无创通气管理策略在玉树地震伤急性呼吸窘迫综合征患者的应用研究
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摘要
[目的]探讨无创通气早期介入联合镇静镇痛和纤维支气管镜(纤支镜)吸痰治疗在地震伤急性呼吸窘迫综合征(ARDS)患者的应用价值。[方法]对四川大学华西医院ICU在玉树地震中救治的ARDS无创通气患者(A组)和汶川地震中的ARDS无创通气患者(B组)临床资料进行双向性队列研究。A组患者采用无创通气早期介入联合镇静镇痛和纤支镜吸痰治疗,B组患者采用传统无创通气治疗方法。观察A组患者无创通气治疗前及治疗后1 h、24 h、48 h,氧合指数(OI)、呼吸频率和心率的变化情况,最终比较A、B两组患者的气管插管率和肺部感染的发生率,机械通气时间和住ICU时间,ICU死亡率。[结果]共收治地震伤ARDS无创通气患者19例,A组6例,B组13例。A组患者无创通气治疗后1 h、24 h、48 h,氧合指数(OI)、呼吸频率和心率均明显改善,气管插管率和肺部感染率均为0,明显较B组低,其住ICU时间较B组短,差异有统计学意义,A、B两组患者均好转。[结论无创通气早期介入联合镇静镇痛和纤支镜吸痰治疗ARDS患者,可有效缓解临床症状,提高无创通气治疗的成功率,减少患者的气管插管率和肺部感染发生率。
[Objective]To assess the clinical effect of the earthquake critically injured acute respiratory distress syndrome patients early treated with non-invasive ventilation combined with appropriate sedation analgesia and bronchoscopy.[Methods]Used bidirectional cohort study to investigate the data obtained from critically injured acute respiratory distress syndrome patients in Yushu Earthquake(group A)and Wenchuan Earthquake(group B),treated by noninvasive ventilation in ICU department of West China Hospital of Sichuan University.Group A was treated with early implementation of non-invasive ventilation and necessary sedation and analgesia and bronchoscopy.Group B was treated with conventional noninvasive ventilation.The oxygenation index(OI),respiratory rate and heart rate were measured before and at 1 h,24 h,48 h after non-invasive ventilation in group A.The endotracheal intubation rate,incidence of pulmonary infection,mechanical ventilation time,ICU stay time and mortality were recorded in group A and group B.[Results]Nineteen critically injured acute respiratory distress syndrome patients were treated with noninvasive ventilation in ICU department of West China Hospital of Sichuan University,including six patients in Yushu earthquake(group A)and thirteen patients in Wenchuan earthquake(group B).After the use of non-invasive ventilation,the oxygenation index(OI)and respiratory rate and heart rate were improved in group A.In group A,tracheal intubation rate and incidence of pulmonary infection were 0,obviously lower than group B,and mechanical ventilation time and ICU stay time were also shorter in group A(P﹤0.05).All the patients were improved.[Conclusion]ARDS patients are early treated with noninvasive ventilation combined with appropriate sedation analgesia and bronchoscopy,which can relieve the clinical symptoms,improve the patients' outcomes and reduce intubation rate.
[Objective]To assess the clinical effect of the earthquake critically injured acute respiratory distress syndrome patients early treated with non-invasive ventilation combined with appropriate sedation analgesia and bronchoscopy.[Methods]Used bidirectional cohort study to investigate the data obtained from critically injured acute respiratory distress syndrome patients in Yushu Earthquake(group A)and Wenchuan Earthquake(group B),treated by noninvasive ventilation in ICU department of West China Hospital of Sichuan University.Group A was treated with early implementation of non-invasive ventilation and necessary sedation and analgesia and bronchoscopy.Group B was treated with conventional noninvasive ventilation.The oxygenation index(OI),respiratory rate and heart rate were measured before and at 1 h,24 h,48 h after non-invasive ventilation in group A.The endotracheal intubation rate,incidence of pulmonary infection,mechanical ventilation time,ICU stay time and mortality were recorded in group A and group B.[Results]Nineteen critically injured acute respiratory distress syndrome patients were treated with noninvasive ventilation in ICU department of West China Hospital of Sichuan University,including six patients in Yushu earthquake(group A)and thirteen patients in Wenchuan earthquake(group B).After the use of non-invasive ventilation,the oxygenation index(OI)and respiratory rate and heart rate were improved in group A.In group A,tracheal intubation rate and incidence of pulmonary infection were 0,obviously lower than group B,and mechanical ventilation time and ICU stay time were also shorter in group A(P﹤0.05).All the patients were improved.[Conclusion]ARDS patients are early treated with noninvasive ventilation combined with appropriate sedation analgesia and bronchoscopy,which can relieve the clinical symptoms,improve the patients' outcomes and reduce intubation rate.
引文
邓丽静,康焰.地震伤患者ARDS临床资料分析[J].中华内科杂志,2008,47(9).
中华医学会重症医学分会.急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南(2006)[J].中国实用外科杂志,2007,27:36.
N.Ambrosino,G.Vagheggini.Noninvasive positive pressure ventilation in acute care setting:wHere are we[J].EurRespirJ,2008,31:874-88.
Graeme M.Rocker,Mary-Gordon Mackenzie,Bruce Williams and P.Noninvasive Positive Pressure Ventilation*:Successful Outcome in Patients WitH Acute Lung Injury/ARDS[J].CHest,1999,115:173-177.
张波.无创正压通气适应证选择之我见—兼与詹庆元和徐思成医师商榷[J].中华结核和呼吸杂志,2004,10(27):717-719.
M.Antonelli,M.A.Pennisi,G.Conti.New advances in the use of noninvasive ventilation for acute Hypoxaemic respiratory failure[J].EurRespirJ,2003,22:Suppl.42,65s-71s.
Sameer Rana,Hussam Jenad,Peter C Gay,et al.Failure of noninvasive ventilation in patients with acute lung injury:observational cohort study.CritCare,2006,10:R79.
Ritesh Agarwal,Chandana Reddy,Ashutosh N,et al.Is there a role for noninvasive ventilation in acute respiratorydistress syndrome A meta-analysis[J].Respir Med,2006,100:2235-2238
Massimo Antonelli,Giorgio Conti,Antonio Esquinas,et al.A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome[J].Critic Care Med,2007,35:18-25.
陈康,冯仕彦,李伟.地震伤患者并发ARDS的危险因素分析[J].四川医学,2009,30(6):976-978.
Constantin JM,Schneider E,Cayot-Constantin S,et al.Remifentanil-based sedation to treat noninvasive ventilation failure:a preliminary study[J].Intensive Care Med,2007,33:82-87
Antonelli M,Giorgio Conti,Monica Rocco,et al.Noninvasive posititve pressure ventilation vs conventional oxygen supplementation in hypoxemic patients undergoing diagnostic bronchoscopy[J].Chest,2002,121:1149-1154.
Carlucci A.Changes in the practice of noninvasive ventilation in treating COPD patients ove 8 years[J].Intensive Care Med,2003,29:519-525.
GirouE.Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients witH exacerbation of COPD and pulmonary edema[J].JAMA,2003,290:2985-2991.
中华医学会重症医学分会.急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南(2006)[J].中国实用外科杂志,2007,27:36.
N.Ambrosino,G.Vagheggini.Noninvasive positive pressure ventilation in acute care setting:wHere are we[J].EurRespirJ,2008,31:874-88.
Graeme M.Rocker,Mary-Gordon Mackenzie,Bruce Williams and P.Noninvasive Positive Pressure Ventilation*:Successful Outcome in Patients WitH Acute Lung Injury/ARDS[J].CHest,1999,115:173-177.
张波.无创正压通气适应证选择之我见—兼与詹庆元和徐思成医师商榷[J].中华结核和呼吸杂志,2004,10(27):717-719.
M.Antonelli,M.A.Pennisi,G.Conti.New advances in the use of noninvasive ventilation for acute Hypoxaemic respiratory failure[J].EurRespirJ,2003,22:Suppl.42,65s-71s.
Sameer Rana,Hussam Jenad,Peter C Gay,et al.Failure of noninvasive ventilation in patients with acute lung injury:observational cohort study.CritCare,2006,10:R79.
Ritesh Agarwal,Chandana Reddy,Ashutosh N,et al.Is there a role for noninvasive ventilation in acute respiratorydistress syndrome A meta-analysis[J].Respir Med,2006,100:2235-2238
Massimo Antonelli,Giorgio Conti,Antonio Esquinas,et al.A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome[J].Critic Care Med,2007,35:18-25.
陈康,冯仕彦,李伟.地震伤患者并发ARDS的危险因素分析[J].四川医学,2009,30(6):976-978.
Constantin JM,Schneider E,Cayot-Constantin S,et al.Remifentanil-based sedation to treat noninvasive ventilation failure:a preliminary study[J].Intensive Care Med,2007,33:82-87
Antonelli M,Giorgio Conti,Monica Rocco,et al.Noninvasive posititve pressure ventilation vs conventional oxygen supplementation in hypoxemic patients undergoing diagnostic bronchoscopy[J].Chest,2002,121:1149-1154.
Carlucci A.Changes in the practice of noninvasive ventilation in treating COPD patients ove 8 years[J].Intensive Care Med,2003,29:519-525.
GirouE.Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients witH exacerbation of COPD and pulmonary edema[J].JAMA,2003,290:2985-2991.
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