临床科研比翼 重症医学腾飞

重症医学的临床研究是重症医学不断发展和进步的动力.2014年,重症医学在急性呼吸窘迫综合征（ARDS）、机械通气、重症感染诊治、急性肾损伤（AKI）、镇痛镇静等方面均获得不同程度的进展,本文对此进行总结,供临床同道参考. ARDS诊治进展 1.发病率及病死率的变化ARDS发病率及病死率高,严重威胁患者生命.2014年Villar等对ARDS发病率及病死率情况进行的研究结果显示,1967-1979年ARDS平均病死率约为70％,1980-1989年约为60％,1990-1997年约为50％,1998-2013年约为40％.     

呼吸系统弹性阻力对急性肺损伤患者肺复张后氧合影响的荟萃分析

目的 探讨呼吸系统弹性阻力(respiratory system elasticity resistance,Ers)在急性肺损伤(acute lung injury,ALI)患者肺复张过程中氧合的影响.方法 收集1999年1月1日至2010年6月30日关于在肺复张对不同Ers急性肺损伤患者氧合影响的随机对照研究、前瞻观察性研究和病例对照研究,对于肺复张对Ers≥33.3 cmH2O/L(1 cmH2O=0.098 kPa)和Ers＜33.3 cmH2O/L(1 mmHg=0.133 kPa)的ALI患者氧合影响作Meta评价.结果 共281篇文献符合纳入标准,纳入文献共20篇,共纳人患者共395人,结果提示肺复张对高Ers患者氧合改善为(51.97±8.89)mmHg,血压下降(4.33±1.32)mmHg;对低Ers患者氧合改善为(35.13±10.33)mHg,血压下降(0.22±1.03)mmHg,肺复张对两组患者之间氧合改善和血压的影响差异具有统计学意义(P＜0.01).结论 肺复张能够改善ALI患者的氧合,对高Ers的ALI患者氧合改善更为明显;但对高Ers的患者循环影响更为明显.

Abstract：

Objective To investigate the effects of elasticity resistance (Ers) in respiratory system on oxygenation in patients with acute lung injury (ALI) after recruitment maneuvers (RM). Method Meta-analysis of data about the effects of recruitment maneuvers on oxygenation in ALI patients with different elasticity resistances in respiratory system carried out with pooling of study-oriented data stored in Pubmed, Embase, Web of Science databases from January 1999 to June 2010. Results A total of 281 articles were taken, and 20 of them included a sample size of 395 ALI patients. In patients treated with RM in different degrees of respiratory system elasticity resistance ( ≥33.3 cmH2O/L and ＜33.3 cmH2O/L), the effect of RM was better in patients with the high respiratory system elasticity resistance than that with the low one [(51.97 + 8.89) mmHg vs. (35.13 ± 10.33 ) mmHg], P ＜ 0. 01 ), but the high respiratory system elasticity resistance was potentially to lower blood pressure [(4. 33 ± 1.32 ) mmHg vs. (0.22 ± 1.03 ) mmHg],P ＜ 0.01 ). Conclusions This study suggests RM could improve oxygenation of ALI patients with high respiratory system elasticity resistance, and caution must be made to avoid hypotension during RM.     

无创正压通气对急性呼吸衰竭患者拔管后再插管率和预后影响的荟萃分析

目的 探讨无创正压通气对急性呼吸衰竭患者拔管后再插管率和预后的影响.方法 通过计算机检索和手工检索中文期刊数据库,Pubmed,Embase,Web of Science数据库,收集1995年1月1日至2010年6月30日关于无创正压通气对急性呼吸衰竭患者拔管后进行呼吸支持和治疗的随机对照研究,按Cochrane协作网推荐的方法对拔管后采用无创正压通气进行呼吸辅助治疗患者的再插管率和病死率行Meta评价.结果 共纳入6篇随机对照研究,其中拔管后无创正压通气组(治疗组)患者381例,拔管后常规氧疗组(对照组)患者379例,治疗组和对照组患者的病死率分别为18.6%(62/334)vs.21.6%(72/333)(P=0.34),再插管率分别为30.2%(115/381)vs.33.5%(127/379)(P=0.27).与常规氧疗相比,拔管后无创正压通气不能降低患者再插管率,也不能改善患者预后.对拔管后即开始进行无创正压通气的患者进行分析,结果提示治疗组患者病死率明显降低[12.2%(22/181)vs.23.9%(44/184),P=0.004],再插管率减少;但与对照组相比,差异无统计学意义[14.0%(32/228)vs.20.4%(47/230),P=0.07].结论 急性呼吸衰竭患者拔管后早期行无创正压通气有助于减少患者再插管率,可显著改善患者预后.

Abstract：

Objective To evaluate the effects of noninvasive positive pressure ventilation (NPPV)used after extubation on mortality and rate of reintubation in patients with acute respiratory failure (ARF).Method Pubmed, Embase, Web of Science databases were searched to collect data from randomized controlled trials (RCT) of the relevant subject from January 1995 to May 2010. Meta analysis of data about NPPV on mortality and rate of reintubation in patients after extubation carried out by using the methods recommended by the Cochrane Collaboration. Results Six RCTs included sample size of 381 NPPV and 379routine medical care. In total, the mortalities of patients in NPPV group and routine medical care group were 18.6% (62/334) vs. 21.6% (72/333), respectively, and the rates of reintubation of the two groups were 30.2% (115/381) vs. 33.5% (127/379), respectively. Compared with routine medical care, NPPV did not significantly reduce the mortality ( OR: 0.83, 95% CI =0.57 ～ 1.21 ,P =0.34) and rate of reintuation( OR: 0.83, 95% CI = 0.59 ～ 1.16, ( P = 0.27). When the analysis was focused to the four studies of them in which patients received NPPV as soon as extubation, the results were quite different. From these four studies, the mortalities of patients in NPPV group and routine medical care group were 12. 2% (22/181) vs.23.9% (44/184),(P=0.004), and the rate of reintubation of the two groups were 14.0% (32/228) vs.20.4% (47/230), (P =0.07). Compared with routine medical care, early application of NPPV to patients after extubation reduced the mortality. Conclusions This study suggests the favorable effects of early application of NPPV to patients after extubation on the mortality of acute respiratory failure.     

急性呼吸窘迫综合征机械通气治疗

急性肺损伤（acute lungin jury，ALI）是以低氧血症为特征的急性呼吸衰竭，急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS）是ALI病情进展的结果。机械通气是纠正ARDS低氧血症的主要手段。ARDS的病理生理特点决定了患者机械通气中必须采用特殊的通气策略。     

无创正压通气对急性呼吸衰竭患者拔管后再插管率和预后影响的荟萃分析

Objective To evaluate the effects of noninvasive positive pressure ventilation (NPPV)used after extubation on mortality and rate of reintubation in patients with acute respiratory failure (ARF).Method Pubmed, Embase, Web of Science databases were searched to collect data from randomized controlled trials (RCT) of the relevant subject from January 1995 to May 2010. Meta analysis of data about NPPV on mortality and rate of reintubation in patients after extubation carried out by using the methods recommended by the Cochrane Collaboration. Results Six RCTs included sample size of 381 NPPV and 379routine medical care. In total, the mortalities of patients in NPPV group and routine medical care group were 18.6% (62/334) vs. 21.6% (72/333), respectively, and the rates of reintubation of the two groups were 30.2% (115/381) vs. 33.5% (127/379), respectively. Compared with routine medical care, NPPV did not significantly reduce the mortality ( OR: 0.83, 95% CI =0.57 ～ 1.21 ,P =0.34) and rate of reintuation( OR: 0.83, 95% CI = 0.59 ～ 1.16, ( P = 0.27). When the analysis was focused to the four studies of them in which patients received NPPV as soon as extubation, the results were quite different. From these four studies, the mortalities of patients in NPPV group and routine medical care group were 12. 2% (22/181) vs.23.9% (44/184),(P=0.004), and the rate of reintubation of the two groups were 14.0% (32/228) vs.20.4% (47/230), (P =0.07). Compared with routine medical care, early application of NPPV to patients after extubation reduced the mortality. Conclusions This study suggests the favorable effects of early application of NPPV to patients after extubation on the mortality of acute respiratory failure.     

肺保护性通气策略在急性呼吸窘迫综合征中的作用

机械通气是急性呼吸窘迫综合征(ARDS)的重要支持手段,为减少或避免机械通气所致的肺损伤,近年来逐步形成ARDS肺保护-性通气策略。深刻认识ARDS病理生理特点,合理评价肺保护性通气策略,对于提高ARDS患者机械通气效果,改善ARDS预后,具有十分重要的临床意义。     

允许性高碳酸血症对急性呼吸窘迫综合征绵羊全身和肠道氧代谢的影响

目的 探讨允许性高碳酸血症（ＰＨＣ）对ＡＲＤＳ肺外器官功能的影响。方法 观察不同潮气量（Ｖｒ）时,１８只ＡＲＤＳ绵羊血液动力学、氧代谢和胃粘膜ｐＨ（ｐＨｉ）的改变。结果 当ＶＴ从１６ｍｌ／ｋｇ降至４～７ｍｌ／ｋｇ,绵羊均出现ＰＨＣ;与ＶＴ１３～１６ｍｌ／ｋｇ比较,ＰＨＣ时心排指数（ＣＩ）显著降低（Ｐ〈０．０５）,体循环和肺循环阻力指数显著增高（Ｐ〈０．０５）,尽管ＰＨＣ时动脉血氧分压及氧饱和度、混     

健康教育在基层医院实施中存在的问题及干预

本文主要研究健康教育在基层医院实施中存在的一些问题;并针对所发现的问题给予的有效干预措施.     

肺内分流量对部分CO2重复吸入法测定心输出量的影响

目的探讨部分CO2重复吸入法测定危重病患者心输出量的准确性及肺内分流量对其影响.方法26例机械通气患者接无创心输出量监测仪(NICO监测仪),利用部分CO2重复吸入法测定心脏指数(CINICO),同时置入肺动脉漂浮导管,以热稀释法测定心脏指数(CITD).公式法与NICO监测仪同时计算肺内分流量并进行比较.公式法计算的肺内分流量≤15%的患者为低分流组,＞15%为高分流组.结果低分流组(n=16)NICO监测仪计算的肺内分流量与公式法测定的肺内分流量无显著差异;CINICO与CITD相关性良好(r=0.91,P＜0.01),CINICO为(2.24±0.42)L/(min·m2),CITD为(2.25±0.40)L/(min·m2),两者差异无显著性.高分流组(n=10)NICO监测仪计算的肺内分流量明显低于公式法计算的肺内分流量(P＜0.01);CINICO与CITD亦显著相关(r=0.81,P＜0.01),但CINICO明显低于CITD(P＜0.01),两者分别为(2.56±0.64)L/(min·m2)和(2.87±0.64)L/(min·m2).结论CINICO与CITD相关性良好,肺内分流量是影响CINICO准确性的重要因素.     

一氧化碳与急性肺损伤的研究进展

血红素氧合酶(HO)-一氧化碳(CO)可调节机体炎症反应．对抗氧自由基损伤，舒张肺血管平滑肌，降低肺动脉高压．对急性肺损伤和其它肺疾病发挥重要的保护和调节作用。HO-CO诱导剂以及外源性应用HO-CO可能开辟急性肺损伤等疾病的防治新途径。