SIMV加PSV/PSV切换结合高碳酸血症治疗慢性阻塞性肺疾病呼吸衰竭的临床研究

Mechanical ventilation of SIMV+PSV or PSV mode combined with permissive hypercapnia in COPD induced hepercapnic respiratory failure

目的探讨同步间歇强制通气加压力支持通气/压力支持通气两种模式切换结合允许性高碳酸血症(PHC)技术治疗慢性阻塞性肺疾病急性呼吸衰竭的可行性和安全性。方法30例接受气管插管和机械通气的慢性阻塞性肺疾病(COPD)急性呼吸衰竭病例随机分为两组,各15例。研究组(A组)予小潮气量(7ml/kg)机械通气并实施PHC技术,对照组(B组)予常规潮气量(12ml/kg)机械通气。观察两组潮气量(VT)、分钟通气量(MV)、气道峰压(Ppeak)、平台压(Pplat)、动脉血气变化、机械通气时间、住院时间、呼吸机相关性肺炎(VAP)例数和气胸例数。结果治疗后2h、24hA组气道峰压Ppeak、平台压Pplat低于B组(p<0.01);机械通气2h、24hA组pH、PaO2值上升,PaCO2值下降的速度滞后于B组,但与机械通气前比较,p<0.05或p<0.01;A、B两组机械通气时间为(7.2±3.2)d和(15.6±10.6)d,p<0.01;住院时间为(10.2±3.2)d和(18.6±10.4)d,p<0.05;发生呼吸机相关性肺炎2例和8例(p=0.022);气胸0例和4例(p=0.049)。结论SIMV+PSV/PSV切换联合PHC技术治疗慢性阻塞性肺疾病急性呼吸衰竭可以缩短机械通气时间和住院时间,降低机械通气的VAP发生率和气压伤风险。

Objective To explore the feasibility and the safety of mechanical ventilation of SIMV ＋ PSV or PSV mode combined with permissive hypercapnia in COPD induced bepercapnic respiratory failure. Methods 30 COPD patients with exacerbated respiratory failure received intubation and invasive ventilation were randomly assigned to receive lower tidal volume ventilation（7ml/kg, group A, n = 15） or large tidal volume ventilation（ 12ml/kg, group B,n= 15）. Permissive hepercapnia ventilation was used in group A. The peak airway pressure, plateau pressure, arterial blood gas , the duration of ventilation, the haspitatization, the incidence of ventilator associated pneumonia , the incidence of pneumothorax were analyzed in two groups. Results The level of Ppeak and Pplat in group A were higher than those in group B during the ventilation（2 hours, 24 hours） P 〈 0.01 ; the increase speed of pH and PaCO2, and the decrease speed of PaO2 after 2 hours and 24 hours ventilation in group A were slower than those in group B, but compared w/th blood gas data before mechanical ventilation, the difference of between was significant（ P 〈 0.05 or P 〈 0.01 ） ; between group A and group B, the duration of ventilation was （7.2±3.2） vs （15.6± 10.6） days, P〈 0.01;the hospitatization was （10.2±3.2） vs （18.6± 10.4） days, P〈 0.05;the incidence of VAP was 2/15 vs 8/15, P = 0.022. the incidence of pnetunothorax were 0/15 vs 4/15, P = 0.049. Conclusions In COPD patients with exacerbated hypercapnie respiratory failure requiting in--on and MV , mechanical ventilation of SIMV ＋ PSV or PSV mode combined with permissive hypercapnia may significantly decrease the duration of ventilation, the hospitalization and the risk of VAP and pneumothorax.