声门下吸引预防气管切开最小意识状态患者吞咽误吸的作用

目的探讨声门下吸引用于神经外科气管切开最小意识状态患者吞咽功能评估的效果,预防评估中误吸的发生,保证吞咽功能评估的安全性。方法选取60例神经外科气管切开最小意识状态患者进行洼田饮水试验评估吞咽功能时给予持续声门下负压吸引。结果声门下吸引对误吸的检出率高于洼田饮水试验(P0.05)。结论声门下吸引技术应用于气管切开最小意识状态患者吞咽功能评估,能及时吸出误入气道的液体,保证吞咽功能评估的安全性。     

不同黏稠度分泌物持续声门下吸引负压值的选择

目的探讨持续声门下负压对不同黏稠度分泌物的吸引效果,旨在为临床患者提供安全有效的吸引负压。方法对行机械通气使用可冲洗式气管导管或套管的33例患者,按照声门下分泌物黏稠度分级标准分为Ⅰ～Ⅲ度,Ⅰ～Ⅲ度组将患者随机排序,依次采用-2.66～0kPa及以下、-5.32～-2.79kPa、-7.98～-5.45kPa、-10.64～-8.11kPa的压力吸引声门下分泌物。观察不同黏稠度分泌物在各压力吸引下分泌物残留、呛咳发生、黏膜损伤、血氧饱和度变化、残留分泌物吸净时间情况。结果Ⅰ、Ⅱ度分泌物在不同压力声门吸引,分泌物吸净时间、残留率、呛咳发生率、黏膜损伤率比较,差异有统计学意义(均P<0.01)。Ⅲ度分泌物在不同压力声门下吸引,分泌物残留率、吸净时间、呛咳发生率比较,差异有统计学意义(均P<0.01)。结论使用-5.32～-2.79kPa压力对Ⅰ度分泌物吸引,在避免黏膜损伤的同时,达到吸引的最大化。使用-7.98～-5.45kPa压力对Ⅱ度、Ⅲ度分泌物吸引,在保持吸引有效性的同时,保证气道黏膜的安全。     

Protection of trachea by maintaining appropriate balloon pressure and simutaneous oral pharyngeal suctioning during removal of endotracheal catheter

目的 减少气管导管拔除时引起的应激反应及囊上滞留物的回落,预防拔管带来的并发症.方法 将120例全麻气管插管患者按手术日期单双日分为常规组(60例)和改良组(60例).常规组采用常规的拔管方法,先吸净口咽及气道内分泌物后抽出气管导管气囊里的气体,吸痰管置于气管导管内持续负压吸引拔管;改良组采取保留适度气囊压力,将气囊上方分泌物随拔管提到口咽部持续吸引清除,拔管中保持气管内压力.比较两组拔管时清除的分泌物量、拔管前后呼吸循环指标的变化和呼吸道不良反应的发生率.结果 常规组气囊上方痰液清除量为(1.73±0.79)mL,改良组为(10.09±1.81) mL;常规组拔管前后R、HR、SBP和SaO2数值变化显著;患者窒息感的发生率显著高于改良组(P＜0.05).结论 保留适度气囊及气管内压的气管导管拔除方法能有效地清除气囊上方的分泌物,减少拔管时不良反应,预防呼吸循环系统并发症发生.     

不同声门下冲洗方式对呼吸机相关性肺炎的影响

目的探讨人工气道患者行持续声门下吸引时,不同声门下冲洗方式对呼吸机相关性肺炎的影响。方法将90例气管切开行声门下吸引的患者随机分为A、B、C组各30例。在持续声门下吸引时,A组给予5mL空气冲洗、B组用5mL生理盐水一次冲洗、C组用5mL生理盐水反复冲洗(直至引流液稀薄),冲洗后10min经人工气道吸痰,观察24h声门下吸引总量及呼吸机相关性肺炎发生率。结果三组24h声门下吸引总量及呼吸机相关性肺炎总发生率比较,差异有统计学意义(均P0.05),B、C组效果相当,但均优于A组。结论在保持有效吸引的前提下,采用5mL生理盐水进行声门下冲洗,可保持声门下吸引的通畅性,从而降低呼吸机相关性肺炎发生率。但反复冲洗存在操作步骤多,有增加分泌物下行的风险,推荐使用5mL生理盐水一次冲洗。     

气管导管拔除时适度气囊压力同步口咽部吸引对气道的保护作用

目的减少气管导管拔除时引起的应激反应及囊上滞留物的回落,预防拔管带来的并发症。方法将120例全麻气管插管患者按手术日期单双日分为常规组(60例)和改良组(60例)。常规组采用常规的拔管方法,先吸净口咽及气道内分泌物后抽出气管导管气囊里的气体,吸痰管置于气管导管内持续负压吸引拔管;改良组采取保留适度气囊压力,将气囊上方分泌物随拔管提到口咽部持续吸引清除,拔管中保持气管内压力。比较两组拔管时清除的分泌物量、拔管前后呼吸循环指标的变化和呼吸道不良反应的发生率。结果常规组气囊上方痰液清除量为(1.73±0.79)mL,改良组为(10.09±1.81)mL;常规组拔管前后R、HR、SBP和SaO2数值变化显著;患者窒息感的发生率显著高于改良组(P<0.05)。结论保留适度气囊及气管内压的气管导管拔除方法能有效地清除气囊上方的分泌物,减少拔管时不良反应,预防呼吸循环系统并发症发生。     

可吸引气管导管在呼吸机治疗中的应用

目的 探讨可吸引气管导管在呼吸机治疗中对呼吸机相关性肺炎(VAP)发生率的影响.方法 将148例预期呼吸机治疗时间＞7 d的患者,应用分层随机化法分为两组各74例.观察组经口置入可吸引气管导管,接10.0～22.7kPa负压引流瓶持续吸引气囊上分泌物,用50 ml无菌注射器抽取0.9%氯化钠溶液经气管导管背侧引流管冲洗气囊上分泌物,每次冲洗不限液体量,直至肉眼观察抽出冲洗液清澈为止.对照组均经口置入普通气管导管,每4小时气管内吸痰后,充分吸引鼻腔、口腔分泌物,并经口腔置入吸痰管,吸引气囊上分泌物.结果 观察组治疗后3 d、7 d及停止呼吸机治疗时VAP发生率显著低于对照组(P＜0.01,P＜0.05),呼吸机使用时间显著短于对照组(P＜0.01).结论 应用可吸引气管导管,可显著缩短呼吸机治疗时间,降低VAP发生率.     

多功能全呼吸道气管组合套管在重型颅脑损伤中的应用

2009年10月,我们收治了一名重型颅脑损伤术后患者,患者因车祸导致头面部损伤,ct提示左侧额颞部硬膜下血肿,右侧额部硬膜外血肿,广泛复杂颌面部骨折.该患者在当地行开颅血肿清除+去骨瓣减压及气管切开术后转入我科.在随后的治疗过程中,患者出现严重的上呼吸道感染,感染源自颌面部,脓液沿口鼻一直流至咽喉及声门下,到气管套管气囊上部,最后充满整个声门下腔,从气管切开皮肤口溢出.我们虽及时从口鼻等处反复吸引,给予大剂量敏感抗生素,但感染始终无法控制.继而患者出现严重高热,血象直线上升,我们被迫从气管切开处在气管套管上放置了一根带有侧孔的细管,给予持续吸引.     

两种气囊测压法预防机械通气患者呼吸机相关性肺炎效果比较

目的 比较持续测压与间断测压对预防机械通气患者呼吸机相关性肺炎的临床效果,为人工气道气囊管理提供依据。 方法 将134例机械通气患者随机均分为间断测压组和持续测压组。间断测压组使用气囊测压表采用改进方法分别间隔4 h、6 h、8 h监测1次气囊压力;持续测压组采用持续测压仪持续测压。比较两组呼吸机相关性肺炎发生率、机械通气时间、ICU住院时间、气囊上滞留物引流量、抗生素使用种类及时间、炎性指标。 结果 两组呼吸机相关性肺炎发生率、机械通气时间、ICU住院时间、抗生素使用种类及时间比较,差异无统计学意义（均P＞0.05）。两组入科第1天、第3天、第7天白细胞、C反应蛋白、降钙素原及24 h气囊上滞留物引流量比较,差异无统计学意义（均P＞0.05）。持续测压组检测值25～30 cmH2O;间断测压组间隔4 h、6 h、8 h检测气囊压力,差异有统计学意义（P＜0.05）,间隔8 h检测气囊压力＜25 cmH2O。 结论 两种测压方法对患者呼吸机相关性肺炎发生率、机械通气时间、ICU住院时间、抗生素应用的影响没有显著差异,提示锥形气囊导管应用两种测压方法可达到相同的临床效果,间断测压间隔时间以≤6 h为宜。     

声门下吸引预防呼吸机相关性肺炎的研究进展

从声门下吸引工具、频率、负压、气囊压力以及声门下引新形式进行综述,以帮助临床医护人员全面了解声门下吸引预防呼吸机相关性肺炎的研究进展,促进临床护理操作执行的精准化。     

ICU护士对声门下吸引相关知识认知及依从性影响因素调查

目的 了解ICU护士对声门下吸引相关知识的认知程度及其依从性的影响因素,为提高声门下吸引实施依从性提供依据.方法 采用自行设计的ICU护士声门下吸引认知及依从性影响因素问卷,对87名ICU护士进行调查.结果 ICU护士对声门下吸引知识认知总分为37.15±2.36,认知最好的条目是监测气囊压力及声门下-气囊上滞留物是VAP重要发病原因之一,认知最低的条目是机械通气患者声门下间隙容积;排前3位的影响因素为工作量大无法顾及声门下吸引操作,声门下吸引会引起患者黏膜受损、呛咳等不适,无精确的声门下吸引配套装置.结论 ICU护士对声门下吸引知识认知总体水平为一般,医院管理者应采取多元化形式对ICU护士及护士长进行声门下吸引培训,针对影响依从性的因素采取相应的对策,提高声门下吸引实施依从性.     

Intra-abdominal pressure measurement: validation of intragastric pressure as a measure of intra-abdominal pressure

Background: The diagnosis of abdominal compartment syndrome depends uponthe demonstration of an elevated intra-abdominal pressure (IAP).Direct measures of IAP are impractical in the critical careunit; intravesical pressure (IVP) and intragastric pressure(IGP) should represent acceptable surrogate measures. IVP isthe preferred measure of IAP in critical care. We consideredthat IGP represents a practical alternative. The objective ofthis preliminary study was to observe the relationship betweenIGP and IAP. Methods: After Institutional Ethics Board approval, 29 patients havingelective laparoscopic surgery were recruited. IAP was measureddirectly via the abdominal trochar. This was compared with IGPmeasured via a commercial balloon catheter placed into the stomach. Results: Measured IGP was always more positive than IAP; both showedlinear correlation (r²>0.9). When IGP was calibrated againstIAP, an estimated difference between the IGP and IAP of ±2.5 mm Hg for 95% of the measurements was seen. Conclusions: The study demonstrates the strength of the relationship betweenIGP and IAP in normal individuals. Application of IGP measurementin the critical care patient is necessary to demonstrate itssuitability for continuous IAP assessment.     

Monitoring central venous pressure,arterial pressure and pulmonary wedge pressure

Direct measurement of vascular pressure requires the insertion of a cannula into a vessel. The cannula is connected to saline filled tubing attached to a transducer apparatus for measurement and display of the vascular pressure waveform. The transducer apparatus is essentially the same for all intravascular pressure measurement. Direct measurement of arterial pressure is indicated where rapid fluctuations in pressure are anticipated, where accurate control of pressure is required, and for repeated sampling of blood gases. Central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) measurement indicate the preload of the right and left side of the heart respectively; and when considered in conjunction with other physiological measures can give a guide to the volume status of a patient. Trends in response to therapeutic intervention should be used rather than any individual value being used in isolation. Direct measurement of vascular pressure involves invasive procedures which carry a risk of complications relating to insertion of the cannulae and duration of use.     

Ambulatory blood pressure monitoring: mean blood pressure and blood pressure load

Ambulatory blood pressure monitoring (ABPM) is commonly used to diagnose pediatric hypertension. Using ABPM, hypertension is usually defined as a mean BP greater than the 95th percentile for height. A BP load >30% (% of BP readings greater than the 95th percentile) is also used for the diagnosis of hypertension. The objective of this study was to determine the agreement between mean BP greater than the 95th percentile and 30% BP load for the diagnosis of hypertension using ABPM. All ABPM records (n =1,009) of patients referred for hypertension to a pediatric center were retrieved. Scans were excluded if: age was >19 and height <115 cm or >185 cm. Mean BP and BP loads were calculated for 728 scans. Agreement between mean BP greater than the 95th percentile for height and various BP loads were calculated using the kappa coefficient. The kappa coefficient of agreement between mean BP greater than the 95th percentile and 30% BP load was 0.56 and 0.57 for daytime systolic and diastolic BP, respectively. The agreement between mean night-time BP greater than the 95th percentile and 30% BP load was 0.70 and 0.66 for systolic and diastolic BP, respectively. Agreement between mean BP greater than the 95th percentile and 30% BP load is only moderate to good. Maximum agreement between mean BP greater than the 95th percentile and BP load is achieved at 50% BP load.     

间歇正压通气和呼气末正压通气对犬眼内压的影响

目的 探讨间歇正压通气(IPPV)和呼气末正压通气(PEEP)对犬眼内压(10P)的影响.方法 实验犬8只,麻醉后分别监测基础条件下和各种机械通气条件下的IOP、CVP、MAP.结果 实施20 ml/kg和30 ml/kg两种不同潮气量的IPPV时IOP差异无统计学意义.实施10、15、20cm H20三种不同压力值的PEEP时IOP均显著升高(P<0.01).结论 IPPV对IOP影响不大,PEEP可使IOP显著升高.     

Role of topical negative pressure in pressure ulcer management

The literature suggests that topical negative pressure can be an effective treatment for severe pressure ulcers. However, research is needed on its effects on variables such as dressing change frequency, quality of life, pain relief and cost-effectiveness.     

Artificial sphincter pressure versus detrusor leakage pressure

Increasing urethral occlusion pressures were created with an artificial sphincter in fresh bladder-urethra specimens of adult pigs. Detrusor leakage pressures remained about 25 per cent below the associated sphincter cuff pressures. The same relation was found when, during abrupt variations of cuff pressure, the detrusor leakage pressures were measured with antegrade urethral perfusion pressure measurement through a new sleeve catheter. Side-hole perfusion pressure measurements showed 100 per cent transmission of abrupt variations of cuff pressures to the inner urethral wall. No rotational differences could be detected. From the results it has been concluded that a probable pressure loss of about 25 per cent must be taken into account when converting artificial sphincter pressures into bladder pressures at which leakage will occur.