程序化撤机在脑梗死患者机械通气中的应用价值

目的评价程序化撤机策略在重症脑梗死患者机械通气(MV)中的应用价值。方法分别采用程序化撤机(程序组,34例)和经验性撤机(经验组,35例)2种方法对MV的重症脑梗死患者进行撤机试验,对比2组撤机成功率、MV时间、住院时间以及呼吸机相关性肺炎(VAP)等并发症的发生率和住院费用。结果程序组撤机成功率高于经验组(67.6%vs 42.9%,P<0.05);与经验组比较,程序组撤机前MV时间、总MV时间和住ICU时间均明显缩短,差异有统计学意义(P<0.05)。程序组VAP发生率、气管切开、住院死亡和住院费用方面均明显低于经验组(P<0.05);2组48h内再插管比较差异无统计学意义(P>0.05)。结论程序化撤机策略能提高撤机成功率,缩短MV时间,降低并发症发生率,减少住院费用,为脑梗死患者提供了一种安全且有效的撤机方式。     

浅快呼吸指数对COPD患者机械通气撤机的预测价值

目的探讨浅快呼吸指数(RSBI)对慢性阻塞性肺疾病(COPD)患者机械通气撤机的预测价值。方法符合撤机条件的70例COPD机械通气患者在无任何呼吸支持条件下测定RSBI值,然后进行撤机试验,观察RSBI值与撤机结果之间的关系。结果 70例COPD机械通气患者撤机成功52例(74.3%),撤机失败18例(25.7%),撤机成功组RSBI值(81.44±14.15)明显低于撤机失败组(108.72±18.81)(P<0.05),RSBI预测脱机成功的灵敏度为78.6%,特异度55.6%。结论 RSBI测定方法简单易行、无创伤性、无需患者主动配合,对COPD患者机械通气撤机具有良好的预测价值。     

影响脑梗死后行机械通气患者撤机的危险因素分析

目的探讨影响脑梗死机械通气患者撤机的危险因素。方法需要机械通气的急性脑梗死患者38例,前瞻性观察机械通气前及撤机前的格拉斯哥昏迷量表（GCS）评分、生命体征、血液生化指标、浅快呼吸指数（RSBI）和血气分析等指标及其动态变化（用两者差值表示）。根据撤机后48h是否需要重新应用呼吸机分为失败组（9例）和成功组（29例）。结果①38例患者中29例成功撤机,9例失败,撤机失败组平均年龄高于成功组,肺部感染和消化道出血的比例亦高于成功组,差异均具有统计学意义,P〈0．01。②呼吸相关指标比较中,呼吸频率、RSBI和氧合指数等指标在成功组和失败组之间以及每组通气前和撤机前的比较中,差异均具有统计学意义,P〈0．05。两组撤机前与通气前的差值比较中,PaCO2、氧合指数和RSBI的差值比较具有统计学意义。③血常规和生化相关指标比较中,GCS评分、ALT等指标在成功组和失败组之间以及每组通气前和撤机前的比较中,差异均具有统计学意义,P〈0．05。两组撤机前与通气前的差值比较中GCS、体温、血小板等的差值比较具有统计学意义。④多因素分析结果表明,与撤机相关的独立因素为机械通气前后RSBI和GCS的差值,两者联合预测撤机成功的敏感性为93．1％,特异性为66．7％,准确性为86．8％。结论动态监测脑梗死机械通气患者的意识状态和浅快呼吸指数有助于对撤机时机的把握。     

脑梗死机械通气患者呼吸机相关肺炎病原学及相关因素分析

目的探讨重症脑梗死进行机械通气后的呼吸机相关肺炎(VAP)发病的相关因素。方法选择137例重症脑梗死行机械通气患者,将发生VAP 56例作为VAP组,未发生VAP 81例作为非VAP组,比较2组临床资料,VAP组检测痰标本中病原菌并分析。结果 VAP组与非VAP组机械通气时间、ICU住院时间比较,差异有统计学意义(P<0.01)。VAP组共检测出89株细菌,革兰阴性杆菌68株,革兰阳性球菌21株,最常见的病原菌依次为金黄色葡萄球菌18株、鲍曼不动杆菌17株、铜绿假单胞菌15株。18株金黄色葡萄球菌中,17株为耐甲氧西林金黄色葡萄球菌,其仅对糖肽类及利奈唑烷敏感性好。鲍曼不动杆菌耐药率较高,对包括碳青酶烯在内的抗生素耐药率均>60%。结论机械通气时间是重症脑梗死患者VAP发生重要的独立危险因素,革兰阴性杆菌及耐甲氧西林金黄色葡萄球菌是导致重症脑梗死患者VAP的主要病原菌,并且其耐药性高。     

综合肺指数对成人ICU机械通气患者撤机失败的预测价值研究

目的 探讨综合肺指数（IPI）对成人ICU机械通气患者撤机失败的预测价值。方法 选取2021年5月至2022年5月于中国人民解放军联勤保障部队第901医院ICU住院,因各种原因导致呼吸衰竭并行机械通气的患者109例,根据撤机结果将患者分为撤机成功组（n=80）和撤机失败组（n=29）。比较撤机成功组与撤机失败组的临床资料。采用多因素Logistic回归分析探讨成人ICU机械通气患者撤机失败的影响因素。采用ROC曲线评估IPI、入ICU时急性生理与慢性健康评价系统Ⅱ（APACHE Ⅱ）评分及两者联合对成人ICU机械通气患者撤机失败的预测价值。根据IPI将患者分为IPI<4分组（n=35）和IPI≥4分组（n=74）,比较IPI<4分组和IPI≥4分组治疗时间及气管切开率。结果撤机成功组入ICU时APACHE Ⅱ评分低于撤机失败组,呼吸频率（RR）、脉率（PR）慢于撤机失败组,血氧饱和度（Pet CO2）、IPI高于撤机失败组（P<0.05）。多因素Logistic回归分析结果显示,入ICU时APACHE Ⅱ评分、IPI为成人ICU机械通气患者撤机失败的独立影响因素（P&...     

智能化撤机和经验性撤机的前瞻性随机对照研究

目的 比较智能化撤机和经验性撤机两种撤机方法对机械通气撤机困难患者的疗效.方法 采用前瞻性随机对照研究,按平衡指数最小的原则进行简易的临床试验随机化分组,将62例综合ICU内的撤机困难患者随机分入智能化Smart Care组(SC组,30例)和同步间歇指令通气联合压力支持通气组(SP组,32例)进行撤机试验,两组患者的疾病构成、年龄、性别、入ICU时急性生理慢性健康状况评分(APACHE)Ⅱ以及撤机前机械通气时间差异均无统计学意义.两组患者除撤机方法不同外,其他处理均相同,观察两组的撤机时间、再插管率和机械通气相关并发症的发生率以及ICU滞留率.结果 SC组神经肌肉病变患者、术后呼吸支持患者和呼吸系统疾病患者的撤机时间分别为(49±13)、(67±37)和(25±96)h,明显少于SP组[分别为(223±38)、(106±34)和(502±91)h,X~2值分别为8.33、4.77和4.43,均P<0.05].SC组神经肌肉病变患者、术后呼吸支持患者的ICU滞留时间分别为(9.0 ±1.7)和(7.3±1.9)d,明显低于SP组的(20.8±5.1)和(14.6±1.7)d(X~2值分别为6.74和7.68,均P<0.05).SC组平均调节呼吸机次数为(5±1)次/人明显低于SP组的(13±3)次/人(t=2.73,P<0.05).两组的再插管率、气管切开率、气胸发牛率、呼吸机相关性肺炎(VAP)发生率和皮下气肿发生率比较差异均无统计学意义.结论 CDW智能化撤机法应用于撤机困难患者能够有效地缩短撤机时间,减少ICU滞留时间,并可以减少医生调节呼吸机的负担而节约医疗资源.     

重症脑梗死机械通气患者死亡因素分析

目的探讨重症脑梗死机械通气死亡相关因素,寻找对重症脑梗死机械通气患者死亡有预测价值的指标。方法回顾性分析脑梗死机械通气患者102例,根据是否院内死亡分为生存组63例和死亡组39例,比较2组基本资料、检查结果及撤机相关因素。结果死亡组年龄≥75岁(66.7%vs 39.7%)、冠心病(61.5%vs 31.7%)、低蛋白血症(66.7%vs 23.8%)、肾功能不全(59.0%vs 36.5%)、电解质紊乱(61.5%vs 30.2%)、机械通气时间[(181.85±146.41)h vs(118.20±109.41)h]、呼吸机相关性肺炎(59.0%vs 33.3%)明显高于生存组,撤机成功(17.9%vs 81.0%)明显低于生存组,差异有统计学意义(P<0.05,P<0.01)。多因素logistic回归分析显示,年龄≥75岁(OR=9.671,P=0.003)、撤机成功(OR=0.038,P=0.000)与重症脑梗死机械通气患者死亡明显相关。结论年龄≥75岁及撤机失败的重症脑梗死患者死亡风险明显增加。     

脑梗死患者呼吸机撤离过程中撤机参数的评价

目的探讨脑梗死患者呼吸机撤离过程中撤机参数的应用价值。方法采用前瞻性研究选择满足撤机标准的急性重症脑梗死患者34例,根据撤机成功与否分为成功组23例和失败组11例。观察3周,记录临床资料,监测常规撤机参数及浅快呼吸指数(RSBI),并进行分析。结果成功组与失败组60min RSBI比较,差异有统计学意义[(61.96±5.43)次/(min·L)vs(86.21±15.25)次/(min·L),P=0.000]。60min RSBI是回归模型中惟一影响撤机的参数(β=0.241,OR=1.273,95%CI:1.069~1.515,P=0.007)。结论在机械通气脑梗死患者实施程序化撤机时,RSBI对判断撤机是否成功有价值,而常规撤机参数价值有限。     

探讨浅快呼吸指数指导COPD患者撤机的临床价值

目的评价浅快呼吸指数（rapid-shallow-breathing index,RSBI）作为COPD患者撤机的临床价值。方法呼吸重症监护病房的20例机械通气的COPD患者,均通过了1h的自主呼吸实验（spontaneous breathing trial,SBT）。记录两个时期的RS-BI：SBT前、SBT1h。同时记录年龄、性别、APACHEⅡ（acute physiology and chronic health evaluationⅡ）评分、撤机前的动脉血气分析。结果 16例COPD患者成功撤机,4例患者撤机失败。在成功和失败两组间年龄、性别、APACHEⅡ评分无明显差异（P〉0.05）,PaCO2（partial pressure of carbon dioxide in arterial blood）有明显差异（P〈0.05）。以RSBI≤105bpm/L为标准预测撤机成功的灵敏度和特异度分别为：SBT前RSBI93.8%、10%;SBT1h的RSBI93.8%、45.5%。SBT1h的RSBI与PaCO2联合预测撤机成功的灵敏度为89.5%,特异度为78%。结论 SBT1h的RSBI预测COPD患者成功撤机的准确性高于SBT前,其与PaCO2联合评价将提高预测撤机成功的准确性。     

浅快呼吸指数、中心静脉血氧饱和度及其变化率对机械通气患者拔管成功率预测价值的差异性研究

【】 目的 探讨浅快呼吸指数(RSBI)、中心静脉血氧饱和度(S_CVO₂)及中心静脉血氧饱和度变化率(ΔS_CVO₂)与机械通气患者拔管成功率的预测价值的差异。方法 采用前瞻性研究方法,选取ICU的机械通气患者70例次,按拔管结果分成2组,比较2组S_CVO₂、ΔS_CVO₂及RSBI。结果 2组患者性别、年龄差异无统计学意义(P>0.05)。2组SBT30min S_CVO₂、ΔS_CVO₂及RSBI差异有统计学意义(P＜0.05)。SBT30min S_CVO₂与拔管成功率正相关(r=0.283,P=0.025),ΔS_CVO₂与拔管成功率负相关(r=-0.425,P=0.001),RSBI与拔管成功率负相关(r=-0.282,P=0.025)。SBT30min S_CVO₂、ΔS_CVO₂和RSBI的ROC下面积分别为0.697、0.190、0.349。结论 SBT30min S_CVO₂、ΔS_CVO₂和RSBI对机械通气患者拔管成功率具有一定的预测价值,SBT30min S_CVO₂优于RSBI 、ΔS_CVO₂。     

The control of breathing during weaning from mechanical ventilation

Using the recruitment threshold technique, we measured the CO2 responsiveness of the unloaded respiratory pump in 14 mechanically ventilated patients prior to weaning. The CO2 recruitment threshold (CO2RT) was compared with the arterial CO2 tension during unassisted breathing (CO2SB) and with the PaCO2 during mechanical ventilation (CO2MV) at machine settings determined by the primary physician. Based on these comparisons, we tested the hypotheses that (1) patients without weaning-induced respiratory distress (group 1) maintain CO2SB near CO2RT, (2) patients with weaning-induced respiratory distress (group 2) retain CO2SB above CO2RT, thereby manifesting incomplete load compensation, and (3) CO2MV is ventilator setting dependent and provides insufficient information about the ventilatory requirement during weaning. Respiratory distress was prospectively defined as sustained tachypnea (rate greater than or equal to 30) or intense dyspnea (Borg scale rating) and limited weaning in nine of 14 patients. The average CO2RT was 40 mm Hg in both groups. All patients in group 1 maintained CO2SB near CO2RT (p greater than 0.1). Seven of nine patients in group 2 retained CO2 by greater than or equal to 3 mm Hg above CO2RT (p less than 0.01). There was no significant difference between CO2MV and CO2SB in either group. We conclude that CO2RT provides a better reference of the adequacy of ventilatory load compensation during weather than CO2MV.     

Diaphragmatic fatigue and breathing pattern during weaning from mechanical ventilation in COPD patients

The medium-term outcome of weaning from mechanical ventilation in COPD patients is not easy to anticipate because a respiratory fatigue may eventually develop. We evaluated the diaphragmatic function and the breathing pattern during 40 weaning trials on 15 patients ventilated after acute respiratory failure. We formed two groups according to the success (group B, n = 18) or failure (group A, n = 19) of the medium-term attempt (group A/less than 10 hours; group B/more than 12 hours). Provided the patients showed the classic weaning criteria (tidal volume greater than 5 ml/kg, respiratory frequency less than 30 breaths per minute, PaO2 greater than 50 mm Hg), the study of the breathing pattern did not allow differentiation between the groups. However, the transdiaphragmatic pressure (Pdi) and the Pdimax, which gave an indication of the power of diaphragm contraction, dropped early in the group that could not stand weaning, with an increase in the Pdi/Pdimax ratio. In addition, this same group showed a diaphragmatic dysfunction attested for by a frequent negative gastric pressure associated with or shortly preceded by an abdominal paradoxic motion.     

自主呼吸试验在COPD机械通气患者撤机中的作用

目的评估自主呼吸试验（SBT）在COPD机械通气患者撤机过程中的作用。方法选择52例COPD机械通气撤机成功的患者,分为两组：S组24例,采用SBT方式撤机拔管;NS组28例,采用逐渐降低机械通气支持水平的方式撤机拔管。对比两组患者的拔管时间、住重症监护病房（ICU）时间、呼吸机相关性肺炎（VAP）发生率、48 h内再插管率以及住院病死率。结果 S组与NS组的拔出气管插管时间120 min和（300.01±65.23）min）、住ICU时间（9.50±4.20）d和（18.60±10.30）d、VAP发生率12.50%和28.57%,均有统计学差异（P〈0.05）,而48 h内再插管率20.83%和21.43%、ICU病死率16.67%和17.85%,无统计学差异（P〉0.05）。结论应用SBT法撤机比渐减机械通气支持水平的方法具有更早拔出气管插管、住ICU时间短的优点,而且降低了VAP的发生率。     

Factors influencing weaning from mechanical ventilation in elderly patients with severe pneumonia

Aims: The purpose of this study was to determine the factors that adversely affect the weaning of elderly patients with community‐acquired pneumonia from mechanical ventilation. Methods: This study retrospectively investigated the medical records of 71 elderly patients (65 years or older) who were admitted to the hospital because of community‐acquired pneumonia and required mechanical ventilation between January 2003 and December 2007. The patients were divided into two groups: group A, which included 33 patients who were successfully weaned from mechanical ventilation, and group B, which included 38 patients who could not be weaned from mechanical ventilation. The study compared the patients' background, vital signs, and laboratory and bacteriological examinations at the beginning of mechanical ventilation. A multiple logistic regression analysis was performed to identify the factors associated with difficulties in weaning patients from mechanical ventilation. Results: In group B, there were significantly more smokers (P < 0.05) and more patients with emphysematous changes on thoracic CT (P < 0.05). In group A, the concentrations of total serum protein (P < 0.05) and albumin (P < 0.05) were significantly higher. A multiple logistic regression analysis revealed that patients with community‐acquired pneumonia who showed emphysematous changes on thoracic CT (OR = 4.92, 95%CI 1.08–22.46) and/or a low concentration of serum albumin <3.0 g/dL (OR = 4.25, 95%CI 1.17–15.45) had difficulty being weaned from mechanical ventilation. Conclusion: Our study suggests that elderly patients with community‐acquired pneumonia with emphysematous changes on thoracic CT and/or a low concentration of serum albumin level have difficulty being weaned from mechanical ventilation. Geriatr Gerontol Int 2012; 12: 277–283.     

浅快呼吸指数指导缺血性脑卒中患者撤机的临床观察

目的探讨浅快呼吸指数(RSBI)指导缺血性脑卒中患者撤机的临床价值。方法前瞻性研究,入选在重症医学科进行有创机械通气24 h 40例缺血性脑卒中患者,根据撤机结果将患者分为成功组26例,失败组14例。应用低水平压力支持通气法进行自主呼吸实验(SBT),40例患者均通过了1 h的自主呼吸实验,记录SBT前和SBT1h、SBT1.5h及SBT2h的RSBI,同时记录年龄、性别、APACHEⅡ评分、撤机前30 min的血气分析。结果成功组和失败组年龄、性别、GCS评分、APACHEⅡ评分无明显差异(P0.05),失败组合并冠心病比例较成功组明显升高(P0.05)。以RSBI≤105 bpm/L为标准预测撤机成功的灵敏度和特异度分别为:SBT前93.8%、10.6%,SBT1 h 100%、40.24%、SBT1.5 h 98.2%、38.7%SBT2 h 96.3%、38.2%。结论SBT1 h的RSBI预测缺血性脑卒中患者撤机成功的准确率高。动态观察RSBI对缺血性脑卒中患者成功撤机有一定的预测价值。