老年COPD合并呼吸衰竭患者综合治疗的临床研究

目的评价综合治疗（有创无创序贯机械通气,纤支镜吸痰,联合雾化吸入异丙托溴铵、沙丁胺醇和布地奈德）在老年COPD所致急性呼吸衰竭患者的临床疗效。方法纳入2006年7月至2009年7月间ICU收治的老年COPD合并急性呼吸衰竭患者59例,随机分为无创通气组（20例）、有创无创序贯通气组（20例）和综合治疗组（19例）,在常规治疗基础上予以相应干预。监测患者治疗0 h、3 h、3 d、12 d的APACHEⅡ评分、临床肺部感染评分（CPIS）、动脉血气、心率、血压,以及肺部感染控制窗出现时间、机械通气时间、ICU住院时间、总住院时间、呼吸机相关性肺炎（VAP）患病率、病死率等。结果三组患者的APACHEⅡ评分、CPIS评分、呼吸频率、心率、PaCO2、白细胞计数随治疗时间的延长而逐渐降低（P〈0.05）,pH值、PaO2随治疗时间的延长而逐渐增高（P〈0.05）。三组间呼吸频率、心率、PaCO2、PaO2在治疗3 d及12 d时有显著差异（P〈0.05）,序贯组优于无创组,综合组优于序贯组。三组肺部感染控制窗和VAP出现时间无显著差异（P〉0.05）。序贯组总机械通气时间、ICU住院时间和总住院时间明显短于无创组（P〈0.05）,综合组总机械通气时间、有创通气时间、ICU住院时间和总住院时间短于序贯组（P〈0.05）。序贯组VAP患病率高于无创组,住院病死率低于无创组。综合组VAP患病率低于序贯组但仍高于无创组（P〈0.05）,住院病死率低于序贯组（P〈0.05）。结论对老年COPD合并急性呼吸衰竭患者,有创无创序贯通气明显优于单用无创通气,且尽早给予综合治疗（有创无创序贯通气、纤支镜吸痰、联合雾化吸入）可缩短机械通气时间和住院时间,降低VAP患病率和病死率。

Integrated Treatment in Elderly Patients with Respiratory Failure due to COPD

Objective To evaluate the clinical efficacy of integrated treatment（sequential non-invasive following invasive mechanical ventilation,bronchoscope suction,combined inhalation） in patients with acute respiratory failure induced by chronic obstructive pulmonary disease（COPD）.Methods 59 elderly patients with COPD and acute respiratory failure in ICU from July 2006 to July 2009 were enrolled in the study.The patients were randomized into three groups,ie.a non-invasive mechanical ventilation group（NIV group）,a sequential non-invasive following invasive mechanical ventilation group（SV group）,a integrated treatment group（IT group）.APACHEⅡ score,clinical pulmonary infection score（CPIS）,arterial blood gas analysis,respiratory rate（RR）,heart rate（HR）,and mean artery blood pressure（MAP） at 0 h,3 h,3 d,12 d after treatment were recorded.Results With the extension of treatment time,APACHEⅡ score,CPIS score,RR,HR,PaCO2,and white blood cells gradually reduced,while pH and PaO2 gradually increased in the three groups（P0.05）.The differences in RR,HR,PaCO2,and PaO2 at the time of 3 d and 12 d were significant between the three groups（P0.05）.The occurrence of pulmonary infection control（PIC） window and ventilation associated pneumonia（VAP） had no difference among the three groups（P0.05）.The duration of total mechanical ventilation,durations of ICU stay and hospital stay were shorter in SV group than those in NIV group（P0.05）.The duration of total mechanical ventilation,duration of invasive mechanical ventilation,durations of ICU stay and hospital stay were shorter in IT group than those in SV group（P0.05）.The incidence of VAP was higher in SV group than NIV group,but lower in IT group than SV group（P0.05）.Hospital mortality was lower in SV group than NIV group,and higher in IT group than SV group（P0.05）.Conclusion In elderly COPD patients with acute respiratory failure,Integrated treatment given early can reduce the duration of mechanical ventilation,the length of ICU and hospital stay,and decrease the morbidity of VAP and mortality.