慢性肺心病患者血小板蛋白激酶C活性变化

慢性肺心病患者血小板蛋白激酶Ｃ活性变化王莉邢伟吴凝萃于润江对象：（１）研究组：慢性肺心病急性期患者１９例（男１２例，女７例），年龄６０±１０岁。全部病例均为Ⅱ型呼吸衰竭，动脉血氧分压（ＰａＯ２）为５．４３±１．２６ｋＰａ；动脉血二氧化碳分压（ＰａＣＯ...     

老年COPD呼吸衰竭机械通气的脱机探讨

老年ＣＯＰＤ呼吸衰竭机械通气的脱机探讨江苏省人民医院（２１００２９）郑崇明徐鑫荣老年慢性阻塞性肺病（ＣＯＰＤ）呼吸衰竭病人机械通气依赖现象较普遍，约３０％的病人无法脱机。现对我科１９８６～１９９５年间收治的老年ＣＯＰＤ呼吸衰竭机械通气２９例进行分析。...     

双水平气道正压通气治疗重症呼吸衰竭的疗效观察

观察在常规治疗基础上加用经鼻（面）罩双水平气道正压通气治疗重症呼吸衰竭的疗效。结果：Ⅰ型呼吸衰竭患者１６例，平均通气２４．４小时（１９～３２小时），ＰａＯ２由６．６９±１．１１上升至９．４３±０．８２ｋＰａ（Ｐ＜０．０１）；Ⅱ型呼吸衰竭患者４２例，平均通气２８．３小时（２４～７２小时）后，ＰａＯ２由７．０６±２．５７上升至８．５８±１．８８ｋＰａ．（Ｐ＜０．０５），ＰａＣＯ２由１０．９１±２．１６下降至７．２９±１．１７ｋＰ３（Ｐ＜０．０１）。表明双压通气在治疗重症呼吸衰竭中是一种行之有效的治疗方法。     

改进的面罩对无创人工通气死腔效应的影响

目的定量评价目前传统使用的面罩通气的重复呼吸量，探讨改进的双通道面罩对减少死腔效应的作用。方法选择７例慢性阻塞性肺疾病（ＣＯＰＤ）并轻中度二氧化碳（ＣＯ２）潴留患者，进行随机交叉自身对照试验。采用中号面罩，ＢｉＰＡＰ－３０呼吸机及平台型排气阀。应用电脑数据采集和分析方法，持续同步监测呼吸流量及ＣＯ２浓度，比较改进与传统面罩的重复呼吸量。结果改进面罩内呼气末ＣＯ２浓度明显低于传统法，分别为（３．０±１．０）％和（７．２±１．７）％（Ｐ＜０．００１）。传统面罩通气存在明显ＣＯ２重复呼吸，重复呼吸量为（８３．１±３２．９）ｍｌ；改进面罩通气几乎能完全消除重复呼吸［（０．１±０．４）ｍｌ，Ｐ＜０．０１］。结论传统面罩正压通气存在明显的ＣＯ２重复呼吸；改进面罩可基本消除 ＣＯ２重复呼吸，在治疗Ⅱ型呼吸衰竭患者时可能有重要的临床意义。     

肺心病患者血小板蛋白激酶C活性的初步研究

目的探讨蛋白激酶Ｃ（ＰＫＣ）活性变化在肺心病发病机制中的作用。方法用放免法测定１９例慢性肺心病急性发作期患者及２０名正常人血小板胞浆、胞膜ＰＫＣ活性,分析与动脉血氧分压（Ｐａｏ２）、动脉血二氧化碳分压（Ｐａｃｏ２）、血小板内游离钙离子浓度（［Ｃａ２＋］ｉ）之间相关关系。结果①肺心病组血小板胞浆ＰＫＣ活性明显低于对照组;血小板胞膜ＰＫＣ活性明显高于对照组（Ｐ＜００５,Ｐ＜００１）。②肺心病组Ｐａｏ２与血小板胞浆ＰＫＣ活性呈显著正相关（ｒ＝０．６０８,Ｐ＜００１）;与血小板胞膜ＰＫＣ活性呈显著负相关（ｒ＝－０．７５３,Ｐ＜００１）。结论肺心病患者存在血小板内ＰＫＣ被激活现象,活化的ＰＫＣ在肺心病发病机制中可能起着重要作用。缺氧是刺激ＰＫＣ活化的重要因素。     

冠心病患者心率变异向量长度和角度指数的非线性分析

应用动态心电图（ＡＥＣＧ）系统记录心率变异性（ＨＲＶ），并经非线性分析的定量指标向量长度指数（ＶＬＩ）和向量角度指数（ＶＡＩ）研究了３２例冠心病（ＣＨＤ）、２０例陈旧性心肌梗死患者和３９例健康人。结果表明：正常对照组Ｐｏｉｎｃａｒｅ散点图呈慧星状占９０％（３５／３９）；陈旧性心肌梗死（ＯＭＩ）组呈鱼雷状占８０％（１６／２０）；而ＣＨＤ组多表现为散点图变短、变窄、角度变小。ＶＬＩ值ＣＨＤ、ＯＭＩ组与对照组分别为１４８．７±３０．３，１２４．０±２７．３和１９７．０±３８．２（Ｐ＜０．０１）。ＶＡＩ值三组分别为０．５４±０．１４，０．４２±０．１５和０．８５±０．１８（Ｐ＜０．０１）。ＳＤ、ＰＮＮ５０、ｒＭＳＳＤ以及左心室舒张功能在ＣＡＤ、ＯＭＩ组也有相应变化。我们认为，非线性分析ＶＬＩ、ＶＡＩ定量指标可为ＣＨＤ提供重要信息。     

慢性阻塞性肺疾患病人行肺切除术的麻醉处理及术后急性呼衰的呼？…

严重慢性肺疾患实施肺切除术时的麻醉处理及加强术中管理。８２例肺切除患者中２８例术后并发急性呼衰。严重低肺功能７例，实施机械通气，２１例拔管后血气分析ＰａＣＯ２〉６．０ｋＰａ，ＰａＯ２〈８．０ｋＰａ采用ＢｉＰＡＰ鼻罩呼吸机，ＦＩＯ２４０－５０％机械通气治疗，脱机１－２小时轿气分析ＰａＯ２、ＰａＣＯ２均在正常范围。     

急性呼吸窘迫综合征的容许性高碳酸血症的机械通气治疗

急性呼吸窘迫综合合征（ＡＲＤＳ）机械通气治疗的探索。方法观察了１０例ＡＲＤＳ患者。为了减低吸气末气道压力（ｐｐｌａｔ），减少肺气压伤，应用较低的潮气量（ＶＴ，ｘ＝６．５ｍｌ／ｋｇ），依靠自身肾脏代偿功能，容许一定限度的呼吸性酸中毒（简称呼酸）存在（ｐＨ≥７．１９）。在维持动脉血氧分压（ＰａＯ２）７．３ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）左右情况下，尽量使用低水平吸氧浓度（ＦｉＯ２，ｘ＝０．５１）及呼气示正压（ＰＥＥＥＰ，ｘ＝０．９２ｋＰａ）（１ｋＰａ＝１０．２ｃｍＨ２Ｏ）。结果７例存活，其中３例在机械通气期间出现过呼酸，２例出现肺气压伤。结论在ＡＲＤＳ机械通气治疗中，使用较低ＶＴ及容许一定限度呼酸存在是值得重视的新观点，应在临床上进一步探索     

炎症性肠病患者树突状细胞的免疫功能研究

研究炎症性肠病（ＩＢＤ）患者外周血树突状细胞（ＤＣ）的免疫功能,探讨ＤＣ免疫功能变化在ＩＢＤ发生中的作用。方法：以健康成人（ｎ＝１０）作为对照,自ＩＢＤ患者（ｎ＝１１）外周血中分离和纯化ＤＣ及Ｔ细胞,按间接免疫荧光法通过流式细胞仪检测ＤＣ表面ＨＬＡ－ＤＲ及Ｂ７－１的表达水平,检测ＤＣ诱导自体混合Ｔ淋巴细胞增殖反应的能力。结果：ＩＢＤ患者 ＤＣ表面 ＨＬＡ－ＤＲ、 Ｂ７－１的表达水平及 ＤＣ诱导自体混合 Ｔ淋巴细胞增殖的能力（１９．６ＶＯＦ±１．３ＶＯＦ,１８．７ＶＯＦ±１．６ＶＯＦ,１２３１０ｃｐｍ±１４６ｃｐｍ）明显高于对照组（１３．６ＶＯＦ±１．２ＶＯＦ,１２．８ＶＯＦ±１．４ＶＯＦ,Ｐ＜０．０５,８６６０ｃｐｍ±１２０ｃｐｍ,Ｐ＜０．０１）。结论： ＩＢＤ患者ＤＣ免疫功能亢进。提示ＤＣ免疫功能亢进可能与ＩＢＤ的发生及发展相关。     

气管内吹气对慢性阻塞性肺疾病呼吸衰竭患者二氧化碳的清除作用

本研究采用自行设计的气管内吹气 (ＴＧＩ)装置 ,观察其对慢性阻塞性肺疾病 (ＣＯＰＤ)呼吸衰竭患者体内ＣＯ2 的清除效果 ,寻求能在低肺容积通气状态下保持动脉血ＣＯ2 分压(ＰａＣＯ2 )大致正常的临床实用性方法。一、对象和方法1.对象 :ＣＯＰＤ呼吸衰竭患者 8例 ,男 6例 ,女 2例 ,年龄48～ 76岁 ,病史 18～ 30年。其中合并肺心病者 2例 ,陈旧性肺结核者 1例 ,肺大疱者 1例 ,左全肺切除术后者 1例。所有患者行机械通气治疗前均已达到Ⅱ型呼吸衰竭的诊断标准。2 .方法 :所有患者均经口 (5例 )或经鼻 (3例 )气管插管建立人工气道 ,接ＳＩＭ…     

有创-无创序贯撤机过程中呼吸与循环功能变化的研究

目的：了解有创－无创机械通气序贯治疗过程中慢性阻塞性肺疾病（COPD）患者呼吸和循环功能的变化,以评价该方法实施中的生理学效应。方法：选择接受气管插管机械通气的COPD患者12例,待“肺部感染控制窗”出现后,拔除气管插管,改用经鼻面罩压力支持通气＋呼气末正压（PSV＋PEEP）。分别于“肺部感染控制窗”出现后有创机械通气条件下,拔管后无创机械通气3h及鼻导管吸氧1h的条件下测定患者的呼吸和循环功能的变化。结果：有创机械通气改为无创机械通气后,呼吸、循环各项指标变化均无统计学意义（P均＞0．05）。结论：有创－无创机械通气序贯撤机过程中,患者的呼吸和循环功能稳定,能够平衡地接受由有创性机械通气向无创性机械通气治疗的转换。     

智能监护脱机模式与间断停机方法在老年慢性阻塞性肺疾病患者脱机中的比较

目的比较智能监护(SmartCare)脱机模式和间断停用呼吸机两种脱机方法,探讨智能监护脱机模式是否可以提高老年慢性阻塞性肺疾病(COPD)患者的脱机成功率。方法2003年1月至2005年4月解放军总医院老年呼吸科收治的男性呼吸衰竭机械通气患者38例,为机械通气时间均超过3 d的COPD患者,年龄70～91岁,平均(83．3±4．3)岁;随机分为智能监护脱机组(SC组,13例)和间断停用呼吸机组(SBT组,25例)进行脱机治疗。所有患者病情稳定,准备脱机。SC组在吸入气氧浓度(FiO2)≤45％,调节吸气压力(IPAP)水平,使动脉血pH值≥7．35,动脉血氧饱和度(SaO2)≥90％,呼吸频率(RR)在10～30次／min。SBT组每天逐渐延长停机时间。记录每位患者脱机开始时的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分,血气分析,血钙、镁、磷,脱机前机械通气时间,脱机时间。脱机成功标准为停用呼吸机48 h以上未再进行机械通气,脱机失败为在脱机过程中患者死亡或者脱机40 d后仍然需要机械通气。结果在脱机开始时,两组患者的机械通气时间,APACHEⅡ评分,血浆白蛋白含量,血清磷、镁、钙含量以及动脉血二氧化碳分压(PaCO2)比较差异均无统计学意义(t分别为0．834,0．696,1．384,0．682、0．467、0．816,0．384,P均>0．05);脱机前SBT组pH值(7．45±0．05)显著高于SC组(7．40±0．04,t=3．263,P<0．05)。SC组脱机时间[(8．54±2．09)d]短于SBT组[(13．32±2．19)d],但差异无统计学意义(t=1．320,P=0．251)。SC组第7天时脱机成功率(77％)显著高于SBT组(40％,X2=4．677,P=0．031);但第14天时两组的脱机成功率比较差异无统计学意义(77％、64％,X2=0．661,P=0．416)。SC组的血气分析次数[(3．5±3．1)次]显著少于SBT组[(6．6±3．7)次,t=2．710,P=0．011]。结论智能监护脱机模式在7 d内的脱机成功率要优于间断停用呼吸机的脱机方法。     

Predicting 3-day and 7-day outcomes of weaning from mechanical ventilation.

OBJECTIVE: To determine the correlation of acute physiology and chronic health evaluation (APACHE) II score and various weaning indexes (WIs) with 3- and 7-day weaning outcomes. DESIGN: Prospective, observational. SETTING: The medical ICU of a teaching, urban hospital. METHODS: The study included 118 adults referred for weaning from mechanical ventilation (MV). Critical care physicians, critical care nurses, and respiratory care practitioners were asked to predict whether it would take < or =3 days, 4 to 7 days, or > or =8 days to wean each patient from MV. The WIs and APACHE II scores were measured or calculated. The causes of respiratory failure, the duration of MV before initiating weaning assessment, and the 3- and 7-day weaning outcomes were obtained. Significance was set at p<0.05. RESULTS: The most common causes of respiratory failure were pneumonia (38 cases) and acute exacerbation of COPD (29 cases). Fifty-seven patients (48%) were successfully weaned from MV within 3 days of weaning assessment, and 67 (57%) were weaned within 7 days. The percentages of correct prediction of 3-day weaning outcome by critical care physicians, critical care nurses, and respiratory care practitioners were 64%, 62%, and 59%, respectively; for 7-day weaning outcome, 60%, 64%, and 58%, respectively. The successfully weaned groups had significantly lower APACHE II scores and higher maximal inspiratory pressures than the unsuccessfully weaned (failure) groups. There were no significant differences between the two groups for the remaining indexes, including rapid shallow breathing, dynamic compliance, static compliance, spontaneous respiratory rate, and the ratio of PaO2 to the fraction of inspired oxygen. CONCLUSIONS: The overall severity of illness as assessed by APACHE II score correlates better with 3- and 7-day weaning outcome than the published WIs.     

Effectiveness and safety of a protocolized mechanical ventilation and weaning strategy of COPD patients by respiratory therapists

Introduction

Prior researches have showed that weaning protocols may decrease the duration of mechanical ventilation. The effect of these protocols on chronic obstructive pulmonary disease (COPD) patients is unknown. The purpose of this study was to evaluate the impact of an extensive mechanical ventilation protocol including weaning applied by a respiratory therapist (RT) on the duration of mechanical ventilation and intensive care unit (ICU) stay in COPD patients.

Materials and methods

A novel mechanical ventilation protocol including weaning was developed and initiated for all intubated COPD patients by a respiratory therapist. Outcomes of patients treated using this protocol during a 6-month period were compared to those of patients treated by physicians without a protocol during the preceding 6 months.

Results

A total of 170 patients were enrolled. Extubation success was significantly higher (98% vs. 78%, P=0.014) and median durations of weaning, mechanical ventilation and ICU stay compared with time to event analysis were significantly shorter in the protocol based group (2 vs. 26 hours, log rank P<0.001, 3.1 vs. 5 days, log rank P<0.001 and 6 vs. 12 days, log rank P<0.001, respectively). Patients who were successfully extubated and patients in the protocol based group were more likely to have shorter ventilation duration [HR: 1.87, 95% confidence intervals (CI): 1.13-3.08, P=0.015 and HR: 2.08, 95% CI: 1.40-3.10, P<0.001 respectively].

Conclusions

In our center, a protocolized mechanical ventilation and weaning strategy improved weaning success and shortened the total duration of mechanical ventilation and ICU stay in COPD patients requiring mechanical ventilation.     

Effects of doxapram on hypercapnic response during weaning from mechanical ventilation in COPD patients.

Failure of weaning from mechanical ventilation in COPD patients is often related to diaphragmatic fatigue. Whether there is a central respiratory drive fatigue and a reserve of excitability is still debated. The purpose of this study was to analyze the following in 13 COPD patients weaned from mechanical ventilation: (1) ventilatory (VE/PETCO2) and neuromuscular (P0.1/PETCO2) response to hypercapnia; (2) the maximum reserve capacity measured through changes in the VE/PETCO2 and P0.1/PETCO2 slopes after doxapram (DXP) infusion, which, given during the test, allows measurement of the maximum response capacity to overstimulation; and (3) analyze the influence of these changes on the outcome of weaning. The results show a variable P0.1/PETCO2 response and a low VE/PETCO2. DXP infusion does not change the slopes of these relations but increases the end-expiratory volume (delta FRCd); (p less than 0.02). Since there was no change in the VE/PETCO2, P0.1/PETCO2, and delta FRC values with or without DXP, there was no excitability reserve in patients who were successfully weaned. When weaning failed, DXP did not change VE/PETCO2 and P0.1/PETCO2 slope, but delta FRCd was greater the delta FRC (p less than 0.001). The excitability reserve in these patients leads to an increase in end-expiratory volume, probably worsening the diaphragm dysfunction.     

序贯机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭临床分析

目的 探讨早期拔管行无创机械通气策略的临床治疗效果.方法 选择接受气管插管和机械通气的慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)病例16例,设为序贯组,行机械通气,待肺部感染控制窗出现,拔除气管导管,改用无创正压通气(noninvasive positive pressure ventilation,NIPPV),以后渐减支持水平直至脱离呼吸机;选择同样病情病例16例作为对照组,在肺部感染控制窗出现后继续按常规行有创机械通气,以压力支持方式撤机.动态观察两组病例的感染、通气及氧合指标,记录有创和总机械通气时间、住重症监护病房天数及复插和院内死亡的情况.结果 序贯组与对照组的治疗前各指标相仿(P＞0.05);序贯组的有创机械通气时间、复插率和院内死亡率较对照组明显降低(P＜0.05).结论 对因肺部感染致COPD急性加重气管插管机械通气病例,以肺部感染控制窗为时机早期拔管,改无创通气可以显著改善治疗效果.     

探讨浅快呼吸指数指导COPD患者撤机的临床价值

目的评价浅快呼吸指数（rapid-shallow-breathing index,RSBI）作为COPD患者撤机的临床价值。方法呼吸重症监护病房的20例机械通气的COPD患者,均通过了1h的自主呼吸实验（spontaneous breathing trial,SBT）。记录两个时期的RS-BI：SBT前、SBT1h。同时记录年龄、性别、APACHEⅡ（acute physiology and chronic health evaluationⅡ）评分、撤机前的动脉血气分析。结果 16例COPD患者成功撤机,4例患者撤机失败。在成功和失败两组间年龄、性别、APACHEⅡ评分无明显差异（P〉0.05）,PaCO2（partial pressure of carbon dioxide in arterial blood）有明显差异（P〈0.05）。以RSBI≤105bpm/L为标准预测撤机成功的灵敏度和特异度分别为：SBT前RSBI93.8%、10%;SBT1h的RSBI93.8%、45.5%。SBT1h的RSBI与PaCO2联合预测撤机成功的灵敏度为89.5%,特异度为78%。结论 SBT1h的RSBI预测COPD患者成功撤机的准确性高于SBT前,其与PaCO2联合评价将提高预测撤机成功的准确性。     

慢性阻塞性肺疾病患者长期人工通气撤机指标的临床研究

目的评价床边综合肺功能作为长期人工通气的慢性阻塞性肺疾病（COPD）患者脱机指标的指导意义。方法监测58例（成功组：43例，失败组：15例）通气时间＞72h的COPD呼衰患者达到临床脱机标准后的血气分析、肺功能及呼吸力学的改变情况。结果两组患者的血气分析、急性生理、慢性健康评分（APACHEⅡ）、氧合指数、动态顺应性及气道阻力均无显著差异（P均＞0．05）；成功组患者的肺活量／潮气量（VC／V_T）、最大吸气负压（Pi_(max)）和浅快呼吸指数（f／V_T）分别为：2．10±0．20、（－21±4）cmH_2O及（74±30）次·min~(-1)·L~(-1)；失败组患者则依次为1．30±0．20、（－13±3）cmH_2O及（115±20）次·min~(-1)·L~(-1)，两组结果比较差异有显著性，P均＜0．05。以VC／V_T＞1．8、Pi_(max)＜－18cmH_2O和f／V_T＜105次·min~(-1)·L~(-1)作为临界值预测此类患者脱机成功与否，具有较高的敏感性（84％）和特异性（90％）。结论　综合肺功能指标（VC／V_T、Pi_(max)及f／V_T）可用于指导长期通气的COPD患者选择脱机时机，适宜在我国目前条件下推广普及。     

Health-related quality of life in patients with chronic respiratory failure after long-term mechanical ventilation

STUDY OBJECTIVES: This study was aimed at assessing health-related quality of life (HRQL) in patients with chronic respiratory failure (CRF) and long-term survival following prolonged intensive care mechanical ventilation. DESIGN: Observational cohort study. SETTING: Patients with CRF who had been transferred to our specialized weaning centre due to prolonged mechanical ventilation (>14 days) and weaning failure. PATIENTS AND PARTICIPANTS: Out of 87 long-term survivors (>6 months), 73 patients (mean age: 60.3+/-13.6 years, chronic obstructive pulmonary disease (COPD, 43%), thoraco-restrictive (21%) or neuromuscular disorders (15%), various chronic diseases (22%)) returned the MOS 36-Item Short-Form Health Status Survey (SF-36) and the St. George's respiratory questionnaire (SGRQ). MEASUREMENTS AND RESULTS: The total ventilation time was 38.7+/-45.9 days. The time between discharge from ICU and HRQL assessment was 31.0+/-22.2 months. Physical health was markedly reduced compared to general population norm, but mental health was mildly impaired. HRQL was comparable to patients with stable CRF receiving non-invasive ventilation who did not need prolonged invasive MV. In addition, general HRQL was better in patients with restrictive respiratory disease compared to patients with neuromuscular diseases (P<0.05). Physiological parameters such as blood gases or lung function parameters were not correlated to any HRQL measurements. CONCLUSIONS: In patients with CRF surviving prolonged ventilation on ICU, the presence of CRF itself is the major determinant of HRQL. Here, the underlying cause of CRF is the major factor which determines the degree of HRQL impairment with patients suffering from restrictive ventilatory disorders reporting the best HRQL when compared to patients with COPD or neuromuscular diseases. Despite severe physical handicaps due to CRF mental health is only mildly compromised.     

不同撤机指标对慢性阻塞性肺疾病患者撤机的预测价值研究

目的比较不同撤机指标对COPD患者撤机的预测价值。方法选取机械通气48h以上且已达到撤机标准的17例COPD患者,采用T型管方法进行自主呼吸试验2h,在自主呼吸试验进行30min时检测气道闭合压（P0.1）、最大吸气压（Pimax）和呼吸浅快指数（RSBI）值,探讨它们在预测COPD患者撤机中的价值。结果lO例COPD患者撤机成功,7例失败。成功组患者的P0.1,和RSBI值明显小于失败组,而Pimax值则明显大于失败组,其差异均具有显著统计学意义（P〈0．05）。P。预测COPD患者撤机的价值明显优于Pimax和RSBI,其灵敏度、特异性和准确性均高于Pimax和RSBI,它们分别为89％、75％和82％。结论P0．1、Pimax和RSBI对COPD患者的撤机均具有指导意义,其中P0．1的价值最大。