自主呼吸试验在撤机中的应用

目的 对应用自主呼吸试验(SBT)撤机方式与逐渐降低机械通气支持水平撤机方式成功拔管的患者进行比较,以寻找最佳撤机方式.方法 选择57例机械通气患者,病情稳定后通过撤机试验前评估,然后准备撤机.采用前后对照的方法将患者分为两组,2004年6月-2005年12月的21例患者作为对照组,采用逐渐降低机械通气支持水平的撤机方式拔管;2006年1月-2007年3月的36例患者作用为试验组,采用SBT的撤机方式拔管.分别观察两组患者的机械通气时间、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、ICU病死率.结果 试验组与对照组的机械通气时间分别为(59.45±37.1)h和(111.4±59.8)h(P=0.001),住ICU时间分别为(8.0±5.5)d和(15.3±14.3)d(P=0.034),VAP发生率分别为16.7%和38.0%(P=0.070),48 h内再插管率分别为19.4%和5.0%(P=0.253),ICU病死率分别为25.0%和24.0%(P=0.920).结论 SBT的撤机方式比逐渐降低机械通气支持水平的撤机方式具有机械通气时间和住ICU时间短的优点,而两组VAP发生率、48 h内再插管率、ICU病死率基本相同.     

两种自主呼吸试验方法在气管插管患者撤机中的应用和研究

目的 两种自主呼吸试验方法在ICU气管插管患者撤机中的应用及观察研究。方法 采用随机对照试验,将符合标准的外科术后机械通气患者分为两组,分别采用T管试验和低水平PSV模式进行SBT,比较两组患者拔管前的气道保护能力、撤机时间、撤机成功率、撤机失败率和再插管率。结果 低水平PSV模式SBT较T管试验在首次SBT成功率上高,差异有统计学意义(P＜0.05)。在气道内分泌物及吸痰频率评估中T管试验少于低水平PSV,差异有统计学意义(P＜0.05)。在撤机成功率、撤机失败率、撤机时间和再插管率的差异无统计学意义(P＞0.05)。结论 两种SBT试验均适合在外科术后机械通气病人撤机中应用,但T管试验组患者的气道保护能力评估总体要优于低水平PSV模式,用于辅助判断拔管风险,减少拔管后并发症的发生。     

呼吸功对机械通气患者撤机的指导意义

目的：研究呼吸功（ＷＯＢ）对机械通气患者撤机的指导意义。方法：选择机械通气并准备撤机的患者２３例，应用ＢＩＣＯＲＥＣＰ１００呼吸监测仪床边监测患者ＷＯＢ及常规撤机指标〔呼吸频率（ＲＲ）、潮气量（ＶＴ）、每分通气量（ＶＥ）和最大用力吸气时口腔闭合压（ＭＩＰ）〕，观察其对撤机的指导意义。结果：１８例撤机成功，其中１０例ＷＯＢ正常（≤０．７５Ｊ／Ｌ），８例ＷＯＢ升高（１．００Ｊ／Ｌ～１．３１Ｊ／Ｌ）；撤机失败患者５例的ＷＯＢ〔（１．９６±０．７６）Ｊ／Ｌ（１．４５Ｊ／Ｌ～２．８６Ｊ／Ｌ）〕明显高于撤机成功的患者〔（０．７７±０．３６）Ｊ／Ｌ，Ｐ＜０．０５〕。常规撤机指标ＲＲ、ＭＩＰ、ＶＥ均显著高于撤机成功组，ＶＴ显著低于撤机成功组。结论：ＷＯＢ值对撤机有一定的指导意义，但并非敏感指标，需考虑肺部基础疾病，结合临床指标等综合因素判断是否撤机。     

基于CICARE沟通模式的模拟诱导式自主呼吸试验对ICU机械通气患者撤机成功率的影响

目的 探讨基于CICARE沟通模式的模拟诱导式自主呼吸试验对于ICU机械通气患者撤机成功率的影响。方法 选取2020年10月—2021年2月入住本院的34名患者设为对照组,2021年3月—2021年7月的38名患者设为干预组,分别采用常规自主呼吸训练和基于CICARE沟通模式的模拟诱导式自主呼吸试验,比较两组患者的撤机拔管成功率、48 h内二次插管率、呼吸机相关肺炎发生率和总机械通气时间等。结果 干预组和对照组患者的撤机成功率分别为89.47%和70.59%,干预组的撤机成功率高于对照组(P<0.05),干预组患者的48 h内二次插管率和总机械通气时间低于对照组(P<0.05),两组的呼吸机相关肺炎发生率无统计学意义(P>0.05)。结论 基于CICARE沟通模式的模拟诱导式自主呼吸试验可以有效提高机械通气患者的撤机成功率,减少48 h内二次插管率,缩短患者总机械通气时间,提高护理满意度。     

程序化撤机策略在脑梗死机械通气病人撤机中的应用

[目的]探讨程序化撤机策略在脑梗死机械通气病人撤机中的应用,总结其护理措施。[方法]对96例脑梗死行机械通气病人采用程序化撤机的方式进行撤机,并进行相应的护理。[结果]3d内成功撤机8例,3d～7d成功撤机69例,〉10d成功撤机8例,撤机不成功11例,撤机成功率为88.5%。[结论]脑梗死机械通气病人应用程序化撤机策略进行撤机,可提高撤机的成功率。     

急性呼吸窘迫综合征病人机械通气的撤机护理

目的 探讨急性呼吸窘迫综合征(ARDS)病人机械通气成功撤机的最佳时机、方式及护理,提高撤机成功率,促进病人呼吸功能康复。方法 回顾分析12例ARDS病人运用机械通气的全身情况及呼吸功能评估,采用过渡撤机和间断撤机两各方式撤机,撤机前后密切观察病人病情、予以营养支持、呼吸道管理及心理护理等护理方法。结果 12例病人撤机成功,其中过渡撤机9例,间断撤机3例。结论 撤机时机及方式的掌握是成功撤机的关键,精心的护理是成功撤机的保障。     

单向活瓣通气给氧在机械通气患者撤机中的应用

目的探讨在机械通气患者撤机过程中,使用单向活瓣通气给氧的方法对脱机训练的影响。方法选择行机械通气72h以上的患者48例。在准备撤机前将患者随机分成观察组和对照组各24例。观察组使用单向活瓣通气给氧的方法对患者进行脱机训练,对照组采用常规氧气管给氧通气的方法。观察2组患者的血气分析、呼吸频率、心率、血压变化,并了解患者的耐受性及舒适度改变等指标。结果2组患者在脱机后1,3,24h动脉血气分析的血氧分压(PaO2)、动脉血氧饱和度(SaO2)、呼吸次数、心率、血压变化相比较,差异有统计学意义。观察组患者的耐受性及舒适度显著优于对照组。结论使用单向活瓣通气给氧用于机械通气患者的撤机,可以使患者能吸入较精确的足够的氧混合气体,降低导管死腔,减少患者的呼吸做功,增加患者的舒适度,从而能使患者达到快速、顺利脱机的目的。     

心理护理在ICU机械通气撤机失败患者中的应用

目的探讨心理护理在改善ICU机械通气撤机失败患者心理状态及提高撤机成功率中的作用.方法选择17例符合撤机标准而撤机失败的ICU患者,予以分析心理原因及分别进行有针对性的心理护理.结果 17例患者在经过有针对性的心理护理后心理状态均有改善,最终撤机成功.结论心理护理能改善患者心理状态、增强患者自信心,从而提高撤机成功率.     

浅快呼吸指数在两种自主呼吸试验方法中的临床研究

目的 观察应用压力支持通气(PSV)和T管(T-piece)方法进行自主呼吸试验(SBT)时浅快呼吸指数(RSBI)及其变化水平(ΔRSBI)对脱机成功的预测作用.方法 将2007年1-12月本科经口气管插管机械通气(MV)可脱机的208例患者随机分为PSV组(93例)和T-piece组(115例),分别进行30 min的SBT,记录两组患者在SBT 3 min和30 min时的气道闭合压(P0.1)、呼吸频率(f)、潮气量(VT),计算RSBI值及ΔRSBI,寻找预测脱机成功的阈值.结果 208例患者脱机成功168例,成功率80.77%;PSV组和T-piece组成功率分别为83.87%和78.26%(P>0.05).SBT 30 min时PSV组和T-piece组RSBI分别为(67.18±11.55)次·min-1·L-1和(99.11±15.53)次·min-1·L-1(P<0.01);ΔRSBI分别为(69±33)%和(119±35)%(P<0.01).PSV组RSBI与脱机成功的受试者工作特征曲线(ROC曲线)下面积为0.747±0.045(P=0.000),当RSBI为75次·min-1·L-1时,诊断准确率为87%;ΔRSBI与脱机成功的ROC曲线下面积为0.709±0.065(P=0.001),当ΔRSBI为90%时,诊断准确率为82%,即在SBT结束时RSBI增加水平≤90%预测脱机成功较好.T-piece组RSBI与脱机成功的ROC曲线下面积为0.821±0.049(P=0.000),当RSBI为100次·min-1·L-1时,诊断准确率为82%;ΔRSBI与脱机成功的ROC曲线下面积为0.738±0.046(P=0.000);ΔRSBI为130%时,诊断准确率为77%,即在SBT结束时RSBI增加水平≤130%预测脱机成功较好.结论 PSV组SBT 30 min时RSBI明显小于T-piece组,其数值分别为75次·min-1·L-1和100次·min-1·L-1时预测脱机成功较好;动态观察RSBI的变化对预测脱机成功很有价值.     

心外科术后长期机械通气失败的原因分析

目的：分析心外科术后长期机械通气（prolonged mechanical ventilation,PMV）的原因及相应的干预方法。方法：以心外科术后机械通气时间超过7d的40例气管切开患者为研究对象，床旁心超评估左心及右心功能，用超声和CT评估肺部渗出情况，膈肌超声评估膈肌功能，并进行针对性处理及康复锻炼。定期评估患者是否能脱机，并分析患者脱机成功及失败的原因。结果：8例患者存在单纯心功能不全，20例存在呼吸功能不全，2例存在膈肌功能不全，5例患者同时存在心肺功能不全，2例存在心脏和膈肌功能不全，3例存在呼吸和膈肌功能不全。最终24例患者脱机成功并转出监护室，16例患者脱机失败。心功能不全患者脱机失败率达80%；膈肌功能不全患者脱机失败率为28.5%；呼吸功能不全患者脱机失败率为20%。对影响脱机的原因进行单因素和多因素分析，发现心功能不全是导致脱机失败的独立危险因素（OR=3.431,95%CI1.083~10.867,P=0.036）；初始存在呼吸功能不全者最终脱机失败率较低（OR=0.039,95%CI0.001~0.751,P=0.003）；膈肌功能不全不影响最终的脱机结局。结论：心功能不全是导致心外科术后PMV患者脱机失败的主要原因。     

Protocolized weaning from mechanical ventilation: ICU physicians' views

BACKGROUND: The use of protocols during weaning from mechanical ventilation is uncommon in the UK, despite research pointing to their potential benefits. This may be because the research evidence is considered not to apply in different settings. Intensive care unit consultant physicians are the major decision-makers in weaning in the UK and any attempt to introduce protocolized weaning will require consideration of their views. AIM: The aim of this paper is to report a study exploring intensive care physicians' views on (i) weaning from mechanical ventilation, (ii) the utility of weaning protocols and (iii) nurses' roles in the weaning process. A specific goal was to identify potential aids and barriers to developing weaning protocols and their introduction into clinical practice. METHODS: Qualitative interviews were conducted with a purposive sample of 10 consultant physicians in two intensive care units in Northern Ireland and subjected to content analysis. FINDINGS: The primary themes identified were (i) information required for weaning decisions and clinical judgement, (ii) professional boundaries, (iii) protocol issues and (iv) timing of weaning. Three types of information were deemed to be required for weaning decisions - empirical objective, empirical subjective and abstract - and interviewees considered that it would be challenging to incorporate all into a protocol. They were divided on whether protocols were useful when nursing experience was limited. Some groups of patients were thought more suitable than others for protocolized weaning. CONCLUSIONS: Although local physicians were supportive in theory, introduction of protocolized weaning is likely to be difficult because of the breadth of information required for successful decision-making. Consultant views in this study were not consistent with American findings that physicians' caution may unnecessarily prolong weaning.     

Issues in weaning from mechanical ventilation: literature review

AIM: The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation. BACKGROUND: Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process. METHOD: In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations. DISCUSSION: Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level. CONCLUSION: Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.     

Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing

Objective Evidence that PS may facilitate weaning from mechanical ventilation (MV), although not confirmed by randomized trials, prompted us to investigate whether patients could be weaned with PS after failing a T-tube trial.Design and setting This was a prospective, non-randomized study in two French intensive care units.Patients and participants One hundred eighteen patients were enrolled and underwent a T-tube trial, after which 87 were extubated. Thirty-one underwent a further trial with PS, after which 21 were extubated.Interventions All patients under MV >24 h meeting the criteria for a weaning test underwent a 30-min T-tube trial. If this was successful, they were immediately extubated. Otherwise, a 30-min trial with +7 cm H₂O PS was initiated with an individualized pressurization slope and trigger adjustment. If all weaning criteria were met, the patients were extubated; otherwise, MV was reinstated.Measurements and Results The extubation failure rate at 48 h did not differ significantly between the groups: 11/87 (13%) versus 4/21 (19%), P=0.39. The groups were comparable with regard to endotracheal tube diameter, MV duration, the use of non-invasive ventilation (NIV) after extubation, initial severity score, age and underlying pathology, except for COPD. A significantly higher percentage of patients with COPD was extubated after the trial with PS (8/21–38%) than after a single T-tube trial (11/87–13%) (P=0.003).Conclusions Of the patients, 21/118 (18%) could be extubated after a trial with PS, despite having failed a T-tube trial. The reintubation rate was not increased. This protocol may particularly benefit patients who are most difficult to wean, notably those with COPD.     

持续气道正压通气、T管及压力支持通气等条件下患者呼吸功的比较性研究

目的：探讨从呼吸功角度评价呼吸机脱机方式优劣的可能性及其意义。方法：通过ＢｉｃｏｒｅＣＰ１００呼吸监测仪测定２２例患者在压力支持通气（ＰＳＶ）、持续气道内正压（ＣＰＡＰ）通气、Ｔ管及拔管后２小时等条件下的呼吸功的变化。结果：ＣＰＡＰ０．４９ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ）、Ｔ管、ＰＳＶ０．４９ｋＰａ时，患者呼吸功依次逐渐降低。ＣＰＡＰ０．４９ｋＰａ时呼吸功（９．９８Ｊ／ｍｉｎ）比ＰＳＶ０．４９ｋＰａ时高２３．７％（Ｐ＜０．００１），比拔管后２小时高４８．５％（Ｐ＜０．０１），与Ｔ管时比较无显著性差异。Ｔ管时呼吸功（９．３１Ｊ／ｍｉｎ）比ＰＳＶ０．４９ｋＰａ时高１５．４％（Ｐ＜０．０５），比拔管后２小时高３８．５％（Ｐ＜０．０１）。结论：患者呼吸功因脱机方式不同而显著不同，ＰＳＶ０．４９ｋＰａ比ＣＰＡＰ０．４９ｋＰａ和Ｔ管更有利于脱机。     

自主呼吸试验在慢性阻塞性肺病患者撤离人工气道中的作用

目的：探讨自主呼吸试验（SBT）对机械通气的慢性阻塞性肺病（COPD）患者脱离呼吸机、拔出气管插管时间的影响。方法：采用规范的SBT方法拔出气管插管的COPD患者26例（男性19例,女性7例）列入本研究,作为SBT组。回顾性分析未采用SBT方法拔出气管插管的机械通气COPD患者28 例（男性24例,女性4例）,作为No-SBT组。比较两组患者机械通气时间、拔出气管插管时间（拔管时间）,拔管后气管插管复插率（拔出气管插管48h内）心及PaO2,PaCO2血清白蛋白,血红蛋白。结果：两组患者的年龄 (P=0.683)、机械通气时间(P=0.167)差异无显著性,但是SBT组拔出气管插管的时间（60min）与No-SBT组(40—540min)比较差异有显著意义（P=0.0001）。SBT组和No-SBT组患者拔出气管插管后,需无创通气辅助的患者均为3例（P=0.717）,48h内再次气管插管患者前者为2例（2/24）,后者为3例（3/28）（P=0.900）,再次气管插管的原因均为气道分泌物排出不畅。结论：对COPD患者,在撤离呼吸机、拔出气管插管的过程中采用规范SBT方法可以明显地缩短拔管时间,而且未增加气管插管的复插率。