1

Galileo 上課講義

成杏股份有限公司 Speaker:楊 東 家 行動 : 0910808466

GALILEO-Classic GALILEO-Gold

2

電池顯示板

3

背面觀

4

安裝噴霧杯組：須注意是安裝在機器「進氣端」

管路組裝說明

5

Flower Senor

藍線為近病人端

白線為近Y Piece端

• 若要加裝AN(人工鼻)請裝於SENSOR與病人之間

※不可使用酒精泡消

6

吐氣閥 &吐氣瓣膜 • 瓣膜鐵片朝上,再置於吐氣閥蓋上

7

Maintainance

• Flow Sensor(與管路更換時一併清潔) – 1、Flowsensor 卸下後，直接以下列2 種溶劑泡消，時間各15 – 20分鐘

• 3M酵素清潔劑 15'--20'

• (korsalax basic ) 15'--20'

– 2、再以清水洗淨，晾乾。(tube內有水可用AIR flow沖出)

– 3、切記勿用尖物搓洗sensor內部，必免損壞sensor瓣膜

• 吐氣閥蓋及吐氣瓣膜(與管路更換時一併清潔)

• Fan Filter(每月換)

• Gas supply filter(每3個月清潔或更換)

• O2 Cell(每年或5000小時更換)

• Backup Battery(每3年)

8

New “Start-up” window

9

面板 M旋鈕

C旋鈕

• -

Connector

靜音

100%O2

手動呼吸

Nebulizer

10

Screen

M旋鈕控制 C旋鈕控制

15

492

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

492 Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

DuoPAP

P-CMV (S)CMV

P-SIMV SIMV

APVCMV SPONT

APVSIMV

ASV APRV

Ventilation Mode

NIV

Standby

Calibration

Patient

Additions

Mode Control Alarm

waveform, loop, Trend freeze, hold, P/ V Tool eventlog

11

M旋鈕 Galileo basic 與 Gold 可看的參數資料不同

12

測試與校正

15

492

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

492 Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

DuoPAP

P-CMV (S)CMV

P-SIMV SIMV

APVCMV SPONT

APVSIMV

ASV APRV

Ventilation Mode

NIV

Standby

Calibration

Patient

Additions

Mode

13

測試與校正

• Tightness Test緊密度測試 : 此測試病人必須脫離呼吸器,檢查各接點是否不緊或管路是否有漏氣

• Flow Sensor Test流量感應器測試 : 此測試病人不可接在呼吸器上,在檢查Flow Sensor之功能正常否？包含TV之測量準確度及Trigger Function觸發功能

• O2 Cell Calibration氧氣校正 : 此測試無須拔除管路，病人可接至呼吸器上，誤差需在±5%以內

(PS.所有測試與校正步驟均依照Monitor Message指示作即可完成)

轉過來

14

C旋鈕-- Alarm

15

Monitor—26 Parameter

30 15

P-SIMV 3.78 492 Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

Trigger

Operating: 1153 h Monitoring 2001/04/12 23:14

Ppeak

Pplateau

Pmean

PEEP/CPAP

Pminimum

AutoPEEP

P01

WOBimp

RSB

VTE

ExMinVol

Vleak

Insp Flow

Exp Flow

Rinsp

Rexp

Cstat

ftotal

fspont

Ti

Te

I:E

RCinsp

RCexp

PTP

Oxygen

Close

16

Smart Apnea Backup (SAB)

Spont breaths

Machine WOB

Patient WOB

(S)CMV

SPONT, P-SIMV,

DuoPAP, APRV, NIV

APVsimv APVcmv

ASV

SIMV

P-CMV

Total

WOB

P-mode

V-modes

adaptive

adaptive

Bi-directional, automatic switchover between

support mode and its backup mode

Xxxxxxxxx

erttrert Xxxxxxxxx

erttrert

Additions

Sigh

TRC

Backup

Backup is a background feature which, once activated or

deactivated, applies to all non-control modes.

17

Apnea backup control window

3.78

SPONT

492 Xxxxxxxxx

erttrert Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert Xxxxxx

erttrert

Confirm

Trigger

30

P-CMV Controls SPONT Adult

Backup

setup

18

Improve patient WOB and comfort

• Flow resistance compensations

- Adjustable tube

resistance compensation (TRC)

- Automatic circuit resistance compensation

TRC Tube resistance compensation

Tube size adjustable 4 – 10 mm

Compensation adjustable 0 – 100%

Xxxxxxxxx

erttrert Xxxxxxxxx

erttrert

Additions

Sigh

TRC

Backup

19

TRC- tube resistance compensation

How To Compensate Tube Resistance

• TRC可在吸氣期及吐氣期補償因ET tube或Trach tube之阻力而損失的Tracheal Pressure

• 使用TRC時,Airway Peak Pressure會增加2~5 cmH2O

• 使用TRC時,螢幕會出現Paw 及Treach Preasure兩種波形

Airway Opening pressure

tracheal pressure

Without TRC

With TRC

Focus on tracheal pressure

20

Wider ETS range(5-70%)

ETS can improve synchrony and change Ti of spontaneous breaths

ARDS---RCe<0.5sec,需配合吐氣時間較短,且Ti較長可增加血氧 ETS設低(5~15%)

COPD--- RCe>1.2sec,Resistance較大,需配合吐氣時間較長 ETS設高(40~70%)

P

flow

Too late switchover Proper switchover Too early switchover

21

Mode介紹

Dual,Auto control modes (closing-loop)

Bi-phasic modes

(variable PEEP)

APRV DuoPAP

APVsimv APVcmv

ASV

15

492

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

492

Xxxxxxxxx

erttrert

Xxxxxxxxx

erttrert

Xxxxxx

erttrert

DuoPAP

P-CMV (S)CMV

P-SIMV SIMV

APVCMV SPONT

APVSIMV

ASV APRV

Ventilation Mode

Standby

Calibration

Patient

Additions

Pressure

modes

Volume

modes

Adaptive

modes

NIV NIV

Conventional

ventilation modes

AC/(S)CMV

NIV P-SIMV

SPONT

P-CMV

SIMV

22

One ventilator for all patients mode type Adult

30–200 kg

Child 10 – 30 kg

Infant < 10 kg

(S)CMV Volume

SIMV Volume

P-CMV Pressure

P-SIMV Pressure

SPONT Pressure

DuoPAP Pressure

APRV Pressure

NIV Pressure

APVcmv Dual Control

APVsimv Dual Control

ASV Adaptive • New modes

• APVcmv and APVsimv in infant should be used for the patients above 2 kg.

• complete set of breathing circuit Adult: 22 mm; Pediatric: 15 mm; Infant: 10 mm

23

APRV Mode

• 在高壓CPAP中對不同時間常數的肺泡提供灌流

• 在低壓的CPAP中如同peep增加氧合,排除CO2

• 嚴重低血氧,呼吸衰竭的病人使用APRV.

24

APRV Mode (airway pressure release ventilation)

= PHIGH

P ……….........PLOW

T

* * * * * * * † † †

病人吸氣 *

CPAP

病人在自主呼吸的前提下，在一個較高的氣道壓力CPAP上進行自主呼吸，然後伴有間斷的，短暫間隙的氣道壓力釋放。

此模式由CPAP模式改良而成,期利用高壓CPAP讓病人自呼及低壓CPAP洩放壓力以排除CO2.

25

Guidelines for adjust APRV

初步設定：

Phigh：20~35 cmH2O(注意Vt)

Plow： 0 cmH20(注意吐氣壓力避免病人collapse)

Thigh：4.5~8秒

Tlow：0.2~0.8秒(restrictive) 0.8~1.5秒(obstructive)

PS：以Plow(PEEP)起算(above PEEP)

※若病人FiO2≦40%，SpO2≧95%，可try weaning

※嚴重COPD病人(無法2秒內完全吐氣) ，勿用APRV

Nader M. Habashi, MD, FACP, FCCP

Other approaches to open-lung ventilation: Airway pressure release ventilation

Crit Care Med 2005 Vol. 33, No. 3

26

DuoPAP mode (Bilevel/BIPAP)

PHIGH + PS

PLOW + Psupport PLOW/PEEP/CPAP PLOW

PHIGH

P

T

- 1989年奧地利Marcel Bawn 提出了：在2個不同氣道壓力(CPAP)水準上 可以有自主呼吸的壓力控制模式(如圖)的Duo PAP新概念。

- 與PCV相比Duo PAP的自主呼吸不會使肺的順應性下降，反而提高了通氣量，同時病人的獨立自主呼吸具有治療價值。

- DuoPAP可說是PCV與APRV的改良

27

Guidelines for adjust DuoPAP

初步設定： Phigh：PC時的PIP 或 VC時的Pplateau

PEEP： PC/VC時的PEEP

Rate：PC/VC時的rate

Thigh：1:1 或 PC/VC時的I:E

PS：以PEEP起算(above PEEP)

※注意病人適當的Vt，可調整Phigh

28

Differences between DuoPAP & APRV

P

P-low = 0

T-high

P-high

P-low = PEEP

t

APRV

T-high

Cycle time = rate / 60

DuoPAP

P-high

T-low

29

APV Mode

• Adaptive pressure ventilation 1.設定 target volume 2. 3 test breath ….V/P =C (VT/Ppeak-PEEP) or based on the previous ventilation 3. 以最小進氣壓力 達到 target volume 4.每次Breath,Pressure只調整1~2 cmH2O 5.Range:(PEEP+5) ~ (High pressure alarm limit-10) Ps: 使用此mode 注意病人氣囊是否有漏氣,若有漏氣會造成呼吸器壓

力不正常調整

Target VT

Pressure

Flow

PEEP/CPAP

30

NIV mode --- 非侵入式通氣(Non Invasive Ventilation)

Benefit: 1.減少病患重複插管造成的痛苦 2.增進病人舒適度 3.降低呼吸作功 4.保留說話及吞嚥能力

NIV可補償從mask或mouth的leakage,維持pressure的穩定,最大可至95% 注意Ppeak (PEEP + Psupport)要在33 cmH2O以下,以防止超過食道括約肌之

opening pressure

NIV適用在有規律自呼的patient,

使用NIV前,須先使用SPONT mode,以確認其自呼性

Setting: ETS >40% (leakage越大,ETS設越大)

Timax (建議 : 0.8~1.2 Sec)

Trigger：1~3 l/s

31

0

500

1000

1500

2000

0 20 40 60

f bpm

Vt

ml

1. Lung-protective rules

0. Calculate MinVol (trivial)

3. Approach the target

2. Optimal breath pattern

Repeat 1,2,3 breath-by-breath

Summary of steps

32

ASV使用動機? 思路?

ASV mode

積極weaning病人

病人依賴呼吸器

無法weaning

%MinVol ↓ %MinVol ↑

33

傳統mode如何轉成 ASV

案例:

• 原先用傳統模式:

CMV: rate =12 ,Vt= 500ml MV = 6L/min • 使用ASV:

病人IBW= 50kg MV = 6 = %MV x 50 故得知設定 %MV =120%

RR x Vt = MV = %MV x IBW

34

ASV Graphic Screen

• It’s Fully Controlled Ventilation

• If you want to try weaning,you must Minvol%

35

如何依呼吸情況調整 %MinVol ?

fspont fcontrol Pinsp 操作指南

0 >10 >10 Full control,可開始

weaning,調降%MinVol

可接受 0 >10 給病人自呼壓力支持良好,可調降%MinVol

可接受 0 <8 病人完全自呼,調降

%MinVol ,80%建議拔管

太高 0 >10 Dyspnea.調升%MinVol或注意其他臨床狀況,Check autotrigger

• 初始設定為150 %MinVol

36

Normal lungs (postOp, Head injury,etc...)

Restrictive patients (ARDS, pneumonia)

Obstructive patients (COPD, asthmatic)

Limitations:

Patients or circuit Leaks (Non invasive ventilation,

Broncho-pleural fistula)

ASV: Which patients?

37

附件: