无创机械通气在食管癌切除术后急性呼吸衰竭患者中的疗效分析

目的：探讨无创机械通气(noninvasive positive pressure ventilation,NPPV)在食管癌切除术后急性呼吸衰竭(acute respiratory failure,ARF)患者中的疗效。方法回顾性分析了2009年6月至2014年6月我院重症医学科收治的食管癌切除术后发生 ARF 的患者,所有患者均首先行NPPV 治疗,根据患者是否最终需要气管插管行有创机械通气治疗,将患者分为 NPPV 成功组(A组)和 NPPV 失败组(B 组)。并记录患者的性别、年龄、入 ICU 时 APACHE Ⅱ评分、基础肺功能、手术方式、术中出血量、无创前和无创2 h 后的血气分析结果、使用 NPPV 的模式和压力支持水平、ICU 停留时间和28 d 死亡率。结果2009年6月至2014年6月我院共有912例患者行食管癌切除术,其中76例(8.3%)发生 ARF 纳入本研究。A 组66例(86.8%),B 组10例(13.2%)。2组性别分布、年龄、APACHE Ⅱ评分、FEV1%pred 和术中出血量差异无统计学意义(P 值均>0.05)。A 组行 NPPV 前氧合指数与 B 组比较差异无统计学意义(162±35.7)mmHg vs (169±40.2)mmHg,t =1.760,P >0.05]；但行 NPPV 2 h 后 A 组氧合指数显著高于 B 组(246±25.4)mmHg vs (188±32.6)mmHg,t =3.210,P <0.05]。无创通气模式在2组间比较差异无统计学意义(χ2=0.451,P >0.05),但 A 组选择较高水平呼气末正压通气(8 cmH 2 O)的比例显著高于 B 组(χ2=16.348,P <0.05)。A 组患者平均 ICU 停留时间为(4.1±2.28)d,显著少于 B 组(11.3±4.32)d,t =3.210,P =0.002]。无患者死亡。结论食管癌切除术后发生 ARF 的患者应该首选 NPPV 治疗,在治疗中需要选择较高水平的呼气末正压通气,可以改善患者的氧合水平,降低患者的插管率,缩短患者的 ICU 停留时间。同时在治疗过程中应该密切观察患者氧合指数的变化,避免插管时机的延误。

Evolution of noninvasive positive pressure ventilation in acute respiratory failure patients post-esophagectomy for esophageal cancer

Objective To evaluate the efficacy of noninvasive positive pressure ventilation(NPPV) in acute respiratory failure (ARF) patients post-esophagectomy for esophageal cancer.Methods The patients with ARF following esophagectomy for esophageal cancer from June 2009 to June 2014 were enrolled.And they were divided into NPPV success group (group A) and NPPV failure group (group B) according to the outcome of NPPV.The following factors were evaluated in two groups:gender,age, APACHE Ⅱ score,FEV1 %pred,intraoperative hemorrhage,the oxygenation before and two hours after NPPV therapy,the performing mode of NPPV,the level of positive end-expiratory pressure (PEEP),the length of ICU-stay and 28-day mortality.Results 912 patients underwent the esophagectomy for esophageal cancer during the period,76 patients (8.3%) who met the criterion were enrolled.They were divided into two groups according to the outcome of NPPV,66 patients in group A(86.8%) and ten patients in group B(13.2%).There was no significant difference in gender,age,APACHE Ⅱ score, FEV1 %pred and intraoperative hemorrhage between two groups (all P >0.05).There was no significant difference in oxygenation index before NPPV therapy between group A and group B(162 ±35.7) mmHg vs (1 69±40.2) mmHg,t =1.760,P >0.05],but two hours after NPPV therapy,the oxygenation index of group A was significantly higher than that of group B(246±25.4)mmHg vs(188±32.6)mmHg,t =3.210,P < 0.05].There was no significant difference in the NPPV mode between two groups (χ2 =0.45 1,P >0.05),but the level of PEEP in group A was significantly higher than that in group B(χ2 =1 6.348,P < 0.05).The length of ICU-stay in group A was significantly shorter than that in group B (4.1±2.28) d vs (1 1.3 ±4.32) d,t =3.210,P =0.002].No patient died finally.Conclusions ARF patients post-esophagectomy for esophageal cancer should initiate the NPPV therapy with a high PEEP level,which can decrease the incidence of intubation and shorten the length of ICU-stay.And the variation of the oxygenation index should be monitored closely to avoid the delay of the timing of intubation.