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test.pptx
1.
ハイフローネーザルカニューラ (ネーザルハイフロー) 2021.09.09 川内市医師会立市民病院
2.
ネーザルハイフローとは? • 鼻カニューラを使用して高流量高濃度の酸素を加温・加湿した 状態で投与できる酸素療法の一つである。
3.
適応 • 高CO2血症を合併していない低酸素性急性呼吸不全患者 • 術後や抜管後の呼吸不全予防もしくは呼吸不全時 •
NPPVの前段階もしくは離脱期 • NPPV困難例、拒否例 • 緩和ケア
4.
NHFのメリット・効果
5.
QOLを維持できる • 高濃度酸素を投与しながら会話および飲水・食事可能 • 違和感が少なく、忍容性が高い
6.
高濃度酸素を正確なFiO2設定で投与できる • 高流量であるため、設定した酸素濃度を安定して投与できる • リザーバー付きマスクでは到達できない100%純酸素も理論上 は投与可能
7.
高濃度酸素を正確なFiO2設定で投与できる • 換気量500mL/回、呼吸数20回、吸気:呼気=1:2→500mL/秒 • 通常の経鼻カニューラ
1L/分→1000mL/分→17mL/秒 空気 483mL 酸素17mL 1回換気量500mL 必ず希釈される!!!
8.
高濃度酸素を正確なFiO2設定で投与できる • 換気量500mL/回、呼吸数20回、吸気:呼気=1:2→500mL/秒 • NHF
30L/分→30000mL/分→ 500mL/秒 酸素500mL 1回換気量500mL 希釈されない!!!
9.
加温・加湿 • ほぼ体温に相当する温度で相対湿度100%までの加温加湿 • 気道の粘液線毛クリアランスの維持 分泌物の移動性維持、無気肺形成予防、呼吸器感染リスクの軽減
10.
解剖学的死腔の洗い出し • 高流量の酸素投与により死腔にたまった呼気ガスを洗い出すこ とでCO2の再吸入を防ぎ、ガス交換、換気効率を上げる。
11.
PEEP効果 • 呼気終末陽圧換気(PEEP):呼気終末時に気道内を陽圧にす ることにより、呼気時に肺胞が虚脱するのを防ぐ。 病気が見える 呼吸器内科より引用
12.
PEEP効果 • 呼気終末陽圧換気(PEEP):呼気時にもわずかな陽圧を残し た状態で再び吸気を開始させる方法。 レジデントのためのやさしイイ呼吸器教室より引用
13.
PEEP効果 • 呼気終末陽圧換気(PEEP):呼気時にもわずかな陽圧を残し た状態で再び吸気を開始させる方法。 • PEEPにより呼吸に関与する肺胞が増える→PaO2改善 •
NHFでかかるPEEPは口を閉じた状態、40L/分で2.58cmH2O。 →おまけ程度の効果と考えた方が良い
14.
• 気道の粘液線毛クリアランス維持 • 上気道抵抗の軽減 •
高濃度高流量酸素 • 解剖学的死腔の洗い出し • PEEP効果 1回換気量増加、呼吸数減少、呼吸困難軽減
15.
実際の使用方法
16.
17.
給水チャンバーの取り付け • キャップを抜く • 給水チューブを止めているブラケット を外す •
付属のアダプタをチャンバーの垂直 ポートにはめ込み、給水チューブを配 置して固定する
18.
給水チャンバーの取り付け • フィンガーガードを押し下げながら給 水チャンバーを押し入れる • 本体の青いチャンバーポートにアダプ タをはめ込む •
フィンガーガードがカチッとはまるま でしっかり押し込む
19.
給水バッグの取り付け • バッグスパイクを蒸留水バッグに穿刺 し、通気キャップを開く • 適切な水位まで自動的に蒸留水が満ち、 バッグが空になるまではその水位が維 持される
20.
熱線入り回路の取り付け • プラスチックスリーブを持ち上げ、接 続しスリーブを押し下げてロックする。 • 適切な水位まで自動的に蒸留水が満ち、 バッグが空になるまではその水位が維 持される
21.
ユニットの起動 • 「オン・オフ」ボタンを押してユニッ トを起動する • 暖機運転が終了すると使用可能となる
22.
鼻カニューラの選択 • 鼻のプロング(鼻孔に入る部分) は3サイズあり、患者の鼻孔に合わ せて選択(鼻孔の50%くらい)す る • バンドは耳の上を通し、回路の重 みに耐えられるようにネックスト ラップを使用する
23.
FiO2・流量の設定 • FiO2は呼吸状態に合わせて調整 • 吸気時も鼻孔脇からフローが漏れるように設定する •
個人的には・・・ 流量40L/分、FiO2 100%から開始して適切なFiO2まで下げる
24.
その他の話
25.
NHF開始後のアセスメント • SpO2 • 呼吸様式の変化(胸郭の動き、呼吸補助筋の使用) •
呼吸数の減少 • 呼吸苦の改善 • 血ガス 30分〜1時間程度で評価を行う 人工呼吸管理の必要性も検討する
26.
皮膚トラブル • 鼻中隔前面、耳介、頬部などに潰瘍、発赤を生じる場合あり • 適宜保護材、ガーゼなどを使用し、カニューラが直接皮膚に触 れないようにする みんなの呼吸器Respica
18(6): 730-731, 2020.
27.
不快感 • 「鼻の奥が痛い」、「熱い」、「音がうるさい」など • 安易に設定は変更せずに協力を得たいところ •
上記の対応のため流量を落とす、温度設定を下げるなどすると メリットが得られにくく、かえって不快感が増す場合もある →協力が得られない場合は設定変更する
28.
電源 • 必ず緑色の無停電非常電源、または赤色の特別非常電源に接続 する
29.
終わり
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