慢性阻塞性肺疾病患者呼吸指导及护理

对252例慢性阻塞性肺疾病急性加重期患者进行呼吸指导和护理,认为在对慢性阻塞性肺疾病的治疗期间,提高护理质量及呼吸指导尤为重要.     

不同治疗方法对晚期慢性阻塞性肺疾病呼吸衰竭患者预后的影响

目的探讨晚期慢性阻塞性肺疾病(COPD)患者临床缓解期最佳的治疗方法。方法将47例晚期COPD患者分为三组:A组为不能或不接受家庭氧疗和家庭无创正压通气(NPPV)者;B组为出院后在医生指导下进行长期家庭氧疗者;C组为能在医生指导下进行长期家庭NPPV加长期家庭氧疗,且能很好耐受者。回顾性对比分析三组患者1年内再住院率、再插管率及病死率。结果B组患者1年内的再住院率、再插管率及病死率较A组分别降低了38.4%、17.3%和18.0%,而C组患者较B组患者又降低了8.0%、35.3%和29.4%,三组患者的再住院率、再插管率及病死率比较,差异均有统计学意义(P<0.05)。结论长期家庭氧疗和长期家庭NPPV能显著降低晚期COPD患者的再住院率、再插管率和病死率,长期家庭氧疗加长期家庭NPPV治疗效果最好。     

肠内营养支持治疗在慢性阻塞性肺疾病并发呼吸衰竭病人的疗效观察

目的:探讨肠内营养(EN)在治疗慢性阻塞性肺疾病(COPD)并发呼吸衰竭使用无创通气治疗病人中的应用价值。方法:将58例COPD并发呼吸衰竭使用无创通气治疗病人按随机数字表法分为治疗组和对照组,每组29例。两组病人均给予常规治疗,避免使用糖皮质激素。治疗组病人给予鼻饲EN液,行EN支持治疗14d。观察两组病人EN治疗前后血红蛋白(Hb)、血清总蛋白(TP)、清蛋白(ALB)、体质量(Wt)、肱三头肌皮皱厚度、上臂肌围、外周血总淋巴细胞计数(TLC)、Ig A、Ig G、Ig M、无创通气时间以及使用有创机械通气的病例数、入住ICU时间等指标。结果:治疗组病人治疗14 d后,Hb、TP和ALB较治疗前明显升高(P0.05),Wt较治疗前显著增加(P0.05)。与对照组比较,治疗组病人Hb、TP、ALB和Wt亦有明显增加(P0.05);TLC、Ig A、Ig G和Ig M明显升高(P0.05);无创通气时间和入住ICU时间明显缩短(P0.05),使用有创通气的病例数明显下降(P0.05)。结论:对COPD并发呼吸衰竭的病人,合理的营养支持治疗可改善机体的营养状态,提高机体的免疫功能,缩短无创通气和入住ICU时间,降低有创通气的比率。     

稳定期慢性阻塞性肺疾病患者护理健康教育效果评价

目的 评价护理健康教育对稳定期慢性阻塞性肺疾病（COPD）患者肺功能及生活质量的影响。方法 将确诊为COPD稳定期的84例患者根据自愿原则随机分为护理健康教育组（A组，n=46）和对照组（B组，n=38），分析干预前及干预后1年FEV1、FEV％预计值、FEV1／FVC及生活质量评分（SGRQ评分）。结果1年后A组FEV1、FEV％预计值、FEV1／FVC下降明显减少．生活质量指数有明显提高，其规律服药率、戒烟率与B组比较，差异均有显著性意义（P均〈0．05）。结论 系统护理健康教育对延缓稳定期COPD患者肺功能下降、提高患者生活质量有明显作用。     

吸烟对慢性阻塞性肺疾病及呼吸道症状的影响

  目的   探讨吸烟对慢性阻塞性肺疾病(chronic obstructive pulmonary disease, COPD)及呼吸道症状的影响。   方法   利用多阶段分层整群随机抽样的方法在安徽5个COPD监测点抽取≥40岁调查对象, 并对其进行问卷调查、身体测量和肺功能检测。利用复杂抽样Logistic回归分析模型分析吸烟对COPD及呼吸道症状的影响。   结果   ≥30包年的吸烟者在总人群中占13.9%(95% CI:10.3%~17.5%, P < 0.001), ≥40年的吸烟者在总人群中占8.5%(95% CI:6.7%~10.3%, P < 0.001)。吸烟者平均吸烟年数为32.4 (95% CI:31.2~33.5)年, 吸烟者日均吸烟量为21.1 (95% CI:19.6~22.7)支/天。调整混杂因素后, COPD和呼吸道症状的患病风险均随吸烟包年和吸烟年数的增加而呈上升趋势(均有P_trend < 0.001)。   结论   吸烟增加COPD及呼吸道症状的患病风险, 吸烟包年和吸烟年数越多, 慢阻肺和呼吸道症状的患病风险越大。     

肺部感染对慢性阻塞性肺疾病患者呼吸功能状态与细胞因子表达的影响

目的探讨肺部感染对慢性阻塞性肺疾病(COPD)患者呼吸功能状态与细胞因子水平的影响。方法2016年1月-2018年1月医院收治的COPD合并肺部感染患者54例作为试验组,COPD无肺部感染患者50例作为对照组。采用酶联免疫吸附试验检测细胞因子白细胞介素-6(IL-6)、白细胞介素-8(IL-8)、肿瘤坏死因子-α(TNF-α)和转化生长因子-β(TGF-β)的水平,使用肺功能检测仪检测患者第一秒末用力呼气量(FEV1)、每分钟最大通气量(MVV)、最大呼气中期流速(MMF)、气道阻力(RAW)、共振频率(Fres)、动态胸肺顺应性(Cdyn)呼吸功能指标。结果试验组血清IL-6、IL-8、TNF-α和TGF-β的水平分别为(11.0±0.8)(pg/ml)、(11.3±1.1)(pg/ml)、(1.8±0.1)(ng/L)、(98.2±6.4)(ng/L),均高于对照组,试验组FEV1、MVV、MMF和Cdyn分别为(61.5±5.0)%、(46.5±3.9)%、(0.8±0.1)L/s、(30.8±5.4)ml/cmH2O,均低于对照组,试验组RAW和Fres分别为(118.3±12.4)%、(22.6±5.4)Hz,均高于对照组(P<0.05);感染程度越高,患者血清IL-6、IL-8、TNF-α和TGF-β的水平越高,FEV1、MVV、MMF和Cdyn越低,而RAW和Fres越高(P<0.05)。结论肺部感染影响了COPD患者的肺功能和炎症细胞因子水平,临床上应注重控制和预防肺部感染。     

慢性阻塞性肺病呼吸衰竭时低磷血症

磷具有许多重要的生物学功能,低磷血症或磷缺乏可引起许多病变.在胸部疾病、呼吸道感染或呼吸衰竭中,低磷血症的发生率为17%～28%.本文综述有关磷的代谢,慢性阻塞性肺病呼吸衰竭时低磷血症的病因,临床表现和处理.     

慢性阻塞性肺疾病患者呼吸道细菌感染的临床特点研究

目的探讨慢性阻塞性肺疾病(COPD)患者呼吸道细菌感染的临床特点,为抗感染治疗提供参考依据。方法回顾性分析2008年3月-2013年1月收治的3 057例COPD患者临床资料,其中672例合并呼吸道细菌感染,从中随机抽取103例病情稳定患者,对其进行痰培养及药敏试验,分析病原菌分布及耐药性,采用法国生物梅里埃公司VITEK-260全自动细菌鉴定仪鉴定菌株,K-B纸片扩散法进行药敏试验。结果 3 057例COPD患者中合并呼吸道细菌感染672例,感染率22.0%;103例COPD合并呼吸道细菌感染患者临床表现为慢性咳嗽97例、咳痰83例、气短66例、胸闷54例,分别占94.17%、80.58%、64.08%、52.43%;痰液中培养出病原菌192株,其中革兰阴性杆菌134株占69.79%,革兰阳性球菌58株占30.21%,革兰阴性杆菌中铜绿假单胞菌检出最多,占50.74%,其次为肺炎克雷伯菌、大肠埃希菌,分别占19.27%、11.49%,革兰阳性球菌中金黄色葡萄球菌检出最多21株,占10.94%;肺炎克雷伯菌、铜绿假单胞菌、大肠埃希菌对亚胺培南和美罗培南的耐药率均明显低于其他常用抗菌药物,分别为0、11.1%、0,差异有统计学意义(P<0.05)。结论 COPD患者呼吸道细菌感染以革兰阴性杆菌为主,其中铜绿假单胞菌、肺炎克雷伯菌、大肠埃希菌检出较多,治疗过程中对于难治感染可以选用亚胺培南和美罗培南。     

慢阻肺患者肺部感染对呼吸功能与细胞因子表达的影响研究

目的研究肺部感染对慢阻肺患者呼吸功能状态与细胞因子表达的影响,为肺部感染患者的机体调节与感染预防控制提供依据。方法选取2015年4月-2016年7月医院收治49例慢阻肺合并肺部感染患者为观察组,选取同时期49例慢阻肺无肺部感染患者为对照组,检测与比较两组血清细胞因子及呼吸功能指标(肺功能指标及其他呼吸指标),并观察组中不同感染程度患者的血清细胞因子及呼吸功能指标。结果观察组血清细胞因子TNF-α、IL-6、IL-8及TGF-β水平分别为(1.78±0.19)ng/L、(10.98±1.31)pg/ml、(11.45±1.40)pg/ml及(97.23±5.30)ng/L,均高于对照组(1.28±0.13)ng/L、(8.41±1.02)pg/ml、(9.20±1.13)pg/ml及(88.48±4.51)ng/L,且肺功能指标及其他呼吸指标均差于对照组,同时观察组中不同感染程度患者血清细胞因子及呼吸功能指标,差异有统计学意义(P<0.05)。结论慢阻肺患者肺部感染对呼吸功能状态与细胞因子表达的不良影响十分突出,应重视对慢阻肺患者肺部感染的预防控制及血清细胞因子TNF-α、IL-6、IL-8及TGF-β的调控。     

Chlamydia pneumoniae infection in patients with chronic obstructive pulmonary disease.

The prevalence of chronic Chlamydia pneumoniae infection was assessed in 54 patients with established chronic obstructive pulmonary disease (COPD), 41 of these with severe COPD (group I), 13 with mild to moderate COPD (group II), and in 23 patients with community-acquired pneumonia (controls, group III). Specific IgG and IgA antibody levels and circulating immune complexes (ICs) were measured in paired sera, and specific secretory IgA (sIgA) levels in sputum specimens. A polymerase chain reaction (PCR) test was used for the detection of C. pneumoniae in sputum. According to our definite diagnosis criterion, 65% of the COPD patients showed evidence of suspected chronic C. pneumoniae infection and the prevalence was still higher (71%) in patients with severe disease. The occurrence of specific markers of infection was invariably highest in patients with severe COPD, next-highest in patients with mild to moderate COPD and lowest in pneumonia patients. The association between COPD and C. pneumoniae infection persisted after controlling for the potential confounding factors.     

Circulating ghrelin in patients with chronic obstructive pulmonary disease

OBJECTIVE: Unexplained weight loss is common in patients with chronic obstructive pulmonary disease (COPD). Because ghrelin plays an important role in energy homeostasis, this study investigated the plasma level of ghrelin in COPD. METHODS: Plasma ghrelin levels and levels of leptin, tumor necrosis factor-alpha, and C-reactive protein were measured in 29 patients with COPD and 17 healthy controls. Body composition was assessed with bioelectrical impedance analysis. RESULTS: Body mass index and percentage of body fat were lower in patients who had COPD than in healthy controls. Plasma ghrelin and leptin concentrations were significantly lower in patients who had COPD than in healthy controls (ghrelin: 0.25+/-0.22 ng/mL versus 0.43+/-0.24 ng/mL, P=0.013; leptin: 1.77+/-0.70 ng/mL versus 2.85+/-0.96 ng/mL, P=0.000). In contrast, tumor necrosis factor-alpha and C-reactive protein were significantly higher in those with COPD than in controls. Plasma ghrelin (log transformed) was positively correlated with body mass index and percentage of body fat in patients with COPD but negatively correlated in control subjects. Plasma ghrelin was negatively correlated with tumor necrosis factor-alpha and C-reactive protein in COPD. CONCLUSION: Plasma ghrelin level was decreased in COPD and this is different from other weight-loss diseases. These data suggest that decreased ghrelin and other factors may contribute to alterations in metabolic status during inflammatory stress in this disease.     

Diaphragm dysfunction in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterised by alterations in the airways and lung parenchyma resulting in an increased respiratory workload. Besides an increased load and hyperinflation of the thorax, additional factors, such as systemic inflammation, oxidative stress, hypoxia and loss of muscle mass, further have a negative influence on diaphragm contractility. The diaphragm seems to adapt only partly to the altered circumstances to which it is exposed. As a consequence, several morphological, biochemical and functional alterations occur in the diaphragm, resulting in diaphragm dysfunction. In an appropriately selected group of patients, the function of the diaphragm can be improved by respiratory muscle training, oral nutritional therapy or hormonal interventions.     

比例辅助通气对撤机阶段慢性阻塞性肺疾病合并呼吸衰竭患者通气参数的影响

目的 观察比例辅助通气(PAV)与压力支持通气(PSV)对撤机阶段慢性阻塞性肺疾病(COPD)合并呼吸衰竭患者通气参数的影响.方法 COPD合并呼吸衰竭患者15例,所有患者均为气管插管并接受机械通气支持1周以上者,在治疗过程中病情稳定准备撤机.随机选用PAV和不同水平的PSV[PSV水平为10 cm H2O(PS10)和PSV水平为15 cm H2O(PS15),1 cm H2O=0.098 kPa]辅助通气60 min,应用PAV前采用最小平方拟合法(LSF)测定患者的呼吸系统弹性阻力(Ers)和气道阻力(Rrs),设置容量辅助(VA)和流量辅助(FA),辅助比例为80%.观察患者在不同通气条件下通气参数及动脉血气分析的变化.结果 与低水平PSV(PS10)时相比,高水平PSV(PS15)与PAV时的潮气量显著增加[(443±12)ml与(532±34)ml、(464±23)ml,P<0.05];PAV时的呼吸频率与气道峰压稍高于PS10时,但差异无统计学意义.PAV支持后,患者的气道闭合压由PS10时的(5.70±0.25)cm H2O降至(4.53±0.25)cm H2O(P<0.05),气道压力及吸气触发压力时间乘积也显著降低[由(0.42±0.04)cm H2O降至(0.32±0.03)cm H2O,P<0.05];而氧合指数与动脉血二氧化碳分压均得到明显改善,与PS15时相近.PAV时的浅快呼吸指数较PS10时无明显改变.结论 PAV通过采用正反馈调节机制,成比例地提供同步辅助,显著减少COPD呼吸衰竭患者的自主吸气做功,改善人机同步性.     

Altered interorgan response to feeding in patients with chronic obstructive pulmonary disease

BACKGROUND: Previously, we reported increased values for whole-body protein turnover in patients with chronic obstructive pulmonary disease (COPD) in the postabsorptive state. OBJECTIVE: The objective was to investigate whether intake of a carbohydrate-protein meal influences whole-body protein turnover differently in COPD patients and control subjects. DESIGN: Eight normal-weight patients with moderate COPD and 8 healthy control subjects were examined in the postabsorptive state and after 2 h of repeatedly ingesting a maltodextrin casein-based protein meal (0.02 g x kg body wt(-1) x 20 min(-1)). Combined simultaneous, continuous, intravenous infusion of L-[ring-2H5]-phenylalanine and L-[ring-2H2]-tyrosine tracer and oral repeated ingestion of 1-13C-phenylalanine were performed to measure whole-body protein synthesis (WbPS) and first-pass splanchnic extraction of phenylalanine. Endogenous rate of appearance of phenylalanine as the measure of whole-body protein breakdown (WbPB) and netWbPS was calculated as WbPS--WbPB. Arterialized venous blood was sampled for amino acid enrichment and concentration analyses. RESULTS: Feeding induced an increase in WbPS and a reduction in WbPB. The reduction in WbPB was larger in the COPD group than in the control group (P < 0.05) and was related to the lower splanchnic extraction of phenylalanine in the patients. Consequently, netWbPS increased more after feeding in the COPD group than in the control group (P < 0.05). CONCLUSION: Feeding induces more protein anabolism in normal-weight patients with moderate COPD than in healthy control subjects. This is probably because these COPD patients are characterized by an adaptive interorgan response to feeding to prevent or delay weight loss at this disease stage.     

Chronic obstructive pulmonary disease severity and cardiovascular outcomes

Objective: To identify predictors of chronic obstructive pulmonary disease (COPD) severity and assess the relation between COPD severity and risk of cardiovascular outcomes. Study design and setting: A␣cohort of patients with diagnosed and treated COPD was compiled from the Saskatchewan Health longitudinal databases. We used multivariate modeling to identify predictors of hospitalization for COPD as an indicator of COPD severity, and we used the model to characterize patients according to quintiles of COPD severity. These severity levels were used as independent variables in multivariate models of cardiovascular outcomes. Results: Determinants of COPD severity included emphysema, recent nebulizer use, home oxygen services, corticosteroid use, frequent bronchodilator use, pneumonia and prior COPD exacerbation. The 20% of patients with the highest COPD severity were 1.27 (CI: 1.07–1.50) times more likely to have arrhythmia, 1.25 (CI: 1.07–1.46) times more likely to have ischemic heart disease, 1.38 (CI: 1.11–1.71) times more likely to have angina, 2.28 (CI: 1.95–2.66) times more likely to have congestive heart failure, and 1.63 (CI: 1.22–2.16) times more likely to die of cardiovascular causes than the least severe 20% of patients. Conclusions: Patients with more severe COPD, as defined by our model, had higher cardiovascular morbidity and mortality than patients with less severe COPD.     

低糖高脂营养膳食对慢性阻塞性肺疾病急性发作并发呼吸衰竭病人疗效的影响

目的:探讨自配低糖高脂营养膳食对慢性阻塞性肺疾病急性发作(AECOPD)并发呼吸衰竭病人疗效的影响. 方法:将78例COPD急性发作(AECOPD)并发呼吸衰竭进行机械通气病人,随机分为试验组(n=38)和对照组(n=40).两组病人均采用鼻饲肠内营养(EN)治疗,试验组采用自配低糖高脂膳食,对照组采用整蛋白营养制剂(瑞素),具体能量摄入依据病人实际情况而定,分别于营养治疗第1天和治疗后第14天测定病人二氧化碳生成量(VCO2)、氧耗量(VO2)、肺活量(FVC)和1 s用力呼气容积占最大肺活量的比值(FEV1/FVC)、二氧化碳分压(PaCO2)、氧分压(PaO2)、pH值以及第14天脱机成功率、机械通气时间、病死率和营养支持费用等指标.结果:治疗前,两组病人的各项指标测定值无显著性差异(P＞0.05).治疗第14天,两组病人的各项指标均较治疗前有所改善,且差异有显著性统计学意义(P＜0.05).试验组较对照组改善更加明显,差异有显著性统计学意义(P＜0.05). 结论:自配低糖高脂营养膳食对AECOPD并发呼吸衰竭病人有明显的临床治疗效果.     

适应性支持通气对COPD及支气管哮喘合并呼吸衰竭患者呼吸力学的影响

目的探讨适应性支持通气(ASV)对慢性阻塞性肺疾病(COPD)及支气管哮喘合并呼吸衰竭患者呼吸力学的影响。方法选择需要行机械通气的呼吸衰竭患者共21例,随机分为两组,分别行常规通气模式容量控制通气(CMV)/压力支持通气(PSV)+同步间歇指令通气(SIMV)和ASV进行机械通气,记录两种模式下的各项呼吸力学参数。结果全部患者均成功脱机,呼吸频率明显降低、潮气量(VT)明显升高(P<0.05),气道峰压(PIP)和吸气阻力(R)下降显著(P<0.05),静脉顺应性(Cstat)逐渐增加(P<0.05)。ASV通气患者的上机时间明显缩短(P<0.05)。结论ASV可根据患者的呼吸力学状况自动调整吸气压力支持水平,提高潮气量,降低呼吸频率,而对血流动力学和生命体征没有影响,并能缩短上机时间,明显优于常规通气。