经鼻高流量氧疗对高血压脑出血术后低氧血症患者的临床疗效及对肠内营养治疗的影响
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摘要
目的探讨经鼻高流量氧疗(HFNO)对高血压脑出血术后低氧血症患者的临床疗效及对肠内营养治疗的影响。方法选择武汉大学人民医院2017年1月至2018年6月收治的高血压脑出血术后低氧血症患者74例,应用随机数字表法分为HFNO组和无创机械通气(NIV)组,各37例。2组患者均给予脑出血术后常规治疗,术后第1天开始经鼻胃肠管肠内营养治疗。比较2组患者临床疗效,包括治疗前和治疗3、7 d后的急性生理学和慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、心率、呼吸频率、平均动脉压(MAP)、氧合指数;比较2组患者预后及并发症发生率,包括有创机械通气、院内获得性肺炎、面部压疮发生率,入住重症监护病房时间和28 d病死率;评估2组患者营养状况,包括肠内营养耐受率和误吸发生率;比较2组患者治疗前及治疗7 d后肠功能评分和血清总蛋白、白蛋白水平。结果 NIV组治疗7 d后APACHEⅡ评分、心率、呼吸频率、MAP均低于治疗前,氧合指数高于治疗前(均P <0. 05)。HFNO组治疗3 d后心率、呼吸频率低于治疗前,氧合指数高于治疗前;治疗7 d后APACHEⅡ评分、心率、呼吸频率、MAP均低于治疗前,氧合指数高于治疗前;心率、呼吸频率低于治疗3 d后,氧合指数高于治疗3 d后(均P <0. 05)。组间比较,HFNO组治疗3 d和7 d后心率、呼吸频率均低于NIV组[治疗3 d后:(77±17)次/min比(84±18)次/min,(19±6)次/min比(22±7)次/min;治疗7 d后:(70±16)次/min比(80±17)次/min,(15±6)次/min比(19±6)次/min],氧合指数均高于NIV组[治疗3 d后:(205±30) mmHg(1 mmHg=0. 133 k Pa)比(196±30) mmHg;治疗7 d后:(267±35) mmHg比(226±33) mmHg],差异均有统计学意义(均P <0. 05)。HFNO组肠内营养耐受率高于NIV组[94. 6%(35/37)比73. 0%(27/37)],差异有统计学意义(P <0. 05)。治疗7 d后2组患者肠功能评分均低于治疗前,且HFNO组低于NIV组;总蛋白及白蛋白水平均高于治疗前,且HFNO组高于NIV组[(56±7) g/L比(52±6) g/L,(39±4) g/L比(34±4) g/L],差异均有统计学意义(均P <0. 05)。HFNO组有创机械通气、院内获得性肺炎及面部压疮发生率均低于NIV组[16. 2%(6/37)比29. 7%(11/37),5. 4%(2/37)比18. 9%(7/37),0比8. 1%(3/37)],入住重症监护病房时间短于NIV组[(5±4) d比(8±3) d],差异均有统计学意义(均P <0. 05); 2组患者28 d病死率比较差异均无统计学意义(均P> 0. 05)。结论 HFNO可以有效改善高血压脑出血术后低氧血症患者的氧合,降低氧耗,增加肠内营养治疗的依从性和舒适性。
Objective To investigate the clinical effect of high-flow nasal oxygen( HFNO) therapy on patients with hyoxemia after hypertensive intracerebral hemorrhage operation and the effect on enteral nutrition.Methods Seventy-four patients with hypoxemia after hypertensive intracerebral hemorrhage operation were enrolled from January 2017 to June 2018 in Renmin Hospital of Wuhan University. The patients were randomly divided into HFNO group and noninvasive ventilation( NIV) group,with 37 cases in each group. Both groups had routine treatments for intracerebral hemorrhage and nasogastric enteral nutrition since the first day after operation. Clinical efficacy indexes including Acute Physiology and Chronic Health Evaluation Ⅱ( APACHEⅡ) score,heart rate( HR),respiratory rate( RR),mean arterial blood pressure( MAP) and oxygenation index were recorded before treatment and3,7 days after treatment. Prognostic indexes including rate of invasive mechanical ventilation,incidences of hospital acquired pneumonia and facial pressure ulcer,length of intensive care unit( ICU) stay and the 28-day mortality rate were observed. Nutritional indexes including enteral nutrition tolerance rate and aspiration rate were analyzed.Intestinal function score,serum total protein and albumin levels were tested before and 7 days after treatment.Results In the NIV group,APACHEⅡscore,HR,RR and MAP 7 days after treatment were significantly lower and oxygenation index was significantly higher than those before treatment( all P < 0. 05). In the HFNO group,HR and RR 3 days after treatment were significantly lower and oxygenation index was significantly higher than those before treatment; at 7 days after treatment,APACHEⅡ score,HR,RR and MAP were significantly lower and oxygenation index was significantly higher than those before treatment; HR and RR 7 days after treatment were significantly lower and oxygenation index was significantly higher than those 3 days after treatment( all P < 0. 05). At 3 and 7 days after treatment,HR and RR in the HFNO group were significantly lower than those in the NIV group[3 d:( 77 ±17) times/min vs( 84 ± 18) times/min,( 19 ± 6) times/min vs( 22 ± 7) times/min; 7 d:( 70 ± 16) times/min vs( 80 ±17) times/min,( 15 ±6) times/min vs( 19 ±6) times/min]; oxygenation index in the HFNO group was significantly higher than that in the NIV group[3 d:( 205 ± 30) mmHg vs( 196 ± 30) mmHg; 7 d:( 267 ± 35) mmHg vs( 226 ±33) mmHg]( all P <0. 05). Enteral nutrition tolerance rate in the HFNO group was significantly higher than those in the NIV group[94. 6%( 35/37) vs 73. 0%( 27/37) ]( P < 0. 05). At 7 days after treatment,intestinal function score significantly decreased and levels of total protein and albumin significantly increased compared to those before treatment in both groups; intestinal function score in the HFNO group was significantly lower than that in the NIV group; levels of total protein and albumin in the HFNO group were significantly higher than those in the NIV group[( 56 ± 7) g/L vs( 52 ± 6) g/L,( 39 ± 4) g/L vs( 34 ± 4) g/L]( both P < 0. 05). Rate of invasive mechanical ventilation,incidences of hospital acquired pneumonia and facial pressure ulcer were significantly lower and length of ICU stay was significantly shorter in the HFNO group than those in the NIV group[16. 2%( 6/37) vs 29. 7%( 11/37),5. 4%( 2/37) vs 18. 9%( 7/37),0 vs 8. 1%( 3/37),( 5 ± 4) d vs( 8 ± 3) d]( all P < 0. 05). There was no significant difference of the 28-day mortality rate between groups( P > 0. 05). Conclusion HFNO can improve the oxygenation,the compliance and amenity of enteral nutrition in patients with hyoxemia after hypertensive intracerebral hemorrhage operation.
Objective To investigate the clinical effect of high-flow nasal oxygen( HFNO) therapy on patients with hyoxemia after hypertensive intracerebral hemorrhage operation and the effect on enteral nutrition.Methods Seventy-four patients with hypoxemia after hypertensive intracerebral hemorrhage operation were enrolled from January 2017 to June 2018 in Renmin Hospital of Wuhan University. The patients were randomly divided into HFNO group and noninvasive ventilation( NIV) group,with 37 cases in each group. Both groups had routine treatments for intracerebral hemorrhage and nasogastric enteral nutrition since the first day after operation. Clinical efficacy indexes including Acute Physiology and Chronic Health Evaluation Ⅱ( APACHEⅡ) score,heart rate( HR),respiratory rate( RR),mean arterial blood pressure( MAP) and oxygenation index were recorded before treatment and3,7 days after treatment. Prognostic indexes including rate of invasive mechanical ventilation,incidences of hospital acquired pneumonia and facial pressure ulcer,length of intensive care unit( ICU) stay and the 28-day mortality rate were observed. Nutritional indexes including enteral nutrition tolerance rate and aspiration rate were analyzed.Intestinal function score,serum total protein and albumin levels were tested before and 7 days after treatment.Results In the NIV group,APACHEⅡscore,HR,RR and MAP 7 days after treatment were significantly lower and oxygenation index was significantly higher than those before treatment( all P < 0. 05). In the HFNO group,HR and RR 3 days after treatment were significantly lower and oxygenation index was significantly higher than those before treatment; at 7 days after treatment,APACHEⅡ score,HR,RR and MAP were significantly lower and oxygenation index was significantly higher than those before treatment; HR and RR 7 days after treatment were significantly lower and oxygenation index was significantly higher than those 3 days after treatment( all P < 0. 05). At 3 and 7 days after treatment,HR and RR in the HFNO group were significantly lower than those in the NIV group[3 d:( 77 ±17) times/min vs( 84 ± 18) times/min,( 19 ± 6) times/min vs( 22 ± 7) times/min; 7 d:( 70 ± 16) times/min vs( 80 ±17) times/min,( 15 ±6) times/min vs( 19 ±6) times/min]; oxygenation index in the HFNO group was significantly higher than that in the NIV group[3 d:( 205 ± 30) mmHg vs( 196 ± 30) mmHg; 7 d:( 267 ± 35) mmHg vs( 226 ±33) mmHg]( all P <0. 05). Enteral nutrition tolerance rate in the HFNO group was significantly higher than those in the NIV group[94. 6%( 35/37) vs 73. 0%( 27/37) ]( P < 0. 05). At 7 days after treatment,intestinal function score significantly decreased and levels of total protein and albumin significantly increased compared to those before treatment in both groups; intestinal function score in the HFNO group was significantly lower than that in the NIV group; levels of total protein and albumin in the HFNO group were significantly higher than those in the NIV group[( 56 ± 7) g/L vs( 52 ± 6) g/L,( 39 ± 4) g/L vs( 34 ± 4) g/L]( both P < 0. 05). Rate of invasive mechanical ventilation,incidences of hospital acquired pneumonia and facial pressure ulcer were significantly lower and length of ICU stay was significantly shorter in the HFNO group than those in the NIV group[16. 2%( 6/37) vs 29. 7%( 11/37),5. 4%( 2/37) vs 18. 9%( 7/37),0 vs 8. 1%( 3/37),( 5 ± 4) d vs( 8 ± 3) d]( all P < 0. 05). There was no significant difference of the 28-day mortality rate between groups( P > 0. 05). Conclusion HFNO can improve the oxygenation,the compliance and amenity of enteral nutrition in patients with hyoxemia after hypertensive intracerebral hemorrhage operation.
引文
[1]Hemphill JC 3rd,Adeoye OM,Alexander DN,et al.Clinical performance measures for adults hospitalized with intracerebral hemorrhage:performance measures for healthcare professionals from the American Heart Association/American Stroke Association[J].Stroke,2018,49(7):e243-e261.DOI:10.1161/STR.0000000000000171.
[2]Hemphill JC 3rd,Greenberg SM,Anderson CS,et al.Guidelines for the management of spontaneous intracerebral hemorrhage:Aguideline for healthcare professionals from the American Heart Association/American Stroke Association[J].Stroke,2015,46(7):2032-2060.DOI:10.1161/STR.0000000000000069.
[3]Ji R,Shen H,Pan Y,et al.Risk score to predict hospitalacquired pneumonia after spontaneous intracerebral hemorrhage[J].Stroke,2014,45(9):2620-2628.DOI:10.1161/STROKEAHA.114.005023.
[4]孙晨靓,陆洋,王林华,等.经鼻高流量氧疗干预急性Ⅰ型呼吸衰竭患者的效果及预后观察[J].疑难病杂志,2018,17(12):1320-1323,1327.DOI:10.3969/j.issn.1671-6450.2018.12.006.Sun CL,Lu Y,Wang LH,et al.Effect and mechanism of transnasal high flow oxygen inhalation on acute type 1 respiratory failure[J].Chinese Journal of Difficult and Complicated Cases,2018,17(12):1320-1323,1327.DOI:10.3969/j.issn.1671-6450.2018.12.006.
[5]中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国脑出血诊治指南(2014)[J].中华神经科杂志,2015,48(6):435-444.DOI:10.3760/cma.j.issn.1006-7876.2015.06.002.Chinese Society of Neurology,Cerebrovascular Disease Group of Chinese Society of Neurology.Guidelines for diagnosis and treatment of cerebral hemorrhage in China(2014)[J].Chinese Journal of Neurology,2015,48(6):435-444.DOI:10.3760/cma.j.issn.1006-7876.2015.06.002.
[6]Porhomayon J,El-Solh AA,Pourafkari L,et al.Applications of nasal high-flow oxygen therapy in critically ill adult patients[J].Lung,2016,194(5):705-714.DOI:10.1007/s00408-016-9885-0.
[7]Curley GF,Laffy JG,Zhang H,et al.Noninvasive respiratory support for acute respiratory failure-high flow nasal cannula oxygen or non-invasive ventilation?[J].J Thorac Dis,2015,7(7):1092-1097.DOI:10.3978/j.issn.2072-1439.2015.07.18.
[8]Matthay MA.Saving lives with high-flow nasal oxygen[J].N Engl JMed,2015,372(23):2225-2226.DOI:10.1056/NEJMe1504852.
[9]Singer P,Rattanachaiwong S.To eat or to breathe?The answer is both!Nutritional management during noninvasive ventilation[J].Crit Care,2018,22(1):27.DOI:10.1186/s13054-018-1947-7.
[10]Slain KN,Martinez-Schlurmann N,Shein SL,et al.Nutrition and high-flow nasal cannula respiratory support in children with bronchiolitis[J].Hosp Pediatr,2017,7(5):256-262.DOI:10.1542/hpeds.2016-0194.
[11]Glackin SJ,O'Sullivan A,George S,et al.High flow nasal cannula versus NCPAP,duration to full oral feeds in preterm infants:a randomised controlled trial[J].Arch Dis Child Fetal Neonatal Ed,2017,102(4):F329-F332.DOI:10.1136/archdischild-2016-311388.
[12]陈佳,高薇薇,许芳,等.两种辅助通气方式治疗极低出生体重儿呼吸窘迫综合征临床疗效分析[J].中国当代儿科杂志,2015,7(8):847-851.DOI:10.7499/j.issn.1008-8830.2015.08.017.Chen J,Gao WW,Xu F,et al.Comparison of clinical efifcacy of heated humidiifed high lfow nasal cannula versus nasal continuous positive airway pressure in treatment of respiratory distress syndrome in very low birth weight infants[J].Chinese Journal of Contemporary Pediatrics,2015,7(8):847-851.DOI:10.7499/j.issn.1008-8830.2015.08.017.
[13]Hoffman SB,Terrell N,Driscoll CH,et al.Impact of high-flow nasal cannula use on neonatal respiratory support patterns and length of stay[J].Respir Care,2016,61(10):1299-1304.DOI:10.4187/respcare.04668.
[2]Hemphill JC 3rd,Greenberg SM,Anderson CS,et al.Guidelines for the management of spontaneous intracerebral hemorrhage:Aguideline for healthcare professionals from the American Heart Association/American Stroke Association[J].Stroke,2015,46(7):2032-2060.DOI:10.1161/STR.0000000000000069.
[3]Ji R,Shen H,Pan Y,et al.Risk score to predict hospitalacquired pneumonia after spontaneous intracerebral hemorrhage[J].Stroke,2014,45(9):2620-2628.DOI:10.1161/STROKEAHA.114.005023.
[4]孙晨靓,陆洋,王林华,等.经鼻高流量氧疗干预急性Ⅰ型呼吸衰竭患者的效果及预后观察[J].疑难病杂志,2018,17(12):1320-1323,1327.DOI:10.3969/j.issn.1671-6450.2018.12.006.Sun CL,Lu Y,Wang LH,et al.Effect and mechanism of transnasal high flow oxygen inhalation on acute type 1 respiratory failure[J].Chinese Journal of Difficult and Complicated Cases,2018,17(12):1320-1323,1327.DOI:10.3969/j.issn.1671-6450.2018.12.006.
[5]中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国脑出血诊治指南(2014)[J].中华神经科杂志,2015,48(6):435-444.DOI:10.3760/cma.j.issn.1006-7876.2015.06.002.Chinese Society of Neurology,Cerebrovascular Disease Group of Chinese Society of Neurology.Guidelines for diagnosis and treatment of cerebral hemorrhage in China(2014)[J].Chinese Journal of Neurology,2015,48(6):435-444.DOI:10.3760/cma.j.issn.1006-7876.2015.06.002.
[6]Porhomayon J,El-Solh AA,Pourafkari L,et al.Applications of nasal high-flow oxygen therapy in critically ill adult patients[J].Lung,2016,194(5):705-714.DOI:10.1007/s00408-016-9885-0.
[7]Curley GF,Laffy JG,Zhang H,et al.Noninvasive respiratory support for acute respiratory failure-high flow nasal cannula oxygen or non-invasive ventilation?[J].J Thorac Dis,2015,7(7):1092-1097.DOI:10.3978/j.issn.2072-1439.2015.07.18.
[8]Matthay MA.Saving lives with high-flow nasal oxygen[J].N Engl JMed,2015,372(23):2225-2226.DOI:10.1056/NEJMe1504852.
[9]Singer P,Rattanachaiwong S.To eat or to breathe?The answer is both!Nutritional management during noninvasive ventilation[J].Crit Care,2018,22(1):27.DOI:10.1186/s13054-018-1947-7.
[10]Slain KN,Martinez-Schlurmann N,Shein SL,et al.Nutrition and high-flow nasal cannula respiratory support in children with bronchiolitis[J].Hosp Pediatr,2017,7(5):256-262.DOI:10.1542/hpeds.2016-0194.
[11]Glackin SJ,O'Sullivan A,George S,et al.High flow nasal cannula versus NCPAP,duration to full oral feeds in preterm infants:a randomised controlled trial[J].Arch Dis Child Fetal Neonatal Ed,2017,102(4):F329-F332.DOI:10.1136/archdischild-2016-311388.
[12]陈佳,高薇薇,许芳,等.两种辅助通气方式治疗极低出生体重儿呼吸窘迫综合征临床疗效分析[J].中国当代儿科杂志,2015,7(8):847-851.DOI:10.7499/j.issn.1008-8830.2015.08.017.Chen J,Gao WW,Xu F,et al.Comparison of clinical efifcacy of heated humidiifed high lfow nasal cannula versus nasal continuous positive airway pressure in treatment of respiratory distress syndrome in very low birth weight infants[J].Chinese Journal of Contemporary Pediatrics,2015,7(8):847-851.DOI:10.7499/j.issn.1008-8830.2015.08.017.
[13]Hoffman SB,Terrell N,Driscoll CH,et al.Impact of high-flow nasal cannula use on neonatal respiratory support patterns and length of stay[J].Respir Care,2016,61(10):1299-1304.DOI:10.4187/respcare.04668.