Noninvasive Positive Pressure Ventilation (NIPPV) in Obese Children

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Noninvasive Positive Pressure
Ventilation (NIPPV) in Obese Children
∏’√‡¥™ §ÿªµ“ππ∑å
„π‡¥Á°∑’¡Ë π’ ”È Àπ—°µ—«¡“°¡—°¡’ª≠í À“‡√◊ÕË ß restrictive lung disease ®“°°“√∑’Ë¡’‰¢¡—π – ¡∑’Ë∫√‘‡«≥
chest wall ∑”„À⬓°µàÕ°“√À“¬„® πÕ°®“°π’¬È ß— ¡’ª≠í À“
‡√◊ÕË ß obstructive lung disease ‡π◊ÕË ß®“°¡’‰¢¡—π – ¡
∑’Ë∫√‘‡«≥∑“߇¥‘πÀ“¬„® à«πµâπ
‚¥¬∑—«Ë ‰ª°“√√—°…“‡∫◊ÕÈ ßµâπ ‰¥â·°à °“√≈¥πÈ”Àπ—°,
πÕπµ–·§ß ·µà„π√“¬∑’√Ë °— …“‡∫◊ÕÈ ßµâπ·≈⫉¡à¥¢’ π÷È ®”‡ªìπ
µâÕß„™â noninvasive positive pressure ventilation
(NIPPV) „π°“√√—°…“ ‚¥¬„π°≈ÿ¡à ∑’¡Ë ¿’ “«–Õÿ¥°—πÈ ∑“߇¥‘π
À“¬„® à«πµâπ °“√„™â NIPPV ·∫∫ continuous positive airway pressure (CPAP) ‡ªìπ°“√√—°…“∑’Ë¥’ ·µà
∂â“¡’µàÕ¡∑Õπ´‘≈À√◊ÕÕ–¥’πÕ¬¥å‚µ §«√æ‘®“√≥“∑”
adenotonsillectomy °àÕπ ∂Ⓣ¡à¥’¢÷Èπ®÷ß®–„™â CPAP
„π°≈ÿà¡∑’Ë¡’ obstructive hypoventilation syndrome(OHS), obesity hypoventilation °“√„™â NIPPV
‡§√◊ËÕߙ˫¬À“¬„®
Corrugated tube
·∫∫ bilevel positive airway pressure (BiPAP) ‡ªìπ
∑“߇≈◊Õ°∑’Ë¥’°«à“
„π∫∑§«“¡π’®È –¢Õ°≈à“«∂÷ß«‘∏°’ “√„Àâ noninvasive
positive pressure ventilation (NIPPV) „πºŸâªÉ«¬‡¥Á°
Õâ«π „πÀ—«¢âÕµà“ßÊ ¥—ßµàÕ‰ªπ’È
1. Õÿª°√≥1å
ª√–°Õ∫¥â«¬ à«π¢Õßµ—«‡§√◊ËÕß®π∂÷ßµ—«ºŸâªÉ«¬
¥—ßπ’È
1. ‡§√◊ËÕߙ૬À“¬„®
2. ¢âÕµàÕ exhalation port ·≈– corrugated tube
3. Àπâ“°“°
4. “¬√—¥Àπâ“°“°
¥—ß· ¥ß„π·ºπ¿Ÿ¡‘∑’Ë 1 ·≈–¿“æ∑’Ë 1
Exhalation port
ÀπÈ“°“°
“¬√—¥ÀπÈ“°“°
·ºπ¿Ÿ¡‘∑’Ë 1
Pressure (cmH2O)
Noninvasive Positive Pressure Ventilation (NIPPV) in Obese Children, ∏’√‡¥™ §ÿªµ“ππ∑å 201
Time
¿“æ∑’Ë 1 · ¥ßµ—«Õ¬à“ߺŸâªÉ«¬∑’Ë„™â‡§√◊ËÕߙ૬À“¬„®·∫∫
noninvasive mechanical ventilation
1.1 ‡§√◊ËÕߙ૬À“¬„®
„π∑’πË ®’È –¢Õ°≈à“«∂÷߇§√◊ÕË ß™à«¬À“¬„®∑’„Ë ™â „π
‡«™ªØ‘∫—µ‘∫àÕ¬Ê ‡™àπ CPAP, BiPAP πÕ°®“°π’È®–
°≈à“«∂÷߇§√◊ËÕߙ૬À“¬„®·∫∫Õ◊ËπÊ ∑’Ë¡’°“√‡√‘Ë¡„™â ‡™àπ
AutoPAP, C flex, Biflex, Auto C flex, Respirator
application
CPAP (continuous positive airway pressure)
‡§√◊ËÕߙ૬À“¬„®™π‘¥π’È®–„À⧫“¡¥—π∫«°
§ß∑’Ë (¿“æ∑’Ë 2) π‘¬¡„™â„πºŸâªÉ«¬∑’Ë¡’ªí≠À“∑“߇¥‘π
À“¬„® à«π∫πÕÿ¥°—Èπ ‚¥¬·√ߥ—π∫«°∑’ˇ°‘¥¢÷Èπ®–™à«¬
„π°“√∂à“ߢ¬“¬∑“߇¥‘πÀ“¬„® ૬∫π ∑”„Àâ∑“߇¥‘π
À“¬„® à«π∫π∫√‘‡«≥®¡Ÿ° ª“° ·≈– hypopharynnx
Pressure (cmH2O)
¿“æ∑’Ë 2 · ¥ß§«“¡¥—π¢Õ߇§√◊ËÕߙ૬À“¬„® CPAP
‡ªî¥‚≈àߢ÷È𠇪ìπ«‘∏’°“√√—°…“∑’Ë¥’∑’Ë ÿ¥„πºŸâ„À≠à∑’Ë¡’ªí≠À“
obstructive sleep apnea (OSA) ·≈–„πºŸâªÉ«¬‡¥Á°∑’Ë¡’
OSA ´÷Ëß„Àâ°“√√—°…“‚¥¬°“√ºà“µ—¥‡Õ“µàÕ¡∑Õπ´‘≈
·≈–Õ–¥’πÕ¬¥åÕÕ°·≈⫉¡à¥’¢÷Èπ πÕ°®“°π’Ȭ—ß¡’°“√„™â
CPAP „πºŸâªÉ«¬‡¥Á°∑’Ë¡’ªí≠À“∑“߇¥‘πÀ“¬„® à«π∫π
Õÿ¥°—πÈ ®“° “‡ÀµÿÕπË◊ Ê ‡™àπ subglottic edema À≈—ß°“√
∂Õ¥∑àÕÀ≈Õ¥≈¡§Õ, laryngotracheaomalacia ‡ªìπµâπ2
BiPAP (bilevel positive airway pressure)
‡§√◊ËÕߙ૬À“¬„®™π‘¥π’È„À⧫“¡¥—π∫«° 2
√–¥—∫ (¿“æ∑’Ë 3) ‚¥¬‡§√◊ÕË ß®–Õ—¥°ä“´À√◊Õ≈¡¥â«¬§«“¡
¥—π Ÿß„π™à«ß∑’˺ŸâªÉ«¬À“¬„®‡¢â“ ·≈–ºàÕ𧫓¡¥—π„Àâ
≈¥≈ß„π™à«ßÀ“¬„®ÕÕ° ∑”„Àâ¡’°“√¢¬“¬µ—«¢Õߪե
‡À¡◊Õπ°—∫°“√„™â‡§√◊ËÕߙ૬À“¬„®·∫∫¥—È߇¥‘¡ Tidal
Inspiration
IPAP
Expiration
EPAP
Time
IPAP = Inspiratory positive airway pressure
EPAP = Expiratory positive airway pressure
¿“æ∑’Ë 3 · ¥ß§«“¡¥—π¢Õ߇§√◊ËÕߙ૬À“¬„® BiPAP
202 Current Concepts in Pediatric Critical Care
volume ∑’˺ŸâªÉ«¬‰¥â√—∫¢÷Èπ°—∫§«“¡·µ°µà“ߢÕß√–¥—∫
§«“¡¥—π∑—Èß Õß√–¥—∫ √«¡∑—Èß compliance ¢Õߪե
·≈– resistance ¢Õß∑“߇¥‘πÀ“¬„®
¡’√“¬ß“π«à“°“√„™â BiPAP ¡’ª√–‚¬™πå„π
°“√√—°…“ºŸªâ «É ¬‡¥Á°·≈–ºŸ„â À≠à∑¡’Ë ’ impending acute respiratory failure4, chronic respiratory failure ®“° “‡Àµÿ
µà“ßÊ5 ‡™àπ neuromuscular weakness, bronchiectasis ®“°‚√§ cystic fibrosis6, central hypoventilation
µ≈Õ¥®π¡’∑’Ë„™â„πºŸâªÉ«¬∑’Ëæ∫«à“¡’ atelectasis ¿“¬À≈—ß
°“√∂Õ¥∑àÕÀ≈Õ¥≈¡§Õ3 ·≈–¬—ß¡’ à«π™à«¬∑”„Àâ°“√
wean ‡§√◊ËÕߙ૬À“¬„®ª√– ∫§«“¡ ”‡√Á®¡“°¢÷Èπ7
AutoPAP (auto positive airway pressure)
‡§√◊ËÕߙ૬À“¬„®™π‘¥π’È„À⧫“¡¥—π∫«°∑’Ë
¡“°¢÷Èπ ∂⓺ŸâªÉ«¬¡’Õ“°“√°√π, decrease of air flow
À√◊Õ À¬ÿ¥À“¬„® (¿“æ∑’Ë 4)
Pressure (cmH2O)
Time
¿“æ∑’Ë 4 · ¥ß§«“¡¥—π¢Õ߇§√◊ËÕß AutoPAP
C-Flex
‡§√◊ÕË ß™à«¬À“¬„®™π‘¥π’§È ≈⓬°—∫ CPAP ·µà
™à«ßÀ“¬„®ÕÕ° “¡“√∂≈¥§«“¡¥—π∫«°‡æ◊ËÕ„À⺟âªÉ«¬
“¡“√∂À“¬„®ÕÕ°‰¥â –¥«°¢÷Èπ (¿“æ∑’Ë 5)
BiFlex
‡§√◊ÕË ß™à«¬À“¬„®™π‘¥π’§È ≈⓬°—∫ BiPAP ·µà
™à«ßÀ“¬„®ÕÕ° “¡“√∂≈¥§«“¡¥—π∫«°‡æ◊ËÕ„À⺟âªÉ«¬
“¡“√∂À“¬„®ÕÕ°‰¥â –¥«°¢÷Èπ (¿“æ∑’Ë 6)
Pressure (cmH2O)
Time
¿“æ∑’Ë 5 · ¥ß§«“¡¥—π¢Õ߇§√◊ËÕß C-Flex
Pressure (cmH2O)
Time
¿“æ∑’Ë 6 · ¥ß§«“¡¥—π¢Õ߇§√◊ËÕß BiFlex
Noninvasive Positive Pressure Ventilation (NIPPV) in Obese Children, ∏’√‡¥™ §ÿªµ“ππ∑å 203
Auto C Flex
‡§√◊ÕË ß™à«¬À“¬„®™π‘¥π’§È ≈⓬°—∫ AutoPAP
·µà™«à ßÀ“¬„®ÕÕ° “¡“√∂≈¥§«“¡¥—π∫«°‡æ◊ÕË „À⺪Ÿâ «É ¬
“¡“√∂À“¬„®ÕÕ°‰¥â –¥«°¢÷Èπ
Respirator application
§◊Õ °“√„™â‡§√◊ÕË ß™à«¬À“¬„®·∫∫∑’„Ë ™â„π ICU
¡“µàÕ°—∫ mask ·≈–ª√—∫ mode ‡ªìπ pressure control À√◊Õ pressure support ´÷Ëß “¡“√∂„™â·∑π‡§√◊ËÕß
™à«¬À“¬„®·∫∫ BiPAP ‰¥â ·µà®–µâÕß√–«—ßÕ¬à“„Àâ¡’ air
leak ∑’ËÀπâ“°“° ‡æ√“–®–∑”„Àâ‰¡à‰¥â tidal volume ∑’Ë
µâÕß°“√ À√◊Õ¡’°“√≈“°¢Õß flow ®π¡’ inspiratory time
¬“«‡°‘π‰ª À√◊Õ‰¡à “¡“√∂√—°…“√–¥—∫ CPAP ‰¥âµ“¡
¿“æ∑’Ë 7 Nasal mask ‡ªìπ mask ∑’Ëπ‘¬¡„™â¡“°∑’Ë ÿ¥
¿“æ∑’Ë 9 nasal prong
∑’µË Õâ ß°“√ ∫“ߧ√—ßÈ °“√∑’¡Ë ≈’ ¡√—«Ë √Õ∫Àπâ“°“° Õ“®∑”„Àâ
ºŸâªÉ«¬ trigger ‡§√◊ËÕߙ૬À“¬„®¬“°À√◊Õßà“¬°«à“∑’˵—Èß
‡Õ“‰«â
1.2 Corrugated tube ·≈– exhalation port
Mask ·∫∫™π‘¥∑’ˉ¡à¡’ exhalation port
µâÕßµàÕ exhalation port „Àâ„°≈â°—∫ mask ∑’Ë ÿ¥ ·≈â«®÷ß
µàÕ°—∫ corrugated tube ‡æ◊ÕË ‡™◊ÕË ¡‰ª¬—߇§√◊ÕË ß™à«¬À“¬„®
Mask ™π‘¥∑’Ë¡’ exhalation port „ÀâµàÕ°—∫
corrugated tube ‡™◊ËÕ¡°—∫‡§√◊ËÕߙ૬À“¬„®‰¥â‡≈¬
1.3 Àπâ“°“° (Mask)
Mask ∑’Ë„™â¡’ 3 ™π‘¥ (¿“æ∑’Ë 7, 8, 9)
1.4 “¬√—¥Àπâ“°“° (¿“æ∑’Ë 10, 11)
¿“æ∑’Ë 8 Full face mask ‡ªìπ mask ∑’˧√Õ∫∑—Èߪ“°·≈–
®¡Ÿ°
204 Current Concepts in Pediatric Critical Care
¿“æ∑’Ë 10 “¬√—¥Àπâ“°“°
¿“æ∑’Ë 11 Chin strap „™â„π°√≥’∑’Ë¡’≈¡ leak ÕÕ°®“°ª“°ª√‘¡“≥¡“°
2. «‘∏’°“√µ‘¥µ—È߇§√◊ËÕߙ૬À“¬„®
‡π◊ËÕß®“°ºŸâªÉ«¬Õâ«π¡—°¡’ªí≠À“ obstructive airway, restrictive lung, obstructive hypoventilation
·≈– OHS ªí≠À“¡—°‡°‘¥¡“°¢÷Èπ„π¢≥–πÕπÀ≈—∫ ‚¥¬
‡©æ“–™à«ß REM sleep ‡æ√“–¡’°“√§≈“¬¢Õß°≈â“¡‡π◊ÕÈ
∑—«Ë √à“ß°“¬ °≈â“¡‡π◊ÕÈ ∫√‘‡«≥∑“߇¥‘πÀ“¬„® à«π∫π ·≈–
intercostal muscles ¡—°®–ÕàÕπ·√߉ª¥â«¬ ∑”„Àâ¡’
ªí≠À“¡“°¢÷Èπ ´÷Ëß°“√ titrate pressure ¢â“߇µ’¬ß ¡—°
∑”‰¥â‡©æ“–„π™à«ß¢≥–Àπ÷ËߢÕß°“√πÕπÀ≈—∫ ·µàÕ“®
®–‰¡à‰¥â¢®—¥ªí≠À“¢ÕߺŸªâ «É ¬´÷ßË ¡’¡“°„π™à«ß REM sleep
¥—ßπ—Èπ°“√ titrate pressure ∑’Ë¡’ª√– ‘∑∏‘¿“æ¡“°°«à“
§«√∑”µ≈Õ¥§◊π¿“¬„µâ°“√µ√«®°“√πÕπÀ≈—∫ (polysomnography) ´÷Ëß®–∑”„Àâ “¡“√∂‡≈◊Õ°§à“§«“¡¥—π∑’Ë
‡À¡“– ¡‰¥â¥’¢÷Èπ
¡’°“√»÷°…“æ∫«à“°“√„™â NIPPV ·∫∫ CPAP
À√◊Õ BiPAP π—Èπ¡’ compliance „π°“√„™â‰¡à·µ°µà“ß
Noninvasive Positive Pressure Ventilation (NIPPV) in Obese Children, ∏’√‡¥™ §ÿªµ“ππ∑å 205
°—π11 ©–π—πÈ §«√‡≈◊Õ°„™â CPAP °àÕπ∂Ⓡªìπ‰ª‰¥â ‡æ√“–
√“§“∂Ÿ°°«à“ BiPAP ¡“°
¢—ÈπµÕπ„π°“√µ‘¥µ—È߇§√◊ËÕߙ૬À“¬„®
1. ºŸâªÉ«¬Õ¬Ÿà„π∑à“π—Ëß
2. Õ∏‘∫“¬„À⺟âªÉ«¬À√◊Õ≠“µ‘‡¢â“„®∂÷ߢ—ÈπµÕπ„π
°“√„™â NIPPV
3. ‡≈◊Õ°™π‘¥¢ÕßÀπâ“°“°„Àâ‡À¡“– ¡°—∫ºŸªâ «É ¬
4. µàÕÀπâ“°“°°—∫¢âÕµàÕ exhalation port, corrugated tube ·≈–‡§√◊ËÕߙ૬À“¬„®µ“¡≈”¥—∫
5. ∂◊ÕÀπâ“°“°·≈–«“ߧ√Õ∫„∫Àπ⓵√ßµ”·Àπàß
∑’ˇÀ¡“– ¡
6. „™â “¬√—¥Àπâ“°“°„Àâ·π∫ π‘∑·µà‰¡àµß÷ ®π‡°‘π
‰ª ‚¥¬§«√®– “¡“√∂ Õ¥π‘È«¡◊Õ√–À«à“ß “¬√—¥·≈–
„∫ÀπⓉ¥â
7. °“√ª√—∫§à“§«“¡¥—π¢Õ߇§√◊ËÕߙ૬À“¬„®12
‡§√◊ËÕߙ૬À“¬„®™π‘¥ CPAP ‡√‘Ë¡µâπ∑’Ë
§«“¡¥—π 4-5 ´¡.πÈ” ‚¥¬‡æ‘Ë¡§«“¡¥—π 1 ´¡.πÈ”∑ÿ°Ê
30 π“∑’ ‡æ◊ËÕ„À⺟âªÉ«¬‰¡à√Ÿâ ÷°Õ÷¥Õ—¥®“°°“√‡æ‘Ë¡§«“¡
¥—π∑’ˇ√Á«®π‡°‘π‰ª §«“¡¥—π∑’ˇÀ¡“– ¡§«√∑”„πºŸâªÉ«¬
‰¡à¡’°“√À¬ÿ¥À“¬„®, ‰¡à¡’‡ ’¬ßπÕπ°√π, ≈¡‡¢â“∂÷ß™“¬
ªÕ¥∑—Èß Õߢâ“ß
‡§√◊ÕË ß™à«¬À“¬„®™π‘¥ BiPAP ‡√‘¡Ë µâπ∑’§Ë «“¡
¥—π IPAP/EPAP = 8/2 ´¡.πÈ”‰¥â¡’°“√»÷°…“æ∫«à“
IPAP/EPAP difference pressure ∑’Ë 6 ´¡.πÈ” ∑”„Àâ
ºŸâªÉ«¬À“¬„®‰¥â ∫“¬·≈–¡’ ventilation ∑’ˇ撬ßæÕ„π
°√≥’∑º’Ë ªŸâ «É ¬¬—ß¡’Õ“°“√À“¬„®≈”∫“°À√◊Õ¡’ obstructive
apnea §«√‡æ‘Ë¡§«“¡¥—π IPAP ·≈– EPAP Õ¬à“ß≈– 1
´¡.πÈ”∑ÿ° 30 π“∑’ ‡™àπ ®“° IPAP/EPAP = 8/2, IPAP/
EPAP = 9/3 ®πºŸâªÉ«¬‰¡à¡’Õ“°“√À“¬„®≈”∫“°„Àâ§ß
§à“¢Õß EPAP ‰«â∑’ˇ¥‘¡ ‡æ‘Ë¡·µà IPAP ®π¡’≈¡‡¢â“∂÷ß
™“¬ªÕ¥∑—Èß 2 ¢â“ß
„π°√≥’ ∑’Ë ºŸâ ªÉ « ¬‰¡à ¡’ Õ “°“√À“¬„®≈”∫“°
“¡“√∂ ‡æ‘Ë¡·µà IPAP §√—Èß≈– 1 ´¡.πÈ”∑ÿ° 30 π“∑’
‡™àπ ®“° IPAP/EPAP = 8/2, IPAP/EPAP = 9/2 ®π
°√–∑—Ëß≈¡∂÷ß™“¬ªÕ¥∑—Èß 2 ¢â“ß ∑—Èßπ’È°“√‡æ‘Ë¡§«“¡µà“ß
¢Õߧ«“¡¥—π IPAP ·≈– EPAP ∑’Ë¡“°°«à“ 15 ´¡.πÈ”
π—Èπ¡—°‰¡à‡°‘¥°“√‡æ‘Ë¡¢÷Èπ¢Õß tidal volume13 ¥—ß· ¥ß
„π¿“æ∑’Ë 12
8. „π°√≥’∑’˵âÕß°“√„ÀâÕÕ°´‘‡®π¡“°°«à“ 21%
„ÀâµÕà ∑àÕπ”ÕÕ°´‘‡®π¢π“¥‡≈Á° ‡ âπºà“»Ÿπ¬å°≈“ß¿“¬„π
0.3 ´¡. µàÕ°—∫ flow meter ·≈–µàÕ‡¢â“°—∫√Ÿ‡ªî¥¢Õß
Àπâ“°“°¥â“π„¥¥â“πÀπ÷Ëß À√◊ÕµàÕ‡¢â“°—∫ adaptor ∑’ËÕ¬Ÿà
Tidal vollume (mL)
1800
1200
600
0
0
5
10
Pressure boost (cm H2O)
15
20
¿“æ∑’Ë 12 · ¥ß§«“¡·µ°µà“ߢÕß pressure ¢≥–À“¬„®‡¢â“·≈–À“¬„®ÕÕ° °—∫°“√‡ª≈’ˬπ·ª≈ߢÕß tidal volume
206 Current Concepts in Pediatric Critical Care
√–À«à“ßÀπâ“°“°°—∫ exhalation port ·≈⫪√—∫ÕÕ°´‘‡®π∑’Ë flow meter ®π°√–∑—Ë߉¥â O2 saturation µ“¡
µâÕß°“√
9. ª√–‡¡‘π°“√À“¬„® ·≈– —≠≠“≥™’æ O2 saturation À√◊Õ arterial blood gases ‡ªìπ√–¬–Ê
3. ªí≠À“∑’Ëæ∫‰¥â∫àÕ¬·≈–°“√·°â ‰¢ (µ“√“ß∑’Ë 1)
ªí≠À“∑’Ë ”§—≠∑’Ë ÿ¥·≈–æ∫‰¥â∫àÕ¬§◊Õ°“√‡≈◊Õ°
™π‘¥¢ÕßÀπâ“°“°
ë °“√‡≈◊Õ° nasal mask æ‘®“√≥“¢π“¥¢Õß
Àπâ“°“°§√Õ∫®¡Ÿ°∑’‡Ë ≈◊Õ°„ÀâæÕ¥’°∫— ºŸªâ «É ¬‚¥¬‡¡◊ÕË §√Õ∫
∫π®¡Ÿ°·≈â« ¥â“π¢â“ߢÕßÀπâ“°“°®–«“ß·π∫ π‘∑°—∫
¥â“π¢â“ߢÕß®¡Ÿ° ¢Õ∫∫π¢ÕßÀπâ“°“°µâÕ߉¡à ߟ ‡°‘π°«à“
2
/3 ¢Õß —π®¡Ÿ° ·≈–¢Õ∫≈à“ß«“ßæÕ¥’∫π√‘¡Ω望°∫π¢Õß
ºŸâªÉ«¬
ë °“√‡≈◊Õ° full face mask „π°√≥’∑’Ë„™âÀπâ“
°“°§√Õ∫ª“°·≈–®¡Ÿ° à«π≈à“ßµâÕßÕ¬Ÿà„µâ√‘¡Ω望°≈à“ß
à«π∫πµâÕ߉¡à Ÿß‡°‘π°«à“ 2/3 ¢Õß —π®¡Ÿ°
4. ª√– ∫°“√≥å „π°“√„™â NIPPV
1. „π‡¥Á°∑’ˉ¡à„À⧫“¡√à«¡¡◊Õ °“√„™â desensitize program Õ“®∑”„Àâª√– ∫§«“¡ ”‡√Á®¡“°¢÷πÈ ‡™àπ
„À⇥Á°‡Õ“ mask ‰ªΩñ°„ à∑’Ë∫â“π®π‡°‘¥§«“¡§ÿâπ‡§¬
2. „π‡¥Á°∑’¡Ë ª’ ≠í À“∑“ߥâ“π ¡Õß (mental retardation) „π°≈ÿ¡à mild mental retardation ¡—°„™â desensitize program ·≈⫪√– ∫§«“¡ ”‡√Á® ·µà„π°≈ÿà¡
severe mental retardation ¡—°®–‰¡àª√– ∫º≈ ”‡√Á®
3. „π‡§√◊ÕË ß BiPAP ¡’ mode „Àâ‡≈◊Õ°Õ¬Ÿà 3 ™π‘¥
1. spontaneous-mode ‡§√◊ÕË ß®–™à«¬À“¬„®·∫∫ pressure support 2. spontaneous-time mode ‡§√◊ËÕß®–
™à«¬À“¬„®·∫∫ pressure support ·≈–¡’ SIMV ™à«¬
3. time mode ‡§√◊ÕË ß®–™à«¬°“√À“¬„®·∫∫ IMV ªí≠À“
°“√µ—Èß SIMV (back up rate) „π spontaneous time
§«√µ—Èߪ√–¡“≥ 20/π“∑’ „π‡¥Á°∑’ËÕ“¬ÿ¡“°°«à“ 2 ªï9,10
4. °“√µ—Èß ramp time À¡“¬∂÷ß √–¬–‡«≈“∑’Ë
‡§√◊ËÕߧàÕ¬Ê ‡æ‘Ë¡§«“¡¥—π®“°√–¥—∫µË” ÿ¥®π∂÷ß√–¥—∫
∑’˵âÕß°“√∑”„À⺟âªÉ«¬√Ÿâ ÷° ∫“¬¢≥–∑’ˇ√‘Ë¡„ àÀπâ“°“°
·≈–®–‰¥â™‘π°—∫§«“¡¥—π∑’˧àÕ¬Ê ‡æ‘Ë¡¢÷Èπ ‚¥¬∑—Ë«‰ª¡—°
®–µ—Èß ramp time ª√–¡“≥ 20-30 π“∑’
5. °“√„™â heated humidification ®–∑”„Àâ≈¥
ªí≠À“¢Õß nasal congestion ·≈– epitaxis
6. À≈—ß®“°„™â NIPPV §«√π—¥ºŸªâ «É ¬¡“¥ŸÕ“°“√
µÕπª√–¡“≥ 1 —ª¥“ÀåÀ≈—ß„ à‡§√◊ËÕ߇æ◊ËÕ¥Ÿ«à“¡’ªí≠À“
„¥Ê∑’ˇ°‘¥¢÷Èπ µàÕ®“°π—ÈπÕ“®®–π—¥µ“¡§«“¡‡À¡“– ¡
‚¥¬∑—«Ë ‰ª mask ¡—°„™âß“π‰¥â 6 ‡¥◊Õπ Õ“®¡’ª≠í À“¢Õß
°“√‡ ◊ÕË ¡¢Õßæ≈“ µ‘° ·≈–ºŸªâ «É ¬§«√¡“µ√«®ª√—∫§«“¡
¥—π∑ÿ°Ê 6 ‡¥◊Õπ
√ÿª
„πºŸªâ «É ¬∑’¡Ë π’ ”È Àπ—°¡“°π—πÈ Õ“®¡’ª≠í À“∑—ßÈ restrictive lung disease ·≈– obstructive lung disease
°“√¥Ÿ·≈√—°…“‡∫◊ÕÈ ßµâπ¡—°™à«¬ºŸªâ «É ¬√–¥—∫Àπ÷ßË ‡™àπ °“√
≈¥πÈ”Àπ—° πÕπµ–·§ß „π°√≥’∑’ˉ¡à¥’¢÷ÈπÕ“®æ‘®“√≥“
„™â NIPPV ∂⓺Ÿªâ «É ¬‰¡à¥¢’ π÷È À√◊Õ‰¡à√«à ¡¡◊Õ„π°“√„™â Õ“®
æ‘®“√≥“∑” tracheostomy
Noninvasive Positive Pressure Ventilation (NIPPV) in Obese Children, ∏’√‡¥™ §ÿªµ“ππ∑å 207
µ“√“ß∑’Ë 1 ªí≠À“∑’Ëæ∫‰¥â®“°°“√„™â NIPPV8
SIDE EFFECTS
Mask Problems
Air leaks
Conjuncitivits
Discomfort
Noise
Skin breakdown
Unintentional mask removal
Nasal Symptoms
Congestion/obstruction
Epistaxis, pain
Rhinitis/rhinnorhea
Other Problems
Mouth leak; mouth dryness
Pressure intolerance
Machine noise
Claustrophobia
INTERVENTIONS
Proper mask fitting
Proper mask application (education)
Different brand/type of mask
Avoid over-tightening; intervene as above for leaks
Alternate between different mask types
Nasal prongs/pillows
Tape barrier for skin protection
Low pressure alarm
Consider increase in pressure
Nasal steroid inhaler
Antihistamines (if allergic component)
Nighttime topical decongestants (oxymetazoline)
Nasal saline
Humidification (heated)
Full face (Oro-nasal) mask
Nasal saline
Humidification (heated)
Nasal ipratropium bromide
Humidification (prevent increased nasal resistance)
Treatment of nasal congestion
Chin straps
Full face mask
Lower pressure/bilevel pressure
Ramp
Bilevel pressure
Auto-titrating device
Lower prescription pressure-accept higher AHI
Lower pressure+adjunctive measures (elevated head
of bed, side sleeping position)
Long tubing with machine removed from bedroom
Different brand of blower
Desensitization
Nasal prongs/pillows
208 Current Concepts in Pediatric Critical Care
‡Õ° “√Õâ“ßÕ‘ß
1. ÿ¡“≈’ ‡°’¬√µ‘∫ÿ≠»√’, ™“≠ ‡°’¬√µ‘∫ÿ≠»√’, ‰∫∑‘æ¬å ®Ÿ±–°“≠®πå. Noninvasive positive pressure ventilation (NIPPV). „π: ÿ¡“≈’ ‡°’¬√µ‘∫ÿ≠»√’,
Õ√ÿ≥«√√≥ æƒ∑∏‘æπ— ∏ÿ,å ÿ§¡‘ æß»åæ≤— π“«ÿ≤‘ ∫√√≥“∏‘°“√. °“√‡≈◊Õ°„™â·≈–¥Ÿ·≈Õÿª°√≥å∫”∫—¥√—°…“∑“ß√–∫∫À“¬„®. °√ÿ߇∑æœ: Àâ“ßÀÿπâ à«π®”°—¥ ¿“ææ‘¡æå,
2545:62-6.
2. Õ√ÿ≥«√√≥ æƒ∑∏‘æ—π∏ÿå. Noninvasive Mechanical Ventilation in Children. „π: «—™√– ®“¡®ÿ√’√—°…å, ÿπ—π∑“ «√√§åªí≠≠“‡≈‘» ∫√√≥“∏‘°“√. 6th BGH
Congress on Critical Care for Nurses. °√ÿ߇∑æœ, À®°. .√ÿàß∑‘æ¬å ÕÕø‡´∑, 2005:173-8.
3. Cheifetz IM. Invasive and noninvasive pediatric mechanical ventilation. Respir 2003;48:442-58.
4. Fortenberry JD, Del Toro J, Jefferson LS, Evey L, Haase D. Management of pediatric acute hypoxemic respiratory insufficiency with bilevel
positive pressure (BiPAP) nasal mask ventilation. Chest 1995;108:1059-64.
5. Padman R, Lawless ST, Kettrick RG. Noninvasive ventilation via bilevel positive airway pressure support in pediatric practice. Crit Care
Med 1998;26:169-73.
6. Serra A, Polese G, Braggion C, Rossi A. Non-invasive proportional assist and pressure support ventilation in patients with cystic fibrosis
and chronic respiratory failure. Thorax 2002;57:50-4.
7. Hertzog JH, Siegel LB, Hauser GJ, Dalton HJ. Noninvasive positive pressure ventilation facilitates tracheal extubation after laryngotracheal
reconstruction in children. Chest 1999;116:260-3.
8. Berry RB. Sleep Medicine Pearls: A Hanley and Belfus Publication. 2002:140.
9. Orem J, Montplaisit J, Dement WC. Changes in the activity of respiratory neurons during sleep. Brain Res. 1974;82:309-15.
10. Orem J. Control of the upper airway during sleep and the hypersomnia sleep apnea syndrome. In: Orem J, Barnes CD, eds. Physiology
in Sleep. Orlando, Fla: Academic Press Inc; 1980:273-313.
11. Reeves-Hoche MK, Hudgel DW, Meck R, Witteman R, Ross A, Zwillich CW. Continuous vs bi-level positive airway pressure for obstructive
sleep apnea. Am J Respir Crit Care Med 1995; 151(2 PT 1):443-9.
12. Marcus CL. Ventilator management of abnormal breathing during sleep. Lung Biology in Health and Disease. 2000;147:797-811.
13. Strumpf DA, Carlisle CC, Millman RP, Smith KW, Hill NS. An evaluation of the Respironics BiPAP bi-level CPAP device for delivery of
assisted ventilation. Respir Care 1990;35:415-22.