【摘要】 目的 探讨双水平无创正压通气(BiPAP)对心脏外科术后需要二次机械辅助通气患者的治疗效果。方法 2008年9月—2009年9月，收集心脏外科手术后成功脱离呼吸机辅助通气后心功能衰竭或呼吸功能衰竭需要二次机械通气的患者,符合纳入及排除标准者共53例，进行回顾性分析,根据治疗方案分为无创通气组(32例)和有创通气组(21例),在需要机械通气时(T1),机械通气后30 min(T2),机械通气后2 h(T3)及预计脱离机械通气时(T4),分别统计患者心率、血气分析等情况,比较氧分压、ICU停留时间及术后至出院时间。结果 给予辅助通气前,两组患者的心率及PO2无统计学差异(Pgt;0.05)。给予辅助通气后,无创通气组患者的心率由T1(130.8±21.10)次/min,下降到T2(125.60±21.36)次/min,T3(101.70±13.73)次/min,T4(87.40±9.35)次/min；PO2由T1(64.70±14.12) mm Hg,上升到T2 (121.40±30.19) mm Hg，T3 (140.40±25.29) mm Hg，T4 (132.90±16.33) mm Hg。有创通气组患者的心率由T1 (138.27±21. 39)次/min,下降到T2(118.18±18.03)次/min，T3(100.00±11.73)次/min，T4(87.00±10.70)次/min；PO2由T1 (61.45±13.56) mm Hg上升到T2(122.55±29.50) mm Hg，T3(138.91±24.77) mm Hg，T4(133.55±18.00) mm Hg。两组患者心率及PO2均较辅助通气前降低(Plt;0.05)。两组患者之间各时间点心率及PO2比较无差异(Pgt;0.05)。无创通气组的ICU停留时间及术后至出院时间分别为(1.75±2.97) d及(9.14±4.11) d，均低于有创通气组的(4.38±5.13) d及(14.00±0.82) d,有统计学意义(Plt;005)。结论 双水平无创正压通气可用于心脏外科术后需要二次机械通气的患者。
ObjectiveTo analyze the influencing factors of ventilator-associated pneumonia (VAP) in comprehensive intensive care units (ICUs) in a certain district of Shanghai, and to provide evidence for developing targeted measures to prevent and reduce the occurrence of VAP.MethodsThe target surveillance data of 1 567 inpatients with mechanical ventilation over 48 hours in comprehensive ICUs of 5 hospitals in the district from January 2015 to December 2017 were retrospectively analyzed to determine whether VAP occurred. The data were analyzed with SPSS 21.0 software to describe the occurrence of VAP in patients and to screen the influencing factors of VAP.ResultsThere were 133 cases of VAP in the 1 567 patients, with the incidence of 8.49% and the daily incidence of 6.01‰; the incidence of VAP decreased year by year from 2015 to 2017 (χ2trend=11.111, P=0.001). The mortality rate was 12.78% in VAP patients while was 7.25% in non-VAP patients; the difference was significant (χ2=5.223, P=0.022). A total of 203 pathogenic bacteria were detected in patients with VAP, mainly Gram-negative bacteria (153 strains, accounting for 75.37%). The most common pathogen was Pseudomonas aeruginosa. The single factor analysis showed that gender, age, Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score, the length of ICU stay, and the length of mechanical ventilation were the influencing factors of VAP (χ2=9.572, 5.237, 34.759, 48.558, 44.960, P<0.05). Multiple logistic regression analysis found that women [odds ratio (OR)=1.608, 95% confidence interval (CI) (1.104, 2.340), P=0.013], APACHE Ⅱ score >15 [OR=4.704, 95%CI (2.655, 8.335), P<0.001], the length of ICU stay >14 days [OR=2.012, 95%CI (1.188, 3.407), P=0.009], and the length of mechanical ventilation >7 days [OR=2.646, 95%CI (1.439, 4.863), P=0.002] were independent risk factors of VAP.ConclusionsNosocomial infection caused by mechanical ventilation in this area has a downward trend, and the mortality rate of patients with VAP is higher. For the patients treated with mechanical ventilation in ICU, we should actively treat the primary disease, shorten the length of ICU stay and the length of mechanical ventilation, and strictly control the indication of withdrawal, thereby reduce the occurrence of VAP.
目的:分析长期机械通气患者脱机成败原因,提高脱机成功率。方法:针对本院2003年5月至2008年10月近6年ICU172例长期机械通气患者成败原因进行分析。结果:总脱机成功率90.69%。脱机失败率 9.31%。结论:长期机械通气患者多存在多种因素的共同参与,如营养不良、全身衰弱、呼吸功能不全、通气泵衰竭和心理因素等,增加了脱机的难度,进而出现撤机困难。
Objective To explore the effect of budesonide nebulization in the treatment of mechanically ventilated patients with chronic obstructive pulmonary disease(COPD).Methods A total of 25 intubated and ventilated COPD patients complicated with respiratory failure was randomly divided into two groups.The control group consisted of 12 patients received salbutamol nebulization on the routine treatment.The budesonide group consisted of 13 patients received budesonide plus salbutamol nebulization on the routine treatment.Variables such as tumor necrosis factor-α(TNF-α) and interleukin-8(IL-8) in the bronchoalveolar lavage fluid(BALF) ， incidence of ventilation-associated lung injury(VALI) ， days of mechanical ventilation ，， days of hospitalization and survival rate were measured and compared.Results The survival rate and incidence of VALI were not different significantly between the two groups.However ， the levels of TNF-α and IL-8 in BALF of the control patients were significantly lower than those in the budesonide group[ （ 1.2±0.2 ） mg/L vs （ 1.5±0.4 ） mg/L ，（ 85.7±26.5 ）（ 125.6±30.4 ）， both Plt;0.05).And the days of mechanical ventilation and hospitalization were statistically shorter in the budesonide group compared with the control group[ (7.2±2.5 ） d vs （ 10.5±6.2 ） d ， (10.5±4.7 ） d vs (15.8±6.6 ） d ， both Plt;0.05].Conclusion Our data suggest that nebulization of budesonide can suppressed the pulmonary inflammation and decreased days of the mechanical ventilation and hospitalization in mechanically ventilated COPD patients.
Objective To analyze the risk factors of treatment failure by noninvasive positive pressure ventilation (NPPV) in patients with acute respiratory failure (ARF) due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and explore the best time that NPPV be replaced by invasive ventilation when NPPV failure occurs. Methods The data of patients with ARF due to AECOPD who were treated with NPPV from January 2013 to December 2015 were retrospectively collected. The patients were divided into two groups: the NPPV success group and the NPPV failure group (individuals who required endotracheal intubation or tracheotomy at any time). The Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score was analyzed; the Glasgow Coma Scale score, respiratory rate (RR), pH value, partial pressure of oxygen (PaO2), PaO2/fraction of inspired oxygen (FiO2) ratio, and partial pressure of carbon dioxide were also analyzed at admission, after 2 hours of NPPV, and after 24 hours of NPPV. Results A total of 185 patients with ARF due to AECOPD were included. NPPV failed in 35.1% of the patients (65/185). Multivariate analysis identified the following factors to be independently associated with NPPV failure: APACHEⅡscore≥30 [odds ratio (OR)=20.603, 95% confidence interval (CI) (5.309, 80.525), P<0.001], RR at admission≥35 per minute [OR=3.723, 95%CI (1.197, 11.037), P=0.020], pH value after 2 hours of NPPV<7.25 [OR=2.517, 95%CI (0.905, 7.028), P=0.070], PaO2 after 2 hours of NPPV<60 mm Hg (1 mm Hg=0.133 kPa) [OR=3.915, 95%CI (1.374, 11.508), P=0.010], and PaO2/FiO2 after 2 hours of NPPV<200 mm Hg [OR=4.024, 95%CI (1.542, 11.004), P=0.010]. Conclusion When patients with ARF due to AECOPD have a higher severity score, have a rapid RR at admission, or fail to improve in terms of pH and oxygenation after 2 hours of NPPV, the risk of NPPV failure is higher.
Objective To compare the humidification effect of the MR410 humidification system and MR850 humidification system in the process of mechanical ventilation. Methods Sixty-nine patients underwent mechanical ventilation were recruited and randomly assigned to a MR850 group and a MR410 group. The temperature and relative humidity at sites where tracheal intubation or incision, the absolute humidity, the sticky degree of sputum in initial three days after admission were measured. Meanwhile the number of ventilator alarms related to sputum clogging and pipeline water, incidence of ventilator associated pneumonia, duration of mechanical ventilation, and mortality were recorded. Results In the MR850 group,the temperature of inhaled gas was ( 36. 97 ±1. 57) ℃, relative humidity was ( 98. 35 ±1. 32) % , absolute humidity was ( 43. 66 ±1. 15) mg H2O/L, which were more closer to the optimal inhaled gas for human body.The MR850 humidification system was superior to the MR410 humidification system with thinner airway secretions, less pipeline water, fewer ventilator alarms, and shorter duration of mechanical ventilation. There was no significant difference in mortality between two groups. Conclusions Compared with MR410 humidification system, MR850 humidification system is more able to provide better artificial airway humidification and better clinical effect.
With the extensive application of laparoscopy in clinical surgery, the advantages of laparoscopic surgery such as less intraoperative bleeding, small and beautiful incision, and rapid postoperative recovery become increasingly prominent. However, prolonged use of carbon dioxide (CO2) pneumoperitoneum or high CO2 pneumoperitoneum pressure during laparoscopic surgery may cause subcutaneous emphysema and hypercapnia, in severe cases which may affect the quality of recovery and prognosis of patients. The use of a protective ventilation strategy during laparoscopic surgery under general anesthesia, a mechanical ventilation model of controlled hyperventilation, can reduce or avoid the effects of hypercapnia caused by prolonged CO2 pneumoperitoneum or high CO2 pneumoperitoneum pressure. This article reviews the effects of laparoscopic CO2 pneumoperitoneum on patients, the application of controlled hyperventilation in laparoscopic surgery under general anesthesia and the effects of controlled hyperventilation on patients. The aim is to provide a theoretical basis for the safe and effective application of controlled hyperventilation in laparoscopic surgery.