神经肌肉疾病合并呼吸衰竭患者机械通气策略研究

Mechanical ventilation strategy in patients with neuromuscular disease and respiratory failure

目的 对神经肌肉疾病合并呼吸衰竭患者的机械通气策略进行研究.方法 57例神经肌肉疾病合并呼吸衰竭患者分为小潮气量通气组（A组27例）和常规潮气量通气组（B组30例）,观察2组患者机械通气后血气和气道压力的变化,支气管肺泡灌洗液（BALF）中TNF、IL-6、IL-8的变化;14 d存活率和14d脱机成功率.结果 机械通气后0.5、24 h A组患者动脉血气pH值分别为7.30±0.08、7.40±0.06,明显低于同时点B组的7.39±0.06、7.47±0.04（P均＜0.05）;机械通气后0.5、24 h A组患者动脉血气PaCO2水平分别为（60.4±16.9）、（38.2±7.3）mm Hg,明显高于同时点B组的（46.6±8.1）、（29.2±6.9）mm Hg（P均＜0.05）;机械通气后0.5、24 hA组患者气道峰压分别为（21.5±4.5）、（18.6±3.8）cmH2O,明显低于同时点B组的（29.4±5.1）、（31.3±4.7）cm H2O（P均＜0.05）;机械通气后24、48 h A组患者BALF中TNF水平分别为（1385±341）、（1345±411）ng/L,明显低于同时点B组的（1914±501）、（2214±544）ng/L（P均＜0.01）;机械通气后24、48 h A组患者BALF中IL-6水平分别为（249±64）、（209±49）ng/L,明显低于同时点B组的（324±79）、（343±60）ng/L（P均＜0.01）;机械通气后24、48 h A组患者BALF中IL-8水平分别为（79.4±23.6）、（92.7±32.5）ng/L,明显低于同时点B组的（143±36）、（162±49）ng/L（P均＜0.01）;A、B组患者14 d存活率分别为100.0%、96.7%,差异无统计学意义（P＞0.05）;A组患者14 d脱机成功率为59.3%,明显高于B组的33.3%（x2=3.85,P＜0.05）.结论 对于神经肌肉疾病合并呼吸衰竭患者,选用小潮气量进行机械通气,可以减轻机械牵拉诱发的细胞因子释放,减轻机械通气相关性肺损伤,提高脱机成功率.

Objective To study the effect of low tidal volume ventilation in patients with respiratory failure due to neuromuscular disease. Methods Fifty-seven patients with neuromuscular disease and respiratory failure requiring mechanical ventilation were divided into low tidal volume ventilation group （ group A： 2 7 cases ） and routine tidal volume ventilation group （group B： 30 cases ）. Indices of airway pressure and blood gas were recorded. The levels of TNF, IL-6, IL-8 in Bronchoalveolar Lavage Fluid （BALF） were measured after ventilation. The survival rates of 14 days and weaning success rates of 14 days were observed. Results The pH value in arterial blood gas at 0.5 and 24 hour after ventilation was 7.30 ± 0.08,7.40 ± 0.06 in group A,which were significantly lower than those of 7. 39 ± 0. 06,7.47 ± 0. 04 in group B at the same time point （ P 〈 0. 05 ）. The PaCO2 levels at0.5 and24 h were （60.4 ± 16.9）mm Hg and （38.2 ±7.3）mm Hg in group A,which were also significantly higher than those of （46. 6 ±8. 1 ）mm Hg and （29. 2 ＋ 6. 9 ） mm Hg at the same time point in group B （P〈0. 05）. The airway peak pressure at 0. 5 and 24 hour were （21.5 ±4. 5）mm Hg and （18.6 ±3.8）cm H2O in group A, which were significantly lower than those of （ 29.4 ±5.1 ） cm H2O and （ 31.3 ±4. 7 ） cm H2O at the same time point in group B （P 〈 0. 05 ）. The levels of TNF in BALF at 24 and 48 hour were （ 1385 ±341 ） ng/L and （1345 ±411 ）ng/L in group A ,which were significantly lower than those of （1914 ±501 ）ng/L and （2214 ±544 ） ng/L in group B at the same time point （P 〈0. 01 ）. The level of IL-6 in BALF at 24 and 48 hour were （249 ±64） ng/L and （209 ±49 ）ng/L in group A, which were significantly lower than those of （324 ±79 ）ng/L and （343 ±60 ） ng/L in group B at the same time point （ P 〈 0. 01 ）. The levels of IL-8 in BALF at 24 and 48 hour were （ 79.4 ±23.6 ） ng/L and （ 92.7 ±32. 5 ） ng/L in group A, which were significantly lower than those of （ 143 ±36 ） ng/L and （ 162 ±49） ng/L in group B at the same time point （ P 〈 0. 01 ）. No significant difference was found in the survival rates of these two groups （ 100% vs. 96. 7% ,P 〉 0. 05 ）. The higher weaning success rate was observed higher in group A （59. 3% ） than group B （33.3% ,P 〈 0. 05 ）. Conclusions For patients with respiratory failure resulting from neuromuscular disease,low tidal volume ventilation can decrease ventilation-induced cytokine release, alleviate ventilator-induced lung injury, and inerease the success rate of ventilator weaning.