呼吸回路延长管在机械通气吸痰中的应用

机械通气是ICU救治危重病人一项重要的治疗措施,机械通气患者最关键是保持呼吸道通畅,因此,吸痰是机械通气患者重要的护理措施。以往使用机械通气的患者吸痰时须先将患者与呼吸机分离,影响了患者血流动力学的稳定,同时也增加了交叉感染的发生。     

机械通气患者吸痰致低氧血症的护理干预研究进展

机械通气是在患者自然通气和(或)氧合功能出现障碍时,应用呼吸机使患者恢复有效通气并改善氧合的方法.有创机械通气患者因人工气道的建立,使会厌功能丧失,咳嗽反射的完整性在一定程度上遭到破坏,导致分泌物不易咳出.因此,及时有效引流气道内分泌物对疾病的转归有着重要的影响[1].临床上常用吸痰的方法来清除气道内分泌物,但吸痰的同时可能降低肺泡气体的氧浓度,使肺泡的容积和压力改变,导致低氧血症[2].低氧血症是吸痰操作所导致的常见并发症之一,导致低氧血症的原因既与吸痰操作对氧浓度、肺通气和换气功能的影响有关,又与原发疾病相关.在吸痰的过程中,我们可以从适度增加吸人氧浓度、减少吸痰对肺通气的影响、控制吸痰操作等方面来寻找预防措施.本文对吸痰致机械通气患者低氧血症的护理干预措施进行综述.探讨吸痰操作的护理安全.     

机械通气患者应用阶梯性吸痰法的可行性研究

目的 探讨阶梯性吸痰法对机械通气患者氧合及血流动力学的影响.方法 将60例患者随机分为试验组和对照组,每组30例.试验组采用阶梯吸痰法,第1阶梯应用最佳呼气末正压(PEEP);第2阶梯为体外振动排痰;第3阶梯为开放吸痰;第4阶梯为持续气道正压(CPAP)肺复张.对照组采用常规开放吸痰加人工气囊肺复张.试验组和对照组均在60min后进行下一次吸痰,同时监测各时间点血流动力学参数、氧代谢指标、肺机械参数的变化.结果 试验组和对照组吸痰后2h血流动力学指标变化不大,试验组氧合指数、肺机械参数较前明显改善并保持2h以上.结论 阶梯性吸痰法可以明显改善氧合,对正常心功能状态下的血流动力学的影响并不显著.     

60例心脏术后机械通气患者应用膨肺吸痰的护理

总结了60例心脏术后机械通气患者应用膨肺吸痰的护理经验.护理重点包括:掌握正确的膨肺吸痰操作方法,严密观察病情变化等.机械通气患者使用膨肺吸痰能有效清除痰液、防止肺不张、预防低氧血症.     

密闭式吸痰深度对机械通气新生儿的影响

目的 探讨不同的密闭式吸痰深度对机械通气新生儿的影响.方法 选择2011年3月至2012年1月在新生儿重症监护病房(NICU)机械通气并密闭式吸痰的新生儿46例,按随机数字表法分为浅层吸痰组和传统深层吸痰组各23例.分别记录24h吸痰次数、脉搏氧饱和度(SpO2)恢复时间、吸痰引起的气道损伤及肺部感染的情况.结果 浅层吸痰组24 h吸痰次数为(1.78±0.83)次,SpO2恢复时间为(8.67±1.66)s,吸痰引起的气道损伤有2例(8.7％),肺部感染有3例(13.0％);深层吸痰组24h吸痰次数为(4.22±1.56)次,SpO2恢复时间为(15.89±2.47)s,吸痰引起的气道损伤有11例(47.8％),肺部感染有10例(43.5％).以上资料两组比较,差异均有统计学意义(t值分别为3.87,6.94;x2值分别为8.69,5.25;P均＜0.05).结论 对于机械通气并密闭式吸痰的新生儿来说,与传统深层吸痰相比,浅层吸痰能有效减少吸痰次数,缩短SpO2恢复时间,减少气道损伤及肺部感染的发生.     

过度通气预防低氧和高碳酸血症的临床观察

气管内吸痰是清除呼吸道分泌物的常规操作,但吸引可导致低氧血症和高碳酸血症。Ｓｔｏｎｅ［１］发现,吸痰期间动脉血氧饱和度降低２５％～３０％,３ｍｉｎ恢复达基础值。由于缺Ｏ２和ＣＯ２潴留对机体各系统均产生不利影响［２］。本研究对４０例心脏直视手术后接受呼吸机辅助呼吸患者,运用呼吸机的“Ｓｉｇｈ”（叹气）作用,在吸痰前后进行过度通气,对吸痰后的动脉血氧分压（ＰａＯ２）和二氧化碳分压（ＰａＣＯ２）情况进行了观察和分析。１　临床资料１．１　对象　本组４０例,按手术的先后随机分为实验组和对照组。实验组２０例…     

长期机械通气患者应用发音气管切开导管的效果研究

目的探讨长期机械通气患者应用自制发音气管切开导管的效果。方法将急性生理和慢性健康评分Ⅱ(APACHEⅡ)15分、意识清楚、气管插管机械通气时间超过1周,需气管切开继续机械通气的呼吸衰竭患者,按随机数字表分为试验组和对照组。试验组选用自制发音气管切开导管,对照组选用普通气管切开导管。全部病例均进行机械通气、标准营养支持等综合治疗。观察两组患者置入气管切开导管前、后1周Zung氏抑郁自评量表(SDS)评分、血清白蛋白、前臂周长变化,同时监测呼吸机相关性肺炎发生率。结果试验组术前术后组内比较Zung评分(t=5.57,P0.01)、血清白蛋白(t=-3.43,P0.01)及前臂周长(t=-3.44,P0.01)的差异均有统计学意义;对照组术前术后组内比较Zung评分差异有统计学意义(t=-4.48,P0.01),血清白蛋白(t=1.76,P0.05)及前臂周长差异无统计学意义(t=2.02,P0.05);两组患者气管切开术后1周呼吸机相关性肺炎发生率比较,差异有统计学意义(χ2=4.84,P0.05)。结论应用自制发音气管切开导管可以改善患者抑郁状况和生理营养指标,降低呼吸机相关性肺炎发生率,更体现人性化的医疗护理服务。     

重症肺炎机械通气1例呼吸机依赖的护理

2011-01-28我院急诊ICU收治了1例重症肺炎并发感染性休克及多脏器功能衰竭(MOSF)的患者,在救治及护理过程中,我们体会到早期诊断治疗,精心护理对患者康复的重大意义,尤其是在其呼吸机依赖撤机困难时,到位的护理工作使其     

机械通气带加热丝呼吸回路湿化效果分析

目的探讨机械通气病人最佳效果的湿化系统。方法将60例机械通气病人随机分成两组,每组各30例,A组使用一次性普通呼吸回路及MR410加温湿化系统,B组使用一次性带加热丝呼吸回路及MR850加温湿化器,记录机械通气过程中吸入气体的温度、吸痰次数、痰液颜色、粘稠度、痰痂的形成、高气道反应、VIP发生率、呼吸回路的更换次数、添加湿化液次数、倾倒冷凝水次数等情况。结果两组患者痰液情况、高气道反应、VIP发生率比较差异有显著意义（P〈0．05）;在添加湿化液次数、倾倒冷凝水次数、管道护理次数及管道使用时间比较,两组差异也有显著意义（P〈0．05）。结论B组采用一次性带加热丝呼吸回路配合MR850湿化器温湿化效果更好,并且能节约护理成本。     

机械通气患者安全吸痰的护理

机械通气的危重患吸痰是主要的护理操作。如操作不当或吸痰过于频繁，易造成诸多并发症，甚至危及患生命。2000年至2002年，我们共收治需机械通气治疗患56例，现将安全吸痰的方法及应用体会报告如下。     

对机械通气患者气管套管气囊压力的临床观察

目的判断机械通气患者气管套管气囊压力和注气量是否合适。方法对30例机械通气老年患者的气管套管气囊压力和注气量的实际值和理想值进行精确测量。结果53.3％的患者气囊实际压力和注气量过高，大于理想值。其中气囊实际注气量大于理想注气量3～5ml，气囊压力超过理想压力2～26cmH2O(0．2～2．6kPa)。结论临床大部分气管套管气囊压力和注气量偏高，应对机械通气患者的气管套管压力和注气量定期进行精确测量和调整，以减少气管套管对气管粘膜的损伤。     

Safety of the endotracheal tube for prolonged mechanical ventilation

RationaleThe endotracheal tube (ETT) is the most common route for invasive mechanical ventilation (MV) yet controversy attends its long-term safety.ObjectiveAssess the safety of ETT compared with tracheostomy tube (TT) for MV support in the intensive care unit (ICU).MethodsRetrospective analysis of five year national dataset of 128,977 adults (age > 15-years) admitted for MV therapy with tracheostomy tube (TT; n = 4772) or without (ETT; n = 124,204), excluding those with neurological diagnoses or likely to require a surgical airway (n = 27,466), in 93 public health service ICUs across Australia, between July 2013–June 2018.MeasurementsHospital survival (including liberation from MV) for ETT Group compared with TT Group using a probit regression model adjusted for confounding using fixed, endogenous and non-random treatment assignment covariates, and their interactions; analysed and plotted as marginal effects by duration of MV.ResultsMedian duration of MV was 2 (IQR =1–4) days, predominantly via ETT (124,205; 96.3%), and 21,620 (16.7%) died. Temporal trend for ETT increased (OR = 1.06 per year, 95%CI =1.03–1.10) compared to TT, even for prolonged (>3 weeks) MV (38.1%). Higher risk-adjusted mortality was associated with longer duration of MV and after 9 days of MV with retention of ETT compared with TT - average (mortality) treatment effect 12.6% (95%CI =10.7–14.5). The latter was not significant after 30 days of MV.ConclusionsThe safety of ETT compared with TT beyond short-term MV (≤9-days) is uncertain and requires prospective evaluation with additional data.     

机械通气对CVP的影响

目的探讨机械通气对CVP的影响 ,提高机械通气病人CVP的准确性和可靠性。方法对 40例机械通气病人进行CVP及机械通气有关参数的监测。结果经监测比较发现 ,机械通气使CVP上升。CVP的上升与平均气道压呈正相关。结论CVP的这种变化并不反映相伴随的血液动力学变化。     

An economic evaluation of prolonged mechanical ventilation

OBJECTIVE: Patients who receive prolonged mechanical ventilation have high resource utilization and relatively poor outcomes, especially the elderly, and are increasing in number. The economic implications of prolonged mechanical ventilation provision, however, are uncertain and would be helpful to providers and policymakers. Therefore, we aimed to determine the lifetime societal value of prolonged mechanical ventilation. DESIGN AND PATIENTS: Adopting the perspective of a healthcare payor, we developed a Markov model to determine the cost effectiveness of providing mechanical ventilation for at least 21 days to a 65-yr-old critically ill base-case patient compared with the provision of comfort care resulting in withdrawal of ventilation. Input data were derived from the medical literature, Medicare, and a recent large cohort study of ventilated patients. MEASUREMENTS AND MAIN RESULTS: We determined lifetime costs and survival, quality-adjusted life expectancy, and cost effectiveness as reflected by costs per quality-adjusted life-year gained. Providing prolonged mechanical ventilation to the base-case patient cost "dollars"55,460 per life-year gained and "dollars"82,411 per quality-adjusted life-year gained compared with withdrawal of ventilation. Cost-effectiveness ratios were most sensitive to variation in age, hospital costs, and probability of readmission, although less sensitive to postacute care-facility costs. Specifically, incremental costs per quality-adjusted life-year gained by prolonged mechanical ventilation provision exceeded "dollars"100,000 with age >or=68 and when predicted 1-yr mortality was >50%. CONCLUSIONS: The cost effectiveness of prolonged mechanical ventilation provision varies dramatically based on age and likelihood of poor short- and long-term outcomes. Identifying patients likely to have unfavorable outcomes, lowering intensity of care for appropriate patients, and reducing costly readmissions should be future priorities in improving the value of prolonged mechanical ventilation.     

机械通气治疗放疗导致的ARDS的疗效及评价

目的　研究机械通气治疗恶性肿瘤放疗导致的ARDS患者临床疗效、并发症及预后 ,进一步提高该类患者的生存率。方法　 4 7例患者中 ,恶性肿瘤放疗导致ARDS患者 15例 ,其他原因导致ARDS 32例 ,比较放疗组和非放疗组机械通气前后氧合情况、机械通气并发症和住院期间死亡率。结果　两组患者机械通气后 12、4 8h时PaO2 、氧合指数均比治疗前显著改善 (P <0 .0 1) ,但放疗组在机械通气后 72h时PaO2 、氧合指数与治疗前无明显差异 (P >0 .0 5 ) ;与放疗组相比 ,非放疗组机械通气后 12、4 8、72h时PaO2 、氧合指数改善更为显著 (P <0 .0 1)。放疗组气胸、呼吸机相关性肺炎 (VAP)、多器官功能障碍综合征 (MODS)发生率均显著高于非放疗组 (P <0 .0 1)。放疗组住院期间死亡率显著高于非放疗组 (P <0 .0 1)。结论　恶性肿瘤放疗导致的ARDS患者预后极差 ,机械通气只能短暂应用于该类患者急救 ,并不能改善预后。对于肿瘤放疗患者重点在于预防ARDS的发生     

临床护理路径在ARDS患者机械通气中的效果评价

目的 探讨临床护理路径(clinical nursing pathway,CNP)护理模式在ARDS机械通气中的应用效果.方法 选择2008年6月至2010年12月入住ICU的59例实施机械通气的ARDS患者,随机分为观察组30例和对照组29例,对照组采用传统的整体护理模式,按常规进行机械通气的监测、治疗和护理;观察组按制订好的临床护理路径进行护理.比较2组患者呼吸机应用时间、机械通气并发症发生率、患者及家属满意度等指标.结果 观察组患者呼吸机应用时间少于对照组,机械通气并发症发生率低于对照组,患者及家属满意度优于对照组.结论 临床护理路径用于ARDS机械通气中,能缩短机械通气时间,降低机械通气并发症发生率,提高患者及家属对护理工作的满意度.

Abstract：

Objective To investigate the effect of clinical nursing pathway on mechanical ventilation effect of ARDS patients. Methods 59 ARDS patients with mechanical ventilation from June 2008 to December 2010 were randomly divided into the observation group (30 cases)and the control group (29 cases). The control group used the traditional care model, conventional mechanical ventilation monitoring,treatment and care according to routine measures; the observation group used clinical nursing pathway. The mechanical ventilation time, complication rate of mechanical ventilation, and the gratification level of patients in the two groups of patients were observed. Results The mechanical ventilation time in the observation group was less than the control group, and incidence of complications was lower, and satisfaction degree of patients and their families was better, the difference was statistically significant. Conclusions The clinical nursing pathway can shorten the time of mechanical ventilation, lower incidence of complications of mechanical ventilation, and it improves satisfaction degree of patients and their families.     

供氧吸痰管与普通吸痰管临床应用效果比较

目的 探讨供氧吸痰管的安全性和有效性.方法 对40例气管插管或气管切开需供氧吸痰的患者采用自身对比观察,分别使用供氧吸痰管和普通吸痰管吸痰,观察吸痰前、吸痰后血氧饱和度和心率的变化.结果 供氧吸痰管吸痰后血氧饱和度无下降,与吸痰前对比无显著差异;普通吸痰管吸痰后血氧饱和度下降,与吸痰前对比有显著差异;供氧吸痰管与普通吸痰管,吸痰前和吸痰后心率变化对比有显著差异.结论 供氧吸痰管在吸痰同时供给氧气,能减轻低氧血症,增强吸痰的安全性.

Abstract：

Objective To investigate the safety and effectiveness of ventilation sputum-aspirating tube. Methods Forty patients with lifesaver or incision of trachea used sputum-aspirating tubes with ventilation and with normal tubes for self-contrasted observation.Then, the heart rate and saturation of blood oxygen before and after suctioning were observed. Results There was no remarkable difference in the value of saturation of blood oxygen in patients who used ventilation sputum-aspirating tube before and after administration.However, there was significant difference in the value of saturation of blood oxygen in the normal sputum-aspirating tube group.Furthermore, there was significant difference in the value of heart rate in both tubes. Conclusions Ventilation sputum-aspirating tube may supply oxygen to lighten hypoxemia.This method may enhance the safety of aspiration.