新冠肺炎重症患者经鼻高流量氧疗护理实践

本文回顾了2020年2月1日—3月10湖北省武汉市金银潭医院南二、北二、北四病区41例新冠肺炎重症患者使用经鼻高流量吸氧治疗的护理流程,总结新冠肺炎重症患者应用经鼻高流量治疗的护理重点及体会。41例患者吸氧浓度为50%～70%,氧流量为40～60 L/min,氧疗过程中患者均未出现压力性损伤、氧疗失效等并发症,且氧疗0.5 h、1 h、2 h、4 h后患者SpO2逐步上升,差异比较有统计学意义(P0.01)。     

早期清醒俯卧位联合经鼻高流量氧疗治疗重型新型冠状病毒肺炎一例

在新型冠状病毒肺炎（简称“新冠肺炎”）疫情防控的早期阶段,由于对疾病的认识不足,重症患者治疗难度大、病死率高,这对ICU医师提出了挑战。皖南医学院弋矶山医院在疫情防控早期阶段收治1例重型新冠肺炎患者,结合既往急性呼吸窘迫综合征（ARDS）的处理经验,采用早期清醒俯卧位联合经鼻高流量氧疗（HFNC）治疗,成功避免气管插管和机械通气,最终患者康复出院。本文报告该病例的综合救治过程,并结合文献,分析清醒俯卧位联合HFNC治疗重型新冠肺炎的循证医学依据、注意事项和及时转为有创机械通气的时机,提出“俯卧位前移”的概念,为重症新冠肺炎患者救治提供有力的医疗决策。     

32例重症新型冠状病毒肺炎患者的护理

目的总结32例重症新型冠状病毒肺炎患者的临床护理经验。方法从重症新型冠状病毒肺炎患者的呼吸支持护理(经鼻高流量鼻导管湿化氧疗、无创机械通气、有创机械通气)、脓毒性休克护理、并发症预防、安全用药、心理护理和防控措施等方面进行临床护理。结果 32例患者中,出院22例,7例患者肺部病变好转,因核酸阳性继续在院治疗,死亡3例。结论对重症新型冠状病毒肺炎患者实施呼吸支持护理、脓毒性休克护理、并发症预防、安全用药、心理护理等,能有效降低重症病例死亡率,为重型患者进一步治疗及康复争取时间。     

经鼻高流量氧疗配合呼吸康复治疗1 例新型冠状病毒肺炎病人的护理

本研究对1例新型冠状病毒肺炎病人经鼻高流量氧疗(high-flow oxygen through nasal cannula,HFNC)配合呼吸康复治疗等康复护理措施进行个案分析,为该病的诊断、预防和治疗提供理论依据。结果显示,HFNC对于新型冠状病毒肺炎呼吸衰竭症状的病人,具有呼气末正压效应(PEEP)、增加呼气末肺容积等优点[1]。配合呼吸功能锻炼可缓解病人负性情绪和消极心理,有助于提高治疗疗效,改善病人整体临床症状、体征。     

高血压合并重症新型冠状病毒肺炎的治疗体会(附1例报告)

目的:本研究旨在探讨高血压合并重症新型冠状病毒肺炎的临床治疗方案。方法:为阳江市人民医院综合病区收治的一例高血压合并重症新型冠状病毒肺炎患者尽早及时的使用经鼻高流量氧疗,巧用ARB类药物监控血压,配合个体化的中药进行治疗。结果:患者经治疗后无发热3天以上,肺部CT病灶吸收,查咽拭子核酸连续3次阴性,予以出院。结论:高血压病病史重型新型冠状病毒肺炎,在常规治疗基础上,早期经鼻高流量氧疗,巧用药物监控血压及不常规使用激素是患者治疗成功的关键。     

ROX指数对新型冠状病毒肺炎患者经鼻高流量湿化氧疗疗效的评估价值

目的:探讨ROX指数在评估新型冠状病毒肺炎（COVID-19）患者经鼻高流量湿化氧疗（high-flow nasal cannula oxygen therapy, HFNC）治疗效果的价值。方法:回顾性分析2020年2月15日至2020年3月15日华中科技大学同济医学院附属协和医院肿瘤中心重症病区收治的接受HFNC的符合重症COVID-19诊断标准的患者的临床资料。根据患者后续是否接受无创正压通气、有创正压通气,将其分为HFNC治疗成功组与HFNC治疗失败组,使用 t检验、χ 2检验或者秩合检验比较两组在基本资料、乳酸、胸片肺部感染所占象限数、APACHEⅡ、淋巴细胞计数、基线呼吸频率、基线经皮氧饱和度、基线氧合指数、基线ROX指数、HFNC治疗2 h后ROX指数、HFNC治疗6 h后ROX指数、HFNC治疗12 h后ROX指数之间的差异。 结果:共有57例患者纳入本研究。成功组与失败组在性别、年龄、合并症、乳酸、胸片肺部感染所占象限数、APACHEⅡ、淋巴细胞计数、基线呼吸频率、基线经皮氧饱和度、基线氧合指数、基线ROX指数差异均无统计学意义（ P>0.05）,Logistic回归分析结果提示,治疗2 h ROX （ OR=0.069）、治疗6 h ROX（ OR=0.194）、治疗12 h ROX（ OR=0.036）均为COVID-19患者HFNC治疗效果的保护因素,ROC曲线示,HFNC治疗2 h、6 h、12 h后ROX指数差异有统计学意义（ P<0.05）。在评价指标中HFNC治疗2 h后ROX指数ROC曲线下面积（AUC）0.838,灵敏度为64.5%,特异度为100%。HFNC治疗6 h后ROX指数AUC为0.762,灵敏度为64.5%,特异度为92.3%。HFNC治疗12 h后ROX指数AUC为0.866,灵敏度为67.7%,特异度为100%。 结论:ROX指数可以及时、简便、实时地在评估COVID-19患者HFNC治疗效果。     

新型冠状病毒肺炎重症隔离病房护理管理策略

摘要：目的 探讨新型冠状病毒肺炎重症隔离病房的护理管理方法。方法 通过建立新冠肺炎重症病房护理组织框架、防控管理制度、严格质控与环节管理、加强人员培训、强调人文关怀和心理疏导，保障新冠肺炎救治和医护人员安全。结果 2020年2月10日至 2020年3月30日，收治确诊重症患者109例，治愈出院98例；所有医护人员未发生新型冠状病毒感染。结论 系统的护理管理策略可保障新型冠状病毒肺炎重症隔离病房有序运行，保障医护人员安全，有效完成救治任务。     

重症肺炎患者呼吸道管理策略探讨

摘要：目的 通过评估经鼻导管高流量湿化氧疗在肺部感染患者中的临床疗效,为肺部感染尤其是重症肺炎的患者呼吸道管理策略提供一定的参考依据。方法 2015年9月至2017年9月,采用方便抽样方法选取收治于复旦大学附属华山医院感染科的375例肺部感染患者作为研究对象。依据时间将2015年9月1日至2016年8月31日、2016年9月1日至2017年8月31日入院的患者分别纳入对照组和观察组,对照组患者接受常规治疗,观察组患者在对照组的基础上根据病情接受经鼻导管高流量湿化氧疗。比较两组患者的住院时长、气管插管（包括无创/有创气管切开）人数比例以及预后转归。在对照组和观察组的重症肺炎患者中评估接受经鼻导管高流量湿化氧疗的患者预后情况。结果 观察组重症肺炎的患者比例较对照组高,预后较对照组好,均有统计学差异（P < 0.05）。与未使用HFNC治疗的患者比较,发现接受HFNC的重症肺炎患者预后更好,有统计学差异（P < 0.05）。使用HFNC治疗后,重症肺炎患者的多个指标如呼吸频率、心率、氧饱和度、氧分压均有显著改善,均有统计学差异（P < 0.05）。结论 近年来,我院感染科收治患者的肺部感染患者人数越来越多,重症化比例也越来越高。在此情况下,医院的管理、医生的诊疗、护士的护理到位,使整体肺部感染患者的住院天数、预后转归与既往病情较轻的时候并无差异。同时,接受HFNC的重症肺炎患者,预后明显好转,表明HFNC对改善肺部感染患者预后有明显疗效。     

经鼻高流量氧疗在慢性阻塞性肺疾病急性加重患者有创呼吸机序贯治疗中的临床效果

目的探讨经鼻高流量（HFNC）氧疗在慢性阻塞性肺疾病急性加重（AECOPD）患者有创呼吸机序贯治疗中的效果是否与无创呼吸机（NIV）类似。 方法将苏北人民医院重症医学科（ICU）2017年9月至2018年4月连续收治的因COPD急性加重需气管插管行有创呼吸机治疗的患者纳入研究，经治疗患者病情改善出现"病情缓解窗"后，将患者随机分为HFNC组和NIV组，主要观察终点是患者48 h内再插管率，次要观察终点是ICU住院时间以及不良事件发生率。 结果共计35例患者纳入分析，HFNC组18例，NIV组17例。48 h内HFNC组3例患者（16.7%）、NIV组2例患者（11.8%）再插管，2组比较，差异无统计学意义（P>0.05）；ICU住院时间HFNC组较NIV组明显降低［（10.4±1.8）d vs （14.2±1.1）d，t=-2.549，P=0.023］，不良事件HFNC组发生1例（5.6%）、NIV组5例（29.4%），2组比较差异有统计学意义（P<0.01）。 结论以"病情缓解窗"为切换点实施有创呼吸机-经鼻高流量序贯通气策略与无创序贯通气治疗效果相似，且可缩短ICU住院时间，显著减少无创通气不良事件的发生。     

辽宁省重症新型冠状病毒肺炎17例临床特征分析

目的分析重症新型冠状病毒肺炎(新冠肺炎)患者的流行病学及临床特征。方法回顾性分析2020年1月22日-3月1日入住辽宁省2所新冠肺炎集中收治医院确诊新冠肺炎患者,符合《新型冠状病毒感染的肺炎诊疗方案(试行第七版)》定义的重型、危重型患者的流行病学及临床特征。结果纳入重症新冠肺炎17例,其中重型15例,危重型2例。17例患者均存在发热,14例发生肝损伤,5例肌酸激酶升高,6例乳酸脱氢酶升高,13例出现D-二聚体升高。所有患者胸部CT均呈双肺典型病毒性肺炎表现。所有患者均需要氧气支持治疗。患者主观感受发病至出现呼吸困难中位时间8 d(1~15 d),但实际开始接受氧气治疗时间为发病第3天(1~16 d)。所有患者均接受抗病毒治疗。8例使用糖皮质激素治疗。截至2020年3月16日,治愈出院16例,死亡1例。治愈患者发病至病毒核酸阴转中位时间(咽拭子、痰液RT-PCR检测)27 d(14~50 d)。结论重症新冠肺炎患者发热持续时间长、淋巴细胞计数早期下降,随病情改善后回升,可伴有肝损害、心肌损害等,双肺典型病毒性肺炎影像表现。经鼻湿化高流量吸氧可以满足大部分患者的氧气供应。小剂量的糖皮质激素可减轻肺部渗出、改善急性呼吸窘迫综合征,未发现严重不良反应。     

High flow nasal cannula for adult acute hypoxemic respiratory failure in the ED setting

IntroductionHigh flow nasal cannula (HFNC) is a noninvasive ventilation (NIV) system that has demonstrated promise in the emergency department (ED) setting.ObjectiveThis narrative review evaluates the utility of HFNC in adult patients with acute hypoxemic respiratory failure in the ED setting.DiscussionHFNC provides warm (37 °C), humidified (100% relative humidity) oxygen at high flows with a reliable fraction of inspired oxygen (FiO₂). HFNC can improve oxygenation, reduce airway resistance, provide humidified flow that can flush anatomical dead space, and provide a low amount of positive end expiratory pressure. Recent literature has demonstrated efficacy in acute hypoxemic respiratory failure, including pneumonia, acute respiratory distress syndrome (ARDS), coronavirus disease 2019 (COVID-19), interstitial lung disease, immunocompromised states, the peri-intubation state, and palliative care, with reduced need for intubation, length of stay, and mortality in some of these conditions. Individual patient factors play an important role in infection control risks with respect to the use of HFNC in patients with COVID-19. Appropriate personal protective equipment, adherence to hand hygiene, surgical mask placement over the HFNC device, and environmental controls promoting adequate room ventilation are the foundation for protecting healthcare personnel. Frequent reassessment of the patient placed on HFNC is necessary; those with severe end organ dysfunction, thoracoabdominal asynchrony, significantly increased respiratory rate, poor oxygenation despite HFNC, and tachycardia are at increased risk of HFNC failure and need for further intervention.ConclusionsHFNC demonstrates promise in several conditions requiring respiratory support. Further randomized trials are needed in the ED setting.     

Feedback of inter-hospital transfer of patients under high-flow nasal cannula oxygen therapy

Severe forms of coronavirus disease 2019(COVID-19)can lead to hypoxemic pneumonia and the need for treatment with high-flow nasal cannula(HFNC)oxygen therapy.[1...     

213例疑似新型冠状病毒肺炎患者的护理实践

回顾性分析2020年1月20日—2月13日浙江大学医学院附属第一医院收治新型冠状病毒疑似患者213例的临床资料，探讨病情观察要点及护理重点。经相关检查及积极治疗后，最终新型冠状病毒确诊患者33例，安置在隔离病房继续接受治疗；157例患者出院继续接受医学居家观察14 d；23例患者转入浙江大学医学院附属第一医院总院普通专科病房继续接受治疗，疑似病房住院时间为1～13 d。患者住院期间，实现工作人员“零感染”。     

层级护理在重症肺炎患者护理服务中的应用效果

目的:对重症肺炎患者护理中应用层级护理的效果进行探究.方法:选择本院收治的重症肺炎患者92例作为本次研究纳入的研究对象,选取时间段为2018年4月至2020年4月.按照随机数字表法将其划分为甲组(n=46)和乙组(n=46).通过常规护理模式护理甲组,在此基础上,应用层级护理模式护理乙组.比较两组的护理效果.结果:乙组...     

High-flow nasal cannula therapy: A multicentred survey of the practices among physicians and respiratory therapists in Singapore

BackgroundUse of high-flow nasal cannula (HFNC) has become a regular intervention in the intensive care units especially in patients coming in with hypoxaemic respiratory failure. Clinical practices may differ from published literature.ObjectivesThe objective of this study was to determine the clinical practices of physicians and respiratory therapists (RTs) on the use of HFNC.MethodsA retrospective observational study looking at medical records on HFNC usage from January 2015 to September 2017 was performed and was followed by a series of questions related to HFNC practices. The survey involved physicians and RTs in intensive care units from multiple centres in Singapore from January to April 2018. Indications and thresholds for HFNC usage with titration and weaning practices were compared with the retrospective observational study data.ResultsOne hundred twenty-three recipients (69.9%) responded to the survey and reported postextubation (87.8%), pneumonia in nonimmunocompromised (65.9%), and pneumonia in immunocompromised (61.8%) patients as the top three indications for HFNC. Of all, 39.8% of respondents wanted to use HFNC for palliative intent. Similar practices were observed in the retrospective study with the large cohort of 63% patients (483 of the total 768 patients) where HFNC was used for acute hypoxaemic respiratory failure and 274 (35.7%) patients to facilitate extubation. The survey suggested that respondents would initiate HFNC at a lower fraction of inspired oxygen (FiO₂), higher partial pressure of oxygen to FiO₂ ratio, and higher oxygen saturation to FiO₂ ratio for nonpneumonia patients than patients with pneumonia. RTs were less likely to start HFNC for patients suffering from pneumonia and interstitial lung disease than physicians. RTs also preferred adjustment of FiO₂ to improve oxygen saturations and noninvasive ventilation for rescue.ConclusionsAmong the different intensive care units surveyed, the indications and thresholds for the initiation of HFNC differed in the clinical practices of physicians and RTs.     

Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index

PurposeThe purpose of the study is to describe early predictors and to develop a prediction tool that accurately identifies the need for mechanical ventilation (MV) in pneumonia patients with hypoxemic acute respiratory failure (ARF) treated with high-flow nasal cannula (HFNC).Materials and methodsThis is a 4-year prospective observational 2-center cohort study including patients with severe pneumonia treated with HFNC. High-flow nasal cannula failure was defined as need for MV. ROX index was defined as the ratio of pulse oximetry/fraction of inspired oxygen to respiratory rate.ResultsOne hundred fifty-seven patients were included, of whom 44 (28.0%) eventually required MV (HFNC failure). After 12 hours of HFNC treatment, the ROX index demonstrated the best prediction accuracy (area under the receiver operating characteristic curve 0.74 [95% confidence interval, 0.64-0.84]; P < .002). The best cutoff point for the ROX index was estimated to be 4.88. In the Cox proportional hazards model, a ROX index greater than or equal to 4.88 measured after 12 hours of HFNC was significantly associated with a lower risk for MV (hazard ratio, 0.273 [95% confidence interval, 0.121-0.618]; P = .002), even after adjusting for potential confounding.ConclusionsIn patients with ARF and pneumonia, the ROX index can identify patients at low risk for HFNC failure in whom therapy can be continued after 12 hours.     

强化心理健康教育对新冠肺炎患者护理依从性的影响

目的：探讨在新冠肺炎患者的护理中,实施强化心理健康教育的意义。方法：采取回顾性分析方法,研究对象为武汉协和医院、武汉大学人民医院2020年2月15日到3月31日收治的新型冠状病毒感染患者共120例,根据护理方法不同分组：对照组60例常规护理,研究组60例在常规护理基础上增加强化心理健康教育,对比两组护理效果。结果：研究组患者干预后的PHQ-9评分、焦虑评分低于对照组(P＜0.05),研究组患者的Herth评分、各项护理依从性、总护理满意率高于对照组(P＜0.05)。结论：新冠肺炎患者经强化心理教育干预,可有效改善患者的不良情绪,提高患者治疗的依从性。     

1例疑似新型冠状病毒性肺炎合并上消化道出血患者的护理

疑似新冠肺炎合并上消化道出血在以往临床护理中很少遇见,本文同过对1例此类患者的护理,进行回顾性分析,总结经验,为合并类似传染性疾病的上消化出血患者护理提供借鉴。     

No evidence of increasing COVID-19 in health care workers after implementation of high flow nasal cannula: A safety evaluation

BackgroundInitial recommendations discouraged high flow nasal cannula (HFNC) in COVID-19 patients, driven by concern for healthcare worker (HCW) exposure. Noting high morbidity and mortality from early invasive mechanical ventilation, we implemented a COVID-19 respiratory protocol employing HFNC in severe COVID-19 and HCW exposed to COVID-19 patients on HFNC wore N95/KN95 masks. Utilization of HFNC increased significantly but questions remained regarding HCW infection rate.MethodsWe performed a retrospective evaluation of employee infections in our healthcare system using the Employee Health Services database and unit records of employees tested between March 15, 2020 and May 23, 2020. We assessed the incidence of infections before and after the implementation of the protocol, stratifying by clinical or non-clinical role as well as inpatient COVID-19 unit.ResultsDuring the study period, 13.9% (228/1635) of employees tested for COVID-19 were positive. Forty-six percent of infections were in non-clinical staff. After implementation of the respiratory protocol, the proportion of positive tests in clinical staff (41.5%) was not higher than that in non-clinical staff (43.8%). Of the clinicians working in the high-risk COVID-19 unit, there was no increase in infections after protocol implementation compared with clinicians working in COVID-19 units that did not use HFNC.ConclusionWe found no evidence of increased COVID-19 infections in HCW after the implementation of a respiratory protocol that increased use of HFNC in patients with COVID-19; however, these results are hypothesis generating.