent Mandatory Ventilation
SIMV Synchronized Intermittent Mandatory Ventilation
PSV Pressure Support Ventilation
APRV Airway Pressure Release Ventilation
BIPAP Biphasic Positive Airway Pressure
IPPB Intermittent Positive Pressure Breathing
CPPV Continuous Posittive Pressure Ventilation
CFV Continuous Flow Ventilation
CPAP Continuous Positive Airway Pressure
MMV Mandatory Minute Volume, Minninum Minute Volume

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CPU Central Processing Unit

PCB Printed Circuit Board

F1 Air Inlet Filter

F2 Oxygen Inlet Filter

F3 Heated Exhalation Filter

AV Air Valve

SOL1 Crossover Solenoid

SOL2 Safety Valve Pilot Solenoid

SOL3 Exhalation Pressure Tranducer Solenoid

SV Safety Valve

PRV Pressure Relief Valve

OS Oxygen Sensor

CV2 Air System Check Valve

CV3 Inspiratory Non-Rebreathing Check Valve

CV4 Exhalation Non-Breathing Check Valve

CV5 Check Valve

PT2 Exhalation Pressure Tranducer

PT3 Inspiratory Pressure Tranducer

PS1 Oxygen Supply Pressure Switch

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FS1 Air Flow Sensor

FS2 Oxygen Flow Sensor

FS3 Exhalation Flow Sensor

OV Oxygen Valve

EV Exhalation Valve

REG1 Oxygen Regulator

MMI Man Machine Interface

VGA Video Graphics Array

LCD Liquid Crystal Display

OTP One Time Programmable

CSI Clock Serial Interface

DAC Digital To Analog Converter

ADC Analog To Digital Converter

LED Light Emitting Diode

GUI Graphical User Interface

SST Short Seft Test

EST Extended Seft Test

BPM Breaths Per Minute

LPM Liter Per Minute

DRPT Diagnostic Report

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CHNG 1. SINH LY H HP
1.1 Cu tao cua h h hp
H h hp lam nhim vu cung cp O 2 cho qua trinh trao i cht cua t bao

nui sng va phat trin c th, ng thi thai khi CO2 t t bao ra ngoai.
H hp gm 4 giai oan:
- S thng khi phi: la s trao i khi gia ph nang vi khi tri (ngoai

h hp)
- Khuch tan O2 va CO2 gia khi ph nang va mau tai phi
- S chuyn ch O2 va CO2 trong mau va dich c th n va ri khoi

t bao
- S trao i gia dich c th va t bao (ni h hp)
Ca 4 giai oan u co s tac ng cua c ch iu hoa h hp gop phn

vao s hng inh ni mi cua c th


1.1.1 ng dn khi
1.1.1.1 Mui
Chc nng cua mui la gi nong, m va lam sach khi tri. Khi

hit vao qua mui, se c iu chinh nhit gn bng nhit c

th va m gn vi 100% bao hoa bt ki nhit va m ngoai

khi quyn nh th nao.


1.1.1.2 Hong
Hong, hay thng goi la c hong, la mt ng co chiu dai

khoang 12cm t ay cua so n thc quan. C hong c chia lam 3

phn: phn trn vom hong (nasopharynx), vom hong (oropharynx),

yt hu (laryngopharynx)

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Hinh 1.1 ng dn khi


1.1.1.3 Thanh quan:
Thanh quan c cu tao bng khung sun va dy chng
1.1.1.4 Khi quan:
La mt ng hinh tru co chiu dai khoang 10 n 12cm va

ng kinh khoang 2 n 2,5cm. Gm 16 n 20 vong sun hinh ch

C. Khi quan tao ng i cho khi vao phi


1.1.1.5 Ph quan (Bronchi):

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Thanh ph quan u co sun, tr phn tiu ph quan va cac si


c trn. im bt u nhanh ph quan la sng li hai, ri chia
nhanh thanh thuy ph quan (Lobar Bronchi) va ph quan s cp
(Primary Bronchi), t thuy ph quan se chia thanh cac tiu ph quan
(Bronchioles)

Hinh 1.2 ng dn khi t thanh quan n ph quan


1.1.2 Lng ngc
La mt lng kin, ay la c hoanh. Bao gm:
- B phn c inh: ct sng
- B phn di ng c: xng sn, xng c
- B phn c ng: cac c hit vao va th ra
1.1.3 Phi va mang phi

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Phi la c quan chinh cua h h hp, no chim phn ln hai bn lng


ngc. Phi c bao boc bi mang phi. c chia lam phi trai va phi
phai. Mi phi lai c chia thanh thuy va phn thuy. Mi phn thuy co rt
nhiu tui nho c goi la ph nang. n vi cua phi la ph nang hay tui
khi. y la ni trao i khi gia mau va khi bn ngoai hit vao. c im
cua phi:
- Do phi c cu tao bi nhiu tui nho nn din tich trao i khi
rt ln
- Mang ph nang rt mong, lai co nhiu mach mau vach ph
nang nn vic trao i khi rt d dang.
- Phi co tinh an hi ln nn d dang thay i th tich, do vy qua
trinh thng khi thun li
- p sut trong khoang mang phi nho hn ap sut khi quyn, do
o d dang thc hin cac ng tac h hp.
1.2 Qu trinh thng khi phi
1.2.1 Thng khi t nhin
Thi hit vao bt u t s chnh lch ap lc gia ph nang va khi quyn. Do
cac c h hp lam gian lng ngc, gy ra mt ap lc trong ph nang thp hn ap
lc khi quyn, ap lc ph nang giam do ap lc mang phi m tinh.
Thi th ra c hoanh y ln cao, c lin sn gian ra lam lng ngc ha
xung va ap lc mang phi tr v binh thng, ap lc ph nang tng ln va ln
hn ap lc khi quyn, do o khi c y t ph nang ra ngoai
1.2.2 Thng khi nhn tao
Da trn nguyn ly cua thng khi t nhin, thng khi nhn tao c thc
hin da trn s chnh lch ap lc gia may va phi. Thng khi nhn tao con
c goi la thng khi ap lc dng nghia la dung may y khi vao phi lam tng
ap lc ng th trung tm. p lc ng th trung tm tng ln se giup y khi
i vao ph nang nh o phi se n ra. Khi phi n ra se dng bm khi vao ng
th, khi o ap lc trong ng th trung tm giam xung. Thi th ra bt u khi ap
lc trong ng th trung tm giam xung thp hn so vi ap lc ph nang.
Thng khi nhn tao co th thay th mt phn hoc toan b nhip t th cua bnh
nhn
1.3 Cc tham s trong qu trinh thng khi

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1.3.1 Ap sut phi


1.3.1.1 p sut ph nang
Trong sut thi th vao lng ngc n ra, lam tng th tich lng
ngc. Theo Boyles Law, ap sut bin i ti l nghich vi th tich.
Do vy, ap sut trong lng ngc giam i -3mmHg so vi ap sut khi
quyn, tao ra mt ap lc m a khng khi t bn ngoai i vao ph
nang. Thi th ra lng ngc xep xung, th tich giam, ap sut ph
nang tng ln khoang +3mmHg so vi ap sut khi quyn, va y khi
t trong ph nang ra ngoai.
1.3.1.2 Cht hoat tinh b mt
Cht hoat tinh b mt la mt lipoprotein c cac t bao hoat
tinh c bit biu m ph nang tit ra. Cht hoat tinh b mt co kha
nng lam giam sc cng b mt cua lp dich lot ph nang. Nu
khng co cht hoat tinh b mt, khuynh hng gian n cua phi se
rt ln (ap sut m trong mang phi co th ln ti -20 n
-30mmHg).
Cht hoat tinh b mt trong ph nang co ba vai tro chinh:
- Anh hng n tinh an hi cua phi: cht hoat tinh b
mt tac dung bng cach lp mt lp phn t trn cht dich
lot ph nang, lam sc cng b mt giam i 2 n 14 ln,
nn tinh an hi cua phi nho. mt vai tre s sinh, nht
la sinh thiu thang, cht hoat tinh b mt tit ra khng u,
lam cho phi kho gian n trong cac nhip th ban u
- Anh hng n ap lc ph nang: Theo inh lut Laplace:
P = T (cm)/ r (cm)
P: ap lc ph nang
T: lc cng thanh (parietal tension) lam xep ph nang
T biu thc ta thy, nu kich thc ph nang r nho,
ma T khng i thi ap lc ph nang P tng. Nhng vi cac
ph nang co kich thc khng bng nhau, nn P trong cac
ph nang r nho se cao hn cac ph nang r ln, do o khi se
dn qua ph nang ln. Kt qua la phi co hang loat cac

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ph nang xep xung va hang loat cac ph nang phng ln,


y la bnh mang trong thiu cht hoat tinh b mt.
Nhng nh co cht hoat tinh b mt nm trn lp dich
lot ph nang, trai mong ra vi ph nang ln, tu lai vi ph
nang nho, lam T giam nhiu hn khi r cang nho. Nh vy,
P co th xem nh khng i, kt qua la ap lc ph nang
ng u.
- Ngn chn s tich tu dich phu trong ph nang: Sc cng
b mt cua lp dich ph nang khng nhng anh hng co
xep ph nang ma con keo dich vao ph nang. Trong phi
binh thng, khi cht hoat tinh b mt y u, sc cng
b mt vn co kha nng keo dich vao ph nang vi ap lc
-3mmHg. Nu thiu cht hoat tinh b mt thi ap lc nay
co th ln ti -10 n -20mmHg keo mt lng dich ln
ra khoi mao quan ph nang gy nn phu phi, suy h hp.
1.3.1.3 gian n cua phi (Compliance)
M ta kha nng gian n cua phi va lng ngc, biu thi s
tng th tich cua phi. No ging nh s tng ln v th tich cua phi
trong mi nhip th khi ap lc trong ph nang giam xung. mt
ngi an ng khoe manh, Compliance la 100mls/cmH 20. Cng thc
tinh:
Compliance = Tidal Volume + Pressure hay C = Vt + P

1.3.1.4 Sc can ng th (Resistance)


Resistance chinh la sc can chng lai khi i trong ng th.
No bao gm cac lc ng hoc cn thit khi phat va duy tri dong
khi xuyn sut ng dn khi trong chu ky h hp. Resistance ging
nh s phn chia ap lc cua dong khi, hoc cmH 2O/Ltrs/sec. Sc can
ng th phu thuc vao dai va ng kinh cua ng dn khi.
Resistance = Pressure + Flow hay R = P + F
1.3.1.5 Dong chay Laminar

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Dong chay Laminar m ta chuyn ng tuyn tinh cua cac


phn t khi trn ng dn khi, cac phn t khi chuyn ng va
cham vao thanh ng dn khi sinh ra ma sat, nhng gia tri nay kha
nho.
1.3.1.6 Dong chay xoay Turbulent
Khi tc nghen, ng kinh ng dn khi giam, hin tng
khi bi ep trn ng th xut hin, hay tc lu lng tng,
xoay tng ln do cac phn t khi cha kip ap ng lai trc iu
kin thay i nhanh. Cac phn t khi nay ln va cham vi thanh ng
dn khi lam ma sat tng. Ma sat tng ti l vi sc can ng th.
1.3.2 Th tich phi
1.3.2.1 Th tich h hp Vt
La lng khi i vao va ra khoi phi trong mi ln th binh
thng, trung binh Vt la 500mls
1.3.2.2 Th tich d tr hit vao IRV
La lng khi hit thm vao c sau khi a hit vao binh
thng, IRV co gia tri khoang 3000
1.3.2.3 Th tich d tr th ra ERV
La lng khi th ra thm sau khi a th ra binh thng, ERV
co gia tri khoang 1100ml
1.3.2.4 Th tich cn RV
La lng khi con lai trong phi sau khi a c gng th ra ht
sc, RV khoang 1200ml
1.3.3 Dung tich phi
1.3.3.1 Dung tich hit vao IC
c tinh bng tng th tich h hp va th tich d tr hit vao,
co gia tri khoang 3500mls
1.3.3.2 Dung tich cn chc nng FRC
Bng tng cua th tich d tr th ra vi th tich cn. Gia tri
cua FRC sau mi ln th ra binh thng la 2300mls

1.3.3.3 Dung tich sng VC


La tng cua 3 loai: th tich d tr hit vao, th tich h hp va
th tich d tr th ra. La lng khi ti a c huy ng trong mi
ln th, binh thng khoang 600mls

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1.3.3.4 Dung tich chung cua phi TLC


Bng tng cua 4 th tich, binh thng co gia tri khoang
5800ml

Hinh 1.3 Th tich va dung tich cua phi

1.4 Phng php Nitrogen-Washout o dung tich cn chc nng FRC

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FRC co tac dung lam tng th tich trao i khi cua phi, giup cho vic
thng khi at hiu qua. Chung ta cn o c FRC. Dung tich cn chc nng FRC
va th tich cn RV cua phi khng th o c bng cac thit bi o th tich. Thit
bi o cn phai s dung may phn tich Nitrogen va ap dung phng phap pha
loang.

Hinh 1.4 S phng php o th tich cn chc nng FRC

Bi vi Nitrogen khng tham gia vao qua trinh h hp, no c coi nh cht
pha loang. Khi hit vao va th ra cha khoang 80% Nitrogen. Gia mi ln th,
FRC cua phi cha mt lng nitrogen m c ging nh khng khi. Do khi hit
vao qua dung cu o dung tich th nht cha 100% O 2 va th ra ti dung cu o
dung tich tp hp th hai, tt ca nitrogen trong FRC a thay th Oxy. Nitrogen
c goi la Wash-out dung cu o dung tich th hai. o c m c cua

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Nitrogen dung cu o dung tich tp hp, cung vi th tich a bit, ta tinh c


lng Nitrogen ban u trong dung tich cn chc nng va t o tinh c FRC

1.5 Cng h hp
Chi tinh cho hit vao, con th ra nu khng gng sc la thu ng. Mun at
c kt qua h hp, c th phai dung cac cng sau:
- Cng thng lc an hi: thng sc an hi cua phi va lng ngc.
Tng ln khi co hin tng x cng phi
- Cng thng lc khang cua m: khang lai sc dinh va quan tinh cua
phi.
- Cng thng lc ma sat: lc xut hin khi khi i qua ng dn khi cua
phi. No khng ang k nhng se tng cao trong cac trng hp nh:
tc nghen ng khi hoc khi th nhanh.

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CHNG 2. TNG QUAN V MY TH


2.1 Gii thiu chung
2.1.1 Vai tro cua may th va chi inh thng khi nhn tao
2.1.1.1 Vai tro
Mt ngi sng khoe manh biu hin la s h hp u n, hit
khi qua mui vao phi ri th ra, nhn khi Oxy va thai khi Cacbonic. o
la s h hp cung cp Oxy cho qua trinh trao i cht cua cac t bao ri
i nui sng c th. Khi h h hp bi tn thng, nguy c tim ngng
hoat ng co th xay ra. Luc o, cac bac sy co th s dung phng phap
ha hi thi ngat, n tay vao phi kich thich tim bnh nhn hoat ng
tr lai. Nhng sau khi s cu nh vy, nu bnh nhn vn con tinh trang
khng t th c hoc th trang con yu qua trinh h hp gp kho
khn, bac sy phai s dung may thng khi nhn tao hay may th h
tr qua trinh h hp cua bnh nhn. S dung may th nhm kich cho
vic th, giup bnh nhn h hp tr lai binh thng.
May th co vai tro rt quan trong trong y t, no gop phn duy tri
s sng cho bnh nhn, giam thiu ti a ti l t vong tai cac phong hi
sc cp cu. Ngoai ra, giup giam thiu cng vic ma bac sy, y ta phai
lam trong qua trinh cng tac.
May th mang lai nim vui, hanh phuc cho ca bac sy va bnh
nhn.
2.1.1.2 Chi inh thng khi nhn tao
Thng khi nhn tao c chi inh khi mc bnh suy h cp hoc
man tinh, nghia la khi bnh nhn thiu Oxy hoc giam thng khi ph
nang hoc ca hai trng hp.
Cac chi inh thng khi nhn tao chinh:
- Tn thng phi cp
- Vim phi do nhim khun, do trao ngc, do hit vao
- Hi chng suy h hp cp ngi ln ARDS
- Phu phi do tim
- Nhi mau c tim cp
- Bnh c tim
- Qua tai th tich
- Bnh phi tc nghen man tinh COPD

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- Cn hen ph quan ac tinh


- Lit c h hp
- Bnh thanh ngc
- Bnh h thng
Thng khi nhn tao cn c chi inh sm va khng c tri
hoan khi co chi inh. Cac du hiu va triu chng lm sang anh gia
mc suy h hp.
Cac ri loan cn chi inh th may:

Thng s Gi tr
Mt kha nng bu tr cua h thng h hp
Tn s th > 35 ln/phut
Vt < 5mL/kg
Dung tich sng < 10mL/kg
p lc m thi hit vao nho hn -25cmH2O
Thng khi phut < 10 L/phut
Tng PaCO2 >10mmHg
Suy h hp khng ap ng vi xy
Chnh ph nang-ng mach (FiO2=1) >450
PaO2 khi co O2 <55mmHg

Muc ich cua th may:


- Muc tiu sinh ly
H tr trao i khi qua phi nh thay i thng khi ph nang
va xy hoa mau ng mach
Giam ganh nng chuyn hoa nh giai phong c h hp
Giam tn thng phi do may th
- Muc tiu lm sang
Giai quyt c tinh trang giam xy hoa mau
Giai quyt c vn suy h hp
Phong va iu tri c xep phi
Giai quyt c vn mt c h hp
Giam mc tiu thu Oxy cua t chc hoc mc tiu thu Oxy
cua c tim
C inh thanh ngc
2.1.2 Tin trinh phat trin cua may th hin ai
Trc khi may th ra i, khi s h hp gp kho khn, ngi ta
thng ap dung phng phap ha hi thi ngat giup bnh nhn khi phuc

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hoat ng cua h h hp. Tuy nhin, phng phap nay chi ap dung cho
nhng bnh nhn bi nhe, con trng hp nng thi phng phap trn khng
giai quyt c. Thng khi nhn tao bng may c s dung va lan rng t
nm 1920 n 1950 khi dich bai lit xut hin. Khi o may Engstrom c
dung ph bin nhm x ly cac trng hp giam thng khi ph nang theo
phng thc thng khi nhn tao iu khin vi ap lc dng tinh ngt
quang.

Hinh 2.1 - Mt thit b thng khi nhn tao iu khin p lc dng


tinh ngt quang
A Ngun cung cp Oxy B B iu chinh lu lng
Oxy
C Van th ra. D Mask
Tip o, ngi ta nghin cu lam giam bt tac dung co hai cua vic
thng khi nhn tao bng cach s dung ap lc m cui ki th ra lam giam
ap lc trung binh trong ph nang. Sau o, ngi ta rut ra kt lun NEEP co
u im lam giam ap lc trung binh ng dn khi MAP. Do o, co th cai
thin c huyt ng nhng lai nhn thy rng NEEP lam cho mt s cac
ph nang ong lai gy xep phi anh hng n s thng khi. n nm

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1963, hai nha nghin cu ngi Phap la Poisvert va Cara ln u tin ap


dung phng thc h hp nhn tao vi ap lc dng cui ki th ra cho
nhng bnh nhn phu phi cp. Ngay nay, khi khoa hoc ki thut phat trin
thi trn cung mt may th co th s dung nhiu phng thc thng khi va
co th kim soat ca v th tich va ap lc, ng thi co h thng bao ng
khi gp nhng thay i. Cac may th nh vy goi la may th hin ai, va
cac may th khng con s dung phng thc NEEP va phanh can th c
thay th bng PEEP va PIP
2.2 Phn loai my th
2.2.1 Phn loai theo chc nng s dung
- May thng khi nhn tao dung trong iu tri
- May thng khi nhn tao dung h tr may gy m trong phu thut.
May th iu tri u ra khi cua may c a trc tip n bnh
nhn, con may th h tr may gy m thi u ra khi cua may phai i qua
binh bc hi va h thng van cua may gy m trc khi a ti bnh nhn.
im khac nhau th hai cua hai loai may nay, la may th h tr may gy
m chay theo chu trinh kin. Khi th ra cua bnh nhn khng a ra ngoai
mi trng ma chay qua binh hp thu CO2 va sau o c tai s dung, iu
nay rt quan trong vi trong khi th ra cua ngi bnh con co khi gy m
tha nn nu thai ra mi trng se anh hng khng tt n sc khoe cua
cac bac sy, y t, ky thut vin trong qua trinh phu thut. Con i vi may
th iu tri thi lai theo chu trinh h, khi th ra cua bnh nhn thoat trc tip
ra ngoai mi trng.

2.2.2 Phn loai theo chc nng iu khin.


- May thng khi nhn tao iu khin ap lc
- May thng khi nhn tao iu khin th tich
May thng khi nhn tao iu khin ap lc thc hin lam cng phi
va kt thuc thi th vao khi mt ap lc t sn may a at c. Cac may
nay oi hoi phai co mt ngun Oxy khi nen t 35 n 80 PSI. May thng
khi nhn tao iu khin ap lc co nhc im ln la khng kim soat th
tich a vao phi bnh nhn. Khi trng hp tc nghen hoc m rai trong

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ng th lam sc can ng th tng, nn ap lc cai t nhanh chong at


c, trong khi o th tich khi vao phi cha u. Do vy, may nay kho co
th s dung trong mt thi gian dai. Khi s dung may cn phai chu y theo
doi vi may khng co bao ng th tich. Tuy nhin, may thng khi nhn tao
kiu nay cung co u im la nu co ro ri, h mach th thi may bao ng bu
sao cho ap lc n bnh nhn ung bng ap lc a t sn. May thng khi
nhn tao iu khin ap lc c s dung chu yu cho tre s sinh va cac
bnh nhn con tinh, khng lit h hp.
May thng khi nhn tao iu khin th tich se a mt lng th tich
cai t sn vao phi bnh nhn ma khng cn quan tm n ap lc. iu
nay rt nguy him vi bnh nhn, vi khi sc can ng th tng ma c a
khi vao se co nguy c lam ap lc tng qua mc gy v ng th. Vi vy,
cac may loai nay phai co b gii han ap lc, va no thich hp cho nhng
bnh nhn ang trong tinh trang hn m, khng tinh tao. May thng khi
nhn tao iu khin th tich thich hp dung cho ngi ln. Tuy nhin, s
phn loai theo chc nng nay it c ap dung vi trong cac may th hin ai
thng tich hp ca hai chc nng trn.
Ngoai hai kiu phn loai trn, hin nay con co loai may thng khi
nhn tao tn s cao. u im cua loai may nay la lam giam ap lc trung
binh cua ph nang mt cach ang k, t o lam giam bt anh hng co hai
ti huyt ng. Loai may chuyn s dung cho cac bnh: Suy h hp cao co
tran khi mang phi, phu thut ph quan va phi Co ba phng thc
thng khi tn s cao la thng khi tn s cao ap lc dng, thng khi bng
phut khi tn s cao va thng khi bng cac xung dao ng khi.
2.3 Cc phng thc thng khi nhn tao
2.3.1 Thng khi nhn tao iu khin CMV
La phng thc thng khi nhn tao bt buc bnh nhn th di s
iu khin cua may du cho bnh nhn vn con th c hay bi c ch hoan
toan.

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Hinh 2.2 Phng thc thng khi nhn tao u


May se y nhng ap lc khng i, u n vao cho bnh nhn vi

tn s, lu lng a c t t trc.
2.3.2 Thng khi nhn tao vi ap lc dng tinh ngt qung IPPV
c thc hin vi mt may thng khi nhn tao trn bnh nhn a

c t ng ni khi quan hoc m ni khi quan (i khi qua mt na)


May y vao phi bnh nhn mt th tich khi vi mt tn s nht

inh, mt ap lc y vao lun lun dng tinh, con thi th ra thu ng, ap

lc ng dn khi luc nay tr v s 0.


Phng thc h hp nay s dung nhiu nht trong hi sc cp cu.

Do co nhiu kha nng khac nhau v iu chinh thng s, phng thc nay

co th am bao mt s thng khi ung n trong a s cac trng hp.

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Hinh 2.3 Phng thc thng khi nhn tao p lc dng ngt quang

2.3.3 Thng khi nhn tao h tr iu khin A/CMV


Vi phng thc nay, cac thng s c cai t trc nh thng khi
nhn tao iu khin nhng vi mt tn s ti thiu va mt mc Trigger nho
nht luc bt u. Khi bnh nhn t th, Trigger may th hoat ng theo tn
s th cua bnh nhn va cac thng s cai t trc. Khi bnh nhn ngng
th hay khng Trigger c may thi may th se t ng khi ng mt chu
ky thng khi nhn tao iu khin vi tn s ti thiu cai t trc, co th
kim soat v th tich hoc ap lc tuy thuc vao kha nng cua may th va
phng thc th c s dung.
y la phng thc thng khi nhn tao thng dung nht, nn ap
dung u tin khi co chi inh th may, no ap ng c hu ht cac trng
hp suy h hp cp, sau o mi cn nhc n vic s dung cac phng thc
thng khi nhn tao khac thich hp hn, nht la khi a co cac kt qua xet
nghim. Li im chu yu cua no la it gy chng may nh thng khi kim
soat, an toan ngay ca khi bnh nhn khng t th hay th qua yu, nhng
bt li la hay gy tng thng khi, kim h hp ang k.

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Hinh 2.4 Minh hoa dang song cua p sut trong phng thc
A/CMV

2.3.4 Thng khi nhn tao ngt qung IMV


Thng khi nhn tao ngt quang IMV la phng thc thng khi nhn
tao iu khin giam dn tn s h hp cua may va tng dn chu ky h hp
t nhin cua bnh nhn qua ng dn khi cua may.
S dung phng thc nay co hai im li:
- Giam bt tac hai ti huyt ng khi th may nh trong
phng thc IPPV
- H tr vic cai th d dang, t t IMV giam dn v 0
Noi mt cach khac, bnh nhn vn th t nhin, nhng thinh thoang
lai c may y vao cho mt chu ky khoang 6 8 ln/phut ( cac chu ky
khac la th t nhin) giup cho phi thng khi tt. Khi IMV giam v 0, bnh
nhn th hoan toan t nhin qua may, luc nay co th thao may khoi bnh
nhn nhng khng nn thao ngay ng ni khi quan.
Ngay nay IMV c dung nh mt phng thc thng quy duy
tri cung mt luc hoat ng cua may th va hoat ng cua cac c h hp sao

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cho bnh nhn t minh dn dn am bao c h hp t nhin va am bao


cho cac c h hp hoat ng, mi ngay mt nhiu ln dn cai c th
may. Phng thc nay rt co ich vi trng hp th nhanh va it anh hng
huyt ng.
2.3.5 Thng khi iu khin vi ap lc dng ngt qung ng thi SIMV
Cac nhip th cua SIMV c thit lp theo tng quang thi gian
inh sn (khoang 6 8 ln/phut) nhng chi bt u thi th vao nh mt h
hp h tr nghia la khi bnh nhn co mt l lc th vao sau mi quang thi
gian. Gia cac khoang thi gian h tr a inh, cac tin hiu hit vao khng
c may ghi nhn va bnh nhn tip tuc th t nhin.
a s may SIMV co thm b phn thit lp mt nhip th bt buc
nu bnh nhn chm khi ng mt nhip th t nhin ung thi im phai
co SIMV. Nhip th cua may luc o la IMV. Ging nh IMV, SIMV giup
cho vic cai th may vi bnh nhn c th t nhin trong phn ln oan
thi gian thc hin th tich/phut. Tn s th SIMV se c giam dn
chuyn thanh th t nhin.
SIMV co th la thng khi th tich hoc la ap lc. Nu bnh nhn
khng gng sc c thi may se t ng chuyn sang ch iu khin. S
dung SIMV th tich cn co cac thng s VT, cung lng dong khi, +/- thi
gian th vao, tn s h hp iu khin va nhay. Nu may la h hp nhn
tao ap lc thi cn co mc ap lc va thi gian th vao.
May giup cho bnh nhn t th d hn va s h tr ap lc lam cho
bnh nhn d cai may hn bnh nhn chuyn dn v h hp t nhin.
Tuy nhin SIMV cung co nhng nhc im nh IMV va A/CMV :
- Tng thng khi va kim h hp.
- Nu may ap ng chm hoc khng u ap lc thi bnh
nhn phai gng sc nhiu hn.
- Nu co auto PEEP thi bnh cang nng hn.

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Hinh 2.5 Phng thc thng khi nhn tao SIMV

2.3.6 Thng khi nhn tao h tr ap lc PSV


Thng khi nhn tao h tr ap lc la thng khi gii han ap lc dong
khi, trong o bnh nhn t tao nn nhip th cho may. PSV co li im la
va thng khi nhn tao dai ngay va cai th may. Thng khi nhn tao
dai ngay mang tinh cht h tr nn b may iu khin h hp phai binh
thng (bnh nhn phai th c du th yu)
thi th vao, ap lc dng ln ngay n mt cao nguyn va keo dai
cho n ht thi th vao. Ca bnh nhn va may u hp tac co cao nguyn
o. PSV la mt thi du in hinh cua khai nim gii han dong chay : thi th
vao kt thuc khi dong chay giam nghia la khi bnh nhn thi khng n lc
hit vao. con trong A/C ap lc, thi ky th vao kt thuc bng mt ng h
inh gi timer. PSV s dung cac thng s sau : mc ap lc va nhay.
a s cac may thng khi nhn tao hin ai u co thm h thng phuc hi
iu khin gii han th tich.
H tr ap lc cung cp khi vi mt ap lc t sn mc cao hn
PEEP trong cac nhip th t nhin. Khi mt n lc t th c cam nhn,
may se phat ra mt nhip th di ap lc, ging nh IPPV. Khi ap lc a at
c inh hoc dong chay giam tut xung ti mt gia tri a inh trc thi
th vao se ngng va bnh nhn se th ra.

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n Tt Nghip

im khac nhau c ban gia thng khi h tr/iu khin A/CMV va


PSV ch thi th vao kt thuc khac nhau. Trong A/CMV, thi gian th vao
a c n inh trc (time-cycled), vi PSV la thng khi nhn tao ap lc,
thi th vao se ngng khi ap lc dong chay giam xung, con A/CMV cung la
thng khi nhn ap lc, thi th vao bt u khi n mt ap lc nht inh
nhng se ngng lai vi thi gian th vao a inh trc. PSV phu thuc vao
s gng sc cua bnh nhn, khng co s bt buc. Khi bnh nhn t nhin
ngng th vi yu sc thi co c ch phan hi (feedback) lam cho may tr
thanh iu khin PSV mang tinh cht cua h hp t nhin c may h tr,
d c bnh nhn chp nhn va thy thuc hoan nghnh, dung cai th
may cac trng hp kho.
Tuy nhin PSV cung co nhng nhc im :
- Phai co h thng phuc hi am bao
- Khi dung khi dung co th lam cho bnh nhn giam thng khi
- Bnh nhn co sc can ng dn khi ln kho chiu ng PSV.
PSV co th phi hp vi PEEP hoc IMV va lam giam cao cua
PEEP. Do co nhiu u im nh vy nn cac may hin ai u co chc
nng PSV.
2.3.7 Thng khi nhn tao vi ap lc giam theo chu ky APRV
Thng khi nhn tao vi ap lc giam theo chu ky la mt phng thc
mi c a vao s dung kim soat ap lc trung binh ng dn khi.
Ty l I/E cua phng thc nay lun ln hn 1. Tac dung cua phng thc
nay ging tac dung cua PEEP co anh hng n huyt ng.
Co hai loai APRV:
- APRV co thi gian giam ap n inh trc
- APRV tao ra nhng thay i thang ap lc dng cui ky th ra
trn c s phng thc thng khi t nhin vi ap lc dng lin
tuc.

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Hinh 2.6 Phng thc thng khi nhn tao APRV

2.3.8 Thng khi nhn tao ap lc ng dn khi dng tinh hai pha
BIPAP
Bnh nhn t th vi hai ap lc dng: mt ap lc dng thp hn
mc PEEP, mt ap lc dng mc cao nh s tham gia cua b inh thi
Timer

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n Tt Nghip

Hinh 2.7 Phng thc thng khi nhn tao BIPAP

2.3.9 Thng khi nhn tao ap lc dng lin tuc CPPV


Phng thc h hp nhn tao vi ap lc dng lin tuc la phng
thc h hp trong o ap lc thi th vao va ca thi th ra u dng tinh nh
1 van can th ra goi la PEEP (Positive End Expiratory Pressure). Phng
phap nay goi la CPPV, bao gm phng thc IPPV kt hp PEEP.
Vai tro cua PEEP :
- mt s bnh nhn suy h hp cp, oxy giam nng kho co th
cha c bng IPPV n thun mc du tng FIO2 ln qua 0,60.
Vic dung PEEP se at c muc ich nay bng cach hi phuc
lai trn bnh nhn mt th tich cn chc nng FRC binh thng
nhng khng gy ra tran khi mang phi, it anh hng n huyt
ng va khng anh hng n thng khi ph nang.
- PEEP dung phi hp cho h hp nhn tao, nhng co th phi
hp vi ca h hp t nhin hoc thng khi hn hp PEEP vi
thng khi bt buc ngt quang IMV.
Tac dung cua PEEP:
- V mt th tich
Tac dung chu yu cua PEEP la lam tng s trao i khi phi :
PEEP lam tng th tich phi bng s tng FRC. Falke nhn thy
rng mi cm H2O PEEP se lam tng FRC (theo Falke, tng
13mmHg PaO2 cho mi cm H2O PEEP).
- V mt ap lc
S tng ap lc trong lng ngc bi PEEP lai co anh hng
khng tt ti tun hoan. Tng ap lc trong lng ngc lam giam
cac ap lc cha trong bung tim vi lam giam tun hoan tr v.
Co th o ap lc trong lng ngc bng ap lc mang phi hay
bng ap lc trong thc quan. p lc nay chiu anh hng trc tip
cua ap lc ph nang va thp hn ap lc ph nang. Song vi phi
co dan n giam nh trong ARDS (hi chng suy h hp cp

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ngi ln), s tng ap lc trong lng ngc rt nho so vi tng ap


lc ph nang. Vi PEEP bng 5 20 cmH2O theo Kuman va
Herman, ap lc lng ngc chi bng 20% ap lc ph nang va anh
hng rt it ti cung lng tim.
p lc ph nang qua cao, trn 20cmH2O se chn ep cac mach
phi gy gian oan tun hoan phi nhng vung co ty l VA/Q
(thng khi/ti mau) cao va anh hng ti ap lc cha cua bung
tim trai
2.3.10 Thng khi nhn tao vi dong chay lin tuc CFV
Trong phng phap nay, mt dong khi lin tuc i t may qua binh
khi dung vao bnh nhn va i thng ra ngoai. Thng khi nhn tao vi dong
chay lin tuc c ap dung ca vao phng thc thng khi iu khin ngt
quang IMV va thng khi nhn tao vi ap lc dng lin tuc CPPV. Trong
phng phap nay cn co Oxy nen vi ap lc cao
2.3.11 Thng khi t nhin vi ap lc dng lin tuc CPAP
Thng khi t nhin vi ap lc dng lin tuc CPAP la mt phng
thc thng khi t nhin vi PEEP. Phng phap nay a c Gregory dung
cho tre s sinh bi bnh mang trong. Hin nay tac gia a dung trong hi
chng suy h hp cp ngi ln ARDS.
CPAP c s dung tranh nhng ri loan huyt ng gy ra do
phng thc IPPV va lam cho chiu c PEEP cao hn. Bnh nhn th
vao t nhin nhng ap lc thi th vao thp hn IPPV ma khng xung qua
0 (vn +) vi co ap lc (+) cua PEEP.
Vi CPAP, bnh nhn th t nhin trn c s ap lc dng lin tuc
PEEP, mc Sensitivity a bnh nhn dn v th t nhin cai hn may.
Co th hiu la trc mui bnh nhn lun lun co mt lung khi ap lc
dng khi nhanh chong chay vao phi. CPAP dung cho bnh nhn bt
u t th va do th may lu ngay co nguy c xep phi mc PEEP thng
la 5cmH2O.

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Hinh 2.8 Thng khi t nhin CPAP

2.3.12 Thng khi nhn tao vi th tich phut bt buc MMV


MMV la th tich phut bt buc khi bnh nhn th t nhin. Khi bnh
nhn th, th tich th ra c cam nhn. Nu th tich phut xac inh bng
may ln hn th tich phut ti thiu, thi bnh nhn c phep th t nhin
va chi nhn mt s nhip th SIMV co han ch th tich a c cai t trn
may.
Nu th tich phut c d tinh nho hn th tich phut ti thiu, may
bt u tng s nhip th SIMV bu cho s chnh lch. Nu bnh nhn
ngng th, may se cung cp toan b th tich ti thiu bng cach phat thm
mt s nhip th tinh theo c ch nhip phuc hi.

Hinh 2.9 Thng khi nhn tao MMV

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2.3.13 Th t nhin SPONT


Trong phng phap nay, bnh nhn c phep th t nhin. Tuy
nhin, nu bnh nhn t ngt ngng th hay th t nhin khng co hiu
qua thi h hp bao ng cua may se thng bao cho bac sy. Trong cac h hp
nhn hoat ng ch nay, cac bac sy hay y ta trc co th yn tm vi khi
bnh nhn th yu hay ngng th thi may se t ng chuyn sang ch
A/CMV va ng se bao ng cho bac sy va y ta bit.
Ngoai ra, thng khi nhn tao nhng nm gn y con co nhng bc
tin ang k, vi khai nim: chin lc bao v phi, giam thng khi
(hypoventilation) va dung PEEP chng auto-PEEP, thng khi inh
hng ap lc la chinh giam thiu ap lc inh trn ng th, giam thiu
tn thng phi, ap dung ngay cang rng rai thng khi c hoc khng xm
nhp, thng khi tn s cao ap lc thp .
Nh cac may th hin ai co h thng kim soat phan hi (Servo
Control) co thm mt s phng thc thng khi nhn tao nh:
- Thng khi nhn tao theo phut tng cng AMV (Augmented
Minute Volume)
- Thng khi h tr thich ng ASV (Adaptive Support Ventilation)
- Thng khi ap lc thich ng APV (Adaptive Pressure Ventilation)
- Thng khi am bao th tich h tr ap lc VAPS (Volume
Assured Pressure Support)
- Thng khi iu chinh ap lc iu khin th tich PRVC
(Pressure Regulated Volume Control)

BIT THM THNG TIN V PHN CU TO, NGUYN LY HOT


NG, BAO TR SA CHA, GIAO TIP CA MY TH ESPRIT, XIN
LIN H VI TC GIA: MN VN HNG, ST: 0975750090. HOC HI
THY: NGUYN PHAN KIN: 0904696928

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