呼吸机撤机困难原因及撤机预测参数的研究进展

呼吸机撤机是机械通气后所面临的一个重要难题。影响撤机的因素是多方面的,涉及多系统功能,主要是呼吸力量与负荷之间的关系以及心肺功能相互影响的结果。结合困难撤机原因,寻找合适预测撤机的参数,可提高撤机成功率,最大限度改善临床预后。     

37例拔管困难患者行序贯机械通气的护理

目的 :探讨呼吸衰竭患者行序贯机械通气的护理干预措施。方法 :对 37例拔管困难患者行序贯机械通气前给予充分评估 ,反复讲解和演示无创通气配合要领 ,认真做好无创通气过程中氧合状况监测和呼吸道管理 ,并预防可能出现的并发症。结果 :37例拔管困难行序贯机械通气患者 ,33例拔管撤机成功 ,有效率为 89.19%。结论 :序贯机械通气模式是针对拔管困难患者采取的一种撤机手段 ,而积极有效的护理是确保撤机成功的关键。     

New techniques for weaning difficult patients from mechanical ventilation

This article compares the weaning of challenging patients from mechanical ventilation to an exercise training program experienced by many athletes. Physically, the importance of the correction and maintenance of chronic health issues, nutrition, and hydration are explored. Psychologically, the degree of preparedness by both the patient and the health care team is presented. Parameters for predicting readiness to wean that include both objective and subjective indices are gaining more support; two tools for weaning are offered. During the weaning process, reconditioning of the respiratory muscles can be promoted through endurance or strengthening exercises or a combination of both. The quality and quantity of exercise performed must be closely monitored to prevent respiratory muscle fatigue or atrophy. Newer modes of ventilation, including pressure support ventilation, mandatory minute ventilation, and continuous flow, decrease the work of breathing, promote ventilator/patient synchrony, and provide a more dynamic weaning process. All of these modes promote exercise, and augment the physical and psychological components of weaning. Nursing considerations for successful weaning are offered.     

呼吸机困难撤机23例治疗分析

目的 总结导致困难撤机的相关因素. 方法 收集2007年1月至2008年1月中国医科大学附属第一医院急诊监护室收治的23例行机械辅助通气,预后为困难撤机的患者的临床资料,回顾性的分析他们的治疗过程及可能与之相关的因素. 结果 23例困难撤机的患者中,在撤机后48 h内出现体温＞38℃,咳痰困难,肺部听诊湿性啰音增多的有6例;出现呼吸肌疲劳,动脉血气回报出现PaCO2＞60 mm Hg的有12例;考虑出现呼吸机依赖心理因素的有3例;撤机时机把握不佳导致的撤机困难的有2例. 结论 对患者的临床状况进行及时的评价,合理地保护性机械通气,足够的营养支持,提高患者主观的撤机信心,能提高撤机成功率,减少困难撤机的发生.     

Pattern of spontaneous breathing: potential marker for weaning outcome

OBJECTIVE: To quantitatively assess the spontaneous breathing (SB) pattern, during minimal ventilatory support, of patients who pass or fail weaning trials from mechanical ventilation. DESIGN: A prospective, clinical trial. SETTING: Intensive care unit of a university teaching hospital. PATIENTS: Fifty-two tracheally intubated and hemodynamically stable patients who were judged clinically ready for extubation. METHODS: Using a computerized respiratory profile monitor, continuous respiratory parameters were obtained while patients were receiving four or less synchronized intermittent mandatory (SIMV) breaths and during CPAP trials. Coefficients of variation (CV) of spontaneous tidal volumes and flows during SIMV trials as well as the entropies and dimensions of the breathing patterns during CPAP trials were used to assess the dynamical breathing behaviors of the patients who passed or failed weaning trials. MEASUREMENTS AND RESULTS: Thirty-nine extubations were successful and 13 were not. The CV of the spontaneous tidal volumes (VT) and the spontaneous peak inspiratory flows (PF), the Kolmogorov entropy and the dimension of the SB patterns were compared in the two groups. The CV of VT (9.13 +/- 4.11 vs 26.07 +/- 6.94), the CV of PF (11.63 +/- 4.18 vs 29.88 +/- 12.07), the Kolmogorov entropy (0.09 +/- 0.03 bits/cycle vs 0.39 +/- 0.09 bits/cycle), and the dimension of the SB pattern (1.33 +/- 0.07 vs 3.93 +/- 0.47) were all significantly smaller (P < 0.05) in the successfully extubated group versus the group that failed extubation. CONCLUSION: The spontaneous breathing pattern during minimal mechanical ventilatory support is more chaotic in patients who failed extubation trials compared to patients who passed extubation trials. Thus, we speculate that characterizing the SB pattern during minimal ventilatory support might be a useful tool in differentiating between extubation success and failure.     

呼吸机撤离困难原因分析与护理

对于各种原因引起的呼吸功能衰竭患者,临床上广泛使用呼吸机辅助呼吸维持生命,以度过疾病的危重期,而随之出现的呼吸机并发症日益显露出来,其中呼吸机依赖、撤机困难是最常见的机械通气并发症。我科ICU病区在2006年8月－2008年10月共收治患者60例,临床护理发现,短时间使用呼吸机辅助呼吸的患者,呼吸功能恢复后能很快停机。但使用呼吸机时间较长,一般为2周以上者,就会对呼吸机产生较强的依赖性,需要一个逐步撤机的过程,     

运动疗法应用于ICU困难撤机患者的效果评价

目的评价困难撤机患者在治疗期间采用运动疗法的干预效果。方法将63例困难撤机患者随机分为实验组33例和对照组30例。实验组在常规呼吸道护理基础上根据患者病情及体力进行循序渐进的4步运动疗法;对照组按常规进行呼吸道护理。比较2组不同时点的潮气量、呼吸频率、氧合指数等指标情况。结果机械通气第21天和第28天,实验组潮气量、呼吸频率、氧合指数（PaO2／FiO2）、急性生理与慢性健康评分（APACHEII评分）指标均显著优于对照组;机械通气第28天,实验组心率显著优于对照组;实验组患者机械通气日及ICU住院日均明显少于对照组;2组的并发症发生率比较差异无统计学意义。结论运动疗法对困难撤机患者具有积极的作用。     

The semi-seated position slightly reduces the effort to breathe during difficult weaning

Purpose

The influence of posture on breathing effort in patients with difficult weaning is unknown. We hypothesized that posture could modulate the breathing effort in difficult-to-wean patients.

Methods

A prospective, crossover, physiologic study was performed in 24 intubated patients breathing with pressure support who had already failed a spontaneous breathing trial or an extubation episode. Their median duration of mechanical ventilation before measurements was 25?days. Breathing pattern, occlusion pressure (P _0.1), intrinsic PEEP (PEEP_i), and inspiratory muscle effort evaluated by the pressure?Ctime product of the respiratory muscles and the work of breathing were measured during three postures: the seated position in bed (90°LD), simulating the position in a chair, the semi-seated (45°), and the supine (0°) positions consecutively applied in a random order. A comfort score was obtained in 17 cooperative patients. The influence of position on chest wall compliance was measured in another group of 11 sedated patients.

Results

The 45° position was associated with the lowest levels of effort (p????0.01) and occlusion pressure (p?<?0.05), and tended to be more often comfortable. Respiratory effort was the lowest at 45° in 18/24 patients. PEEP_i and PEEP_i-related work were slightly higher in the supine position (p????0.01), whereas respiratory effort, heart rate, and P _0.1 values were increased in the seated position (p?<?0.05).

Conclusion

A 45° position helps to unload the respiratory muscles, moderately reduces PEEP_i, and is often considered as comfortable. The semi-seated position may help the weaning process in ventilator-dependent patients.     

脑出血术后撤机困难的原因分析及护理对策

目的探讨脑出血术后撤机困难的原因及护理对策。方法对6例脑出血术后患者肺部感染致p(CO_2)高行机械通气伴撤机困难的病例资料进行回顾,并分析原因。结果撤机困难的原因与肺部感染、呼吸衰竭、缺乏呼吸功能锻炼、营养不良及心理因素有关,经针对性护理干预后,6例患者均成功撤机。结论对于脑出血术后肺部感染致p(CO_2)高行机械通气伴撤机困难的患者,应严格实施呼吸道管理,控制感染,合理氧疗,逐步降低p(CO_2),实施安全、有效的间断撤机,循序渐进实施呼吸功能锻炼,针对性给予营养支持和心理护理,这是成功撤机的重要措施。     

Laribacter hongkongensis: a potential cause of infectious diarrhea

In this study, we describe the isolation of Laribacter hongkongensis, a recently described genus and species of bacterium, in pure culture on charcoal cefoperazone deoxycholate agar from the stool of six patients with diarrhea. Three patients were residents of Hong Kong, and three of Switzerland. In none of the stool samples obtained from these six patients was Salmonella, Shigella, enterohemorrhagic Escherichia coli, Vibrio, Aeromonas, Plesiomonas, or Campylobacter recovered. Rotavirus antigen detection, electron microscopic examination for viruses, and microscopic examinations for ova and cysts were all negative for the stool samples obtained from the three patients in Hong Kong. Enterotoxigenic E. coli was recovered from one of the patients in Hong Kong. Unlike L. hongkongensis type strain HKU1, all the six strains were motile with bipolar flagellae. Sequencing of the 16S ribosomal RNA genes of the six strains showed that they all had sequences with only 0-2 base differences to that of the type strain. Pulsed field gel electrophoresis of the SpeI digested genomic DNA of the six isolates and that of the type strain revealed that the seven isolates were genotypically unrelated strains. More extensive epidemiologic studies should be carried out to ascertain the causative association between L. hongkongensis and diarrhea and to define the reservoir and modes of transmission of L. hongkongensis.     

B超监测下腔静脉变异度对心功能不全患者困难撤机的预测价值

目的 研究下腔静脉变异度对心功能不全患者困难撤机的预测价值。方法 回顾性研究2014年1月-2015年12月苏州大学附属第一医院重症医学科行机械通气的心功能不全患者。对通过撤机前筛查的患者行自主呼吸试验(SBT)30分钟,按照SBT结果分为成功撤机组和困难撤机组。记录两组患者SBT过程中的下腔静脉变异度(△D_IVC)、呼吸浅快指数(RBSI)及一般临床指标。比较成功撤机组和困难撤机组患者上述指标的统计学差异,采用受试者工作曲线(ROC)分别评价下腔静脉变异度和呼吸浅快指数对心功能不全患者困难撤机的预测价值。结果 本研究共纳入99例患者,其中成功撤机组59例,困难撤机组40例,成功撤机组与困难撤机组患者的一般情况,包括年龄、急性生理学与慢性健康状况评分II(APACHE II)、生命体征、血气指标等均无统计学差异(p＞0.05)。成功撤机组△D_IVC(0.28±0.07)%vs. (0.19±0.04)%明显大于困难撤机组患者(p<0.05)。△D_IVC预测心功能不全患者困难撤机的ROC曲线下面积为0.839(95%CI：0.752-0.925),以△D_IVC≤0.25为截点预测心功能不全患者困难撤机的敏感度为69.5%,特异度为94.7%。RBSI预测心功能不全患者困难撤机的ROC曲线下面积为0.816(95%CI：0.727-0.905),以RBSI＞105为截点预测心功能不全患者困难撤机的敏感度为91.7%,特异度为35.2%。结论 超声下下腔静脉变异度的监测对心功能不全患者困难撤机的预测具有一定的指导价值。     

Ventilatory weaning: a case study of protracted weaning

Background: Dysfunctional ventilatory weaning response (DVWR) is characterized by interrupted and prolonged weaning. This reflective analysis presents how using nursing diagnoses in critical care can raise awareness of, and provide strategies for, managing problems related to ventilatory weaning. Aim: To examine and reflect upon why one patient took so long to wean from the ventilator using the structured approach of instrumental case study and nursing diagnosis to explain aspects of the weaning process. Analysis: This case study examines one patient’s experiences around ventilatory weaning using selected nursing diagnoses, exploring the implications that physiological, social, emotional and psychological factors have on both weaning and healing processes in critical care. By using dialogue, an explicit texture is presented of how one patient felt, with particular resonance to the relationships she had and the impact they made. Various nursing diagnoses proved useful in determining why this patient had an extended weaning trajectory and included DVWR, ineffective breathing pattern, impaired spontaneous ventilation, anxiety and impaired verbal communication. There were specific points of interest, in particular her anxiety, which proved a major factor, and her significantly improved functional status after the critical care episode. A DVWR may be minimized by nursing presence, reassurance and respect for patient autonomy. Complex anatomy and physiology contributes to protracted weaning and a DVWR and is compounded by anxiety. Furthermore, there is a significant element of nursing care, timely reassurance and presence, which can have a positive impact on patient well‐being. Conclusions: This reflective analysis highlights the benefits and importance of the nurse‐patient relationship during what was a very protracted ventilatory wean. This shared trajectory enabled significant patient empowerment, and this case study gives the patient the voice she temporarily lost.     

输尿管硬镜上镜困难原因分析及处理

目的总结和评价输尿管镜手术时上镜困难的原因及其对策。方法分析了2002年10月～2005年6月收治的326例次输尿管镜手术患者的临床资料。结果24例上镜困难者，10例是采用技巧性的旋转及其变换角度才能入镜，14例有不同程度的狭窄或迂曲，经扩张或调整体位后有12例成功，1例中转开放，1例插管碎石。结论输尿管上镜困难并不少见，熟悉输尿管解剖与技巧性操作可提高取石率。