Ⅰ. Indications/There is no unified indication yet
The drive function of the respiratory center must be normal
Have better spontaneous breathing ability
Mainly used in the early intervention of respiratory failure, can also be used to assist weaning
For those with clear indications for invasive ventilation, it is not appropriate to use non-invasive instead of invasive
It can be considered in the following clinical situations:
(1) Mild to moderate dyspnea, manifested as shortness of breath, three concave signs and nasal agitation, and skin cyanosis
(2) Abnormal arterial blood gas: pH < 7.35, pac02 > 45 mmHg or P/F < 250 mmHg
heartbeat or breathing stops;
Weak spontaneous breathing, frequent apnea;
There are many airway secretions, the airway protection ability is poor, and the risk of aspiration is high;
Massive upper gastrointestinal bleeding;
Permanent anatomic abnormalities of the nasopharyngeal cavity;
Neck and facial trauma, burns and deformities;
After recent surgery on the face, neck, mouth, pharynx, esophagus and stomach;
congenital diaphragmatic hernia;
Ⅲ. Common connection methods: nasal congestion, nasal mask, mouth and nose mask, full face mask
The connection method and specification should be selected according to the child's age, weight, head and face shape, nasal patency, mouth opening, comfort and the child's ability to adjust the device to ensure that it is suitable for the child's nasal cavity size and face shape, reduce air leakage, and avoid Adverse reactions.
Nasal congestion is easy to fix and well tolerated, more commonly used by infants and easier to care for, and nasal and face masks are suitable for older children.
Ⅳ. Commonly used non-invasive ventilation techniques
Ⅴ. nCPAP: single-level pressure, maintaining the same target pressure in inspiratory and expiratory phases
1. Parameter setting: pressure 4-6cmH2O (subsequent adjustment does not exceed 10cmH2O)
2. Parameter adjustment and evacuation: If SPO2 remains stable, gradually reduce FiO2 by 5%. If FiO2 < 35%, SPO2 can still be maintained, and the pressure can be gradually reduced by 1cmH2O each time, until 2-3cmH2O can be tried to evacuate CPAP.
Ⅵ. Bi-level CPAP (Biphasic) alternately provides CPAP with two stress levels
1. Parameter setting:
10-30 times /min
According to SpO2
2. Compared with nCPAP: On the basis of CPAP, there are periodic pressure changes, and the support is strong, but due to the fixed time of high pressure and low pressure, it is prone to man-machine asynchrony.
3. Parameter adjustment and evacuation: when Phigh<8cmH2O, Plow<4cmH2O, FiO2≤30%, the breathing state is stable and the blood gas index is normal, intermittent evacuation can be attempted, or it can be changed to CPAP mode and then gradually evacuate noninvasively.
Ⅶ. NIPPV simulates mechanical ventilation through a "non-invasive" mode
1. Including S, T, S/T, AVAPS and other modes, the most commonly used is S/T mode.
2. Initial parameter setting of S/T mode:
2~4 times /min lower than the physiological frequency of the same age
According to SpO2
3. Adjustment and evacuation of parameters: Adjust parameters appropriately according to the improvement of blood gas and respiratory failure in children, EPAP should not exceed 8cmH2O, and IPAP should not exceed 20cmH2O.
When IPAP drops to 8cmH2O, EPAP drops to 4cmH2O, Fi02≤30%, and RR drops to 50% of physiological, if the child has no obvious dyspnea and can maintain a good blood gas index, stop BiPAP and use nasal cannula instead. Oxygen. Non-invasive ventilation can be reconnected if breathing difficulties occur.
Ⅷ. Curative effect observation
After non-invasive ventilation is applied to children, the improvement of respiratory failure in children should be observed, and parameters should be adjusted or ventilation methods should be upgraded in time.
1. Evaluation of initial curative effect: 1 to 2 hours after the initial treatment, it can be evaluated whether it has the effect of assisting ventilation and whether it can improve the clinical and physiological indicators of respiratory failure. It can be judged by observing the changes of clinical and arterial blood gas.
Clinical manifestations: improvement of shortness of breath, reduction of auxiliary respiratory muscle movement and disappearance of paradoxical breathing, slowing of respiratory rate, increase of blood oxygen saturation and improvement of heart rate, etc.;
Blood gas standards: PaCO2, pH and PaO2 improved.
2. After 1-2 hours of non-invasive ventilation, the patient's condition is not relieved, and the ventilation mode should be considered.
3. Evaluation of the final treatment effect: The final evaluation index is usually the tracheal intubation rate and the fatality rate.
Ⅸ. Adverse reactions and treatment
1 ) The pressure is too high
2 ) Poor compliance of children
Choose a suitable mask and fix it reasonably. When the air leakage is too large, check whether the fixation is appropriate and adjust the pressure in time. If the child has poor compliance, it can be appeased or properly sedated.
facial pressure injury
Nasal congestion, nasal mask or mask is fixed too tightly, compressing the skin and mucous membranes
Choose a mask of the right size and material, not too tight when connecting and fixing, and use a protective film for the pressure.
Masks, hoods, etc. may cause
Strengthen mission, observation and communication
Poor sputum drainage
Airway care is difficult
Strengthen airway care, older children should cough, the head of the bed is too high 30 degrees
Dry mouth and nose, thick sputum
If the gas flow rate is too high , the humidification may not be sufficient
Fully humidified by active humidification
Children are easy to swallow air , and when the pressure or flow rate is too large, the air is also easy to enter the gastrointestinal tract through the esophagus
Adjust ventilator parameters in time, avoid excessive pressure, indwelling gastric tube and gastrointestinal decompression if necessary
Bloating and vomiting caused by flatulence can easily lead to aspiration
Strengthen observation, appropriate semi-sitting position, and appropriately reduce pressure under the condition of ensuring curative effect, nasal mask and nasal congestion are lower risk of aspiration than mask
1) Excessive CPAP pressure leads to difficulty in exhaling CO2
2 ) Inspiratory pressure is too low resulting in insufficient tidal volume
3 ) Insufficient exhalation time
4) The flow rate is too low, and the CO2 is repeatedly inhaled
Set proper pressure and flow rate
1. Air leakage: timely adjust the position and tightness of the nasal obstruction (or nasal mask, mask, etc.), and properly appease the child.
2. Airway care: pay attention to opening the airway, strengthen airway clearance, and clear airway secretions in time.
3. Monitor respiratory rate, heart rate, transcutaneous oxygen saturation and other changes.
4. Pay attention to the situation of flatulence, especially if infants and young children cannot express abdominal discomfort, they should be dealt with in time. Severe flatulence may cause the diaphragm to rise and affect breathing.
5. Gastric tube care: gastrointestinal decompression if necessary.