经鼻高流量氧疗加俯卧位通气在1名新冠肺炎重型患者救治中的分析

目的：分析经鼻高流量氧疗加俯卧位通气在新冠肺炎重型患者救治中的应用。方法：选取1例在本院接受经鼻高流量氧疗加俯卧位通气治疗的新冠肺炎重型患者,对患者的治疗过程展开回顾性分析,在治疗初期给予患者抗病毒、抗炎、抗感染等治疗措施,并根据患者气血分析结果的变化情况,给予患者呼吸支持治疗,并在患者出现急性呼吸窘迫综合征表现时,及时给予患者经鼻高流量氧疗与俯卧位通气治疗,以此提升患者的救治成功率。结果：治疗后患者的各项临床症状表现均已消退,患者的血气指标与生命体征逐渐恢复正常并趋于稳定,鼻拭子与咽拭子核酸检测结果均为阴性,于5月8日顺利出院。结论：采用经鼻高流量氧疗加俯卧位通气方案对新冠肺炎重型患者实施治疗,对改善患者的血气分析结果具有显著效果,有利于缓解患者的临床症状表现,降低病死率,对新冠肺炎重型患者患者的临床诊治具有重大的参考应用价值。     

新冠肺炎的护理体会

目的:总结新冠肺炎患者的护理经验。方法:19例新冠肺炎患者的护理重点包括加强序贯氧疗、俯卧位通气等呼吸支持护理、中西医结合治疗护理、心理护理和早期康复锻炼,同时做好疫情防控工作。结果:患者病情均得到有效控制,出院13例、好转6例,未出现死亡病例。结论:在治疗及护理过程中,护理人员应发挥主观能动性,采取个体化、具体化的优质护理措施,及时更新疫情知识,熟练掌握相关理论,立足早期干预,科学、有效地做好治疗、护理及疫情防控工作。     

36例新冠肺炎危重症患者实施俯卧位通气治疗的护理体会

总结了36例新冠肺炎危重症患者实施俯卧位通气治疗的护理.主要包括俯卧位机械通气前的准备、俯卧位机械通气的实施方法、俯卧位机械通气过程中的护理及并发症的预防.认为有效的护理可保障患者俯卧位机械通气安全顺利的实施,提升患者的治疗质量.     

联合护理团队模式在新冠肺炎俯卧位通气患者中的应用

目的：探讨联合护理团队模式在新冠肺炎患者实施俯卧位通气中的应用效果。方法：选择2020年4月-5月新冠疫情期间上海市某新冠肺炎定点医院的患者作为研究对象，采用数字随机表法将其分为观察组与对照组各30人，对照组给予呼吸科常规护理措施及俯卧位通气，观察组给予呼吸科常规护理措施及联合护理团队模式下俯卧位通气管理方案。于通气2、4、24h检测患者pH、SpO2、PaCO2、PaO2、氧合指数（PaO2 /FiO2）、心率、呼吸、血压。结果：通气24h，观察组pH、SpO2、PaCO2、PaO2、PaO2 /FiO2、HR、平均动脉压( MAP)指标较对照组改善，差异均有统计学意义(P＜0.05)。结论：联合护理团队模式对新冠肺炎患者实施俯卧位通气可有效改善患者氧合状况，提高护理人员对俯卧位通气有效性的重视和认知。     

高龄新型冠状病毒肺炎患者重症护理：防“危”杜渐

高龄新型冠状病毒肺炎（简称新冠肺炎）患者由于原发病本身、生理因素、伴有多种基础疾病等原因，发病后容易在短期进展为重症。特殊时期的重症护理需要“关口前移”，加强早期筛查，同时制定个体化的护理方案，包括俯卧位等。针对这一特殊群体，还需加强多方位护理，包括气道管理、容量评估、营养治疗、康复锻炼、心理干预等。在疫情防控期间，重症护理应充分发挥核心作用，防“危”杜渐，改善高龄新冠肺炎患者的临床预后及生活质量。     

新型冠状病毒肺炎老年重症患者的救治策略

新型冠状病毒肺炎（简称新冠肺炎）老年重症患者因高龄、基础疾病多、器官功能处于代偿边缘等一系列问题，在感染新冠肺炎后，易进展为重型和危重型。本文总结了新冠肺炎老年重症患者救治的经验，通过在原发新冠肺炎控制的基础上，积极治疗基础疾病、重视器官功能维护及并发症预防、早期评估患者的病情风险、实施康复及心理护理，为以后该类患者的临床治疗提供依据。     

极危重症新冠肺炎合并糖尿病患者护理体会

目的：总结极危重症新冠肺炎合并糖尿病患者的护理经验。 方法：52例极危重症新冠肺炎合并糖尿病患者的护理重点包括人工气道管理、体外膜肺（ECMO)护理、俯卧位通气等呼吸支持护理、血流动力学监测护理、糖尿病患者护理和心理护理,同时做好院内感染预防工作。 结果:患者病情及血糖均得到有效控制。 结论:在治疗及护理过程中,护理人员应发挥积极作用,采取个体化的整体护理措施,并且熟练掌握相关理论,做到早期干预,科学、有效地做好极危重症新冠肺炎合并糖尿病患者治疗、护理及疫情防控工作。     

新冠肺炎定点救治医院护理管理应急体系构建

目的 制定新冠肺炎定点救治医院应急护理管理策略,探讨其实施效果,为新冠肺炎定点医院的疫情防控护理工作提供建议和指导。方法 基于新冠肺炎定点救治医院病区筹备、医护人员防护用品穿脱程序培训、新冠定点医院相关护理常规和操作技术的培训、危重症患者的护理、医疗废弃物处理、合理排班、心理支持及后勤保障等方面实施疫情防控应急策略及护理管理。结果 2022年4月8日-6月5日,我院累计收治新冠肺炎阳性患者956例,其中重症203例,重症患者好转率(从重症转为普通型或轻型)达到97.8%。结论 新冠肺炎在上海流行期间,制定新冠肺炎定点救治医院护理管理策略、应急体系的构建有效地防止院内交叉感染的发生、有效地治愈重症患者和避免疫情地蔓延和扩散。     

新冠肺炎护理专题

正【编者按】为了贯彻落实习近平总书记关于坚决打赢新型冠状病毒肺炎疫情防控阻击战重要指示精神,把研究成果快速应用到疫情防控中,早日战胜疫情,本刊设立"新冠肺炎护理专题"。本期新冠肺炎护理专题从重症患者护理、资源管理、流程优化等角度组织了8篇文章,包括重型危重型新型冠状病毒肺炎患者整体护理专家共识、新型冠状病毒肺炎疫情防控中人力、     

新冠肺炎疫情严重地区急腹症处置策略

湖北省武汉市是此次新冠肺炎疫情的严重地区,大量的医护工作者已投入到抗击疫情的防治中,非新冠肺炎普通患者的诊疗基本停止。急腹症病情急,进展迅速,如未得到及时有效救治有可能耽误病情,严重时可能危及生命。如何在新冠肺炎疫情防控同时做好急腹症患者的救治是目前亟待解决的问题。为确保急腹症救治的时效性和医护人员防控工作的有效性,本文依据各项指南、诊疗及防控方案等文件,结合抗疫期间的一点经验,提出应对新冠肺炎疫情严重地区急腹症处理建议,旨在为湖北武汉地区普外科医护人员处理急腹症提供参考。     

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。     

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.     

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.     

侧卧位通气治疗新型冠状病毒肺炎重症患者的临床研究

目的探讨侧卧位通气对重症新型冠状病毒肺炎（COVID-19）患者的临床价值。 方法采用回顾性研究,收集2020年1月20日至3月7日在重庆三峡中心医院重症应急病区住院的41例COVID-19并中、重度急性呼吸窘迫综合征（ARDS）患者的临床资料。在经鼻高流量湿化氧疗（HFNC）或无创通气（NIV）的基础上,按是否进行侧卧位通气将患者分为侧卧位组（24例）和仰卧位组（17例）。统计2组患者的性别、年龄、急性生理与慢性健康状况（APACHEⅡ）评分和合并基础疾病情况,比较治疗前及治疗后第1、3、5天的心率（HR）、呼吸频率（RR）、氧合指数（PaO₂/FiO₂）、二氧化碳分压（PaCO₂）、平均动脉压（MAP）,以及轻症化率、HFNC或NPPV时间、气管插管发生率、住院时间、压疮发生情况等预后指标。 结果41例患者中,男性21例,女性20例;年龄43~79岁,平均（60.9±11.1）岁。2组患者年龄、性别、APACHEⅡ评分、合并基础疾病,以及治疗前RR、PaO₂/FiO₂、PaCO₂和MAP等比较,差异均无统计学意义（P均＞0.05）。2组患者治疗后HR、RR、MAP较治疗前下降,而PaCO₂、PaO₂/FiO₂上升,其中PaO₂/FiO₂在第5天较治疗前明显改善［侧卧位组：（166.4±45.4）mmHg vs（253.0±66.0）mmHg,仰卧位组：（183.8±54.4）mmHg vs（227.4±62.8）mmHg,P均＜0.05,1 mmHg=0.133 kPa］。2组间比较,侧卧位组在治疗后第1天RR较仰卧位组降低（P=0.006）;侧卧位组的中、重度ARDS患者PaO₂/FiO₂在治疗后第5天较仰卧位组改善,差异有统计学意义［（260.8±58.5）mmHg vs （221.6±64.9）mmHg,P=0.043］。2组HFNC或NIV时间和气管插管发生率比较,差异无统计学意义（P均＞0.05）,而侧卧位组总住院时间明显短于仰卧位组,差异有统计学意义［（15.5±7.2）d vs （21.5±9.8）d,P=0.028］,ICU住院时间也短于仰卧位组,差异有统计学意义［（10.3±6.3）d vs （16.9±11.0）d,P=0.021］,侧卧位组病死率低于仰卧位组,差异有统计学意义（8.3 % vs 23.5 %,P = 0.047）。 结论侧卧位通气能改善COVID-19并中、重度ARDS患者的氧合,缩短住院时间,降低病死率,提高疗效,促进患者康复。     

扬州地区老年COVID-19患者临床特征分析及俯卧位通气疗效评价

目的评价扬州地区老年新型冠状病毒肺炎（COVID-19）患者的临床特征及俯卧位通气的疗效。 方法纳入2021年8月至9月我院新区分院符合COVID-19诊疗方案（试行第八版）诊断标准的老年患者82例,年龄（74±8）岁,重症（重型、危重型）、非重症（轻型、普通型）患者分别为22、60例。重症患者分为气管插管组和非气管插管组,比较COVID-19患者的临床特征以及俯卧位通气对重症患者氧合、呼吸驱动等的影响。 结果82例患者28 d病死率为0。入院第7天（D7）重症患者比例显著高于入院第14天（D14）重症患者比例,差异有统计学意义（26.8% vs 7.3%,P＜0.05）。D7需机械通气患者比例较入院第1天（D1）显著增加,差异有统计学意义（11.0% vs 3.7%,P＜0.05）,与D14（6.1%）相比,差异无统计学意义（P＞0.05）。与非重症患者相比,重症患者年龄、合并2种及以上基础病的比例、C反应蛋白（CRP）水平、白介素-6（IL-6）水平显著升高,基础动脉血氧饱和度（SpO₂）显著降低,差异均有统计学意义（P＜0.05）。22例重症患者中有5例患者行气管插管机械通气,气管插管组男性比例、平均年龄、吸气努力（Pmus）、体外膜肺氧合（ECMO）比例、住院时间显著高于非气管插管组,ROX指数、氧合指数（P/F）、插管前俯卧位时间显著低于非气管插管组,差异均有统计学意义（P＜0.05）。重症患者俯卧位通气1 h后ROX指数较俯卧位通气前显著升高,呼吸频率（RR）、Pmus较俯卧位通气前显著下降,差异均有统计学意义（P＜0.05）。5例患者出现压疮不良反应。 结论扬州地区老年COVID-19患者入院7 d左右重症患者比例最高,14 d左右重症患者比例显著降低。年龄越大、基础病越多、炎症指标水平越高、氧合越差者病情更重。俯卧位通气能改善氧合、降低呼吸驱动。     

Prone position combined with high-flow nasal oxygen could benefit spontaneously breathing,severe COVID-19 patients: A case report

BACKGROUNDSince the outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China in December 2019, the overall fatality rate of severe and critical patients with COVID-19 is high and the effective therapy is limited. CASE SUMMARYIn this case report, we describe a case of the successful combination of the prone position (PP) and high-flow nasal oxygen (HFNO) therapy in a spontaneously breathing, severe COVID-19 patient who presented with fever, fatigue and hypoxemia and was diagnosed by positive throat swab COVID-19 RNA testing. The therapy significantly improved the patient''s clinical symptoms, oxygenation status, and radiological characteristics of lung injury during hospitalization, and the patient showed good tolerance and avoided intubation. Additionally, we did not find that medical staff wearing optimal airborne personal protective equipment (PPE) were infected by the new coronavirus in our institution.CONCLUSIONWe conclude that the combination of PP and HFNO could benefit spontaneously breathing, severe COVID-19 patients. The therapy does not increase risk of healthcare workers wearing optimal airborne PPE to become infected with virus particles.     

Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19

Abstract

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.     

肺部超声与CT对新型冠状病毒肺炎肺损伤的评估:优与劣

肺部CT是新型冠状病毒肺炎(以下简称“新冠肺炎”)暴发初期最主要的筛查手段和分级诊疗依据,是肺部损伤影像学诊断的金标准。随新冠肺炎病情进展,患者肺部CT呈现不同的病变范围与类型。肺部超声与CT相一致,随病程发展呈特征性表现。与肺部CT相比,肺部超声检查具有床旁便捷、无创等优点,减少了院内传染和转运风险,且其有助于快速鉴别呼吸衰竭的病因,实现连续动态监测,指导呼吸机参数设置、肺复张、俯卧位治疗等,在急危重症新冠肺炎的救治过程中发挥无可替代的作用。另一方面,肺部超声在探测远离胸膜病变、辨别过度通气、操作者依赖方面亦有其局限性。本文对肺部超声与CT的优劣势进行梳理,临床医师在实践过程中应取长补短,以促进新冠肺炎患者的精准诊治。