侧卧位通气治疗新型冠状病毒肺炎重症患者的临床研究

目的探讨侧卧位通气对重症新型冠状病毒肺炎（COVID-19）患者的临床价值。 方法采用回顾性研究，收集2020年1月20日至3月7日在重庆三峡中心医院重症应急病区住院的41例COVID-19并中、重度急性呼吸窘迫综合征（ARDS）患者的临床资料。在经鼻高流量湿化氧疗（HFNC）或无创通气（NIV）的基础上，按是否进行侧卧位通气将患者分为侧卧位组（24例）和仰卧位组（17例）。统计2组患者的性别、年龄、急性生理与慢性健康状况（APACHEⅡ）评分和合并基础疾病情况，比较治疗前及治疗后第1、3、5天的心率（HR）、呼吸频率（RR）、氧合指数（PaO₂/FiO₂）、二氧化碳分压（PaCO₂）、平均动脉压（MAP），以及轻症化率、HFNC或NPPV时间、气管插管发生率、住院时间、压疮发生情况等预后指标。 结果41例患者中，男性21例，女性20例；年龄43~79岁，平均（60.9±11.1）岁。2组患者年龄、性别、APACHEⅡ评分、合并基础疾病，以及治疗前RR、PaO₂/FiO₂、PaCO₂和MAP等比较，差异均无统计学意义（P均＞0.05）。2组患者治疗后HR、RR、MAP较治疗前下降，而PaCO₂、PaO₂/FiO₂上升，其中PaO₂/FiO₂在第5天较治疗前明显改善［侧卧位组：（166.4±45.4）mmHg vs（253.0±66.0）mmHg，仰卧位组：（183.8±54.4）mmHg vs（227.4±62.8）mmHg，P均＜0.05，1 mmHg=0.133 kPa］。2组间比较，侧卧位组在治疗后第1天RR较仰卧位组降低（P=0.006）；侧卧位组的中、重度ARDS患者PaO₂/FiO₂在治疗后第5天较仰卧位组改善，差异有统计学意义［（260.8±58.5）mmHg vs （221.6±64.9）mmHg，P=0.043］。2组HFNC或NIV时间和气管插管发生率比较，差异无统计学意义（P均＞0.05），而侧卧位组总住院时间明显短于仰卧位组，差异有统计学意义［（15.5±7.2）d vs （21.5±9.8）d，P=0.028］，ICU住院时间也短于仰卧位组，差异有统计学意义［（10.3±6.3）d vs （16.9±11.0）d，P=0.021］，侧卧位组病死率低于仰卧位组，差异有统计学意义（8.3 % vs 23.5 %，P = 0.047）。 结论侧卧位通气能改善COVID-19并中、重度ARDS患者的氧合，缩短住院时间，降低病死率，提高疗效，促进患者康复。

Clinical study of lateral position ventilation in severe coronavirus disease 2019 patients

ObjectiveTo investigate clinical effects of lateral position ventilation in the patients with severe coronavirus disease 2019 (COVID-19). MethodsRetrospectively collecting data of 41 COVID-19 patients with moderate and severe acute respiratory distress syndrome (ARDS) hospitalized in the critical emergency ward of Chongqing Three Gorges Central Hospital from January 20 to March 7, 2020. The patients treated with high-flow nasal canula therapy (HFNC) or noninvasive ventilation (NIV) were divided into two groups: lateral position group (n=24) and supine position group (n=17). The gender, age, acute physiology and chronic health evaluation (APACHE) Ⅱ score,comorbidities of the two groups were compared. Respiratory rate (RR), oxygenation index (PaO₂/FiO₂), partial pressure of carbon dioxide (PaCO₂) and mean arterial pressure (MAP) of the two groups were compared before and on the first, third and fifth day of treatment. The amelioration rate, duration of HFNC or NPPV, incidence of tracheal intubation, length of stay in hospital and occurrence of bedsore of the two groups were compared too. ResultsAmong 41 patients, 21 were male and 20 were female, with an average age of (60.9±11.1) years (43-79 years). There was no significant difference in age, gender, APACHE Ⅱ score, comorbidities, RR, PaO₂/FiO₂, PaCO₂and MAP before treatment between the two groups (P all＞0.05). HR, RR and MAP decreased after treatment in both groups,while PCO₂ and PaO₂/FiO₂ increased. PaO₂/FiO₂ improved significantly on the 5th day in both groups (166.4±45.4) mmHg vs (253.0±66.0) mmHg in lateral position ventilation group and (183.8±54.4) mmHg vs (227.4±62.8) mmHg in supine position ventilation group, P all＜0.05, 1 mmHg=0.133 kPa]. Compared with supine position ventilation group, RR was lower in the lateral position ventilation group on the first day after treatment (P=0.006); PaO₂/FiO₂ increased significantly in moderate and severe ARDS patients in lateral position group on the 5th day after treatment (221.6±64.9) vs (260.8±58.5) mmHg, P=0.043],compared with supine position ventilation. There was no significant difference in duration of HFNC or NIV and the incidence of endotracheal intubation between the two groups (P all＞0.05). Compared with the supine position ventilation group, the length of stay in hospital and in ICU was significantly shorter in the lateral position ventilation group (15.5±7.2) d vs (21.5±9.8) d, P=0.028; (10.3±6.3) d vs (16.9±11.0) d, P=0.021], and the mortality was also lower in lateral position ventilation group (8.3% vs 23.5%, P=0.047). ConclusionLateral position ventilation can improve oxygenation, reduce length of stay in hospital and ICU, mortality in COVID-19 patients with moderate and severe ARDS.