食管癌术后急性肺损伤运用无创正压通气的研究

Non-invasive positive pressure ventilation for patients with lung injury or acute respiratory distress syndrome after esophagectomy

目的评价无创正压通气(noninvasive positive pressure ventilation,NPPV)联合纤维支气管镜吸痰来治疗食管癌术后并发急性肺损伤(acute lung injury,ALI)或呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)伴有排痰障碍的治疗效果,探讨失败的相关因素,减少创伤性治疗。方法回顾性分析2010年1月至2011年8月我院胸外科食管癌术后并发ARDS/ALS并伴有排痰障碍病例64例,其中男59例,女5例,年龄在49～83岁,平均61.1岁,食管癌58例,贲门癌6例。按照是否转为有创机械通气分为无创组和有创组,各32例。主要评价指标为28 d病死率,实际病死率;研究主要指标:性别,年龄,发病时及治疗24 h后的pH值、氧合指数、SOFA(sequentialorgan failure assessment)评分及APACHEⅡ(acute physiology and chronic health evaluation scoring system)评分,有无严重外科并发症(如大量失血、吻合口瘘、急性肾功能不全等)。结果两组性别,年龄,发病时氧合指数(PaO2/FiO2)、SOFA评分及APACHEⅡ评分无差异,治疗24 h后氧合指数(P<0.05)及严重外科并发症有统计学差异(P<0.01)。结论 NPPV联合纤维支气管镜吸痰是食管癌术后并发ARDS/ALI伴有排痰障碍时的有效治疗手段,但是当伴有严重并发症如急性肾功能衰竭、心跳骤停时需要早期有创性呼吸治疗。治疗24 h后氧合指数<200是NPPV治疗失败的原因。

Objective To assess the application of non-invasive positive pressure ventilation（NPPV） in treatment of patients with acute lung injury（ALI） or acute respiratory distress syndrome（ARDS） after esophagectomy.Methods Sixty four patients with ALI/ARDS,who were disable for expectoration after esophagectomy were admitted to ICU of Shanghai Chest Hospital from January 2010 to August 2011.Thirty two patients received NPPV and another 32 received invasive positive pressure ventilation（IPPV）.The clinical data including age,gender,28-day-mortality,serious surgical complication,PaO2/FiO2,sequential organ failure assessment（SOFA） and acute physiology and chronic health evaluation（APACHE） II score at the onset of the ventilating and 24h after ventilated were retrospectively analyzed.Results There were no differences in gender,age,initial oxygenation index between NPPV and IPPV groups.Compared to IPPV group the PaO2/FiO2 after 24h was higher in NPPV group（P0.05） and more complications occurred in NPPV group（P0.01）.Conclusion NPPV can be alternatively applied in patients with ALI/ARDS after esophagectomy,but cannot be recommended for patients with serious complications such as acute renal failure or cardiac arrest.