早期支气管镜配合机械通气治疗重型颅脑损伤致呼吸衰竭并气道误吸的应用

目的探讨纤维支气管镜（纤支镜）配合有创机械通气治疗在重型颅脑损伤致呼吸衰竭（呼衰）并气道误吸治疗中的价值及安全性。方法对32例重型颅脑损伤致呼衰并气道误吸的患者于伤后3h内实施有创机械通气支持下经纤支镜作支气管肺泡灌洗术，观察术前、中、后心率（HR）、血压（BP）、动脉血氧分压（PaO2）、氧合指数（OI）、吸气峰压（PIP）、吸氧浓度（FiO2）变化。结果32例患者均术程顺利，未发生并发症。术中HR、BP、PaO2、OI较术前无改变（P〉0.05），术后FiO2较术前显著减少，HR、PaO2、OI明显好转（P〈0.01）。经治疗无一例出现吸入性肺炎及阻塞性肺不张。结论经纤支镜支气管肺泡灌洗配合机械通气治疗，对防止吸入性肺炎及阻塞性肺不张的发生，预防和纠正低氧血症，保证脑供氧，提高救治成功率及改善预后有重要价值，并具有良好的安全性。     

免疫冲击加机械通气抢救重症肌无力危象的研究

目的研究重症肌无力(MG)危象的有效治疗方法,提高MG危象抢救的成功率和缩短机械通气的时间。方法应用静脉注射丙种球蛋白(IVIG)、甲基强的松龙、环孢霉素A及机械呼吸治疗3例重症肌无力危象患者,根据临床症状判断疗效。结果3例MG危象患者症状缓解,随诊6个月~2年,3例可以正常生活。结论IVIG、甲基强的松龙、环孢霉素A联合治疗加机械呼吸是治疗MG危象的有效措施。     

支气管灌洗治疗呼吸肌麻痹合并肺部感染的疗效观察

目的 评价支气管灌洗治疗呼吸肌麻痹合并肺部感染的疗效.方法 选择2006-03～2009-09我院重症监护病房内呼吸肌麻痹合并肺部感染患者43例,随机分成2组,治疗组22例予以支气管灌洗治疗,并根据经验或药敏结果选择抗生素抗感染治疗,对照组21例根据经验或药敏结果选择抗生素抗感染治疗,分别观察2组治疗前后动脉血气变化,胸片、痰量、体温、肺部罗音变化;2组抗生素、住院时间、病灶基本吸收时间变化.结果 治疗组上述各项指标均较对照组明显改善(P<0.05或P<0.01).结论 支气管灌洗治疗呼吸肌麻痹合并肺部感染的疗效显著.     

重症肌无力危象的机械通气治疗

目的　探讨机械通气治疗重症肌无力危象的指征、通气模式的选择及撤离机械通气的方法和指征。方法　分析 2 0例重症肌无力危象患者机械通气治疗前后血气指标 ,以及 1 2例患者机械通气初和撤离机械通气前床边呼吸功能检查。结果　 2 0例重症肌无力危象患者机械通气前后 3项血气指标有显著性差异 (P <0 0 5) ,其中 1 2例患者机械通气初和撤离机械通气前 2项呼吸功能检查有显著性差异 (P <0 0 5)。结论　呼吸衰竭是直接威胁重症肌无力危象患者生命的首要因素 ,及时气管切开行机械通气治疗 ,改善患者的通气功能是抢救成功的关键 ,积极控制肺部感染 ,消除诱因 ,使用大剂量糖皮质激素是患者早日撤离机械通气的保证。     

22例重症肌无力合并胸腺瘤的手术治疗体会

目的 探讨重症肌无力(myasthenia gravis,MG)合并胸腺瘤患者的围手术期处理方法及手术治疗效果.方法 对本院2006-03～2008-03接受手术治疗的22例重症肌无力合并胸腺瘤患者的临床资料进行回顾性分析.采用改良Osserman标准分为:Ⅰ型9例,Ⅱa型5例,Ⅱb型7例,Ⅲ型1例,手术切口采用胸骨正中切口.手术均行胸腺瘤、胸腺脂肪组织切除及纵隔脂肪组织清扫.结果 22例无手术死亡,3例术后早期发生MG危象,经气管切开、辅助呼吸等抢救治疗治愈.结论 完善围手术期处理措施,减少MG危象的发生,手术治疗重症肌无力合并胸腺瘤可获得良好的疗效.     

神经外科重症监护病房昏迷患者吸入性肺炎的防治

目的探讨神经外科重症监护病房昏迷患者吸入性肺炎的防治措施。方法对46例昏迷合并吸入性肺炎患者的临床资料作回顾性分析。结果治愈14例,好转20例,死亡12例,死亡率为26.1%。结论预防返流和误吸是控制吸入性肺炎重要措施。保持呼吸道通畅,积极的纤维支气管镜灌洗和适当机械通气治疗,以及合理应用抗生素是治疗吸入性肺炎的主要措施。     

重型颅脑损伤机械通气患者支气管镜吸痰术的护理配合及疗效

目的：探讨重型颅脑损伤机械通气患者床旁支气管镜吸痰术的护理配合方式及临床疗效。方法对26例重型颅脑损伤机械通气患者,采用床旁纤维支气管镜直视下吸痰术,并进行护理配合。结果26例患者纤支镜下吸痰术全部获得成功：听诊痰鸣音显著减弱或消失;术后30 min血氧饱和度平均95％;5例肺不张患者中4例顺利复张;未出现严重并发症。结论对于常规吸痰术失败的重型颅脑损伤病例,支气管镜下吸痰术可迅速改善临床症状,不良反应发生率低,值得在重症监护中心推广。     

研究重症肌无力危象发生的危险因素及其防治措施

目的研究重症肌无力(MG)危象发生的危险因素及防治措施。方法对我院2010-03—2015-10收治的100例重症肌无力患者临床资料进行整理、归纳分析,包括患者年龄、激素治疗、胸腺切除与否等,行单因素及多因素Logistic回归分析,总结重症肌无力危象危险因素并提出相应防治措施。结果 MG危象组平均年龄(33.4±10.5)岁,显著低于MG非危象组的(38.8±11.0)岁,差异有统计学意义(P0.05)。MG危象组激素治疗、合并感染、胸腺切除史比例分别为85.7%、57.1%、54.8%,显著高于MG非危象组的56.9%、12.1%、27.6%,差异有统计学意义(P0.05)。多因素Logistic回归分析年龄、激素治疗、合并感染及胸腺切除史是重症肌无力危象发生的独立危险因素。结论激素治疗、合并感染、胸腺切除术史是重症肌无力危象发生危险因素,需规范激素治疗,积极预防感染及严格筛选胸腺切除手术指征。     

重症肌无力169例临床分析

目的研究重症肌无力(MG)临床特点、误诊原因与MG危象临床表现。方法分析本院收治的169例MG患者的临床资料。结果本文患者均行新斯的明试验,阳性率100%。85例行重复神经电刺激(RNS)检查,64例低频波幅递减,8例同时高频波幅递减。157例行胸腺影像学检查,发现胸腺异常80例。发生肌无力危象31例次。121例行甲状腺功能(FT3、FT4、TSH)检测,发现甲状腺功能异常17例。结论MG临床表现多样,时有误诊,易于合并胸腺瘤或胸腺增生及甲状腺功能异常。肌无力危象发生率高。     

机械通气患者最佳吸痰时机临床观察与护理

目的 探讨机械通气患者的最佳吸痰时机.方法 回顾分析48例机械通气患者的临床资料,观察吸痰时机对吸痰效果的影响.结果 48例机械通气治疗的患者,机械通气持续时间4～21 d,无1例发生人工气道堵塞、低氧血症、呼吸机相关性肺炎等,做到了安全有效吸痰.结论 正确掌握最佳吸痰时机,适时进行吸痰,才能使吸痰护理更加安全及时有效...     

Myasthenia gravis: management of myasthenic crisis and perioperative care

Myasthenic crisis may be defined as respiratory failure or delayed postoperative extubation for more than 24 hours resulting from myasthenic weakness. Myasthenic crisis results from weakness of upper airway muscles leading to obstruction and aspiration, weakness of respiratory muscles leading to reduced tidal volumes, or from weakness of both muscle groups. About one-fifth of patients with myasthenia gravis experience crisis, usually within the first year of illness. Over the last four decades, prognosis from myasthenic crisis has dramatically improved from a mortality rate of 75% to the current rate of less than 5%. Common precipitating factors for myasthenic crisis include respiratory infections, aspiration, sepsis, surgical procedures, rapid tapering of immune modulation, beginning treatment with corticosteroids, exposure to drugs that may increase myasthenic weakness, and pregnancy. Myasthenic crisis should not be fatal, as long as patients receive timely respiratory support and appropriate immunotherapy to reduce myasthenic weakness of the upper airway and respiratory muscles. Myasthenic patients with oropharyngeal or respiratory muscle weakness should receive preoperative plasma exchange or intravenous immunoglobulin therapy to a minimal level of weakness to prevent postoperative complications.     

The Role of Non-invasive Ventilation and Factors Predicting Extubation Outcome in Myasthenic Crisis

Introduction  Myasthenic crisis is a great threat to patients with myasthenia gravis. Usage of non-invasive ventilation (NIV) to prevent intubation and timing of extubating of patients in myasthenic crisis are important issues though not well documented. Methods  To explore the factors predicting NIV success and extubation outcome in myasthenic crisis, we reviewed the records of 41 episodes of myasthenia crisis. Results  NIV was applied to 14 episodes of myasthenic crisis and eight (57.1%) of them were successfully prevented from intubation. An Acute Physiology and Chronic Health Evaluation (APACHE) II score of <6 and a serum bicarbonate level of <30 mmol/l were independent predictors of NIV success. For patients undergoing invasive mechanical ventilation, extubation failure was observed in 13 (39.4%) of 33 episodes, and the most common cause was sputum impaction due to a poor cough strength (61.5%). A maximal expiratory pressure (Pemax) of ≥40 cmH₂O was a good predictor of extubation success. Extubation failure led to poorer outcomes. Conclusions  NIV may be applied to those patients with a low APACHE II score and a lesser degree of metabolic compensation for respiratory acidosis. For patients undergoing invasive mechanical ventilation, extubation failure is associated with significant in-hospital morbidity in myasthenic crisis. Adequate levels of Pemax and cough strength correlate significantly with extubation success.     

Myasthenic crisis: clinical features, complications and mortality

BACKGROUND AND OBJECTIVE: Myasthenic crisis is a life-threatening complication of myasthenia gravis (MG) and when treated aggressively is associated with good outcome. MATERIALS AND METHODS: Retrospective study of case records of patients with episodes of myasthenic crisis. RESULTS: Twenty-one (22%) of the 95 patients with MG (9 with thymoma), experienced 23 episodes of myasthenic crisis, 3 (33%) in patients with thymoma. The crisis episodes occurred within 2 years of disease onset in 11 (52%) patients. Infection was the most common primary precipitant of the crisis occurring in 65%. The median duration of the crisis episode was 11 days (7-39 days), and the median neurological intensive care unit stay was 15 days (range 9-47 days). Fifteen (65%) episodes were treated with small volume plasma exchange (PE) and 8 (35%) episodes received intravenous immunoglobulin (IVIg). The time taken for disease stabilization, the median number of days for extubation, was 8 days (range 7-12) in the PE group and 10 days (range 7-39) in the IVIg group. Disease stabilization could not be achieved in one patient in the IVIg group. Ventilator-associated pneumonia (VAP) was the commonest complication, seen in 30%. Two (8%) of the 23 episodes of crisis were fatal, one resulting from VAP and septicemia, and the other due to crisis itself. All the 19 patients who survived to discharge had complete resolution of admission symptoms. CONCLUSIONS: In patients with myasthenic crisis, both therapeutic options, PE and IVIg, are equally effective in disease stabilization. To achieve good outcomes all efforts should be directed at decreasing the duration of intubation and also aggressively treating the associated medical complications.     

沐舒坦联合肺灌洗对重型颅脑损伤气管切开术后患者肺部感染的疗效

目的 观察沐舒坦静脉注射联合纤支镜下肺灌洗对重型颅脑损伤气管切开术后患者肺部感染的疗效.方法 将广州市花都区人民医院神经外科自2009年1月25日至2010年11月25日收治的42例重型颅脑损伤气管切开术后患者按随机数字表法分为联合治疗组(沐舒坦静脉注射+纤支镜下肺灌洗)和对照组(纤支镜下肺灌洗),每组各21例.气管切开术后第1、3、5、7天取患者支气管肺灌洗液做细胞学检查,并观察气管切开术后1月内患者肺部感染及控制情况、气管套管拔除例数.结果 联合治疗组患者支气管肺灌洗液中白细胞数在气管切开术后第5、7天明显降低,多形核细胞数在第3、5、7天明显降低,与对照组比较差异均有统计学意义(P＜0.05).联合治疗组患者气管切开术后1月内肺部感染例数(12例)、感染控制时间[(7.08±2.10)d]以及拔除气管套管例数(13例)与对照组[19例,(11.86±3.63)d,5例]比较差异均有统计学意义(P＜0.05).结论 沐舒坦静脉注射联合纤支镜下肺灌洗可减轻重型颅脑损伤气管切开术后患者早期气道炎症反应,对肺部感染防治及气道恢复较单纯肺灌洗疗效更明显.     

Low-dose tacrolimus for two cases of myasthenia gravis with invasive thymoma that relapsed shortly after thymectomy

Two patients with myasthenia gravis (Ossermann IIb) involving invasive thymoma who underwent extensive thymectomy manifested myasthenic crisis shortly after the procedure; however, both patients were treated with intravenous immunoglobulin and recovered from myasthenic crisis that had been deteriorating for about 1 week. Subsequently, the patients were administered a low-dose of tacrolimus (3 mg/day) in addition to prednisolone. Several months later, tacrolimus continued to control fluctuations of myasthenic symptoms and maintained remission in these patients. The serum titer of anti-Ach-receptor antibodies decreased in parallel with clinical improvement due to tacrolimus, and we accordingly reduced the dosage of prednisolone. Tacrolimus is a new immunosuppressive agent acting through the selective inhibition of helper-T-cell activation that can be reduced dosage of steroids and can maintain remission of myasthenia gravis with invasive thymoma.     

Fiberoptic endoscopic evaluation of swallowing with simultaneous tensilon application in diagnosis and therapy of myasthenia gravis

Background Dysphagia is a common symptom in myasthenia gravis (MG). Clinical examination alone fails to detect and grade myasthenic dysphagia sufficiently. For a more precise examination of swallowing function in myasthenia gravis additional technical tools are necessary. Objective To investigate the diagnostic and therapeutic impact of fiberoptic endoscopic evaluation of swallowing with simultaneous Tensilon application (FEES-Tensilon Test) in myasthenia gravis. Methods FEES-Tensilon Test was performed following a standardized protocol. Four severely affected patients with dysphagia as their leading symptom were examined. Dysphagia was characterized by five salient endoscopic findings: leakage, delayed swallowing reflex, penetration, aspiration and residues. If a normalisation or at least an improvement of swallowing function occurred shortly after Tensilon administration the FEES-Tensilon Test was rated as being positive. Results In three patients the FEES-Tensilon Test successfully detected MG-related dysphagia. In one patient with dysphagia caused by oculopharyngeal muscular dystrophy the FEES-Tensilon Test was truly negative. Beside an early diagnosis of MG-related dysphagia, the FEES-Tensilon Test was useful in the differentiation between myasthenic and cholinergic crisis and in guiding treatment decisions. In all patients the FEES-Tensilon Test was superior to clinical evaluation of dysphagia. No severe side effect occurred while performing the FEES-Tensilon Test. Conclusion The FEES-Tensilon Test is a suitable tool in the diagnosis and therapy of myasthenia gravis with pharyngeal muscles weakness.     

The value of artificial respiration for patients with myasthenia gravis (author's transl)]

The value of artificial respiration for the bridging of crises in patients with myasthenia gravis is emphasized on some typical cases. Further use, beyond a life-saving indication, for limited periods is described. Such relative indications may exist, when there is not yet complete respiratory failure but when a worsening of myasthenic weakness or cholinergic intoxication may threaten a respiratory crisis. In order to prevent serious complications, early artificial respiration may be indicated in the following situations: deterioration of cardio-pulmonary complications, important changes in therapy, particularly at the start of immuno-suppressive treatment, following tracheobronchial aspiration, in chronic cholinergic intoxication, following operations under general anesthesia, particularly after thymectomy. The importance of careful psychotherapy of myasthenics threatened by respiratory crises and the well-timed information on the chances, intentions and goals of intensive care including artificial respiration is emphasized.     

重症肌无力危象的多因素分析(附252例报告)

目的 探讨重症肌无力危象发生的危险因素.方法 回顾性分析2000年1月至2011年2月间我院收治的 252例II型重症肌无力患者的临床资料,选性别、发病年龄、病程、激素治疗、免疫抑制剂的应用、合并感染、胸腺切除术史、伴随自身免疫病等因素,进行多因素回归分析,分析其对重症肌无力危象发生的影响.结果 共发生危象108例,危象的发生与合并感染、胸腺切除术史、发病年龄及激素的使用有关.结论 合并感染、胸腺切除术史、发病年龄及激素的使用是重症肌无力危象发生的危险因素,认识这些危险因素对于预防危象的发生,改善预后提供了依据.