以改良格拉斯哥昏迷评分15分为切换点在有创-无创机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭中的应用

The application of improved Glasgow coma scale score of 15 as switching point for invasive-noninvasive mechanical ventilation in treatment of severe respiratory failure in chronic obstructive pulmonary disease

目的 探讨以改良格拉斯哥昏迷评分（GCS）15分为切换点指导慢性阻塞性肺疾病（COPD）合并呼吸衰竭（呼衰）患者早期拔管改换无创机械通气的可行性,并评价其治疗效果.方法 选择接受气管插管和机械通气的COPD并呼衰患者,采用前瞻性对照研究方法,以2007年3月至2009年11月收治的20例患者为治疗组,采用同步间歇指令通气＋压力支持通气（SIMV＋PSV）方式行机械通气,待改良GCS评分达15分并稳定2 h的窗口期拔除气管导管,改用经鼻面罩PSV＋呼气末正压（PEEP）通气,以后逐渐减小压力支持（PS）水平直至脱机;以2005年3月至2007年3月收治的19例患者为对照组,按常规机械通气及传统脱机方式脱机.动态观察两组患者机械通气前通气及氧合指标,接受有创机械通气时间、总机械通气时间、总住院时间、再插管及呼吸机相关性肺炎（VAP）发生例数.结果 两组机械通气前通气及氧合指标均无明显差异.治疗组较对照组有创通气时间（d：3.2±1.1比10.5±3.2）、总机械通气时间（d：4.8±2.5比10.5±3.2）、总住院时间（d：17±3比22±7）均明显缩短（均P＜0.01）;VAP发生数减少（例：0比5,P＜0.01）,再插管数稍增加,但无统计学意义（例：3比1,P＞0.05）.结论 对COPD合并呼衰的机械通气患者,以改良GCS评分达15分稳定2 h窗口期为时机早期拔管改用经鼻面罩无创通气,可以显著改善患者的治疗效果.

Objective To estimate the feasibility and the efficacy of early extubation and the sequential non-invasive mechanical ventilation （MV） in severe respiratory failure of chronic obstructive pulmonary disease （COPD） with the improved Glasgow coma scale （GCS） score of 15 as the switching point. Methods By a prospective control study, 20 patients with COPD and respiratory failure who had undergone endotracheal intubation and MV from March 2007 to November 2009 were enrolled as treatment group.Invasive MV with synchronous intermittent mandatory ventilation and pressure support ventilation （SIMV＋PSV） pattern were given to these patients. When the period of ＂improved GCS score of 15 standard＂ window period appeared and being kept for 2 hours, endotracheal tube was extubated, and nasal mask with PSV±positive end-expiratory pressure （PEEP） was used, followed by gradual decrease of the level of pressure support till weaning of MV. Nineteen patients who were treated with MV with ordinary way of weaning from March 2005 to March 2007 served as the control group. Prior to the MV, the ventilation and oxygenation index, the length of invasive MV, total MV time, total hospital stay, re-intubation and ventilator-associated pneumonia （VAP） occurred in the number of cases were observed and compared between two groups. Results There was no significant difference in the ventilation and oxygenation index prior to the MV. Compared with control group, in treatment group, the length of invasive ventilation （days： 3. 2±1.1 vs. 10. 5± 3. 2）,the total duration of MV （days： 4. 8±2. 5 vs. 10. 5±3. 2）, the length of hospital stay （days：17±3 vs. 22±7） were significantly shorter （all P〈0.01）, and the incidence of VAP was significantly lower （cases： 0 vs.5, P〈 0. 01）, while the number of re-intubation was slightly higher but without statistical significance （cases：3 vs. 1, P〉0. 05）. Conclusion The application of improved GCS score of 15 as the switching point with 2 hours as window period for early extubation and non-invasive nasal mask ventilation can significantly improve the therapeutic effect in patients with severe respiratory failure in COPD.