机械通气治疗急性呼吸功能衰竭患者的护理

目的 探讨机械通气治疗急性呼吸衰竭的缶床护理.方法 回顾性总结2008年6月至2010年6月我院应用机械通气治疗45例急性呼吸衰竭患者的缶床护理方法.结果 45例安全撤机35例,抢救成功率为77.8%;死亡10例.上机时间4～16 d,平均(7±2)d.35例安全撤机患者发生胃肠胀气3例,面部皮肤受压红肿2例,口干1例,精神恐惧2例,经对症治疗和护理均不影响机械通气.结论 机械通气是目前治疗急性呼吸功能衰竭有效安全的方法,病情监护、气道管理、撤机护理等护理方法的正确掌握是提高抢救成功率的关键.     

Economics of mechanical ventilation and respiratory failure

For patients with acute respiratory failure, mechanical ventilation provides the most definitive life-sustaining therapy. Because of the intense resources required to care for these patients, its use accounts for considerable costs. There is great societal need to ensure that use of mechanical ventilation maximizes societal benefits while minimizing costs, and that mechanical ventilation, and ventilator support in general, is delivered in the most efficient and cost-effective manner. This review summarizes the economic aspects of mechanical ventilation and summarizes the existing literature that examines its economic impact cost effectiveness.     

Influence of mechanical ventilation on blood lactate in patients with acute respiratory failure

Objectives: To determine whether mechanical ventilation (MV) may affect blood lactate concentration in patients with acute respiratory failure. Design: Prospective observational study with follow-up to hospital discharge. Setting: A 17-bed medical and coronary intensive care unit in a 650-bed general hospital. Patients: 55 adult patients mechanically ventilated for acute respiratory failure between May 1996 and April 1997 were recruited. Measurements and results: Arterial blood samples for determination of plasma lactate and blood gas analysis were taken just before tracheal intubation on spontaneous breathing, and 20 and 60 min after the initiation of controlled MV. Cuff systemic arterial pressure was measured before tracheal intubation and every 10 min during the first h of MV. Hyperlactatemia (arterial blood lactate ≥ 2 mmol/l) was present in 21 of the 55 patients studied. After 20 min of MV, there was a decrease in blood lactate from 4.74 ± 1.78 to 3.07 ± 1.69 mmol/l (p < 0.01); 40 min later there was a further decrease to 2.63 ± 1.35 mmol/l (p < 0.05). The decrease in blood lactate was also observed in those patients who after starting MV developed systemic arterial hypotension (p < 0.01). In patients with a normal lactate concentration at the entry to the study, lactate remained the same after 60 min on MV (NS). Conclusions: Controlled MV decreases substantially the severity of hyperlactatemia in patients with acute respiratory failure, and any adverse circulatory effects of MV do not alter this beneficial outcome. Received: 16 December 1997 Accepted: 11 June 1998     

Outcome of mechanical ventilation for acute respiratory failure in patients with pulmonary fibrosis

OBJECTIVE: During the course of idiopathic pulmonary fibrosis patients may need invasive mechanical ventilation because of acute respiratory failure. We reviewed the charts of all patients with idiopathic pulmonary fibrosis admitted to our ICU for mechanical ventilation to describe their ICU course and prognosis. DESIGN AND SETTING: Retrospective, observational case series, from December 1996 to March 2001, in an 18-bed medical ICU in a tertiary university hospital. PATIENTS: Fourteen consecutive patients with idiopathic ( n=11) or secondary ( n=3) pulmonary fibrosis admitted to the medical ICU for mechanical ventilation. MEASUREMENTS AND RESULTS: Relevant factors of history and hospital course such as diagnostic and therapeutic interventions were retrieved as well as laboratory and radiological results. All patients were admitted for severe acute hypoxemic respiratory failure (PaO(2)/FIO(2) 111+/-64 mmHg), with a high clinical suspicion of lower respiratory tract infection. Despite ventilatory support and adjunctive therapies (antibiotics, steroids, or immunosuppressive drugs), all patients gradually worsened and eventually died in the ICU after a mean stay of 7.6+/-4.6 days. CONCLUSIONS: In this study mechanical ventilation for acute respiratory failure in pulmonary fibrosis patients was associated with a 100% mortality, despite aggressive therapeutic and diagnostic procedures.     

COPD伴严重呼吸衰竭病人的反复机械通气治疗研究

目的 探讨反复机械通气在慢性阻塞性肺疾病(COPD)伴严重呼吸衰竭治疗中的作用、临床效果及其并发症.方法 回顾性分析近年来收治的15例慢性阻塞性肺疾病伴严重性呼吸衰竭病人采用反复机械通气治疗的临床资料.结果 本组15例患者中,脱机拔管成功率达86%,首次通气后的平均存活时间＞1 093 d,中位生存期为1 673 d,1年生存率为73%,2年生存率为64%,3年生存率为33%.结论 对慢性阻塞性肺疾病伴呼吸衰竭患者,正确掌握机械通气的指征,及时建立人工气道,经气管插管或气管切开进行机械通气是抢救COPD急性加重期严重呼吸衰竭的有效措施.     

慢性阻塞性肺病呼吸衰竭患者机械通气预后预测模型研究

目的探讨判断慢性阻塞性肺病(COPD)呼吸衰竭患者机械通气预后的预测模型。方法将153例研究对象按死亡与否分为病例组和对照组,分别记录患者入院时的状态、辅助检查以及治疗过程。结果逐步Logistic回归建立的COPD呼吸衰竭患者机械通气预后预测模型有统计学意义,模型预测的灵敏度92.0%,特异度84.6%,模型预测与实际预后情况的符合率为88.2%。结论使用Logistic模型预测COPD呼吸衰竭患者机械通气的预后(死亡概率)具有可行性。     

肺结核合并呼吸衰竭患者机械通气治疗的护理

报告1例肺结核合并呼吸衰竭患者行机械通气治疗的护理.护理要点:加强负压病房的管理及消毒隔离;做好人工气道护理;给予心理支持;做好镇痛与镇静、发热、安全护理.经过6d治疗,患者成功脱机.     

机械通气的呼吸衰竭患者血清甲状腺素变化的意义

目的 探讨机械通气的呼吸衰竭患血清甲状腺素变化对病情严重程度、预后及脱机的意义。方法 对56例机械通气的呼吸衰竭患测定机械通气前及脱机前的血清甲状腺素与血气分析。结果 机械通气的呼吸衰竭患TT3、TT4、FT3、TSH均低于正常对照组，死亡组TT3、TT4、FT3、TSH、Pa02均低于存活组，脱机成功组TT3、TT4、FT3、TSH均恢复正常，脱机失败组血清甲状腺素持续低下，TT3、TT4、与Pa02成正相关。结论 血清甲状腺素水平监测可反映呼吸衰竭患病情的严重程度、预后，对脱机有指导意义。     

Indications for mechanical ventilation in adults with acute respiratory failure

Increased understanding of the mechanisms and effects of acute respiratory failure has not been accompanied by more precise criteria by which the clinician can determine when intubation should be carried out and invasive positive-pressure ventilation (IPPV) instituted in a given patient. The indications traditionally offered in reviews and textbooks have tended to be either so broad as not to be very helpful in an individual case, or of questionable clinical relevance and too cumbersome for practical use. This review updates the indications for IPPV in adult patients with acute respiratory failure by examining available evidence from clinical trials and by considering new management alternatives that have become available in the last 20 years. Indications for IPPV based on specific threshold values for P(CO2) and pH or on various indices of arterial oxygenation have generally not been validated by clinical evidence, and it is unlikely that any cutoff value would be applicable to all patients or all categories of acute respiratory failure. Stated another way, there is probably no single value for arterial P(CO2), pH, or P(O2) that by itself constitutes an indication for IPPV. Compelling face validity justifies the use of IPPV in cases of apnea or when it appears certain that respiratory arrest is about to occur. However, dyspnea, tachypnea, or the subjective impression of respiratory distress are probably not in themselves justification for emergency intubation. It should be possible to avoid IPPV and its attendant complications in many cases of acute hypercapnic respiratory failure. In acute exacerbations of chronic obstructive pulmonary disease, noninvasive positive-pressure ventilation (NPPV) should be the initial ventilation approach unless the patient has one of several specific exclusion criteria such as cardiovascular instability or severely impaired mental status. It may also be possible to avoid intubation through the use of NPPV in certain immunocompromised patients with early acute hypoxemic respiratory failure. However, in other settings of acute hypoxemic respiratory failure, such as acute lung injury and acute respiratory distress syndrome, this has not been shown. The use of IPPV may improve outcomes in patients with severe cardiogenic shock. However, IPPV has not proven to be beneficial in traumatic brain injury and flail chest, in the absence of other indications.     

慢性阻塞性肺病急性加重期合并呼吸衰竭有创机械通气拔管失败危险因素分析

目的 探讨有创通气的慢性阻塞性肺病急性加重期(AECOPD)合并呼吸衰竭患者在通过自主呼吸试验后拔管失败的危险因素.方法 对2008-01～2009-02我科收治的68例接受有创通气的AECOPD患者进行分析,采用压力支持模式进行SBT,记录拔管前后的临床资料、咳嗽能力、气道分泌物量及利用床边肺功能仪测定FEV1%.按结局将患者分为拔管成功组和失败组.结果 通过SBT后拔管,其中48例拔管成功,20例失败.单因素 Logistic回归分析提示,年龄大,慢性阻塞性肺病病程长,FEV1%较低,浅快呼吸指数较高,插管时间较长,血浆白蛋白水平较低,咳嗽能力较弱,中、大量的气道分泌物与拔管失败呈正相关.多因素Logistic回归分析提示,FEV1%较低、气道分泌物中大量、插管时间较长和浅快呼吸指数较高可能是机械通气拔管失败独立的危险因素.尤其是FEV1%<50%的患者,拔管失败的可能性是>50%的52.63倍(95%CI=6.22～445.64).结论 FEV1%低、气道分泌物中大量、插管时间较长和浅快呼吸指数较高可能是拔管失败的独立危险因素.     

序贯机械通气治疗肺结核呼吸衰竭的临床观察

目的探讨序惯性机械通气在治疗肺结核合并呼吸衰竭的临床疗效。方法对肺结核继发呼吸衰竭并接受有创通气(n=46,单纯有创通气治疗组)与序贯机械通气(n=23,序贯治疗组)患者临床资料进行回顾性分析,比较两组基本情况、血气分析、呼吸机相关性肺炎(VAP)、病死率及机械通气时间。结果序贯治疗组与对照组比较改善显著,序贯组有创通气时间为(8.3±5.2)天vs(15.2±6.7)天,气道损伤8例vs 28例,VAP发生率为26.1%vs52.2%,死亡2例vs 14例(P0.05)。但在总机械通气时间及住ICU时间比较差异无统计学意义。结论在肺结核并呼吸衰竭机械通气过程中,采用有创与无创序贯性机械通气治疗可以降低有创通气天数,气道损伤,VAP发生率及病死率。     

Strategies to minimize breathing effort during mechanical ventilation

A primary objective of mechanical ventilation is to alleviate the intolerable effort of breathing while allowing the patient to perform enough work to prevent atrophy. By assuming the workload associated with breathing, mechanical support averts ventilatory failure, prevents respiratory arrest, assures CO2 removal and pH homeostasis, while permitting the overtaxed respiratory muscles to replenish energy reserves as the primary process is addressed. Skillful manipulation of the breathing workload can often facilitate the ventilator withdrawal process. The objectives of this article are to characterize the magnitude of ventilatory work performed by the machine and patient during mechanical ventilation and to formulate a strategy for minimizing the breathing workload.     

机械通气治疗呼吸衰竭62例护理体会

目的:总结机械通气治疗呼吸衰竭的护理方法。方法:62例呼吸衰竭患者在接受常规治疗的同时,经口腔气管插管接呼吸机进行辅助通气,据血气分析调整呼吸机参数,使pH值、PaO2、PaCO2恢复或接近正常。结果:52例患者24h内症状明显缓解,呼吸频率、血气分析恢复正常,10例患者治疗3~7d后试行撤机,观察24h病情无变化后给予拔管,均未出现严重并发症。结论:机械通气是抢救治疗呼吸衰竭的重要措施,保持呼吸道通畅,配合心理护理、生活护理、专科护理及健康教育,同时密切观察病情、与医生配合,是护理机械通气患者的关键。     

呼吸衰竭患者不同吸痰方式吸痰效果的比较

目的探讨不同吸痰方式对呼吸衰竭机械通气患者吸痰前后呼吸循环参数的影响。方法将40例呼吸衰竭使用呼吸机的患者随机分为对照组和观察组,各20例。观察组采用密闭式吸痰,对照组采用传统的开放式吸痰,采取受试者自身前后对照的方法,观察患者吸痰前后呼吸循环参数的变化。结果密闭式吸痰前后患者呼吸循环参数差异无统计学意义（P〉0．05）,开放式吸痰前后心率、SpO2、Ppeak、Pplat参数差异有统计学意义（P〈0.01）,收缩压、RR、PaO2参数差异有统计学意义（P〈0.05）,Vt、PaCO2参数差异无统计学意义（P〉0.05）。结论呼吸衰竭患者使用密闭式吸痰方法较开放式吸痰方法安全有效。     

改良呼吸机脱机指数在急诊重症监护病房急性呼吸衰竭中的应用

目的 探讨急诊重症监护病房(EICU)急性呼吸衰竭患者机械通气的脱机预测指标.方法 对78例机械通气患者的原发病、年龄、昏迷评分、气道闭合压、咳嗽能力、浅快呼吸指数、上机时间、自主呼吸频率、潮气量、氧合指数、动脉血二氧化碳分压、营养状况、血红蛋白、脱机试验、严重并发症等与脱机关系密切的因素进行回顾性分析,应用呼吸机脱机指数进行评估.结果 脱机指数0～9分组无一例脱机成功(0/8),10～18分组脱机成功率为21.43%(3/14),18～28分组脱机成功率为98.21%(55/56);3组间差异有统计学意义(P<0.01).如果将脱机指数>18分作为临界值预测脱机成功率,其敏感性94.83%,特异性95.00%,准确性94.87%,阳性预测值98.21%.结论 脱机指数能全面反映急性呼吸衰竭患者的自主呼吸能力及其全身状况,可作为较可靠的脱机预测指标来指导临床工作.     

COPD合并呼吸衰竭应用有创机械通气患者的护理

<正>慢性阻塞性肺疾病(COPD)合并呼吸衰竭是临床上呼吸内科最常见的使用机械通气的原因。2006年10月～2009年4月,我科采用有创机械通气治疗COPD合并呼吸     

机械通气救治脑出血并发中枢性呼吸衰竭患者的护理

在临床上,对呼吸衰竭患者通常用气管插管和气管切开建立人工气道进行机械通气,以帮助患者度过危险期,直到呼吸功能好转和恢复[1].脑出血(ICH)是内科的常见病,具有起病急,病情重,进展快,致残、致死率高等特点,若并发中枢性呼吸衰竭(CRF),则预后更差,死亡率更高.     

The effects of inversed ratio ventilation (IRV) on arterial oxygenation during mechanical ventilation in patients with acute respiratory failure.

We investigated the effects of inversed ratio ventilation by altering the inspiratory:expiratory (I:E) ratio and assessing the time course changes in the intrapulmonary shunting (Qs/Qt) in 14 patients with acute respiratory failure. Stepwise prolongation of the I:E ratio from 1:1.9 to 2:1 and then to 2.6 or 4:1 was applied when PEEP failed to raise the PaO2 above 80 mmHg while breathing oxygen. A significant decrease in Qs/Qt was observed following prolongation of the I:E ratio from 1:1.9 (Qs/Qt = 45 +/- 9%) to 2:1 (Qs/Qt = 29 +/- 9%) but not with further prolongation of the I:E ratio (Qs/Qt = 27 +/- 7%). Improvement of the pulmonary ventilation/perfusion imbalance became more marked with continued IRV and a significant increase in PaO2 was observed at 6 h after initiating prolongation of the inspiratory time (P less than 0.05). There were no significant changes in hemodynamics, PaCO2, or peak inspiratory pressure during IRV. This ventilatory pattern may be indicated when PEEP fails to improve PaO2, but prolongation of the inspiratory time above an I:E ratio of 2:1 did not produce a greater improvement in Qs/Qt and further increases in PaO2 did not occur after more than 10 h of IRV in our 14 patients.     

肺保护性机械通气对脑损伤患者脑灌注压和脑氧代谢的影响

目的 观察肺保护性机械通气对颅脑损伤患者脑灌注压(CPP)及脑氧代谢的影响.方法 选择ICU需要机械通气的严重颅脑损伤伴呼吸衰竭患者40例,所有患者均行颅内压(ICP)监测、右侧颈内静脉逆行穿刺置管.将患者随机(随机数字法)分为①肺保护性通气组:潮气量为6～8mL/kg,初始吸氧体积分数40％,逐步提升呼气末正压(PEEP),PEEP与吸氧(FiO2)匹配同步升高,保持FiO2允许性低值;②常规通气组(对照组):潮气量为8～ 12 mL/kg,FiO2与PEEP匹配同步升高,保持PEEP允许性低值.监测桡动脉血气、平均动脉压(MAP)、颈静脉血氧饱和度(SjVO2),颈静脉血二氧化碳分压(PjVCO2),计算CPP=MAP-ICP;氧合指数PaO2/FiO2.结果 肺保护性通气组PEEP(8.2 ±3.3) cmH2O(1 cmH2O=0.098 kPa)、ICP (19.7±3.6) mmHg(1 mmHg=0.133 kPa)、PaCO2 (54±7.3 mmHg)高于对照组,VT、FiO2低于对照组,差异具有统计学意义;两组PaO2/FiO2、SjVO2、MAP、CPP差异无统计学意义.相关分析提示PaCO2与CPP呈正相关(r=0.368,P=0.019),与ICP、PaO2、SjVO2、Pjv CO2等并无相关性(P＞0.05);PEEP与ICP呈正相关;PEEP分为≤5 cmH2O、6～ 10 cmH2O及＞10 cmH2O三组,各组间ICP两两比较差异有统计学意义;PEEP在0～ 10 cmH2O上升,CPP变化不明显;PEEP＞ 10cmH2O时与CPP呈明显负相关(r=-0.395,P=0.017),CPP(58.5±7.2) mmHg,低于PEEP 0 ～ 5cmH2O时的(69.1±9.7) mmHg,差异具有统计学意义;PEEP越高,氧合指数越低;不同的PEEP水平下MAP、SjVO2、PjVCO2无明显变化.将PaCO2分为35～45 mmHg和46～60mmHg组,后者的CPP高于前组者,差异具有统计学意义(P＜ 0.05).SjVO2与PaO2及PjvCO2相关,与PaCO2、CPP、ICP、MAP及PEEP等均无相关性.结论 肺保护性通气策略对颅脑损伤患者来说是相对安全的.适当的CO2潴留联合较高的PEEP不影响脑灌注.肺保护性通气与常规通气相比SjVO2差异无统计学意义.提示两种通气方式下脑氧代谢无变化.