机械通气相关性肺炎的危险因素及其护理

对机械通气相关性肺炎(VAP)的危险因素及护理措施进行分析,认为口咽部分泌物误吸、胃十二指肠定植菌逆行与吸入、呼吸道与全身防御机制受损、呼吸治疗器械以及空气和手的污染等为造成VAP的主要原因.提出减少或消除口咽部病原菌的定植和吸入,喂养采取适当卧位;切断外源性传播途径,勤洗手,严格消毒隔离和环境管理;充分湿化气道,加强吸痰管理和口腔护理;严格消毒呼吸治疗器械等护理对策.     

应用灭吐灵预防麻醉期间返流误吸

胃内容物返流误吸是麻醉时窒息和麻醉后发生并发症的一个重要原因。许多与手术和麻醉有关的因素诸如:妊娠、外伤、疼痛等应激状态以及某些药物(麻醉性镇痛药、阿托品等)均可减慢胃的排空、增加返流误吸的发生率。此类病人术前常规禁食并不能保证胃的完全排空。术前采用经胃管吸出胃内容物的方法,效果并不满意,甚至可因降低胃—食管括约肌的功能造成吸引期间误吸的危险。近年来,国外报道术前应用灭吐灵以防止全麻下饱食病人的返流误吸,取得一定效果。本文就此问题作一综述,供临床参考。     

综合抗返流技术在近端胃大部切除术中的临床应用研究

目的:评价综合抗返流术式在近端胃大部切除术中的临床应用效果。方法:12例胃底部肿瘤手术采用综合抗返流技术(A组),未行综合抗返流术的11例为对照组(B组),通过手术前后食管胃腔内测压以及24hpH测定评价抗返流效果。结果:A组术后食管体部出现新的高压区;A组患者pH<4的总时间(%)、pH<4的返流次数、>5min的返流次数和最长反流时间(min)均较B组明显减少(P<0.01)。结论:综合抗返流术式方法简便,临床抗返流效果好。     

胃食管返流病

胃食管返流病(gastroesophageal reflux disease,GERD)是最常见的上消化道疾病之一,症状因十二指肠内容物返流入食管所引起,可直接导致食管病理性损害。它还可引起食管外的组织损害及相应的临床表现,该病严重影响患者的生活质量甚至生命,其发病率随年龄增长而增加。在西方人群中,约有7%～15%患有GERD,40%的成年美国人和欧洲     

嗜血细胞综合征患儿全麻诱导过程中发生严重返流误吸

嗜血细胞综合征(hemophagocytic syndrome,HPS)是一种罕见的威胁生命的临床疾病,它可以导致患者全血细胞的减少及肝功能不全,严重影响患者的凝血功能.报道1例“有HPS的6岁患儿在全麻诱导期发生了严重的返流误吸”而误吸的胃内容物推测为术前未察觉的胃内陈旧性的自发性出血.详细地报道该患儿的临床处理和疾病转归,介绍HPS患者的麻醉关注点并且系统地回顾与麻醉有关的返流误吸的危险因素评价与风险处理,麻醉方式的选择以及发生误吸后的临床策略.     

内镜下经皮胃肠造口联合食管内支架置入术患者的护理

24例晚期肺或食管肿瘤并发癌性食管梗阻或食管气管瘘患者在内镜下实施经皮胃肠造口联合食管内支架术。术前给予心理支持及常规用药;术中注意观察生命体征;术后给予饮食指导,肠内营养支持,观察和处理并发症。病情稳定者实施家庭营养支持。结果24例无腹膜炎、误吸、食管穿孔、支架脱落等严重并发症发生;1例术后1 d出现呕血,经止血处理后好转;2例经皮肠造口营养管返入胃内,后在胃镜辅助下重新放入空肠。2例在住院期间死亡;22例营养状态明显改善,体力恢复,生活质量明显提高,4~15 d后出院,继续行家庭肠内营养支持。     

逆行感染在院内获得性肺炎发病中的地位

目的为确证胃→咽→下呼吸道逆行感染途径存在与否，研究胃液pH值变化与院内感染性肺炎(nosocomial pneumonia，NP)发生的关系。方法以气管切开(或插管)病人为研究对象，用防污染标本刷(PSB)采集标本，由细菌表型分型，直至质粒DNA、酶切、任意引物PCR(AP-PCR)等基因分型，前瞻性观察NP的发生情况。结果儿名患者有逆行感染存在(发生率为22．0％)，即在胃部分离出病原菌1～2d后，PSB在咽部及下呼吸道也检出相同的细菌，应用质粒图谱、酶切图谱和AP-PCR等分子生物学技术进行同源性分析，证明其有很高的同源性。将美蓝经胃管注入病人胃内，1～2d后在咽部及下呼吸道可检出蓝色分泌物。随着胃液pH值升高，胃内细菌定植增加，NP的发生率升高。结论存在胃→咽→下呼吸道逆行感染途径。NP的发生与胃液pH值显著相关。     

快速顺序诱导—目前的争议和进展

快速顺序诱导(rapid sequence induction,RSI)是目前临床上为解决饱胃或有反流误吸风险的患者全麻气管插管问题而采取的一种全麻诱导技术。其主要目的是缩短从保护性气道反射消失到气管插管成功的时间间隔,因为在这个阶段,气道失去保护,很可能发生胃内容物误吸,因此是诱导的关键期。RSI概念的形成经历了1951年琥珀胆碱问世、1961年Sellick在《Lancet》上首次提出环状软骨压迫(cricoid pressure,CP)可以预防反流误吸,到1970年包含了目前全部的内容作为一个完整的概念在《Anesthesia & Analgesia》第一次发表。RSI传统的内容包括:充分的预氧合、快速按     

胃食管反流病诊疗新进展

胃食管反流病(gastroesophageal reflux disease,GERD)是由胃内容物反流入食管或以上部位,进入口腔(包括咽部)或肺引起的症状或并发症~[1]。GERD患者在全球分布较为广泛,近年来随着我国人民生活水平的提高,GERD发病率也呈迅速上升趋势,同时对GERD的认识也在不断深入,发现越来越多的疾病与之相关。若GERD得不到有效的控制,轻则对患者生活质量产生不良影响,重则导致严重的并发症甚至致命,因此,对GERD合理诊治具有重要意义。笔者现对GERD的症状、诊断方法和治疗做一总结。     

管状胃代食管在老年食管癌手术中的应用

目的 评价管状胃和全胃代食管在老年食管癌患者(年龄大于60岁)手术中的应用效果.方法 选取2008年5月至2012年5月我院收治的127例60岁以上食管癌患者,按手术方式不同随机分为全胃代食管手术组(全胃组)和管状胃代食管手术组(管状胃组).全胃组63例,管状胃组64例,观察两组患者术中出血、手术时间、术后乳糜胸、术后喉返神经麻痹、吻合口瘘、吻合口狭窄、心律失常、胸胃综合征、返流性食管炎、肺部并发症及住院时间等临床指标.结果 两组患者均顺利完成根治手术,无探查手术,无围手术期死亡.在术中出血、手术时间、术后乳糜胸、术后喉返神经麻痹、吻合口瘘和吻合口狭窄发生率比较,差异均无统计学意义,而两组心律失常、胸胃综合征发生率、返流性食管炎发生率、肺部并发症发生率、术后住院时间等指标比较,差异均有统计学意义.结论 管状胃在老年食管癌手术中,可以降低部分并发症发生率,可缩短住院时间和改善患者的生活质量,收到较好的临床效果.     

New approaches for the prevention of airway infection in ventilated patients. Lessons learned from laboratory animal studies at the National Institutes of Health

Despite early diagnosis and appropriate antibiotic therapy, ventilator-associated pneumonia (VAP) remains the leading cause of death from hospital-acquired infection in ventilator-dependent patients. Strategies to prevent bacterial colonization of the trachea and lungs are the key to decrease mortality, hospital length of stay, and cost. It is well established that the VAP can result from entry of infected oropharyngeal/gastric secretions into the lower airways. Aspiration may occur during 1) intubation, 2) mechanical ventilation through leakage around the tracheal tube cuff, 3) suctioning of the tracheal tube when bacteria can detach from the biofilm within the tube, or 4) areosolization of bacterial biofilm during mechanical ventilation through the tracheal tube or the ventilator circuit biofilm. From experimental studies in sheep, we drew 3 relevant conclusions: 1) The tracheal tube and neck should be oriented horizontal/below horizontal to prevent aspiration of colonized secretions and subsequent bacterial colonization of the lower respiratory tract. 2) Continuous aspiration of subglottic secretions (CASS) can lower bacterial colonization of the respiratory tract, but at the price of severe tracheal mucosal damage at the level of the suction port. 3) Coating the interior of the tracheal tube with bactericidal agents can prevent bacterial colonization of the tube surface and of the entire respiratory circuit, during 24 hours of mechanical ventilation.     

Closed tracheal suction systems for prevention of ventilator-associated pneumonia

We have assessed the evidence that closed tracheal suction systems (TSS) prevent ventilator-associated pneumonia (VAP), using a meta-analysis of randomized controlled trials (RCTs). We searched PubMed and Cochrane databases to identify RCTs that compared closed with open TSS for the management of mechanically ventilated (MV) patients. Nine RCTs were included in the meta-analysis. There was no difference in the incidence of VAP between patients managed with closed and open TSS [odds ratio (OR)=0.96, 95% confidence intervals (CI) 0.72-1.28]. There was no heterogeneity among the eligible trials (I2=0, 95% CI 0-0.65). The compared groups did not differ with respect to mortality (OR=1.04, 95% CI 0.78-1.39) or intensive care unit (ICU) length of stay [two RCTs: 12.3 (sd 1.1) vs 11.5 (1.4) days and 15.6 (13.4) vs 19.9 (16.7) days]. Suctioning with closed systems was associated with longer MV duration (weighted mean differences: 0.65 days, 95% CI 0.28-1.03) and higher colonization of the respiratory tract (OR=2.88, 95% CI 1.50-5.52) than open TSS. The available evidence suggests that closed as opposed to open TSS usage did not provide any benefit on VAP incidence, mortality, or ICU stay of MV patients.     

不同体位对心脏术后气管插管患者生命体征的影响

目的研究体位交替更换对心脏术后气管插管患者生命体征的影响,了解其可行性,以确保体位护理在此类患者中的有效实施。方法对35例气管插管时间>24h的心脏手术后患者于清醒后实施半卧位,左、右侧卧位各1h交替及晨、晚间仰卧位各1h的体位护理,比较不同体位HR、SBP、SaO2值及不适情况。结果不同体位对HR、SBP无显著影响(均P>0.05);半卧位,左、右侧卧位即刻及30min时SaO2值均比仰卧位高(均P<0.05);半卧位和左、右侧卧位不同时间SaO2值比较,差异无显著性意义(均P>0.05)。不适症状除腰痛外,伤口胀痛、胸闷和紧张发生率仰卧位均显著高于其他卧位(均P<0.05)。结论体位改变对患者的生命体征无负面影响,可促进肺氧合功能,增加患者舒适度。     

Alternative approaches to ventilator-associated pneumonia prevention

Ventilator-associated pneumonia (VAP), which develops in patients receiving mechanical ventilation, is the most common nosocomial infection in patients with acute respiratory failure. The major mechanism of lower respiratory tract colonization is aspiration of bacteria-colonized secretions from the oropharynx into the lower airways. The hydrostatic pressure of the secretions that collect in the subglottic space, which is the area above the endotracheal tube (ETT) cuff, or aerosolization of bacteria from the secretions collected within the respiratory tubing may facilitate the leakage into the lower airways. Ideally, the elimination of the mechanisms responsible for aspiration would decrease the incidence of VAP. Several preventive measures have been tested in clinical trials with little success.Here we present the results of our efforts to develop novel approaches for the prevention of VAP. Specifically, we found that keeping ventilated patients in a lateral position, which eliminates gravitational forces, is feasible and possibly advantageous. Additionally, several novel medical devices have been recently developed to prevent bacterial biofilm formation from the ETT and breathing tubing. These devices include coated ETTs, mucus shavers and mucus slurpers. Prevention of ETT bacterial colonization showed decreased bacterial colonization of the respiratory circuit and of the lower respiratory tract in laboratory studies and clinical trials. Future large studies should be designed to test the hypothesis that VAP can be prevented with these novel strategies. While there is a current focus on the use of respiratory devices to prevent biofilm formation and microaspiration, it is important to remember that lower respiratory tract colonization is multifactorial. Prevention of VAP cannot be achieved solely by eliminating bacterial biofilm on respiratory devices, and more comprehensive care of the intubated patient needs to be implemented.     

川芎嗪对兔胃液吸入性肺损伤中白细胞介素-8的影响

目的:探讨白细胞介素-8(IL-8)在兔胃液吸入性肺损伤中的变化及川芎嗪(Ligustrazini,Lig)的保护作用和机制。方法:通过兔气管内注入胃液的方法复制误吸性肺损伤动物模型,并以Lig为干预因素,侧重观察在其急性发病过程中支气管肺泡灌洗液(BALF)中IL-8的变化。结果:胃液误吸后BALF中IL-8含量升高,Lig治疗后IL-8显著降低。结论:Lig通过拮抗IL-8的产生,有效地减轻了由胃液误吸引起的急性肺损伤。     

肺灌洗及外源性肺表面活性物质治疗烟雾吸入性损伤的实验研究

为探讨肺灌洗与外源性肺表面活性物质（ＰＳ）治疗对严重烟雾吸入伤后内源性ＰＳ功能障碍和急性呼吸衰竭的防治效果,作者将重度烟雾吸入伤后Ｗｉｓｔａｒ大鼠经气管插管注入含ＰＳ的等渗盐水或等量盐水行肺灌洗,机械通气４小时,观察２４小时,检测动脉血气、肺水量、静态肺顺应性（Ｃｓｔ）、支气管肺泡灌洗液（ＢＡＬＦ）蛋白含量、ＢＡＬＦ表面张力特性和２４小时病死率等。结果显示：动物伤后立即出现严重缺氧和一氧化碳中毒。烟雾吸入组发生急性呼吸衰竭、高通透性肺水肿和ＰＳ功能障碍。烟雾吸入加灌洗加ＰＳ加机械通气组Ｃｓｔ和ＢＡＬＦ表面张力特性明显改善,氧合能力显著增强,肺水量和ＢＡＬＦ蛋白含量降低,２４小时病死率明显下降。烟雾吸入加灌洗加机械通气组也有一定疗效。作者认为,早期肺灌洗和外源性ＰＳ治疗能有效恢复烟雾吸入所致内源性ＰＳ功能抑制,改善肺功能,防止高通透性肺水肿和呼吸衰竭,降低早期病死率。     

Ventilator associated pneumonia

Ventilator associated pneumonia (VAP) is a nosocomial lower respiratory tract infection that ensues in critically ill patients undergoing mechanical ventilation. The reported incidence of VAP varies between 9% and 68% with a mortality ranging between 33% and 71%. Two key factors are implicated in the pathogenesis of VAP: bacterial colonization of the upper digestive-respiratory tract and aspiration of oral secretions into the trachea. Preventive measurements are advocated to reduce the incidence of VAP, such as selective decontamination of the digestive tract (SDD), supraglottic aspiration and positioning. Prompt recognition and treatment of established VAP has also been demostrated to affect outcome. Therefore, the knowledge of risk factors associated with the development of VAP and the implementation of strategies to prevent, diagnose and treat VAP are mainstems in the nursing of mechanically ventilated patients.     

Nosocomial pneumonia. Prevention and diagnostic

Pneumonia occurring more than 48?h after induction of mechanical ventilation is called ventilator-associated pneumonia (VAP). VAP is the most common nosocomial infection in intensive care medicine and is associated with prolonged intensive care and hospital stay and a higher mortality. The main pathomechanism for development of ventilator-associated pneumonia is not so much the mechanical ventilation per se but more the pathogens passing along the tube towards the lungs. Avoidance of tracheal intubation, strict hygienic measures, reduction of oropharyngeal colonization and the avoidance of microaspiration are the most promising prevention strategies. Therapeutic success in treatment of VAP is coupled to an early diagnosis and therapy. Suspicion of pneumonia is based on clinical and radiologic criteria. Biomarkers and microbiological findings are important for follow-up and reevaluation of the suspected diagnosis.     

The Effect of Reflux and Bile Acid Aspiration on the Lung Allograft and Its Surfactant and Innate Immunity Molecules SP-A and SP-D

Gastro-esophageal reflux and related pulmonary bile acid aspiration were prospectively investigated as possible contributors to postlung transplant bronchiolitis obliterans syndrome (BOS). We also studied the impact of aspiration on pulmonary surfactant collectin proteins SP-A and SP-D and on surfactant phospholipids--all important components of innate immunity in the lung. Proximal and distal esophageal 24-h pH testing and broncho-alveolar lavage fluid (BALF) bile acid assays were performed prospectively at 3-month posttransplant in 50 patients. BALF was also assayed for SP-A, SP-D and phospholipids expressed as ratio to total lipids: phosphatidylcholine; dipalmitoylphosphatidylcholine; phosphatidylglycerol (PG); phosphatidylinositol; sphingomyelin (SM) and lysophosphatidylcholine. Actuarial freedom from BOS was assessed. Freedom from BOS was reduced in patients with abnormal (proximal and/or distal) esophageal pH findings or BALF bile acids (Log-rank Mantel-Cox p < 0.05). Abnormal pH findings were observed in 72% (8 of 11) of patients with bile acids detected within the BALF. BALF with high levels of bile acids also had significantly lower SP-A, SP-D, dipalmitoylphosphatidylcholine; PG and higher SM levels (Mann-Whitney, p < 0.05). Duodeno-gastro-esophageal reflux and consequent aspiration is a risk factor for the development of BOS postlung transplant. Bile acid aspiration is associated with impaired lung allograft innate immunity manifest by reduced surfactant collectins and altered phospholipids.     

Aspiration and hypoxia after extubation

The period of extubation was observed for the occurrence of aspiration and hypoxia. Two basically different methods of extubation were used. The risk of aspiration, according to the literature and our own investigations (40 cases), can not be totally eliminated in spite of various preventive measures. But hypoxia can be prevented without an increased risk of aspiration by the following method: after oxygenation with 100% oxygen for 3 min, oropharyngeal suction is done with the table tilted in 10 degrees Trendelenburg position (tracheal suction is only done in patients with apparently increased bronchial secretions). Then the lungs are inflated maximally the cuff is deflated, and the endotracheal tube removed at maximal inspiration. After extubation the patient breathes 100% oxygen by mask for another 3 min.