RICU慢性阻塞性肺疾病急性加重期下呼吸道病原菌分布及耐药性

目的 研究医院呼吸重症监护病房(RICU)慢性阻塞性肺疾病急性加重期(AECOPD)下呼吸道病原菌分布及耐药性,探讨机械通气与非机械通气AECOPD下呼吸道病原菌分布的差异.方法 收集医院RICU收治AECOPD患者的痰标本,对微生物病原学分离、鉴定和药物敏感试验结果进行分析.结果 病原菌以革兰阴性菌为主,占71.77％,革兰阳性菌占11.76％,真菌占16.47％;亚胺培南、头孢哌酮/舒巴坦、哌拉西林/他唑巴坦及阿米卡星对革兰阴性菌的耐药率较低,产ESBLs肺炎克雷伯菌和大肠埃希菌检出率分别为28.57％和65.38％,差异有统计学意义(P＜0.01),嗜麦芽寡养单胞菌对磺胺甲噁唑/甲氧苄啶、环丙沙星及头孢哌酮/舒巴坦保持高敏感性,未发现耐利奈唑胺、万古霉素及替考拉宁MRSA及MRCNS,机械通气的AECOPD患者的MASA感染率和混合培养比例显著高于未机械通气的患者(P＜0.01).绪论 RICU的AECOPD患者感染以假单胞菌属、不动杆菌属及肠杆菌科为主,病原菌耐药率高,应重视病原学检查.     

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.     

Anti-inflammatory and anticatabolic effects of short-term beta-hydroxy-beta-methylbutyrate supplementation on chronic obstructive pulmonary disease patients in intensive care unit

Elevated inflammatory markers and muscle wasting were common in chronic obstructive pulmonary disease (COPD) patients. The purpose of this study was to investigate the effect of 7-day beta-hydroxy-beta-methylbutyrate (HMB) supplementation on inflammation, protein metabolism, and pulmonary function in COPD patients in an intensive care unit. Thirty-four COPD patients who required mechanical ventilators were randomly assigned to HMB (n=18) or control (n=16) groups. The HMB group received HMB 3 g/d for 7 days. White blood cell count, C-reactive protein, and creatinine were significantly lower, while cholesterol and total protein were significantly higher after HMB supplementation. The body weight remained unchanged in both groups. Ten subjects (55.6%) in the HMB group and 4 subjects (25.0%) in the control group had improved pulmonary function, indicated by their ventilator modes. This short-term study suggests that HMB supplementation may have anti-inflammatory and anticatabolic effect and improve pulmonary function in COPD patients in an intensive care unit setting.     

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.     

慢性阻塞性肺疾病急性加重期呼吸衰竭预后因素分析

目的探讨影响慢性阻塞性肺疾病急性加重期（AECOPD）合并呼吸衰竭预后的危险因素。方法回顾性分析120例AECOPD合并呼吸衰竭患者,根据其治疗结果分为病情好转组（96例）和病情加重（包括死亡）组（24例）,分析其临床资料及治疗措施等因素。结果两组年龄、性别构成、病程、动脉血氧分压比较差异无统计学意义（P〉0.05）。病情好转组体质量指数、白蛋白、pH值、咳嗽咳痰能力良好率、营养支持率、无创机械通气率高于病情加重组[（28．5±9．8）kg/m2比（23_3±7．4）kg/m2、（21．4±7．9）g／L比（19．3±6．8）s／L、7．23±0．20比7．11±0．17、79．2％（76／96）比25．0％（6／24）、58．3％（56D6）比33．3％（8／24）、81．2％（78/96）比62．5％（15/24）],动脉血二氧化碳分压、轻度神志障碍率、多重耐药感染率、真菌感染率、鼻饲率、激素使用时间及心力衰竭、肺性脑病、肝肾功能损害、上消化道出血发生率均低于病情加重组[（10．08±1．71）kPa比（11．98±2．03）kPa、13．5％（13,96）比58．3％（14／24）、22．9％（22／96）比41．7％（10／24）、0比29．2％（7,24）、50．0％（48D6）比75．0％（18／24）、（5．3±1．3）d比（11.3±3．8）d、8.3％（8／96）比25．0％（6／24）、13．5％（13／96）比70．8％（17124）、28．1％（27/96）比41．7％（10／24）、5．2％（5,96）比12．5％（3,24）],差异有统计学意义（P〈0．05）。结论在AECOPD合并呼吸衰竭患者中,并发症、营养状况、神志、咳嗽咳痰能力、感染情况、有效的无创正压通气、血气指标等可作为影响其预后的相关因素。     

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。     

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.     

慢性阻塞性肺病患者营养素摄入和营养状态的研究

通过对34例慢性阻塞性肺部疾病(COPD)患者每日膳食中营养素摄入量的调查和营养状态评定表明,虽然患者的习惯饮食中热量摄入超过被推荐的标准供应量(RDA),但仍普遍存在营养不良.研究提示,给与COPD患者合理的营养支持能改善营养不良,增强治疗效果,对预后产生积极作用.     

Role of increased environmental Aspergillus exposure for patients with chronic obstructive pulmonary disease (COPD) treated with corticosteroids in an intensive care unit

We report about a 75-year-old woman and a 62-year-old man hospitalised for infection-related exacerbation of chronic obstructive pulmonary disease (COPD). In both patients, respiratory function worsened after initial stabilisation and the disease took a fatal course. A careful inspection of the intensive care unit (ICU) revealed several circumstances known to be risk factors for invasive aspergillosis (reconstruction activities near to the ICU, contamination of the window sills with pigeon droppings, moist building materials due to water leakage). The case reports suggest that both critically ill patients receiving high dose corticosteroid medication possibly have acquired aspergillosis on account of increased environmental exposure to Aspergillus conidia (> 10(2) CFU/m3 air). However, due to the severity of the disease confirmation by invasive diagnostic procedures was not possible. The role of high dose corticosteroid treatment as a risk factor for invasive aspergillosis should be taken into consideration, and increased exposure to fungi consequently be reduced in health care environments, especially for patients at risk.     

煤工尘肺合并慢性阻塞性肺病患者的营养状况比较与分析

对246例稳定期煤工尘肺合并慢性阻塞性肺病(COPD)Ⅰ级、Ⅱ级、Ⅲ级及Ⅳ级四组患者的相关营养指标进行分析,煤工尘肺合并COPDⅣ级患者胖瘦程度、免疫功能及蛋白质营养状况等方面指标均低于其余三组患者。提示临床工作中应重视尘肺合并COPD患者,尤其是肺功能较差患者的营养状况,处于稳定期时给予恰当的营养支持治疗至关重要。     

重度慢性阻塞性肺疾病误吸导致急性呼吸衰竭的临床探讨

目的探讨重度慢性阻塞性肺疾病（COPD）误吸导致急性呼吸衰竭的临床特点及治疗方法。方法对33例重度COPD误吸导致急性呼吸衰竭患者的临床资料进行回顾性分析。结果33例重度COPD误吸均发生在进食过程中，误吸会引起致死性的急性呼吸衰竭发作（pH值、PaO2较误吸前明显下降，PaCO2较误吸前明显上升）；误吸后有24例患者痰培养阳性；混合细菌感染11例；12例需要使用双水平无创正压（BiPAP）呼吸机面罩辅助通气治疗，13例需要气管插管使用BP-840呼吸机进行机械通气治疗；死亡6例。结论重度COPD误吸导致的急性呼吸衰竭与进食不当有关，临床表现为致死性的呼吸衰竭发作，病死率高，应采用综合治疗。     

Impact of nutritional status on body functioning in chronic obstructive pulmonary disease and how to intervene

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease is the fifth leading cause of mortality in the world. This study reviews diet as a risk or protective factor for chronic obstructive pulmonary disease, mechanisms of malnutrition, undernutrition consequences on body functioning and how to modulate nutritional status of patients with chronic obstructive pulmonary disease. RECENT FINDINGS: Different dietary factors (dietary pattern, foods, nutrients) have been associated with chronic obstructive pulmonary disease and the course of the disease. Mechanical disadvantage, energy imbalance, disuse muscle atrophy, hypoxemia, systemic inflammation and oxidative stress have been reported to cause systemic consequences such as cachexia and compromise whole body functioning. Nutritional intervention makes it possible to modify the natural course of the disease provided that it is included in respiratory rehabilitation combining bronchodilators optimization, infection control, exercise and, in some patients, correction of hypogonadism. SUMMARY: Diet, as a modifiable risk factor, appears more as an option to prevent and modify the course of chronic obstructive pulmonary disease. Reduction of mechanical disadvantage, physical training and anabolic agents should be used conjointly with oral nutrition supplements to overcome undernutrition and might change the prognosis of the disease in some cases. Major research challenges address the role of systemic inflammation and the best interventions for controlling it besides smoking cessation.     

重度慢性阻塞性肺疾病误吸导致急性呼吸衰竭的临床探讨

目的 探讨重度慢性阻塞性肺疾病(COPD)误吸导致急性呼吸衰竭的临床特点及治疗方法.方法 对33例重度COPD误吸导致急性呼吸衰竭患者的临床资料进行回顾性分析.结果 33例重度COPD误吸均发生在进食过程中,误吸会引起致死性的急性呼吸衰竭发作(pH值、PaO2较误吸前明显下降,PaCO2较误吸前明显上升);误吸后有24例患者痰培养阳性;混合细菌感染11例;12例需要使用双水平无创正压(BiPAP)呼吸机面罩辅助通气治疗,13例需要气管插管使用BP-840呼吸机进行机械通气治疗;死亡6例.结论 重度COPD误吸导致的急性呼吸衰竭与进食不当有关,临床表现为致死性的呼吸衰竭发作,病死率高,应采用综合治疗.     

高脂肪低糖肠内营养对呼吸科危重症病人营养状况和呼吸功能的影响

目的:观察呼吸科危重症病人进行高脂肪低糖类肠内营养(EN)治疗后,营养状况和呼吸功能指标的变化。方法:选择呼吸科危重症病人120例,随机分为营养组(60例)和对照组(60例)。两组病人均接受相同的抗感染和对症治疗,营养组采用高脂肪低糖EN液(瑞能),对照组采用普通匀浆膳。分别于营养治疗前1 d和治疗后第14天测定血p H值、二氧化碳分压(Pa CO2)、氧分压(Pa O2)、呼吸商(RQ)、每分钟通气量(VE)、二氧化碳生成量(VCO2)、氧耗量(VO2)、氧合指数(Pa O2/Fi O2)以及血清总蛋白(TP)、清蛋白(ALB)、血红蛋白(Hb)、氮平衡(NB)等指标。结果:治疗第14天后,营养组病人的RQ、VCO2、VO2Pa CO2、Pa O2、Pa O2/Fi O2均较对照组显著改善(P0.05);营养组TP、ALB、NB均明显优于对照组(P0.05)。两组病人治疗后各项指标均较治疗前有明显的改善(P0.05)。结论:呼吸科危重症病人应用高脂肪低糖EN支持可显著改善营养状况和呼吸功能。     

舒利迭在老年慢性阻塞性肺疾病致呼吸衰竭抢救中的价值研究

目的：研究舒利迭在老年慢性阻塞性肺疾病致呼吸衰竭抢救中的临床价值.方法：选取98例老年慢性阻塞性肺疾病致呼吸衰竭患者资料,随机分为观察组（舒利迭联合无创正压通气治疗）和对照组（单纯使用无创正压通气治疗）.检测应激反应指标及血气指标并分析其相关性.结果：治疗后观察组患者的肾上腺素、去甲肾上腺素、肾素、血管紧张素Ⅱ水平以及动脉二氧化碳分压低于对照组,动脉血氧分压高于对照组;动脉血氧分压与肾上腺素、去甲肾上腺素、肾素以及血管紧张素Ⅱ水平呈负相关,动脉二氧化碳分压与其呈正相关.结论：舒利迭可以有效降低患者的应激水平,改善血气水平,且应激水平与动脉血氧分压呈负相关,与动脉二氧化碳分压呈正相关.     

Optimizing oral nutritional drink supplementation in patients with chronic obstructive pulmonary disease

Nutritional support is indicated in some patients with chronic obstructive pulmonary disease to restore nutritional status and improve functional capacity. However, the efficacy of nutritional supplements is sometimes disappointing, partly owing to a compensatory drop in habitual food intake. We retrospectively studied the effect of nutritional drink supplements, differing in portion size and energy content, on weight gain and body composition. Thirty-nine patients with stable chronic obstructive pulmonary disease, participating in an 8-week pulmonary rehabilitation programme and eligible for nutritional support, were studied. Group A (n 19) received three portions of 125 ml (2380 kJ), whereas group B (n 20) received three portions of 200 ml (3350 kJ) daily. The macronutrient composition of the regimens was similar (20 % protein, 60 % carbohydrates and 20 % fat). Lung function, body weight, body composition (by bio-electrical impedance analysis), habitual dietary intake (by dietary history) and resting energy expenditure (by ventilated hood) were determined. Weight gain was compared with expected weight as predicted by a computer simulation model. Although patients in both groups significantly increased in weight, this increase was higher in group A (A, 3.3 (sd 1.9) kg; B, 2.0 (sd 1.2) kg; P=0.019), while receiving less energy. The observed weight gain in group A was similar to that expected, but in group B it was lower than expected (P<0.001). In both groups, fat-free mass and fat mass were gained in a ratio of 2:1, fat-free mass increasing primarily during the first 4 weeks. This study illustrates that there might be an optimum for the portion size of nutritional drink supplements in chronic obstructive pulmonary disease and that more is not always better.     

慢性阻塞性肺疾病并发呼吸衰竭相关危险因素分析

目的 探讨慢性阻塞性肺疾病(COPD)并发呼吸衰竭相关危险因素和预后因素.方法 对2005年3月至2008年2月收治的110例COPD患者的临床资料进行回顾性分析,根据是否发生呼吸衰竭分为呼吸衰竭组(40例)和非呼吸衰竭组(70例).结果 呼吸衰竭组每年急性发作次数、尿酸、总蛋白、白蛋白、体重指数与非呼吸衰竭组比较差异有统计学意义[分别为(5.54±1.16)次/年比(2.75±0.78)次,年、(283.75±72.49)mmol/L比(359.87±41.50)mmol/L、(58.77±1.54)g/L比(63.95±2.04)g/L、(36.15±1.08)g/L比(36.96±1.48)g/L、(20.33±0.99)kg/m2比(21.16±1.36)kg/m2](P<0.01);COPD分度、院内感染、酸碱平衡紊乱两组比较差异有统计学意义(P<0.05或<0.01).呼吸衰竭死亡患者和好转患者动脉血氧分压比较差异无统计学意义(P>0.05),pH值、动脉血二氧化碳分压、血钠、血氯比较差异有统计学意义(P<0.01).结论 COPD并发呼吸衰竭相关危险因素多.     

慢性阻塞性肺病急性加重合并呼吸衰竭病人早期肠内营养联合胸腺肽a1的疗效观察

目的 :探讨早期肠内营养(EN)联合胸腺肽a1对AECOPD合并呼吸衰竭的疗效。方法 :135例AECOPD病人随机分为试验A组(EN)45例,试验B组(EN+胸腺肽a1)45例,和对照组45例,对照组予常规临床治疗,试验A组在此基础上予瑞能早期肠内营养鼻饲,试验B组在此基础上予瑞能早期肠内营养鼻饲联合皮下胸腺肽a1针,观察三组机械通气时间,检测炎症指标、营养指标以及T细胞亚群。结果 :治疗一周后,试验A组的炎症指标明显低于对照组(P0.05)、营养指标以及T细胞亚群明显高于对照组(P0.05)、机械通气时间较对照组明显缩短(P0.05);而与试验A组相比,试验B组的炎症指标明显降低(P0.05)、营养指标以及T细胞亚群明显升高(P0.05)、机械通气时间明显缩短(P0.05)。结论 :早期肠内营养治疗不仅能缩短AECOPD合并呼吸衰竭病人机械通气时间,而且能改善病人营养状况,降低其炎症指标,增强其免疫功能,进而提高临床疗效,而早期肠内营养联合胸腺肽a1治疗能进一步改善AECOPD合并呼吸衰竭病人的临床疗效。