CN101023902B - 向患者自动传递胸部按压及通气的设备 - Google Patents

向患者自动传递胸部按压及通气的设备 Download PDF

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CN101023902B
CN101023902B CN2007100051696A CN200710005169A CN101023902B CN 101023902 B CN101023902 B CN 101023902B CN 2007100051696 A CN2007100051696 A CN 2007100051696A CN 200710005169 A CN200710005169 A CN 200710005169A CN 101023902 B CN101023902 B CN 101023902B
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加里·A.·弗里曼
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Abstract

一种向患者自动传递胸部按压及通气的设备，所述设备包括：胸部按压装置，其设置成传递按压阶段和解压阶段，在所述按压阶段期间施加压力按压胸部，在所述解压阶段期间向胸部施加近似为零的压力；通气机，其设置成向气路传递正向、负向、或近似为零的压力；控制电路和处理器，其中所述控制电路和处理器设置成使胸部按压装置重复地传递包括多个心脏收缩血流周期的集合和介于所述多个心脏收缩血流周期集合之间的至少一个心脏舒张血流周期，每个所述心脏收缩血流周期包括心脏收缩解压阶段和心脏收缩按压阶段，每个所述心脏舒张血流周期均包括心脏舒张解压阶段和心脏舒张按压阶段，其中心脏舒张解压阶段基本上长于心脏收缩解压阶段。

Description

向患者自动传递胸部按压及通气的设备
技术领域
本发明涉及心脏复苏装置，更具体地涉及胸按压及通气的自动控制的装置。
背景技术
对心搏停止患者的复苏处理通常包括清洁并打开患者的气路(airway)，用手工操作的袋式阀(bag-valve)或电动便携通气设备向患者提供人工呼吸，并施加胸按压向受难者的心脏、大脑和其它重要器官提供血流。可以通过手工地按压患者胸骨区域内的胸部的方式或者通过使用电动胸按压器传递胸按压。如果患者有可电击(shockable)心律，复苏还可以包括除颤治疗。术语基本生命维持(basic life support)(BLS)包括全部下面要素：初始评估；气路维护；呼出的气体换气(人工呼吸)；和胸部按压。当组合全部三个【气路呼吸、和循环，包括胸部按压】时，使用术语心肺复苏(CPR)。
有许多不同种类的异常心脏心律，其中一些(“可电击心律”)可用除颤治疗处理，而有一些(不可电击心律)不能用除颤治疗。例如，产生有效(significant)心脏输出的多数ECG心律被认为是不可电击的(例子包括正常窦性心律、心动过缓、和窦性心动过速)。还有一些异常ECG心律不会导致有效心脏输出但仍被认为是不可电击的，因为在这些情况下除颤治疗通常是无效的。这些不可电击心律的例子包括心搏停止、电机械分离(electromechanical disassociation)和其他无脉动电活动。虽然患者在这些无法生活的、不可电击心律的情况下不能继续活下去，施加电击不会有助于改变心律。医护人员(caregiver)应当实施除颤的可电击心律的主要例子包括心室纤维颤动、心室心动过速、和心室悸动。
在利用除颤器向患有可电击ECG心律的患者施加一次或更多次电击之后，患者可能仍然保持无意识的、处于可电击或不可电击的、灌注或非灌注心律。如果出现了非灌注心律，医护人员可当时采取实施一段时间的CPR以便向患者心脏、大脑及其他重要器官提供连续血流和氧气。如果在传递CPR期间可电击心律持续存在或进一步发展，在紧接着这个心肺复苏期进行进一步的除颤尝试。只要患者保持无意识并且没有有效的循环，医护人员可以交替除颤器的使用(用于分析电节律和可能地施加电击)与实施心肺复苏(CPR)。在大多数美国心脏学会(AHA)2005年发布的最近版本的指南中，目前还是在除颤电击之前传递CPR，即使患者表现给救助者的是例如心室纤维颤动的可电击心律。在大多数最近的AHA指南中，CPR一般包括30次胸部按压后暂停的重复模式，期间施加两次人工呼吸。
在治疗心搏停止期间通气是心肺复苏的关键部分。耗尽了氧气(O2)并充满了二氧化碳(CO2)的静脉血从肌肉和器官回到心脏。来自人体不同部分的血液在心脏里混合(混合的静脉血)并泵送到肺部。在肺内血管分散为围绕微小肺囊(气泡)的小血管网络。围绕气泡的血管的网络总和提供了大表面面积用于借助沿其浓度梯度扩散的方式进行气体交换。浓度梯度存在于混合的静脉血(PvCO2)内的CO2局部压力(PCO2)与泡囊的PCO2之间。从吸气的开始CO2从混合的静脉血扩散进泡囊直到在呼吸期间的某些时刻在PvCO2与泡囊的PCO2之间达到平衡。当人呼气时，呼出的最初气体来自不允许气体交换的气管和主要支气管并因此会有与吸入的气体相似的气体成分。在这个呼气末期的气体被认为来自泡囊并且反映毛细管与泡囊之间的平衡CO2浓度；这个气体中的PCO2称为潮气(tidal)末PCO2(PetCO2)。
当血液通过泡囊并被心脏泵送到动脉时已知为动脉的PCO2(PaCO2)。动脉血的PCO2等于毛细管与泡囊之间平衡时的PCO2。随着每次呼吸一些CO2从肺排除并且包含很少或没有CO2(CO2浓度假设为0)的新鲜空气被吸入并稀释残留的泡囊PCO2，建立一个新的CO2梯度以便扩散出混合的静脉血进入泡囊。呼吸速率，或通常表示为L/min的分钟通气(V)，是精确地，需要其排除带到肺部的CO2并保持大约40mmHg(正常人)的平衡PCO2(和PaCO2)。当一个人产生了更多CO2(例如，作为感冒或锻炼的结果)，产生更多的CO2并运载到肺部。因此人必须更深地呼吸(强力呼吸)以便从泡囊去除额外的CO2，并因此维持同样的平衡PaCO2。但是如果CO2产量保持正常，并且人进行强力呼吸，那么PaCO2降低。相反地，如果CO2产量保持恒定并且通气降低，动脉PCO2上升。吸入的空气容积的一部分到达空气通道(气管和主要支气管)和泡囊，有很少的血液灌注它们，并因此在呼气期间不对CO2的移除起作用。这个部分术语叫做“死区”气体。到达充分灌注的泡囊并参与气体交换的V的那个部分称为泡囊通气(VA)并且参与泡囊内气体交换的呼出气体术语叫做“泡囊气体”。
能够传递需要的气路压力的自动通气机也是已知的。美国专利号为5,664,563，描述了一种能够传递负压气路压力的通气系统。美国专利号为4,676,232，5,020,516和5,377,671描述了一种具有与心脏周期同步的通气周期增强循环的通气机。美国专利号为4,326,507描述了一种组合的胸部按压器及通气机，其在多个按压周期传递通气和然后在通气间期内传递另一个系列的按压周期。
虽然目前的AHA建议是每三十个按压有两个通气，该建议的发布是针对大部分(in large part)，因为已经发现由于救助者在按压与通气之间来回转换的延迟会导致胸部按压和总循环的水平不充分。需要的是，在机械装置集成胸部按压和通气功能。
美国专利号为6,179,793和6,752,771描述了一种可膨胀的背心帮助患有心脏疾病的患者心脏。背心的膨胀与心脏的收缩阶段(phase)的开始(on-set)同步，当左心室按压强迫血液流出心脏并通过大动脉。膨胀的背心压迫患者胸部并增加胸内压力。这种压力的增加帮助心脏将血液移出心脏并通过大动脉。美国专利号为4,198,963和6,171,267描述了一种使胸部按压周期与心动收缩阶段同步的装置。美国专利号为6,213,960描述了一种在复苏期间自动胸部按压的装置。
美国专利号为4,397,306中描述了通气周期与按压周期同步。该专利意图使自动胸部按压设备与自动通气机同步，并推荐将高压通气脉冲与按压阶段(即，当施加胸部压力时)同步地传递，以及把略微地负压的通气脉冲与减压阶段(即，当没有胸部压力施加时)同步地传递。按压和减压阶段为等长度(50％占空因数)。负压通气脉冲就是“在心脏舒张期移动更多数量的血液进入胸部”。而且，该专利推荐当没有按压发生时在大约每个第六按压/减压周期引入传统的通气周期。这据说对充分的泡囊气体交换是有价值的，因为在与按压阶段同步的正压通气压力周期内有非常少的空气流动产生。虽然美国专利号为4,397,306报道利用该发明观察到压力与流动的显著改进，典型患者的生理状态与那些试验使用的动物模型有相当大的不同。
在典型的心搏停止中，患者没有任何血流的时间量通常大于十到十二分钟，不像动物模型没有血流的时间总是小于8分钟，并且在大多数试验中小于5分钟。在这些延长的局部缺血条件下，由于不充分的新陈代谢能量基质和氧化氮的释放，患者的脉管音将会被显著地包括。这种音调的丢失证明自身身体上脉管系统的顺应性(compliance)显著增加，其与电路中的电容的增加一样，导致系统的固有时间常数增加。这可以在例如Crit Care Med 2000Vol.28，号为11(Suppl.)中描述的模型或具有延长持续时间的局部缺血的动物模型中得到验证。正如作者所述，系统的微分方程已经在许多公开文本中描述了。在这个特定实例中，用通过阻力连接的七个顺应性(complicant)腔来表示人体循环，其中血液可通过所述顺从性腔流动。顺应性对应于胸大动脉、腹部大动脉、上腔静脉和右心、腹部和下部末端血管、颈动脉、和颈静脉血管。另外，胸隔膜容纳代表肺脉管和左心顺应性的泵。这个泵构造成用作心脏状的心脏泵，其中施加的压力从心脏自身压迫血液通过大动脉瓣，或者用作整个胸部压力泵，其中施加的压力从肺脉管床压迫血液通过左心并进入外围。描述教科书正常“70公斤的人”的生理变化的值用于规定模型中的顺应性和阻力。脉管电导系数(1/阻力)的分布进入颅侧的、胸的、和尾部部件反映了心脏输出到不同身体区域的教科书分布。尤其是，在解压阶段期间静脉血回流(return)的时间常数在局部缺血的延长期内显著地增加。
发明内容
在第一个方面，本发明以一种向患者自动传递胸部按压及通气的设备为特点，所述设备包括：胸部按压装置，其设置成传递按压阶段和解压阶段，在所述按压阶段期间施加压力按压胸部，在所述解压阶段期间向胸部施加近似为零的压力；通气机，其设置成向气路传递正向、负向、或近似为零的压力；控制电路和处理器，其中所述控制电路和处理器设置成使胸部按压装置重复地传递包括多个心脏收缩血流周期的集合和介于心脏收缩血流周期集合之间的至少一个心脏舒张血流周期，每个心脏收缩血流周期包括心脏收缩解压阶段和心脏收缩按压阶段，每个心脏舒张血流周期包括心脏舒张解压阶段和心脏舒张按压阶段，其中心脏舒张解压阶段基本上长于心脏收缩解压阶段。
本发明的这个方面的优选实施例包括下述实施例中的一个或多个。控制电路和处理器设置成使通气机在心脏舒张解压阶段传递负通气压力。心脏收缩按压阶段和心脏舒张解压阶段的持续时间大约相同。心脏舒张解压阶段的持续时间大于心脏舒张按压阶段的持续时间的两倍。心脏舒张解压阶段的持续时间大约是心脏舒张按压阶段的持续时间的四倍。心脏舒张血流周期包括第二按压阶段和第二解压阶段，并且其中在第一与第二解压阶段中的一个期间传递负通气压力和在第一与第二解压阶段中的另一个期间传递正通气压力。通气机在心脏收缩血流周期期间传递正和负通气压力。在心脏收缩血流周期的多数解压阶段期间传递负通气压力。在心脏收缩血流周期的多数按压阶段期间传递正通气压力。通气压力以大约斜坡形状的变化从负到正而后回到负逐渐地改变，同时在按压阶段的开始处压力近似为零。压力在解压阶段的开始处或恰好早于解压阶段的开始处从正到负快速地变化。通气压力波形在解压开始处为峰值或接近峰值。按压和通气与患者的ECG同步以便增加患者的潜在心脏收缩和心脏舒张活性。所述的设备还包括流体灌注装置。通气机可提供负和正压力。氧气水平被提高到大于40％。设备设置成用于既有心脏疾病又外伤的患者，其中出现总体缺血的情况并且在复苏期间的再充氧过程使患者冒着再灌注损伤的风险。
在第二个方面，本发明以一种向患者自动传递胸部按压及通气的设备为特点，所述设备包括：胸部按压装置，其设置成传递按压阶段和解压阶段，在所述按压阶段期间施加压力按压胸部，在所述解压阶段期间向胸部施加近似为零的压力；通气机，其设置成向气路传递正向、负向、或近似为零的压力；控制电路和处理器，其中所述控制电路和处理器设置成使胸部按压装置重复地传递包括心脏收缩血流周期，每个心脏收缩血流周期包括心脏收缩解压阶段和心脏收缩按压阶段，和其中控制电路和处理器设置成使通气机在按压阶段期间传递通气压力，其从按压阶段开始处近似为零的压力增加到在按压阶段末端处或靠近按压阶段末端处大约最大值。
本发明的这个方面的优选实施例包括下述中的一个或多个。控制电路和处理器设置成使通气机传递在解压阶段开始处为负的通气压力。由灌注器灌注的流体设置成在再灌注(reperfusion)期间提供新陈代谢物质。所述物质是氨基酸。所述氨基酸是天冬氨酸盐或谷氨酸盐。所述设备还包括除颤器和灌注器，和其中除颤器、胸部按压装置、通气机、和灌注器是单独的装置并且通过通信线路连接。所述设备还包括用于使除颤器、胸部按压装置、通气机、和灌注器同步的附加装置。
在第三个方面，本发明以一种向患者自动传递胸部按压及通气的设备为特点，所述设备包括：胸部按压装置，其设置成传递按压阶段和解压阶段，在所述按压阶段期间施加压力按压胸部，在所述解压阶段期间向胸部施加近似为零的压力；通气机，其设置成向气路传递正向、负向、或近似为零的压力；冷却设备，用于冷却通气机传递的气体，其中冷却设置成冷却肺、心脏和肺部血流。
本发明的许多优势(其中一些仅仅可通过其变化的方面和实施方式获得)如下：通过交替一组心脏收缩血流周期与至少一个心脏舒张血流周期获得改进的血流。心脏收缩血流周期具有延长的与负通气压力同步的解压阶段。延长的心脏舒张血流周期提供更多的静脉充盈时间，并因此得到比用美国专利号为4,397,306教导的方法更好的血流。
本发明的其它特点和优势将在详细的说明、附图、及权利要求书中得到。
附图说明
图1是本发明的一个实施例的方框图。
图2是本发明的一个实施例的通气机的方框图。
图3是本发明的一个实施例的集成按压和通气周期的时序图。
图4是本发明的另一个实施例的集成按压和通气周期的时序图。
具体实施方式
本发明有相当多可能的实施例，由于太多而不能在此描述。下面描述了目前优选的一些可能的实施例。不能太强烈地强调，但是，这些是本发明的实施例的描述，而不是本发明的描述，其不局限于在这个部分中详细描述的实施例而在于权利要求书中用更概括术语的描述。
图1示出了一个实施例的方框图。微处理器14以集成的方式控制通气机功能15、胸部按压器12、药物灌注器14、和除颤器/调博器13。生理传感器2，例如基于加速器的胸骨移动检测3的胸骨运动检测方法，和滤波并处理这些不同的信号例如潮气末二氧化碳检测(EtCO2)的信号处理9和脉搏血氧测量(SpO2)用于判断患者11的生理和身体状态。单独的膝上型电脑17与微处理器14通信，并且，实际上，用于控制通气机15、胸部按压器12、药物灌注器14、和除颤器13传递的治疗。
参照图2，其示出了一个实施例的通气机部分的方块图，微处理器14控制各种治疗气体、压缩CO226、O225、和室内空气24的传递。这些气体的压力由调整器34控制并由阀35混合以获得需要的每种气体的局部压力。提供冷却器/加热器/加湿器33调节空气。在一个实施例中，提供了热交换器冷却气体混合物至1-2摄氏度作为一种温和降低体温的手段。热交换器可以是结合帕而帖效应元件的电动元件或可以结合例如液氮或干冰的冷存储元件的存储元件。在冷存储元件的情况下，通过绝缘冷存储元件的方式控制冷却速率，在绝缘体内提供热传导窗，并调节热传导窗的表面面积。
图3示出了一个实施例的时序图。示出了三个波形。第一个是患者的ECG(示出的ECG代表在自发循环(ROSC)回流之后的ECG；极不相同的ECG将典型地在ROSC之前出现)。第二个波形是自动胸部按压装置施加的胸部按压力(图中，随着波形向下移动按压力上升)。第三个波形是施加到气路的通气压力(图中，压力在轴上为正，在轴下为负)。
在一些实施例中，压力到通气比率可以不同于目前AHA推荐的每30秒两次通气。例如，每五次胸部按压传递一次通气(比率接近正常成年人的比率)。
图3所示的实施例中，在期间50内有五个胸部按压周期48。每个按压周期有50％的按压到解压比率的占空因数和800毫秒周期长度(400毫秒按压阶段；400毫秒解压阶段)。每个周期包括按压或下行程(44)的开始和解压或上行程的开始(46)。这些按压周期设置成改进心脏收缩血流，并因此称为“心脏收缩血流周期”。
“心脏舒张周期”52跟随在五个心脏收缩血流周期之后。心脏舒张血流周期开始于缩短的为期200毫秒的按压阶段54，后面跟随着延长的为期600毫秒的解压周期56，然后第二个缩短的按压阶段58(200毫秒)，和第二个延长的解压阶段60(600毫秒)。在心脏舒张血流周期中，自动通气机产生负压阶段62(600毫秒)以便诱导出与解压阶段56对齐的负向胸内压力(约-2kPa)。这导致了增加的静脉回流到右心房(心脏舒张血流)，因而在随后的按压阶段58期间增加了血流。通气压力在按压阶段58期间倾斜上升(64)到约+2kPa并在随后的600毫秒解压阶段66期间内保持恒定在+2kPa。在图3的实施例中，在心脏收缩血流周期内(在那些周期内通气压力为零)不提供通气辅助。
图4示出了另一个实施例，其中用与心脏收缩血流周期50短通气周期68进一步增强心脏收缩血流。通气周期与心脏收缩血流周期的按压和解压阶段同步，其采用在按压阶段的开始70处大约为零的压力的斜坡形状，并在按压期间上升到最大正压力。在周期的解压阶段，使用类似的三角通气压力波形，最大负压72发生在恰好稍微先于(大约早40毫秒)解压阶段的开始，以便气路压力在解压开始处最后地为负向，从而使心脏舒张回流最大化。这种在按压的开始处为零的交叉的线性斜坡具有在按压的开始处提供接近均匀中性压力气路的优势，以便在按压下行程44和总的胸内压力上升处，气路在按压阶段的部分期间内萎陷。通过萎陷气路，在胸部按压周期内维持肺自身的容积，有效地在心脏的每侧用作风箱在按压期间压迫心脏因此增强心脏收缩血流。在一些实施例中，由例如ZOLL Circulatory Systems of SunnyvaleCA制造的负荷分配带提供胸部按压。心脏舒张血流周期52在多个、优选为五个或六个心脏收缩血流周期50之后发生。心脏舒张血流周期有大约20-30％的按压占空因数，解压阶段62大约为期640毫秒。紧随ROSC之后，患者自己的心脏泵送并循环血液，但是通常效率降低。在一些实施例中，ROSC之后无按压地传递通气。但是在其他实施例中，ROSC之后的按压也可以用与心搏停止期间类似的方式传递。ROSC之后的按压在两个重要方面不同：(1)它们与患者ECG的QRS同步，如图3所示；和(2)它们是降低的按压力。降低力度及与ECG QRS同步的按压将增加患者增强恢复的血液动力学的自然血流。
许多不同于上述的其他实施例也在本发明的范围内，本发明由后面的权利要求书限定。例如，可以使用与图3和4中不同的形状及不同数量的按压及通气波形。

Claims (12)

1.一种向患者自动传递胸部按压及通气的设备，所述设备包括：
胸部按压装置(12)，其设置成传递按压阶段和解压阶段，在所述按压阶段期间施加压力按压胸部，在所述解压阶段期间向胸部施加近似为零的压力；
通气机(15)，其设置成向气路传递正向、负向、或近似为零的压力；
控制电路和处理器，其中所述电路和处理器设置成使所述胸部按压装置(12)重复地传递
包括多个心脏收缩血流周期(50)的集合，每个心脏收缩血流周期包括心脏收缩解压阶段和心脏收缩按压阶段，和
至少一个心脏舒张血流周期(52)，其介于所述多个心脏收缩血流周期(50)的集合之间，每个心脏舒张血流周期均包括第一心脏舒张解压阶段(56)和第一心脏舒张按压阶段(54)，
其中所述第一心脏舒张解压阶段(56)基本上长于所述心脏收缩解压阶段。
2.如权利要求1所述的设备，其中所述控制电路和处理器设置成使所述通气机(15)在所述第一心脏舒张解压阶段传递负通气压力(62)。
3.如权利要求2所述的设备，其中所述心脏收缩按压阶段和心脏收缩解压阶段的持续时间大约相同。
4.如权利要求3所述的设备，其中所述第一心脏舒张解压阶段(56)的持续时间大于所述第一心脏舒张按压阶段(54)的持续时间的两倍。
5.如权利要求4所述的设备，其中所述第一心脏舒张解压阶段(56)的持续时间近似为所述第一心脏舒张按压阶段(54)的持续时间的四倍。
6.如权利要求2所述的设备，其中所述心脏舒张血流周期包括第二心脏舒张按压阶段(58)和第二心脏舒张解压阶段(60)，并且其中在第一心脏舒张解压阶段(56)与第二心脏舒张解压阶段(60)中的一个心脏舒张解压阶段期间传递负通气压力(62)，而在所述第一心脏舒张解压阶段(56)与第二心脏舒张解压阶段(60)中的另一个心脏舒张解压阶段期间传递正通气压力(66)。
7.如权利要求2所述的设备，其中所述通气机(15)在所述心脏收缩血流周期期间传递正通气压力和负通气压力。
8.如权利要求2所述的设备，其中按压和通气与患者的ECG同步以便增加患者的潜在心脏收缩和心脏舒张活性。
9.如权利要求2所述的设备，其中所述设备还包括除颤器(13)和灌注器(14)，其中所述除颤器(13)、胸部按压装置(12)、通气机(15)和灌注器(14)是单独的装置并且通过通信线路(16)连接。
10.如权利要求9所述的设备，其中所述设备还包括用于使所述除颤器(13)、胸部按压装置(12)、通气机(15)和灌注器(14)同步的附加装置。
11.如权利要求2所述的设备，其中所述通气机(15)能够提供负压力和正压力。
12.如权利要求2所述的设备，其中氧气水平被提高到大于40％。
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