ICU机械通气治疗27例患者的体会

目的探讨如何提高ICU机械通气治疗的水平，从而达到治疗及挽救生命的目的。方法通过近一年来ICU病房施行机械通气治疗的27例患者的治疗体会，总结经验教训，指导今后的治疗，预防并发症的发生。结果27例患者中，急性呼吸窘迫综合征（ARDS）患者8例，死亡1例；急性重症哮喘病例2例，无死亡；慢性阻塞性肺疾病（COPD）患者10例，死亡2例；格林-巴利综合征患者1例，无死亡；重症肌无力患者1例，无死亡；急性中毒致呼吸衰竭5例，死亡1例。结论外伤、重症肺炎所致ARDS患者应早上机，以肺的保护措施为主，并在上机的过程中注意患者的体位、液体出入量及肺损伤等情况，急性重症哮喘患者经常规治疗无效，应立即上机治疗，以缓解症状，COPD患者急性发作时，经药物治疗不能缓解严重的CO2潴留及低氧血症时，应尽早上机治疗。格林-巴利综合征患者及重症肌无力患者累及呼吸肌时，应立即上机治疗。在机械通气治疗过程中，要注意痰的细菌培养及药敏，选用敏感抗生素，加强抗感染治疗，预防呼吸机相关性肺炎的发生；要加强基础护理，加强营养支持治疗，同时要注意肺的试验保护，避免肺机械性损伤。     

双水平无创正压通气在慢性阻塞性肺疾病并发肺性脑病治疗中的作用

目的：评价双水平无创正压通气（BiPAP）对慢性阻塞性肺疾病（COPD）并发肺性脑病治疗中的作用。方法：32例COPD并发肺性脑病患者在综合治疗基础上用BiPAP治疗观察前后血气分析与临床症状的变化。结果：28例患者治疗后血气分析与临床症状较治疗前明显改善，4例患者病情加重，2例自动出院，2例死亡。结论：BiPAP对COPD并发肺性脑病具有积极的治疗意义。     

肺保护性通气策略治疗急性呼吸窘迫综合征的临床探讨

目的探讨肺保护性通气策略治疗急性呼吸窘迫综合征（ARDS）的临床疗效。方法 36例ARDS患者采用肺保护性通气策略,给予适当的呼气末正压（PEEP）,小潮气量（6～8 ml/kg）,平台压控制于30～35 cm H2O以下,观察抢救成功率、机械通气时间、病死率及机械通气并发症。结果 36例患者中成功脱机30例,病情平稳后转出ICU,抢救成功率83.3%。出现呼吸机相关性肺炎2例。6例患者死亡,病死率16.7%。结论对于ARDS患者应用肺保护性策略进行机械通气,能够改善氧合,降低呼吸机相关肺损伤的发生率,提高抢救成功率,改善预后。     

降钙素原在慢性阻塞性肺疾病急性加重期中指导抗生素使用的价值

目的：评价降钙素原（PCT）对于慢性阻塞性肺疾病急性加重期（AECOPD）患者使用抗生素的指导价值。方法：本研究纳入74例AECOPD患者,随机分成PCT组和对照治疗组。其中PCT组根据PCT策略决定抗生素的使用;对照组根据患者临床症状进行经验性抗生素使用。主要观察指标包括抗生素的使用时间、住院时间、加重例数和死亡例数等。结果：两组数据结果对比显示,在死亡率和病情加重例数无显著差异的情况下,PCT组患者抗生素使用时间、住院时间明显减少,与对照治疗组具有显著差异。结论：PCT指导AECOPD抗感染治疗在不影响病情的情况下能够有效减少抗生素使用并且缩短患者的住院时间。     

双水平无创通气治疗慢性阻塞性肺疾病并肺性脑病临床分析

目的：评价双水平无创通气（BiPAP）对慢性阻塞性肺疾病（COPD）并肺性脑病的临床疗效。方法：27例COPD并肺性脑病患者在综合治疗基础上用BiPAP治疗,观察治疗前后血气分析与临床症状的变化。结果：24例患者治疗后,血气分析与临床症状较治疗前明显改善,余3例患者病情加重,1例自动出院,2例死亡。结论：BiPAP对COPD呼吸衰竭并肺性脑病具有积极的治疗意义。     

机械通气早期乳酸清除率对重症COPD患者预后的影响

目的探讨早期乳酸清除率对机械通气治疗慢性阻塞性肺疾病加重期（AECOPD）合并呼吸衰竭患者预后的影响。方法选取AECOPD合并呼吸衰竭住院患者48例进行观察研究,根据患者病情转归分为存活组32例和死亡组16例;测定患者治疗前与治疗6 h后的动脉血乳酸、动脉血气、APACHEⅡ评分及早期（6 h）乳酸清除率。结果存活组中高乳酸清除率为84.4%,高于死亡组的18.8%,差异有统计学意义（P〈0.01）。结论早期乳酸清除率有助于AECOPD合并呼吸衰竭的预后判断和治疗指导。     

慢性阻塞性肺疾病伴Ⅱ型呼吸衰竭应用机械通气治疗的护理体会

目的:总结慢性阻塞性肺疾病伴Ⅱ型呼吸衰竭患者应用机械通气治疗的临床护理经验。方法:回顾性分析68例慢性阻塞性肺疾病伴Ⅱ型呼吸衰竭患者在接受常规性治疗基础上进行机械通气治疗与护理,观察并总结患者预后及转归情况。结果:68例患者中有60例病情逐渐好转并安全脱机,8例因多脏器功能衰竭死亡。结论:对慢性阻塞性肺疾病伴Ⅱ型呼吸衰竭患者在应用机械通气治疗期间,积极采取相应的、有效的护理措施,严密观察治疗反应和病情变化是治疗成功的重要保障。     

无创正压通气辅助治疗慢性阻塞性肺疾病患者的观察与护理

目的总结双气道正压通气（BiPAP）治疗慢性阻塞性肺疾病的护理特点和注意事项。方法对30例COPD合并呼衰的患者在其他综合治疗的同时加用BiPAP呼吸机无创通气治疗，治疗前后进行心理护理、监测和评估通气效果、加强管道护理、加强消毒隔离、加强营养、防止并发症、撤机护理等做好对症护理。结果28例坚持无创通气至病情稳定获得满意疗效，2例患者合并并发症而死亡。结论应用BiPAP呼吸机无创正压通气治疗COPD患者是一种安全有效的方法，细致、周到的护理是治疗成功的重要保证。     

无创正压通气法治疗慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭

目的：探讨无创正压通气法治疗慢性阻塞性肺疾病（COPD）合并Ⅱ型呼吸衰竭的临床疗效。方法：57例COPD患者按受了无创正压通气治疗，观察治疗后患者临床疗效，采用t检验比较治疗前后动脉血气分析变化。结果：51例患者（89.5％）经无创正压通气法治疗后病情明显好转，动脉血PH值及氧分压分别显著高于治疗前水平（P〈0．05），二氧化碳分压显著低于治疗前水平（P〈0．05）。结论：早期使用无创正压通气可以有效治疗慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭。     

有创机械通气抢救重度急性左心衰竭23例分析

目的：观察有创机械通气辅助治疗重症急性左心衰的治疗效果。方法：回顾分析23例常规治疗无效而加用有创机械通气治疗的重度急性左心衰患者的临床资料,比较机械通气前后血气分析结果的变化和治疗前后病情情况。结果：机械通气后2h患者pH值、PO2、PCO2、SPO2、心率和呼吸频率等各项监测指标较机械通气前明显改善（P〈0.01）。23例患者中有20例患者在24～96h内成功撤机,呼吸困难明显缓解,口唇发绀、肺部湿罗音明显减少,动脉血氧分压及动脉二氧化碳分压基本恢复正常,总有效率86.9%（20/23）;3例患者撤机后死亡,其中1例因多脏器功能衰竭死亡,2例为心源性休克死亡,病死率13.1%（3/23）。结论：有创机械通气可明显改善重度急性左心衰患者的病情和血气分析各项指标,是治疗重度急性左心衰的有效手段。     

Early initiation of extracorporeal membrane oxygenation (ECMO) in emergency department to rescue severe diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a serious disease whose main clinical manifestations are hemoptysis and dyspnea. In some cases, invasive mechanical ventilation is ineffective and patients can die quickly. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy that can provide oxygenation support to patients when mechanical ventilation fails. This article reports successful early initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO) in an emergency department to rescue an adult patient with diffuse alveolar hemorrhage caused by viral pneumonia.     

Noninvasive ventilation in neuromuscular disease: equipment and application

Noninvasive support of ventilation is commonly needed in patients with neuromuscular disease. Body ventilators, which are used rarely, function by applying intermittent negative pressure to the thorax or abdomen. More commonly, noninvasive positive-pressure ventilation (NPPV) is used. This therapy can be applied with a variety of interfaces, ventilators, and ventilator settings. The patient interface has a major impact on comfort during NPPV. The most commonly used interfaces are nasal masks and oronasal masks. Other interfaces include nasal pillows, total face masks, helmets, and mouthpieces. Theoretically, any ventilator can be attached to a mask rather than an artificial airway. Portable pressure ventilators (bi-level positive airway pressure) are available specifically to provide NPPV and are commonly used to provide this therapy. Selection of NPPV settings in patients with neuromuscular disease is often done empirically and is symptom-based. Selection of settings can also be based on the results of physiologic studies or sleep studies. The use of NPPV in this patient population is likely to expand, particularly with increasing evidence that it is life-prolonging in patients with diseases such as amyotrophic lateral sclerosis. Appropriate selection of equipment and settings for NPPV is paramount to the success of this therapy.     

A clinical case of botulism

A patient with botulism (type E) has been subject to complex therapy, which involved specific serotherapy, infusion therapy, and controlled lung ventilation with the following assisted lung ventilation.     

无创呼吸机治疗慢性阻塞性肺疾病22例疗效观察

目的探讨慢性阻塞性肺疾病（COPD）合并Ⅱ型呼吸衰竭患者无创呼吸机治疗的疗效性和安全性。方法对我院2006年7月至2009年8月因COPD合并Ⅱ型呼吸衰竭常规药物治疗无效时使用无创呼吸机治疗的22例患者的临床资料进行系统回顾性分析,观察患者使用无创呼吸机前后的神志,血气分析,呼吸和心率的变化。结果 18例患者经无创机械通气治疗后呼吸频率（RR）、心率（HR）、动脉血pH、氧分压（PaO2）、二氧化碳分压（PaCO2）均明显改善。1例患者出现皮下气肿,1例患者治疗无效而改为有创机械通气,3例患者最终治疗无效死亡。结论无创呼吸机通气治疗COPD急性加重期并发Ⅱ型呼吸衰竭可明显提高PaO2,降低PaCO2,纠正缺氧和二氧化碳潴留,是一种行之有效的方法 。     

无创正压通气治疗慢性阻塞性肺疾病合并呼吸衰竭的护理干预

目的探讨护理干预对无创正压通气（NIPPV）治疗慢性阻塞性肺疾病（COPD）急性加重期合并呼吸衰竭的影响。方法2006年1月-2008年1月将47例患者随机分为干预组和对照组,两组均给予常规药物加NIPPV治疗。干预组24例应用NIPPV治疗期间,专人给予护理干预,与对照组（给予常规护理）23例比较,观察两组2、24、48、72h血气变化及病情转归。结果两组动脉血气分析差异有统计学意义（P〈0.01）。干预组24例中仅1例改换为有创机械通气,余23例顺利完成治疗。对照组12例顺利完成治疗,3例勉强完成治疗,5例于治疗中改换为有创机械通气,2例上机后1h内不能耐受而拒绝NIPPV,放弃抢救自动出院,1例因急性消化道大出血抢救无效死亡。结论专人护理干预提高了双水平NIPPV治疗COPD急性加重期合并呼吸衰竭的临床疗效,减少气管插管有创机械通气给患者带来的痛苦及相关并发症,节约了费用,提高了生活质量。     

Successful treatment of acute respiratory distress syndrome and severe pulmonary hypertension in a child with Bordetella pertussis infection

Infection with Bordetella pertussis can cause severe illness with neurological and pulmonary complications in children. Pulmonary hypertension is an early sign of potentially fatal disease and can cause failure of conventional respiratory therapy in severe acute respiratory distress syndrome (ARDS). We report a 4 1/2-year-old boy with B. pertussis infection who developed severe ARDS and pulmonary hypertension. Because of severe neurological signs the patient did not qualify for extracorporal membrane oxygenation (ECMO). After conventional ventilation, surfactant and high frequency oscillation ventilation (HFOV) failed, treatment with nitric oxide (NO) improved oxygenation, allowing recovery without the need for ECMO. The patient survived with few sequelae. Thus, this treatment may be an option in high-risk children who meet the criteria for ECMO but are excluded because of poor neurological status, as in our patient.     

早期清醒俯卧位联合经鼻高流量氧疗治疗重型新型冠状病毒肺炎一例

在新型冠状病毒肺炎（简称“新冠肺炎”）疫情防控的早期阶段,由于对疾病的认识不足,重症患者治疗难度大、病死率高,这对ICU医师提出了挑战。皖南医学院弋矶山医院在疫情防控早期阶段收治1例重型新冠肺炎患者,结合既往急性呼吸窘迫综合征（ARDS）的处理经验,采用早期清醒俯卧位联合经鼻高流量氧疗（HFNC）治疗,成功避免气管插管和机械通气,最终患者康复出院。本文报告该病例的综合救治过程,并结合文献,分析清醒俯卧位联合HFNC治疗重型新冠肺炎的循证医学依据、注意事项和及时转为有创机械通气的时机,提出“俯卧位前移”的概念,为重症新冠肺炎患者救治提供有力的医疗决策。     

High-frequency chest-wall oscillation in a noninvasive-ventilation-dependent patient with type 1 spinal muscular atrophy

With the recent increased use of noninvasive ventilation, the prognoses of children with neuromuscular disease has improved significantly. However, children with muscle weakness remain at risk for recurrent respiratory infection and atelectasis. We report the case of a young girl with type 1 spinal muscular atrophy who was dependent on noninvasive ventilation, and in whom conventional secretion-clearance physiotherapy became insufficient to clear secretions. We initiated high-frequency chest-wall oscillation (HFCWO) as a rescue therapy, and she had improved self-ventilation time. This is the first case report of HFCWO for secretion clearance in a severely weak child with type 1 spinal muscular atrophy. In a patient with neuromuscular disease and severe respiratory infection and compromise, HFCWO can be used safely in combination with conventional secretion-clearance physiotherapy.     

Physical therapy for a patient in acute respiratory failure

BACKGROUND AND PURPOSE: The main indications for physical therapy for patients in intensive care units (ICUs) are excessive pulmonary secretions or atelectasis. Timely physical therapy interventions may improve gas exchange and reverse pathological progression, thereby curtailing or avoiding artificial ventilation. The purpose of this case report is to illustrate 24-hour availability of physical therapy for a patient with acute respiratory failure. CASE DESCRIPTION: The patient was a 66-year-old man who was admitted to an ICU for acute respiratory failure. Intensive physical therapy, based on Dean's physiologic treatment hierarchy for treatment of patients with impaired oxygen transport, consisted of upright body positioning, mobilization and exercise, and active cycles of breathing techniques every 2 hours for the first 12 hours he was in the ICU. OUTCOMES: In total, the patient received 11 physical therapy sessions over his 48-hour stay in the ICU (6 sessions on day 1 and 5 sessions on day 2). Arterial oxygenation improved markedly with radiographic resolution of infiltrates, and planned endotracheal intubation and mechanical ventilation were avoided. DISCUSSION: This patient with acute respiratory failure received physical therapy in a timely manner afforded by 24-hour access to physical therapy. The intensive physical therapy might be more cost-effective than if the patient had been managed with intubation and mechanical ventilation. Patients in ICUs who have excessive pulmonary secretions or atelectasis may benefit from access to physical therapy 24 hours a day.     

The i-gel supraglottic airway device improves airway management during endobronchial ablative therapy under general anesthesia: a case report

Endobronchial ablative therapy (EAT) in patients with preexisting obstructive airway disease can cause hypoxemia because bronchoscope insertion interferes with ventilation and a low fraction of inspired oxygen (FiO₂) is essential to avoid airway fire. A man in his early 50s with moderately severe obstructive airway disease was scheduled for EAT for treatment of tracheal papillomatosis. Ventilation and oxygenation would have been difficult because of narrowing of the endotracheal tube by bronchoscopic insertion and a low FiO₂; therefore, an i-gel supraglottic airway device with a larger inner diameter was inserted. All visible intratracheal papillomas were ablated by a potassium titanyl phosphate laser through the bronchoscopic port that passed through the lumen of the i-gel at an FiO₂ of 0.3. During anesthesia for EAT, the i-gel supraglottic airway device provided a wider lumen for ventilation. We were thus able to provide stable ventilation at an FiO₂ of 0.3 during EAT in this patient with obstructive airway disease, avoiding airway fire and hypoxemia.