建立人工气道实施机械通气是治疗严重呼吸衰竭过程中挽救患者生命最常用的措施之一，然而通过人工气道的机械通气也增加了相关并发症发生的机会，如呼吸机相关性肺炎（VAP）等[1]。多数患者在应用呼吸机进行通气支持治疗中，当呼吸衰竭及其病因的病情缓解或明显改善时就可以解除人工气道和终止通气支持，但20%~30%的患者需要逐渐解除呼吸机的通气支持，谓之撤机（Weaning）[1]。尽管文献中撤机的定义略有不同，但主要指的是需要逐步减弱及停止通气支持和解除人工气道的一个时间过程。有慢性呼吸功能不全的患者撤机尤为困难，撤机困难患者的撤机时间可占总机械通气时间的40%[2]。机械通气时间延长与VAP发生率和病死率增加相关。一般来说，机械通气时间gt;3 d，VAP的发生率增加；机械通气时间gt;5 d，并发的VAP为晚发性医院获得性肺炎（HAP），其感染的病原体多为耐多药细菌，治疗难度加大，病死率高于早发性HAP。因此，对于机械通气患者来说，一旦建立人工气道实施有创通气，就应该积极创造条件，尽快撤机，去除人工气道。然而过快地降低和停止通气支持以及过早的气管拔管，可导致撤机失败和再插管。因此时机不成熟的撤机和延时撤机同样可造成机械通气时间过长，导致VAP发生率和病死率升高，以及医疗费用增加[2]。撤机的模式和方法有多种，但最佳的撤机方式仍有争议[1]。近年来无创通气（NIV）作为一种撤机方式用于临床已引起人们的兴趣和关注，但至今临床研究所得结论并未达到一致，NIV是否可以作为一种常规撤机方式用于临床尚无定论。本文通过总结近年来相关的临床研究，评价NIV用于机械通气撤机的可行性和利弊，探讨需进一步优化研究方案来解决的有关问题。
【摘要】 目的 总结先天性心脏病术后无创通气的监护。 方法 2008年1-12月胸外ICU 36例先天性心脏病术后患儿，在使用无创通气前后监测血压、心率、呼吸及血气变化。 结果 与无创通气前相比，无创通气后30 min、1 h、2 h的指标均恢复到满意水平，循环稳定。 结论 通过采用无创通气，80%的患儿避免了再次插管，缩短有创通气时间，同时避免了相关的呼吸道并发症，缩短了患儿住院时间，节省了医疗费用，提升了先天性心脏病患儿术后成活率。【Abstract】 Objective To summarize the nursing experience of noninvasive ventilation for infants with congenital heart disease after the surgery. Methods A total of 36 patients who underwent noninvasive ventilation from January to December 2008 were enrolled. The blood pressure, heart rate, respiration, and blood gas were recorded and analyzed before and after noninvasive ventilation. Results Compared with the results before noninvasive ventilation, all of the indexes returned to a satisfying level and the circulation kept stable 30 minutes, one hour, and two hours after noninvasive ventilation. Conclusion Noninvasive ventilation may avoid reintubation, shorten the invasive ventilatory time, decrease the respiratory complications, shorten the time of hospitalization, save the medical expenses, and promote the survival rate of infants with congenital heart disease.
ObjectiveTo investigate the effect of noninvasive ventilation (NIV) in patients with myasthenic crisis after thymectomy. Methods31 myasthenic crisis patients after thymectomy who initially used NIV,admitted in the First Affiliated Hospital of Guangzhou Medical University between January 2011 and June 2013,were analyzed retrospectively.They were assigned to two groups according to the successful application of NIV or not,with 13 patients in the NIV success group and 18 patients in the NIV failure group.The related factors including gender,age,APACHEⅡ score when admitted to ICU,the results of blood gas analysis before NIV,thymoma or not,the history of myasthenic crisis,the history of chronic lung disease,and minute ventilation accounted for the largest percentage of predicted value (MVV%pred)were analyzed. ResultsThere were no significant differences in age,gender,or APACHEⅡ score between two groups (P>0.05).The PaCO2 in the NIV success group was lower than that in the NIV failure group.The preoperative MVV%pred in the NIV success group was higher than that in the NIV failure group.There were no significant differences between two groups in pH,PO2,thymoma or not,the history of myasthenic crisis,or the history of chronic lung disease (P>0.05).If using the 45 mm Hg as the cut-off value of PaCO2 and 60% as the cut-off value of MVV%pred,the incidence of PaCO2<45 mm Hg and the incidence of MVV%pred>60% were higher in the NIV success group than those in the NIV failure group (84.6% vs.33.3%, P<0.05;100% vs. 55.6%,P<0.05).Logistic regression analysis revealed that PaCO2<45 mm Hg was an independent influence factor for successful application of NIV in patients with myasthenic crisis after thymectomy. ConclusionPaCO2<45 mm Hg can be a predictor of successful application of NIV in patients with myasthenic crisis after thymectomy.For the patients underwent NIV whose PaCO2<45 mm Hg or MVV%pred<60%,the clinician should predict the possibility of failure and prepared for intubation.
Objective To study the changes of receptor activator of nuclear factor-κB ligand (RANKL, an osteoclastogenesis-promoting factor) and osteoprotegerin (OPG, the decoy receptor for RANKL), oxidative stress and bone turnover markers in obstructive sleep apnea-hypopnea syndrome (OSAHS), in order to understand the potential mechanisms underlying bone loss in OSAHS patients. Methods Ninety-eight male patients with OSAHS, confirmed by polysomnography (PSG) study, were enrolled. The patients were divided into mild-moderate groups and severe groups. Forty-two male subjects who were confirmed as not having OSAHS served as the controls. The subjects’ bone mineral density (BMD) and T-score were assessed in lumbar spine and femoral neck using dual-energy X-ray absorptiometry. Blood samples were collected from all subjects for measurement of RANKL, OPG, the bone formation marker bone-specific alkaline phosphatase (BAP), the bone resorption marker tartrate-resistant acid phosphatase-5b (TRAP-5b), total antioxidant capacity (TAOC). Twenty-eight severe OSAHS patients accepted continuous positive airway pressure (CPAP) treatment voluntarily. After 6 months, PSG was conducted, and serum RANKL, OPG, TAOC, TRAP-5b, BAP was measured after six months treatment. Results The BMD, T-score of the femoral neck and the lumbar spine were significantly lower in OSAHS patients as compared to the control group. The level of BAP was significantly decreased in the OSAHS group as compared to the control group, and there was no significant difference in TRAP-5b level between two groups. As compared with the control group, levels of OPG, TAOC and the OPG/RANKL ratio decreased significantly. None of these parameters (BMD, T-score, RANKL, OPG, TRAP-5b, BAP) showed significant difference between patients with mild-moderate and severe OSAHS group. Correlation analysis showed that the apnea hypopnea index and oxygen desaturation index were correlated with TAOC. BAP level was positively correlated with TAOC and lowest pulse oxygen saturation. The serum level of TAOC was lower in the OSAHS group after CPAP therapy, but the levels of RANKL, OPG, TRAP-5b, BAP were not different. As compared with the OSAHS group before CPAP therapy, the BMD of the femoral neck and the lumbar spine were not significant difference. Conclusions In patients with OSAHS, the oxidative stress response is enhanced, and imbalance of OPG/RANKL is shifted, which participates in the occurrence of osteoporosis. The oxidative stress injury of severe OSAHS patients was relieved after non-invasive ventilation treatment, but the effect of oxidative stress response on bone metabolism still needs further evaluation.
Objective To explore the predictive value of serum procalcitonin (PCT), D-dimer (D-D) and decoy receptor 3 (DcR3) for prognosis of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and respiratory failure undergoing non-invasive ventilation (NIV). Methods A total of 95 patients with AECOPD and respiratory failure undergoing basic treatment and NIV in the hospital were retrospectively enrolled between September (n=65) 2017 and February 2021. According to prognosis after treatment, they were divided into a good prognosis group and a poor prognosis group (n=30). The general data of all patients were collected. The influencing factors of prognosis were analyzed by multivariate logistic regression model. The levels of DcR3, PCT and D-D were detected by enzyme-linked immunosorbent assay, colloidal gold colorimetry and immunoturbidimetry. The patients condition was assessed by scores of acute physiology chronic health evaluation scoring system Ⅱ (APACHEⅡ). The partial pressure of arterial oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) were recorded. And the above indexes between the two groups were compared. The relationship between DcR3, PCT, D-D and APACHEⅡ score, PaO2, PaCO2 was analyzed by Pearson correlation analysis. The prognostic value of DcR3, PCT and D-D was analyzed by receiver operating characteristic (ROC) curve. Results There was no significant difference in gender, GOLD grading or underlying diseases between the poor prognosis group and the good prognosis group (P>0.05), but there were significant differences in age, DcR3, PCT, D-D, APACHEⅡ score, PaO2 and PaCO2 after treatment (P<0.05). DcR3, PCT, D-D, APACHEⅡ score and PaCO2 in the poor prognosis group were higher than those in the good prognosis group, while PaO2 was lower than that in the good prognosis group (P<0.05). Logistic regression analysis showed that DcR3 ≥5.50 ng/mL (OR=21.889), PCT ≥ 5.00 μg/L (OR=3.782), D-D ≥3.00 μg/L (OR=4.162) and APACHEⅡ score ≥20 points (OR=2.540) were all influencing factors of prognosis (P<0.05). The results of Pearson correlation analysis showed that DcR3, PCT and D-D were positively correlated with APACHEⅡ score and PaCO2, while negatively correlated with PaO2 (P<0.05). The results of ROC curve analysis showed that area under ROC curve of DcR3, PCT and D-D for predicting the prognosis were 0.745 (95%CI 0.631 - 0.859), 0.691 (95%CI 0.579 - 0.803) and 0.796 (95%CI 0.696 - 0.895), respectively (P<0.05). Conclusion The serum DcR3, PCT and D-D levels are related to disease progression in patients with AECOPD and respiratory failure after NIV, which have good predictive efficiency for prognosis and can be applied as important biological indexes to evaluate prognosis and guide treatment.
Without artificial airway though oral, nasal or airway incision, the bi-level positive airway pressure (Bi-PAP) has been widely employed for respiratory patients. In an effort to investigate the therapeutic effects and measures for the respiratory patients under the noninvasive Bi-PAP ventilation, a therapy system model was designed for virtual ventilation experiments. In this system model, it includes a sub-model of noninvasive Bi-PAP respirator, a sub-model of respiratory patient, and a sub-model of the breath circuit and mask. And based on the Matlab Simulink, a simulation platform for the noninvasive Bi-PAP therapy system was developed to conduct the virtual experiments in simulated respiratory patient with no spontaneous breathing (NSB), chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS). The simulated outputs such as the respiratory flows, pressures, volumes, etc, were collected and compared to the outputs which were obtained in the physical experiments with the active servo lung. By statistically analyzed with SPSS, the results demonstrated that there was no significant difference (P > 0.1) and was in high similarity (R > 0.7) between the data collected in simulations and physical experiments. The therapy system model of noninvasive Bi-PAP is probably applied for simulating the practical clinical experiment, and maybe conveniently applied to study the technology of noninvasive Bi-PAP for clinicians.
Objective To investigate the influence of pulmonary infection on noninvasive ventilation ( NIV) therapy in hypercapnic acute respiratory failure ( ARF) due to acute exacerbation of chronic obstructive pulmonary disease ( AECOPD) , and evaluate the predictive value of simplified version of clinical pulmonary infection score ( CPIS) for the efficacy of NIV therapy in ARF patients with AECOPD. Methods Eighty-four patients with ARF due to AECOPD were treated by NIV, and were divided into a successful group and an unsuccessful group by the therapeutic effect of NIV. The CPIS and simplified version of CPIS between two groups was compared. The predictive value of simplified version of CPIS for the efficacy of NIV wasevaluated using ROC curve analysis. Results The CPIS and the simplified version of CPIS of the successful treatment group ( 4. 0 ±2. 8, 3. 2 ±2. 4) were lower than those of the unsuccessful group ( 8. 0 ±2. 1, 7. 2 ±1. 8) significantly ( P =0. 006, 0. 007) . The area under ROC curve ( AUC) of CPIS and simplified version of CPIS were 0. 884 and 0. 914 respectively, the cut oint of CPIS and simplified version of CPIS were 6 ( sensitivity of 78. 0% , specificity of 91. 2% ) and 5 ( sensitivity of 80. 0% , specificity of 91. 2% ) respectively. Conclusions The level of pulmonary infection is an important influencing factor on the therapeutic effect of NIV in patients with ARF due to AECOPD. Simplified version of CPIS is a helpful predictor for the effect of NIV on ARF of AECOPD.
目的 比较无创双水平正压通气（BiPAP）平均容积保证压力支持（AVAPS）模式与同步/时间控制（S/T）模式在肥胖的慢性阻塞性肺疾病（COPD）患者并发急性Ⅱ型呼吸衰竭中的治疗作用。 方法 选取2012年3月－2013年6月入院治疗且体质量指数（BMI）＞25 kg/m2的COPD发生急性Ⅱ型呼吸衰竭患者36例，按数字随机表法分为AVAPS组与S/T组。两组的基础治疗相同，AVAPS组采用飞利浦伟康V60呼吸机BiPAP AVAPS模式进行无创通气治疗，S/T组采用相同机型BiPAP S/T模式治疗。分别比较两组患者治疗1、6、24、72 h的格拉斯高昏迷（GCS）评分变化、血气分析结果、呼吸机监测数据。 结果 AVAPS组患者在最初治疗的6 h内GCS评分高于S/T组[1 h：（13.2 ± 0.6）、（11.9 ± 0.6） 分，P＜0.05；6 h：（13.8 ± 0.5）、（12.1 ± 0.6）分，P＜0.05]；24 h内的动脉血气酸碱度pH值改善[1 h：7.31 ± 0.03、7.26 ± 0.02，P＜0.05；6 h：7.37 ± 0.05、7.31 ± 0.04，P＜0.05]；24 h：7.40 ± 0.04、7.33 ± 0.03，P＜0.05]及二氧化碳分压下降[1 h：（65.2 ± 5.1）、（69.5 ± 4.1）mm Hg（1 mm Hg=0.133 kPa），P＜0.05；6 h：（61.4 ± 4.2）、（66.7 ± 4.3） mm Hg，P＜0.05；24 h：（58.2 ± 4.5）、（64.3 ± 5.4） mm Hg，P＜0.05）]优于S/T组，24 h内浅快呼吸指数低于S/T组[1 h：（35.2 ± 8.1）、（62.8 ± 13.2）次/（min·L），P＜0.05]；6 h（33.4 ± 7.8） 、（54.8 ± 11.6）次/（min·L），P＜0.05]，同时，减少了额外的人工参数调整次数[3.4 ± 1.1、1.2 ± 0.6），P＜0.05] 结论 对超重的COPD合并急性Ⅱ型呼吸衰竭患者采用AVAPS模式进行无创通气治疗，较S/T模式能更快地恢复意识水平，更快地降低血二氧化碳分压、改善pH值，同时减少了呼吸治疗师的人工操作次数。