慢性阻塞性肺疾病急性呼吸衰竭患者从有创过渡到无创机械通气的时机探讨

目的探讨慢性阻塞性肺疾病(COPD)急性呼吸衰竭从有创过渡到无创机械通气的适宜时机。方法24例COPD急性呼吸衰竭患者有创机械通气3天后随机分成两组,每组12例。A组予拔除气管导管改面罩机械通气,B组继续有创机械通气。观察两组呼吸机相关性肺炎(VAP)例数、死亡例数、机械通气时间、住院时间。结果A、B两组发生VAP的例数分别为0和7例(P=0.027);死亡例数为0和3例(P=0.217);有创机械通气3天后尚需机械通气时间为（7±5）天和（15±12）天(P<0.05);住院时间为（16±6）天和（25±12）天(P<0.05)。结论COPD急性呼吸衰竭有创机械通气3天后拔除气管导管改面罩机械通气能降低VAP发生率,缩短机械通气时间和住院时间。     

有创与无创序贯通气治疗在COPD并急性呼吸衰竭中的应用

目的 探讨有创无创机械通气在COPD并急性呼吸衰竭中的疗效。方法 将24例COPD并急性呼吸衰竭患者随机平均分为两组。治疗组给予有创-无创序贯机械通气,对照组给予有创机械通气,观察两组患者病情变化、血气分析、呼吸机相关肺炎（VAP）、死亡数、机械通气时间等。结果 治疗组及对照组患者发生VAP的例数分别为0和4例（P〈0．05）,总机械通气时间为（12．26．2）d和11（22．4±15．3）d（P〈0．05）;住院时间为（15±7）d和（18±14）d（P〈0．05）。结论 在适当时机将有创通气改为无创通气,可降低COPD并急性呼吸衰竭患者VAP发生率,缩短机械通气和住院时间,明显提高治疗效果。     

有创与无创序贯通气治疗COPD重症呼吸衰竭

目的探讨有创与无创序贯机械通气在COPD呼吸衰竭患者救治的方法与疗效。方法对36例COPD重症呼吸衰竭患者进行气管插管并行人工机械通气,在治疗中,当出现PIC窗后,将46例患者随机分为序贯通气组和常规通气组,每组23例。序贯通气组给予拔除气管插管改面罩机械通气,常规通气组继续有创机械通气观察两组患者病情变化、呼吸机相关肺炎（VAP）例数、机械通气时间及住院时间。结果序贯通气组和常规通气组两组患者发生VAP例数分别为1和10例（P〈0．05）,总机械通气时间为（11．58±1．16）d和（15．33±1．886）d（P〈0．05）,住院时间为（15．87±1．68）d和（25．41±1．92）d（P〈0．01）。结论以PIC窗为切换点实施序贯通气策略可降低患者VAP发生率,缩短机械通气时间及住院时间,是救治COPD重症呼吸衰竭患者值得提倡的机械通气策略。     

有创-无创序贯机械通气治疗COPD合并Ⅱ型呼吸衰竭临床分析

目的评价有创-无创序贯机械通气治疗COPD合并Ⅱ型呼吸衰竭临床疗效。方法序贯组：COPD患者23例,肺部感染控制窗出现后,撤离有创通气,改为无创通气。对照组：回顾性研究既往行常规机械通气治疗COPD患者25例,以SIMV＋PSV方式撤机。观察两组的血气、有创通气时间、总机械通气时间、住ICU时间、VAP发生例数。结果序贯治疗组有创通气时间、总机械通气时间、入住ICU时间、发生VAP例数与对照组比较有显著性差异（P〈0.05）。结论有创-无创序贯机械通气治疗COPD合并Ⅱ型呼吸衰竭可以缩短有创通气时间、总机械通气时间、入住ICU时间,VAP发生例数显著减少。     

有创-无创序贯机械通气治疗老年慢性阻塞性肺疾病合并呼吸衰竭临床研究

目的:探讨有创-无创序贯机械通气对老年慢性阻塞性肺疾病(COPD)合并呼吸衰竭患者的疗效.方法:对46例老年COPD合并呼吸衰竭患者早期进行气管插管机械通气治疗,随机分为有创-无创序贯机械通气组(治疗组)和有创机械通气组(对照组),在肺部感染控制窗出现后,治疗组拔出气管插管,改用经鼻面罩无创通气模式,逐渐减低压力参数,直至成功脱机.对照组继续有创通气治疗,逐渐减低SIMV频率及PSV水平直至脱机成功.观察2组患者有创通气时间、总机械通气时间、呼吸机相关性肺炎(VAP)发生例数和住ICU时间.结果:治疗组的有创通气时间、总机械通气时间较对照组明显缩短(P<0.05),VAP发生率明显减少(P<0.05),住ICU时间明显缩短(P<0.05).结论:对于老年重症COPD合并呼吸衰竭患者在肺部感染控制窗出现后,应用有创-无创序贯机械通气可缩短机械通气时间,减少VAP发生率,缩短ICU住院时间.     

有创-无创序贯性机械通气治疗慢性阻塞性肺疾病严重呼吸衰竭患者的时机探讨

目的探讨慢性阻塞性肺疾病（COPD）所致严重呼吸衰竭（呼衰）患者早期拔管后过渡到面罩机械通气（FMMV）的时机。方法24例研究对象均以支气管-肺感染为诱因,随机分为A、B两组,每组12例。两组均采取气管插管机械通气（ETI-MV）,分别于ETI-MV2～3d、6d拔除气管插管,经鼻导管吸氧（氧浓度为35%）观察1～3h,不管是否存在呼衰均采取FMMV。观察在拔管后与FMMV之前两组仍存在呼衰的例数、呼吸机相关性肺炎（VAP）例数、死亡例数、总机械通气时间和住院时间。结果拔管后两组仍存在呼衰例数分别为12和5例（P=0.007）;VAP例数分别为0和5例（P=0.019）;死亡例数为0和2例（P=0.478）;总机械通气时间（15.2±1.6）d和（18.2±2）d（P=0.001）;住院时间为（18.3±1.4）d和（20.8±1.8）d（P=0.001）。结论COPD呼衰患者在支气管-肺部急性感染减轻的基础上,于ETI-MV2～3d拔管,序贯FMMV是安全可行的,而且可明显减少VAP发生,缩短总机械通气时间和住院时间。     

有创与无创序贯通气治疗在COPD并急性呼吸衰竭中临床效果

目的探讨有创与无创序贯通气治疗在COPD并急性呼吸衰竭中临床效果及注意事项。方法 COPD合并呼吸衰竭患者56例,给予抗感染、解痉、平喘等综合治疗,插管上机用同步间歇强制通气＋压力支持通气（SIMV＋PSV）模式通气,在肺部感染控制窗出现后,随机分观察组及对照组各28例：观察组实施有创-无创通气序贯通气治疗,对照组继续实施有创通气。结果两组脱机时呼吸频率、心率、收缩压、PaO2、PaCO2、PH值比较无差异（P〉0.05）;观察组有创通气时间、总机械通气时间、住院时间均短于对照组、VAP发生例数、死亡例数也少于对照组（P〈0.05）。结论有创-无创通气序贯治疗抢救COPD合并急性呼吸衰竭患者,效果满意,是临床有效脱机方案。     

有创-无创序贯机械通气治疗COPD合并Ⅱ型呼吸衰竭患者疗效观察

目的 评价有创-无创序贯机械通气治疗COPD合并Ⅱ型呼吸衰竭的疗效.方法 序贯组30例,对照组28例.序贯组以“肺部感染控制窗”作为有创和无创通气的切换点.结果 序贯组有创机械通气时间缩短[ (5.16±1.23)d比(13.12±3.58)d,P＜0.05];住院时间缩短[(15.35±2.12)d比(24.69±2.78)d,P＜0.05];VAP发生率减少[6.67％比32.14％,P＜0.05];病死率减少[3.33％比10.71％,P＜0.05];总机械通气时间无显著差异.结论 对COPD合并Ⅱ型呼吸衰竭病例,采用有创-无创序贯机械通气可缩短有创机械通气时间,减少住院时间,降低病死率和VAP的发生率.     

序贯机械通气治疗慢性阻塞性肺疾病重症呼吸衰竭临床研究

目的探讨有创与无创序贯性机械通气在慢性阻塞性肺疾病(COPD)重症呼吸衰竭患者救治中的方法与疗效。方法对30例COPD重症呼吸衰竭患者进行气管插管并施行机械通气,“出窗后”,随机分为序贯治疗组和对照组,序贯组治疗方法:出窗后,立即拔出气管插管,改用口鼻面罩双水平气道正压通气(BiPAP)。对照组治疗方法:肺部感染控制窗出现后,继续按常规有创机械通气方法治疗,以目前临床常用压力支持通气(PS)模式脱机,两组同时进行监护,观察两组患者有创通气时间、呼吸机相关肺炎(VAP)发生例数、总机械通气时间、住院时间、监护时间、撤机成功例数、住院费用和院内死亡例数。结果两组患者发生VAP的例数分别为0和7例(P<0.05),总机械通气时间为(12.2±1.2)d和(18.4±1.5)d(P<0.05);住院时间为(16.3±1.8)d和(26.4±3.9)d(P<0.01)。结论在肺部感染控制窗指导下的有创-无创序贯性脱机治疗方法,可以明显缩短机械通气,降低VAP发病率,缩短ICU和总住院时间,改进治疗效果,降低治疗费用,是具有一定临床实用价值的有效脱机方案。     

有创及无创序贯通气治疗COPD呼吸衰竭19例

目的探讨有创及无创序贯通气治疗慢性阻塞性肺疾病(COPD)合并呼吸衰竭的疗效。方法19例COPD患者无序贯治疗组,在达到“肺部感染控制窗”(Pulmonaryinfectioncontrolwindow,PIC)后即撤离有创通气,继之以无创通气;对照组为回顾性研究既往行常规机械通气治疗COPD合并呼吸衰竭患者20例,以SIMV PSV方式至撤机,分别观察血气分析、胸片、通气时间、呼吸机相关性肺炎(VAP)、重新插管例数等指标。结果序贯治疗组有创通气时间、VAP等与对照组相比P<0.01,总机械通气时间、死亡率与对照组相比P<0.05,均有显著差异。结论序贯通气治疗COPD合并呼吸衰竭能明显缩短有创通气时间,减少重新插管和呼吸机相关肺炎,优于机械通气法。     

Noninvasive ventilation after intubation and mechanical ventilation.

Patients with chronic airflow obstruction who are difficult to wean from mechanical ventilation are at increased risk of intubation-associated complications and mortality because of prolonged invasive mechanical ventilation. Noninvasive positive pressure ventilation may revert most of the pathophysiological mechanisms associated with weaning failure in these patients. Several randomized controlled trials have shown that use of noninvasive ventilation to achieve earlier extubation in difficult-to-wean patients or in patients who develop respiratory failure after apparently successful extubation can result in reduced periods of endotracheal intubation and complication rates and improved survival. However, this is not a consistent finding, and the currently available published data with outcome as the primary variable are exclusively from patients who had pre-existing lung disease. In addition, the patients were haemodynamically stable, with a normal level of consciousness, no fever and a preserved cough reflex. It remains to be seen whether noninvasive positive pressure ventilation has a role in other patient groups and situations, such as prevention of postextubation failure or unplanned extubation. The technique is, however, a useful addition to the therapeutic armamentarium for a group of patients who pose a significant clinical and economic challenge.     

High-frequency mechanical ventilation principles and practices in the era of lung-protective ventilation strategies

The term high-frequency ventilation is used to describe a heterogeneous group of ventilation modes that are characterized by high respiratory frequencies and low tidal volumes. The increasing understanding of the pathogenesis of VILI, including concepts such as volutrauma and atelectrauma, has led to a renewed interest in the role of HFV in lung-protective ventilation strategies. Inherent to many modes of HFV are low tidal volumes and small pressure swings during the respiratory cycle, which allow for higher mean airway pressures than those safely achieved with CMV. This has the potential to reduce lung injury by limiting volutrauma, whereas maintaining bigger lung volumes at end-expiration may reduce atelectrauma. Of the various forms of HFV, HFO is the only mode with an active expiration phase. This characteristic, combined with superior gas conditioning, may make HFO a promising ventilatory strategy for adults. Although a significant amount of data exists in the literature to support the application of HFO in infants and children who have acute respiratory failure, clinical data on the use of HFO in adults is only now emerging. Early studies of applying HFO in ARDS patients have demonstrated its safety and benefit in terms of oxygenation. Additionally, limited data exist on the comparison between HFO and CMV in this patient population; however, encouraging preliminary results have been reported. The optimum strategy for the application of HFV, including the timing of HFV initiation, remains unclear.     

Bicarbonate and the regulation of ventilation

The regulation of ventilation involves a multifactorial control system with several feedback loops transmitting deviations from normal in pH, carbon dioxide tension (pCO₂) and oxygen tension (pO₂) to the control area. Variations in the size of the bicarbonate pool, caused by ventilatory or metabolic disturbances, can be expected to modify resting ventilation if hydrogen ion activity is the ultimate stimulus of the regulation of ventilation. A relationship between serum bicarbonate and resting ventilation can be identified in patients with stable acid-base disturbances including those in whom correction of the arterial blood pH was not achieved by respiratory adaptation. Why the pH in arterial blood is rarely returned to the normal range is not well understood. It may be an inadequacy of the control system, a “compromise” solution avoiding hypoxia in metabolic alkalosis or increasing work of breathing in metabolic acidosis, or a consequence of discrepancies in hydrogen ion activity in body fluids adjacent to and remote from the control site.Additional information about the role of bicarbonate in the control of ventilation may be obtained by measuring the response to carbon dioxide inhalation at varying extracellular bicarbonate concentrations. The increments in ventilation during inhalation of carbon dioxide are within individual limitations, inversely and exponentially related to the bicarbonate concentrations in blood.These observations are in accord with the concept that the extracellular bicarbonate concentration modulates resting ventilation and the ventilatory response to inhalation of fixed concentrations of carbon dioxide by acting as a determinant for the hydrogen ion activity within or adjacent to the central chemosensitive control area.     

New modalities of mechanical ventilation: high-frequency oscillatory ventilation and airway pressure release ventilation

Management of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) is largely supportive, with the use of mechanical ventilation being a central feature. Recent advances in the understanding of ALI/ARDS and mechanical ventilation have revealed that lung-protective ventilation strategies may attenuate ventilator-associated lung injury and improve patient morbidity/mortality. High-frequency oscillatory ventilation and airway pressure release ventilation are two novel alternative modes of ventilation that theoretically fulfill the principles of lung protection and may offer an advantage over conventional ventilation for ALI/ARDS.     

肺保护通气及容量控制通气模式应用于单肺通气老年患者术后的效果比较

<正>胸外科手术中,由于老年患者肺功能较差,且术中机械牵拉作用于肺泡表面的牵张感受器,导致其机体炎性介质大量分泌,诱发患者术后全身性炎症反应[1-2]。同时,采用单肺通气(one-lung ventilation,OLV)方式容易诱发低氧血症,导致患者脑组织代谢异常,从而加重患者术后认知功能障碍(postoperative cognitive dysfunction,POCD)程度[3-4]。以上两种原因均明显导致患者术后治疗效果较差,且手术满意率明显下降。目前肺保护通气(lung protective ventilation,LPV)及容量控制通气(volume control ventilation,VCV)两种模式都有改善患者术后认知功能及降低全身性炎症反应的作用,但对于两者孰优孰劣却没有明确的研究[5-6]。本文比较两种     

Sleep deprivation and the control of ventilation

Sleep deprivation is common in acutely ill patients because of their underlying disease and can be compounded by aggressive medical care. While sleep deprivation has been shown to produce a number of psychological and physiologic events, the effects on respiration have been minimally evaluated. We therefore studied resting ventilation and ventilatory responses to hypoxia and hypercapnia before and after 24 h of sleeplessness in 13 healthy men. Hypoxic ventilatory responses (HVR) were measured during progressive isocapnic hypoxia, and hypercapnic ventilatory responses (HCVR) were measured using a rebreathing technique. Measures of resting ventilation, i.e., minute ventilation, tidal volume, arterial oxygen saturation, and end-tidal gas concentrations, did not change with short-term sleep deprivation. Both HVR and HCVR, however, decreased significantly after a single night without sleep. The mean hypoxic response decreased 29% from a slope of 1.20 +/- 0.22 (SEM) to 0.85 +/- 0.15 L/min/% saturation (p less than 0.02), and the slope of the HCVR decreased 24% from 2.07 +/- 0.17 to 1.57 +/- 0.15 L/min/mmHg PCO2 (p less than 0.01). These data indicate that ventilatory chemosensitivity may be substantially attenuated by even short-term sleep deprivation. This absence of sleep could therefore contribute to hypoventilation in acutely ill patients.     

闭环通气模式在机械通气脱机阶段的观察及护理配合

脱机是从完全通气支持向自主呼吸转变的一个过程,过去常用的脱机模式需要密切监测患者的临床表现及血气分析变化,便于及时调节呼吸参数,无疑增加了医务人员的负担,同时也增加了患者的痛苦。新的闭环通气模式的应用对提高患者的脱机效率、减轻医务人员的工作负担均起到重要作用,然而此阶段的观察及护理配合对减轻患者的痛苦,缩短脱机进程显得尤为重要。笔者就闭环通气模式阶段的观察及护理配合谈谈自己的护理体会。