两种鼻腔气管插管时的通气方法的比较

在经鼻腔气管插管全麻诱导时，常用面罩加压供氧获得一定的效果，但有部分患者，由于下颌托起困难、口唇开启受限、舌根后坠、和术前留置的鼻胃管、气管导管、小下颌等因素，致使面罩弥盖不严或通气时阻力增大，因无通气时间延长，而可能引发缺氧性并发症。本文采用气管插入鼻腔后，在肌肉松弛下直接连接麻醉机，人工加压通气，较好的克服了面罩加压通气时的困难。     

机械通气呼吸道护理44例分析

机械通气的应用，通常是治疗呼吸衰竭的最后手段，如处理得当，可起到其它治疗方法难以替代的挽救重危患者生命的作用。人工气道建立后，人工气道的护理就成为呼吸机治疗中很重要的环节，人工气道的护理质量直接影响着机械通气的疗效。本文着重总结机械通气呼吸道护理的实践体会。     

经鼻气管插管并胃管置入常见问题的处理

对呼吸道不畅需经鼻气管插管机械通气不能经口进食患者，需通过另一侧鼻腔置入胃管进行鼻饲，以保证其营养，满足机体代谢需要，促进身体康复。我院2003／2006—03经鼻气管插管机械通气抢救50例，均行鼻饲提供营养。现将胃管置入过程中存在的问题的处理如下。     

高频部分液体通气对吸入性损伤犬呼吸功的影响

目的　观察高频喷射通气结合小剂量氟碳 (3ml/kg)液体通气对吸入性损伤犬呼吸的功影响。方法　将 16条犬经蒸气吸入造成吸入性损伤模型 ,并随机分为两组 ,即对照组和治疗组。两组动物致伤后均行高频喷射通气 ,但治疗组动物同时经气管导管将氟碳液体 (3ml/kg)缓慢注入肺内 ,在 90min内测机械通气功 (WOBvent)。结果　治疗组在给予小剂量氟碳后的WOBvent与致伤后比较差异无显著意义 (P >0 0 5 ) ,对照组治疗后的WOBvent与致伤后比较差异亦无显著意义 (P >0 0 5 ) ,治疗组与对照组各时间点的WOBvent比较差异均无显著意义 (P >0 0 5 )。结论　高频喷射通气合并小剂量氟碳 (3ml/kg)部分液体通气并不增加动物的呼吸功。     

允许性高碳酸血症通气法治疗呼吸窘迫综合征

目的：探讨允许性高碳酸血症通气法在治疗呼吸窘迫综合征中的价值。方法：随机选择46例需机械通气治疗的呼吸窘迫综合征患儿分为两组，对照组以传统通气方式治疗；允许性高碳酸血症通气法（治疗组）调节吸气峰压、呼气末压力、平均气道压等通气条件，维持血气PaCO2在45～55mmHg。比较两组通气条件、通气过程中血气值、并发症发生率和．病死率。结果：两组在通气过程中，氧舍指数（PaO2／FiO2）、pH值7LPaO2差异无显著性（P〉0．05），PaCO2差异有显著性（P〈0．01），允许性高碳酸血症通气法组上机时间显著减少（P〈0．05），气漏等并发症发生率明显降低．可降低病死率。结论：允许性高碳酸血症通气法在呼吸窘迫综合征治疗中较传统通气方式能降低并发症的发生率和缩短通气时间。     

胸壁挤压吸痰法在NICU机械通气新生儿呼吸道管理中的应用

目的：探讨胸壁挤压法在NICU机械通气新生儿排痰护理中的应用及效果。方法：将101例人住NICU病房需机械通气排痰的新生儿按住院号的单双号，随机分为干预组51例和对照组50例。对照组采取常规排痰护理措施，干预组除采取常规排痰护理措施外，加用胸壁挤压法，并对两组新生儿排痰后的血氧饱和度上升幅度、肺部听诊情况及医院获得性肺炎、刺激性干咳、肺不张等并发症的情况进行比较。结果：干预组新生儿排痰后的血氧饱和度上升幅度、肺部听诊优良率高于对照组（P〈0．01），并发症发生情况低于对照组（P〈0．01）。结论：胸壁挤压法在NICU机械通气新生儿排痰护理中的应用效果较好，值得临床推广应用。     

双水平气道正压通气治疗慢性阻塞性肺疾病并重症Ⅱ型呼吸衰竭的效果

[目的]探讨双水平气道正压（BiPAP）通气在治疗慢性阻塞性肺疾病（COPD）合并重症Ⅱ型呼吸衰竭的效果。[方法]在常规应用抗菌药物及时症治疗的基础上给予BiPAP通气，分别于机械通气前及通气后2h～4h、12h～24h行血气分析测定，并观察病情变化。[结果]BiPAP通气后，血二氧化碳分压（PaCO2）和pH均明显改善，以通气12h～24h较通气2h～4h更明显，血氧分压（PaO2）仅在通气后2h～4h升高，血HCO2-在通气前后则无明显变化。23例在BiPAP通气后症状改善，有效率达88．5％，2例BiPAP通气无效者给予气管插管机械通气后抢救成功，1例未行气管插管者治疗无效死亡。[结论]BiPAP通气是抢救COPD并重症Ⅱ型呼吸衰竭的一种有效措施。     

有创与无创序贯性机械通气在慢性阻塞性肺疾病并急性呼吸衰竭病人中的应用

目的探讨慢性阻塞性肺疾病（COPD）并发急性呼吸衰竭病人从有创通气过渡到无创通气时机和效果。方法将26例COPD并发急性呼吸衰竭且实施有创机械通气的病人，待肺部感染明显控制时，随机分为两组，各13例。序贯组拔除气管插管，改用经鼻面罩压力支持通气＋呼气末正压（PSV＋PEEP）通气，以后渐减PSV水平直至脱离呼吸机；对照组继续按常规行有创机械通气，以SIMV＋PSV方式撤机。动态观察并比较两组通气及氧合指标、有创和总机械通气时间、住院天数、呼吸机相关肺炎的发生情况。结果序贯组与对照组治疗前各项指标比较差异无显著性（P〉0．05）。序贯组有创机械通气时间、总机械通气时间、住院天数较对照组明显缩短，差异有显著性（t′=2．545～3．498，P〈0．05、0．01）；呼吸机相关肺炎发生率低于对照组，差异有显著性（P=0．019）。结论对并发明显支气管、肺部感染行有创机械通气病人，以肺部感染明显控制为时机早期拔管，改用经鼻面罩无创通气可以显著改善治疗效果。     

机械通气192例人工气道的护理管理

目的：探讨机械通气患者实施人工气道护理管理的临床意义。方法：对192例机械通气患者实施人工气道管理进行临床观察和分析。结果：实施有效的人工气道管理后,本组患者拔管后痊愈181例。结论：实施有效的人工气道管理可使患者机械通气时间缩短,促进治疗和恢复。     

停通气大鼠脑电和神经功能的变化

目的：观察大鼠给予不同时间停通气后脑电图和神经功能的变化。 方法：实验于2005-03在北京神经外科研究所提供实验室完成。4月龄雄性清洁级Wistar大鼠144只，体质量260-290g，随机数字表法分为停通气1，2，3，4，5，6和7min组和对照组，每组18只。气管插管后应用肌松药消除大鼠自主呼吸，停通气相应预定的时间（停通气1，2，3，4，5，6和7min）后立即恢复通气和心肺复苏，记录从开始停通气至平均动脉压〈25mmHg的时间（TCA）和从开始复苏至收缩压≥60mmHg的时间（TROSC），复苏成功者继续呼吸机支持60min，全程记录脑电图变化。记录复苏后24，48和72h神经功能评分情况。 结果：①对照组、停通气1，2，3min组大鼠全部存活；停通气4，5，6min组分别有12，8和3只大鼠复苏成功，停通气4和5min组各有1只大鼠在复苏后24h内死亡，以上3组死亡率分别为33％、61％和83％；停通气7min组大鼠无1只复苏成功，死亡率100％。②停通气3min以上组所有大鼠均发生循环停止，开始停通气到循环停止的时间组间差异无显著性意义。停通气4，5和6min组开始复苏到自主循环恢复的时间较停通气3min组明显延长（p〈0．05），停通气5和6min组较停通气4min组亦明显延长（P〈0．05）。③停通气后脑电图频率和波幅降低直至等电位，随停通气时间的延长，恢复通气后持续脑电图出现时间明显延长（P〈0．05）。④对照组和停通气1，2，3min组神经功能评分均正常，停通气4，5和6min组神经功能评分显著低于对照组（P〈0．01），停通气6min组较停通气4min组亦明显降低（P〈0．01），各组神经功能评分组内比较差异无显著性意义。 结论：大鼠停通气2min内无循环停止，恢复通气后可直接出现持续脑电图；3min时均循环停止，但都可成功复苏且神经功能评分未受影响，恢复通气后首先出现单个爆发棘波，随后棘波出现频率逐渐增多并最终出现持续脑电图；4min以上时仅部分大鼠可成功复苏，随停通气时间的延长，复苏后神经功能评分明显降低，死亡率明显升高，棘波出现时间和持续脑电图出现时间也明显延长；7min时无一复苏成功。通过实验建立了不同时间停通气损伤后大鼠死亡率、脑电图和神经功能的变化规律的动物模型。     

Hemodynamic and metabolic changes during and following operation

During anesthesia and operation, there appears to be a common state wherein oxygen consumption is inadequate to meet intraoperative metabolic requirements. Although there is insufficient information to fully explain this problem, decreased intraoperative levels of cardiac output and oxygen delivery, altered intraoperative oxygen transport at the microcirculatory and cellular levels, and altered delivery of oxidative substrate are possible contributors. Anesthesia and operation thus appear to produce a physiologic pattern similar to other shock states. Postoperative physiologic changes include increased cardiac output and increased oxygen delivery, necessary to support increased oxygen consumption. These postoperative changes may represent compensatory physiologic responses to preoperative and intraoperative oxidative and metabolic deficits. There are also significant energy needs of the healing surgical wound. These additional energy requirements for wound healing add to the degree of increase in metabolism necessary for recovery from operation. The postoperative increase in oxygen consumption appears to be essential to reverse intraoperative deficits, and has been reported to have survival value. Clinically, a major goal of postoperative therapy should thus be to support these necessary physiologic compensations. Titration of postoperative therapy should therefore not be to "normal" physiologic endpoints, but to the supernormal cardiac output and oxygen transport necessary for recovery in postoperative patients.     

Comparison of two different oxygen delivery methods in the early postoperative period: randomized trial

Title.  Comparison of two different oxygen delivery methods in the early postoperative period: randomized trial.
Aim.  This paper is a report of a study conducted to compare the effects of two different oxygen delivery methods on both patient peripheral oxygen saturation and patient satisfaction.
Background.  One of the most serious problems encountered in the early postoperative period is hypoxemia. Giving oxygen to patients in the perioperative period reduces the incidence of hypoxemia. Oxygen is generally delivered to patients through oxygen masks or nasal cannulae. Previous studies have shown that face masks and nasal cannulae are effective in the early postoperative period.
Method.  A randomized trial was conducted between 2007 and 2008 with patients undergoing thyroidectomy. In the early postoperative period, 5 L/minute of oxygen was given to patients via an oxygen mask ( n  = 53) or nasal cannulae ( n  = 53). Peripheral oxygen saturation were measured by pulse oxymeter every 5 minutes for a 30-minute period. The Postoperative Nausea Vomiting Scale was used and patient satisfaction was evaluated using a 10-point scale.
Results.  Average peripheral oxygen saturation for the nasal cannulae group was statistically significant higher than that in the mask group. This difference arose from more frequent removal of the oxygen mask than the nasal cannulae by patients and healthcare professionals. Average satisfaction scores for patients in the nasal cannulae group were statistically significantly higher than those in the mask group.
Conclusion.  During the early postoperative period, using nasal cannulae for patients undergoing thyroidectomy increases oxygenation.     

Effect of postoperative supplemental oxygen on nausea and vomiting after cesarean birth.

Postoperative nausea and vomiting (PONV) has a significant impact on patients and health care providers. Some nonpharmacologic methods may have an effect on PONV. Administration of supplemental oxygen (80%) during and for 2 hours after surgery has been shown to reduce the incidence of PONV from 44% to 22%. However, the effect of limiting supplemental oxygen to the immediate postoperative period on PONV is unknown. The purpose of this study was to test the efficacy of postoperative supplemental oxygen in reducing the incidence of PONV. Patients (n = 106) undergoing cesarean birth were given general anesthesia with 50% oxygen balanced nitrous oxide and in the postoperative period were randomly assigned to 2 groups. Patients in the experimental group received 8 L/min oxygen by a simple face mask for 6 hours. The control group received routine care of oxygen 5 L/min in the PACU and no supplemental oxygen on the ward. Trained nurses evaluated pulse oximetry and PONV after surgery. The incidence of PONV during the first 6 postoperative hours was 28.3% in the experimental group and 24.5% in the control group ( P = .659). There was no statistically significant difference between the 2 groups. In this study, postoperative supplemental oxygen 8 L/min did not prevent PONV in patients undergoing cesarean birth.     

Tissue and wound healing effects of short duration postoperative oxygen therapy

The purpose of this study was to determine the effects of 28% oxygen given in the first 36 hours after surgery on tissue oxygen, collagen deposition, and clinical healing outcomes. Twenty-four subjects having cervical spine surgical procedures participated in a randomized, repeated-measures pilot study of tissue and healing effects of postoperative supplemental oxygen. The treatment group (n = 13) received 28% oxygen for the first 36 postoperative hours, whereas the control group (n = 11) was maintained on room air. Subcutaneous tissue oxygen and temperature were measured at intervals up to 36 hours postsurgery. Wound healing was evaluated by hydroxyproline content in a subcutaneous polytetrafluoroethylene tube removed on the 7th postoperative day. Clinical outcomes were evaluated for the 30 days post-hospital discharge. Subjects in the treatment group had significantly higher tissue oxygen tension overall, and at postoperative hours 1, 2, 18, and 36, with mean values 10 to 20 mm Hg higher than control subjects. Significant differences were not found in hydroxyproline levels or clinical wound outcome measures. Low level, short duration, supplemental oxygen increased and sustained wound tissue oxygen and was well tolerated by subjects. Larger studies of populations at risk for wound complications are needed to investigate variables of dose and duration of oxygen therapy in relation to clinical and cellular wound healing outcomes.     

肝移植后机械通气50例分析

背景:人工机械通气是肝移植后必须经历的一个阶段,移植后机械通气与多种因素有关。目的:探讨影响肝移植机械通气撤机的影响因素。方法:采用回顾性方法分析机械通气时间的长短(24h)与移植前并发症,移植中氧代谢,移植后肝、肾功能和脱机前、后血气及电解质的关系。结果与结论:肝移植后机械通气时间的长短与移植前并发症、移植中氧代谢、移植后肝肾功能有关(P<0.05),而与脱机前后血气及电解质无关(P>0.05)。说明移植前并发症、移植中氧代谢、移植后肝肾功能可影响肝移植后机械通气时间。     

Time course of and stimuli to compensatory growth of the lung after pneumonectomy.

Left pneumonectomy in the mature rat led to an increase of [3Ha1 thymidine incorporation into DNA of the remaining lung in the first 3 postoperative days, and resulted in a subsequent 38% increase of lung weight and 41% increase of lung tissue volume measured 1 wk after surgery. Despite these early changes, total lung volume (TLV) did not increase until the 2nd postoperative wk, reaching values 33% greater than in controls. Analysis of lung pressure-volume curves revealed that lung recoil was increased at low lung volumes 1 wk after surgery, but returned to normal by the 2nd postoperative wk, suggesting that synthesis of both lung elastin and collagen had occurred by this time. Increased inspired oxygen concentration (28% or 35%) during the 1st but not the 2nd postoperative wk abolished the change in TLV without influencing the increase in lung weight, while diminished inspired oxygen (17% or 14%) accentuated the postoperative increase in TLV. Lung pressure-volume curves demonstrated changes in distensibility at low lung volumes, suggesting that oxygen may have influenced synthesis or cross-linking of lung elastin. Alterations of minute ventilation in the postoperative period produced by 3% CO2 did not influence the compensatory growth process, nor did administration of cyclophosphamide. These studies suggest that postpneumonectomy lung growth is a two-phase process, beginning with cell proliferation and increased tissue volume, followed by increasing lung volume associated with formation of lung structural proteins. The latter process is profoundly influenced by inspired oxygen concentration in the early postoperative period.     

Are nasal spectacles adequate for supplementary oxygen in patients after anaesthesia?

Two methods of oxygen delivery were compared when used postoperatively after a general anaesthetic had been administered. There were 255 patients randomly allocated to receive oxygen via nasal spectacles or a Hudson face mask in the initial postoperative period. Oxygen saturation was monitored using pulse oximetry. Seven percent of patients who received the Hudson mask and 14% of patients who received nasal spectacles desaturated below 94% (P = 0.10). Age, weight or American Society of Anesthesiologists (ASA) status did not predict oxygen desaturation; however, desaturation occurred more frequently in male patients with nasal spectacles undergoing abdominal surgery. If male patients who had abdominal surgery with muscle relaxants are excluded from the nasal spectacle group, the desaturation incidences for spectacles and masks are similar (10% versus 7%, P = 0.38). Using nasal spectacles for all postoperative oxygen therapy in selected patients is therefore feasible and could provide substantial cost-saving.     

Hypoxemia after coronary bypass surgery modeled by resistance to oxygen diffusion

OBJECTIVE: To evaluate a model describing postoperative hypoxemia after cardiac surgery by using two variables, i.e., shunt and resistance to oxygen diffusion (Rdff). DESIGN: Estimation of these two variables in normal subjects and postoperative cardiac patients. SETTING: The pulmonary function laboratory for the normal subjects and the intensive care unit for the cardiac patients. PATIENTS/SUBJECTS: Nine postoperative cardiac patients and six healthy subjects. INTERVENTIONS: Inspired oxygen fraction was varied in normal subjects and in cardiac patients 3-6 hrs after surgery. This variation occurred in four to seven steps to achieve arterial oxygen saturations in the range 0.90-1.00. MEASUREMENTS AND MAIN RESULTS: Measurements were taken of arterial oxygen saturation, cardiac output, ventilation, and end-tidal gases at each inspired oxygen fraction. These measurements gave the following estimates for the normal subjects: shunt = 3.9+/-5.4% (mean +/- SD) and Rdiff = -5+/-16 torr/(L/min) [-0.7+/-2.2 kPa/(L/min)]; for the cardiac patients: shunt = 7.7+/-1.8% and Rdiff = 212+/-230 torr/(L/min) [28.2+/-30.6 kPa/(L/min)]. The increase in Rdiff (P = .01) was sufficient to explain the observed hypoxemia in these patients. The value for shunt was not significantly increased in the patients (p = .09). The two-variable model (shunt and Rdff) gave a better prediction of arterial oxygen saturation than a model with shunt as the only variable (p = .02). CONCLUSIONS: In cardiac patients requiring supplementary oxygen, the respiratory abnormality could, in our model, be best described by an increased Rdiff, not by an increased shunt value.     

两种不同雾化方式对老年患者术后血氧含量影响的研究

目的探讨两种不同雾化方式对老年患者插管全麻术后血氧含量的影响,从而选择最佳的雾化方式,防止术后肺部感染等并发症。方法采用自身对照研究,患者分别采用A、B两种不同雾化方式。A方式采用电动超声雾化吸入;B方式采用高频有氧射流雾化吸入,动态记录两组雾化吸入前、后的血氧饱和度变化及测定其血气分析的变化。结果两种雾化方式血气分析比较,在PO2、STO2、SPO2、pH方面P<0.05,差异有显著性意义。结论采用高频有氧射流雾化吸入可有效提高患者的血氧饱和度和PO2,减少老年患者术后肺及心脑血管并发症的发生。     

64例非体外循环冠状动脉旁路移植患者手术后低氧血症的监护

总结64例非体外循环冠状动脉旁路移植患者手术后低氧血症的护理经验,认为心功能维护、呼吸管理以及出血监护和疼痛护理,是监护重点和难点。尤其要严密监测心率、血压、中心静脉压、心输出量、血氧饱和度和氧合指数的变化,及时掌握心功能和氧的供需平衡情况;实施限制性液体管理对策,术后早期保持轻度负平衡状态,特别对高龄、心肺功能较差的患者,以助于改善氧合;掌握低氧血症患者吸痰的正确方法,进行加温湿化氧疗,做到合理通气管理。经精心护理,63例低氧血症患者得以纠正,1例患者因重度低心排、低氧血症不能纠正而死亡。