磁刺激诱发的膈肌复合动作电位的多导食道电极记录及其在重症监护室患者中的应用

目的探讨在重症监护室(ICU)里,用多导食道电极是否能满意地记录由磁刺激膈神经诱发的膈肌复合肌肉动作电位(CMAP)。方法运用1根具有5个记录导联的新型多导食道电极记录由电和磁刺激膈神经诱发的膈肌CMAP。10名正常人和10例因各种原因在ICU病房治疗的患者被纳入研究。结果不论在正常人还是ICU患者均可记录到高质量的信号。在正常人,电刺激诱发的膈神经传导时间(PNCT)、膈肌CMAP幅值[(7.2±0.8)ms、(1.52±0.40)mV]与磁刺激诱发的相似[(7.1±0.8)ms、(1.56±0.38)mV,P均>0.05]。ICU患者磁刺激诱发的膈肌CMAP幅值[(0.73±0.38)mV]显著小于正常人[(1.58±0.38)mV,P<0.01]。结论这一研究提示磁刺激可取代传统的电刺激去测量膈肌CMAP和PNCT。把磁刺激和多导食道电极结合在一起能有效地评价ICU患者的膈肌功能。     

膈肌功能测定及其在慢性阻塞性肺疾病中的应用

目的　比较最大跨膈压 (Pdimax)、最大口腔吸气压 (MIP)、最大吸鼻跨膈压 (Pdisniff)和颤搐性跨膈压(Pdi(t)ele)在评价膈肌功能中的差异及其在慢性阻塞性肺疾病 (COPD)中的应用。方法　对 13例正常者和 7例轻度与 7例重度COPD病人分别测定Pdimax、MIP、Pdisniff和Pdi(t)ele。结果　 (1)正常对照组的Pdimax、MIP、Pdisniff与轻度COPD组比较差异无显著性 ,与重度COPD组比较差异有显著性 (P 分别为 :<0 0 1、0 0 5和 0 0 5 ) ;而正常对照组Pdi(t)ele均比轻度和重度COPD组的高 (P均 <0 0 1)差异显著。 (2 )Pdi(t)ele的个体内变异性在正常对照组中均比Pdimax、MIP、Pdisniff小 (P分别为 :<0 0 1、0 0 1和 0 0 5 ) ;在COPD组中 ,明显比Pdimax小 (P <0 0 1) ,而与MIP和Pdisniff比较差异没有显著性。 (3)Pdi(t)ele与FEV1具有显著相关性 (P <0 0 5 )。结论　Pdi(t)ele能更客观、更敏感地反映膈肌功能。     

俯卧位呼吸时悬空腹部对呼吸动力学的影响

目的 :探讨稳定期慢性阻塞性肺疾病(COPD)患者和健康志愿者在俯卧位状态下是否悬空腹部对呼吸和循环动力学的影响。方法:12例稳定期COPD患者和9名健康志愿者采取仰卧位、俯卧位悬空腹部、俯卧位3种不同体位,通过NICO和BioZ无创心肺功能监测仪连续测定患者的呼吸和循环动力学指标,通过呼吸功能检测电极测定膈肌肌电、跨膈压(Pdi)等指标,每个体位均观察10 min。结果:1呼吸动力学:健康志愿者俯卧位的Pdi与俯卧位悬空腹部和仰卧位比较显著升高[(13.5±1.6)比(11.5±2.2)、(10.1±1.7)cmH_2O(1 cmH_2O=0.098 kPa),P<0.05],稳定期COPD患者俯卧位的Pdi与俯卧位悬空腹部和仰卧位比较明显升高[(22.6±2.5)比(15.6±2.6)、(18.2±3.2)cmH_2O,均P     

呼吸锻炼在慢性阻塞性肺疾病康复治疗中的应用现状及展望

慢性阻塞性肺疾病（COPD）是严重危害中老年人身体健康和生活质量的常见慢性病。2004年世界卫生组织制定了关于COPD的全球防治创议（GOLD）,明确提出治疗COPD的目标是：阻止病情发展,减轻症状,增加运动耐量,提高健康水平,防治和治疗并发症,预防和处理急性发作,降低病死率。至今,所有治疗COPD的方法都不能阻止肺功能的持续降低。文献显示呼吸肌锻炼是COPD病人缓解期康复治疗的有效手段,不仅降低了医疗费用,增强了患者的生活信心,且便于在社区及家庭中推广。现将近年来护理同行在此临床护理方面进行的研究和取得的经验综述如下。     

呼吸操在重度慢性阻塞性肺疾病患者呼吸肌力量训练中的作用研究

目的观察中医养生呼吸训练操结合氧疗方法对重度慢性阻塞性肺疾病（COPD）稳定期患者康复治疗的作用。方法重度COPD男性病人39例中20例为对照组,采用单纯鼻导管吸氧,另19例为实验组,鼻导管吸氧结合呼吸操训练,治疗前以及六个月治疗后分别检测运动能力、血气分析、肺功能和呼吸肌力指标。结果六个月治疗后,鼻导管吸氧结合呼吸操训练组的各项指标均优于对照组（P〈0．05）。结论鼻导管结合呼吸操训练可有效提高慢性阻塞性肺疾病患者的呼吸肌的强度和耐力,增加肺活量,促进有效气体交换。     

慢性阻塞性肺疾病患者在二氧化碳重复呼吸及运动过程中的膈肌肌电变化

研究发现，慢性阻塞性肺疾病(COPD)患者在激烈运动后，并不出现膈肌疲劳，提示COPD患者在运动时可能存在着呼吸中枢的反馈抑制以防止呼吸肌疲劳。要证明这一假设就必须准确地评价中枢驱动。膈肌肌电可能是评价中枢驱动的一个好方法。研究提示多导食道电极记录的膈肌肌电能有效地反映正常人的呼吸中枢驱动。我们运用多导食道电极记录膈肌肌电，观察COPD患者在CO2重复呼吸及运动过程中膈肌肌电的变化，以探讨其是否存在呼吸中枢反馈抑制现象。     

电阻抗呼吸图仪在慢阻肺患者膈肌疲劳检测上的应用研究

作者采用自制的电阻抗呼吸图仪测定20例正常人和75例COPD患者的胸腹呼吸运动。在平静呼吸和最大自主呼吸状态下,20例正常人和22例患者呈同步呼吸运动。53例患者可摘记三种不同类型的非同步呼吸运动曲线。在膈肌疲劳的早期诊断上,运动负荷试验较呼吸负荷试验更为敏感。电阻抗呼吸图与膈肌肌电图的结果基本相似。     

呼吸训练在慢性阻塞性肺疾病患者康复中的应用

现代康复医学认为呼吸训练不仅可以增强胸廓的活动,协调各种呼吸肌的功能,还可以增加肺活量和吸氧量,并通过影响神经、循环、消化等系统的功能,改善全身状况;同时由于呼吸训练无创无痛,简单方便,且无需任何额外开支,容易被患者接受,因此有学者建议把呼吸训练作为多种疾病恢复阶段早期主要的锻炼方法,并可作为其他康复方法的辅助措施~([1]).     

体外膈肌起搏结合腹式呼吸锻炼治疗COPD的临床观察

24例缓解期COPD患者应用体外膈肌起搏结合腹式呼吸锻炼5周(30次)为1疗程,结果气短和活动后气急均见明显减轻,潮气量(V_T)和吸气流速(V_i)显著提高,作者认为这是两种疗法相辅相成的效果。     

无创机械通气在心肺血管疾病中的应用

无创正压通气（NIPPV）广泛应用于各种原因引起的急性呼吸衰竭,尤其是在慢性阻塞性肺疾病（COPD）引起的慢性呼吸衰竭急性发作、心力衰竭方面治疗效果肯定,可以明确降低气管插管率、住ICU的时间、减少病死率、增加存活率;对继发于呼吸衰竭的轻中度肺性脑病有肯定的疗效;对于肺炎导致的呼吸衰竭治疗效果差;NIPPV在哮喘、急性呼吸窘迫综合征、COPD恢复期的治疗效果尚不肯定。NIPPV治疗效果与患者耐受程度、治疗后生理指标改善的程度直接相关。NIPPV是否会增加心力衰竭患者的心肌梗死发病率仍有争议。     

The application of muscle endurance training techniques to the respiratory muscles in COPD

Standard treatments for chronic obstructive pulmonary disease (COPD) that are directed at reducing the degree of obstruction may be insufficient to relieve symptoms and improve exercise tolerance in severe cases. Many severely affected patients have reduced respiratory muscle endurance, which makes them less able to tolerate their excessive respiratory workloads. Despite the absence of a naturally-occurring endurance-training effect, the respiratory muscles of patients with COPD can be trained for increased endurance when periodic respiratory exertion is deliberately induced by isocapnic hyperventilation or added inspiratory resistance. Such training has resulted either in improved sustainable ventilatory capacity or in improved exercise tolerance. These improvements due to respiratory muscle training were better than those observed with whole body exercise training programs in some cases but not in others. Respiratory muscle training is a promising new adjunct in the management of COPD, but further investigation is required to delineate its indications and contraindications.     

呼吸肌训练联合正压呼气对稳定期COPD患者临床的研究

目的:分析呼吸肌训练联合振动正压呼气治疗对稳定期慢性阻塞性肺疾病(COPD)患者的疗效。方法:本研究为病例对照研究。采用单纯随机抽样法,选取2018年12月至2020年2月上海市第一康复医院及海军军医大学第一附属医院(长海医院)呼吸科门诊符合慢性阻塞性肺疾病全球创议2018诊断标准的稳定期COPD患者80例为研究对象。...     

Comparison of international and Japanese predictive equations for maximal respiratory mouth pressures

Respiratory muscle weakness has attracted attention because sarcopenia and respiratory muscle dysfunction may play a key role in the development of respiratory failure. To evaluate respiratory muscle strength appropriately, individual factors such as sex, age, body size, and ethnicity should be considered. This study aimed to compare equations available in Japan and other countries for predicting respiratory muscle strength. We tested 21 equations for maximal inspiratory pressure (MIP) and 17 for maximal expiratory pressure (MEP) for each sex (76 equations in total) in 159 normal, healthy subjects. We observed wide variations in the overall agreement among the MIP and MEP equations. Some equations showed a proper normal distribution, with median values of almost 100%, and the Japanese equations released in 1997 generally showed the best distributions of both %MIP and %MEP. We can conclude that it is better to use Japanese equations when evaluating respiratory muscle strength in Japanese subjects.     

阿斯美对老年哮喘患者中枢驱动力的作用

目的 探讨阿斯美对老年哮喘患者呼吸中枢驱动力（P0.1）和气道阻力的作用.方法 应用西德耶格生产的呼吸中枢驱动检测仪（MasterScreen）,检测老年哮喘患者静息态下和经阿斯美治疗前、后呼吸中枢驱动和气道阻力的变化.结果 （1）哮喘组患者P0.1较正常人高且有显著性差异（p＜0.01）,FEV1.0、PEF较正常人明显减低（p＜0.05）.（2）老年哮喘患者中枢驱动力P0.1与FEV1.0、PEF、R4Hz、R8Hz、R16Hz密切相关而与MIP、MEP无明显相关关系.（3）经阿斯美治疗后老年哮喘患者中枢驱动力P0.1和气道阻力均较前减低,肺功能指标有显著改善.结论 老年哮喘患者呼吸中枢驱动力（P0.1）与呼吸功能指标FEV1.0、PEF和气道阻力指标R4Hz、R8Hz、R16Hz密切相关.经阿斯美治疗后老年哮喘患者中枢驱动力和气道阻力有显著改善作用,这对提高其呼吸中枢驱动能力,改善呼吸功能以达预防呼吸衰竭提高生活质量方面具有一定的临床意义.     

健康中老年人肺功能下降与呼吸中枢驱动变化的关系

目的 探讨健康中老年人肺功能下降与呼吸中枢驱动变化的关系. 方法 随机选择8例健康中老年人及8例性别匹配的健康青年人,平均年龄分别为(57.3±5.0)岁和(28.3±3.4)岁,检测其肺功能.同时,通过多导食道电极记录膈肌肌电反映呼吸中枢驱动,观察静息状态下及最大用力吸气时的膈肌肌电. 结果 中老年组平均肺活量(VC)(3.2±0.5)L,显著低于青年组(4.0±0.8) L(t=-2.27,P＜0.05)；中老年人最大用力吸气动作时的膈肌肌电与青年人相似,分别为(172.2±54.6)μV与(175.0±55.7)μV(t=- 0.10,P=0.921)；中老年人安静状态下的潮气量及每分通气量与青年人相似,但其呼吸中枢驱动占最大值的百分数显著高于青年人,分别为( 27.8+12.9)％与(16.4±7.2)％(t=2.18,P＜0.05):中老年人呼吸中枢驱动有效性比青年人小1倍,分别为(62.7±23.2)％与(128.6±96.2)％. 结论 中老年人的呼吸中枢驱动储备低于青年人,肺功能随增龄减退并不是因为呼吸中枢驱动下降,而可能是因为肺结构本身改变所致.     

Muscle fatigue in acute respiratory failure

Fatigue of the respiratory muscles is now well documented but still remains a process that cannot be assessed easily. Several methods are available to detect fatigue; they represent windows allowing different viewpoints on the same phenomenon. The definition and determinants of respiratory muscle fatigue and some of the methods used to detect it are reviewed. On the basis of the available evidence provided by each of these methods, the role played by muscle fatigue in acute respiratory failure (ARF) is discussed.     

神经调节辅助通气对急性呼吸窘迫综合征兔呼吸机相关性膈肌功能障碍的影响

目的 探讨神经调节辅助通气(NAVA)对ARDS呼吸机相关性膈肌功能障碍(VIDD)的预防作用.方法 将20只成年新西兰大白兔按随机数字表法分为对照组、容量控制通气组(VC组)、压力支持通气组(PSV组)和NAVA通气组(NAVA组),每组5只.VC、PSV及NAVA组在机械通气4 h后取膈肌标本,对照组麻醉后立即取膈肌标本.测定各组膈肌中丙二醛、超氧化物歧化酶(SOD)以及还原型谷胱甘肽(GSH)含量,观察各组膈肌纤维病理结构的改变.结果 (1)丙二醛:NAVA组膈肌中丙二醛含量为(0.28±0.19)nmol/mg,与对照组的(0.15±0.06)nmol/mg、PSV组的(0.30±0.11)nmol/mg比较,差异无统计学意义(F=2.730,P＞0.05);VC组膈肌中丙二醛含量为(0.40±0.16)nmol/mg,明显高于对照组(P＜0.05).(2)SOD:NAVA组膈肌中SOD含量为(94±9)U/mg,与对照组的(111±12)U/mg、PSV组的(93±4)U/mg比较,差异无统计学意义(F=4.422,P＞0.05);VC组膈肌中SOD含量为(80±21)U/mg,明显低于对照组(P＜0.05).(3)GSH:NAVA组膈肌中丙二醛含量为(5.6±1.0)mg/g,与对照组的(5.3±1.0)mg/g、PSV组的(4.5±1.2)mg/g比较,差异无统计学意义(F=3.001,P＞0.05);VC组膈肌中GSH含量为(3.3±1.7)mg/g,明显低于对照组(P＜0.05).(4)光镜观察:VC组出现肌纤维变性、坏死,部分肌纤维萎缩;NAVA、PSV组以及对照组肌纤维形态基本正常.(5)电镜观察:VC组肌原纤维断裂,线粒体肿胀;NAVA组、PSV组以及对照组超微结构无明显异常.(6)膈肌纤维横截面积:NAVA组平均肌纤维横截面积(像素)为2573±278,与对照组的3070+175、PSV组的2508±670比较,差异无统计学意义(F=1.775,P＞0.05);VC组Ⅱ型肌纤维横截面积为2210±971,明显低于对照组的3477±187(P＜0.05).结论 与控制通气相比较,NAVA可减轻ARDS膈肌氧化应激、膈肌萎缩和膈肌结构损伤,NAVA较控制通气更能预防VIDD.

Abstract：

Objective To evaluate the effect of neurally adjusted ventilatory assist (NAVA) on prevention of ventilator-induced diaphragmatic dysfunction (VIDD) in ARDS rabbits.Methods Twenty New Zealand white rabbits were randomly divided into 4 groups: ( 1 ) control group ( n = 5 ); ( 2 ) Volume control (VC) group ( n = 5 ); ( 3 ) Pressure support ( PSV ) group ( n = 5 ); (4) NAVA group ( n = 5 ).In VC, PSV and NAVA groups, the rabbits were killed and the diaphragm was removed after 4 hours of ventilation.Animals in the control group were not mechanically ventilated, and the diaphragm was also removed immediately after anesthetizing.In all rabbits, malondialdehyde ( MDA), superoxide disrmutase (SOD) and glutathione(GSH) of diaphragm were measured.Structure of diaphragm was observed by light microscope, electron microscope, constituent ratio and mean cross-sectional area (CSA) of diaphragm fiber.Results (1)MDA: Compared with the control [(0.15 ±0.06)nmol/mg], PSV group[(0.30 ±0.11)nmol/mg], there was no significant difference in MDA of diaphragm in NAVA group [( 0.28 ± 0.19 )nmol/mg] (F = 2.730, P ＞ 0.05).MDA in VC group [(0.40 ±0.16)nmol/mg] was significantly higher than the control group (P＜0.05).(2) SOD: Compared with control [( 111 ± 12) U/mg], PSV group [(93 ± 4) U/mg], there was no significant difference in SOD of diaphragm in NAVA group [( 94 ± 9 )U/mg] (F=4.422,P ＞0.05).SOD in VC group [(80 ±21 )U/mg] was significantly lower than the control group(P ＜0.05).(3)GSH: Compared with control [(5.3 ± 1.0)mg/g] and PSV group [(4.5 ±1.2)mg/g], there was no significant difference in GSH of diaphragm in NAVA group [(5.6 ± 1.0) mg/g](F =3.001 ,P ＞ 0.05 ).GSH in VC group [(3.3 ± 1.7)mg/g] is significantly lower than control and NAVA groups ( P ＜ 0.05 ).( 4 ) Light microscope: In VC group, many changes were observed in the muscle, such as myofibrosis, necrosis, and some of muscle fibers became atrophy, but these were no obvious changes of pathological structure in control, PSV or NAVA groups.(5)Electron microscope: In control, PSV and NAVA groups, the ultrastructure of diaphragm was normal Different from the above 3 groups, some abnormal ultrastructure was observed in VC group, including disrupted myofibrils, swollen mitochondria.(6)CSA of diaphragm fiber: Compared with control and PSV group, there was no significant difference in CSA of diaphragm fiber in NAVA group ( P ＞ 0.05 ); The CSA of type Ⅱ fibers in VC group was markedly lower than control group ( P ＜ 0.05 ) .Conclusions Compared with volume control ventilation, NAVA may mitigate diaphragmatic oxidative stress, atrophy and injury, and prevent VIDD better than VC.