早期有创机械通气对胸外伤致急性呼吸窘迫综合征患者缺氧改善及预后的影响

Effects of early invasive mechanical ventilation on anoxia and prognosis of acute respiratory distress syndrome after chest injury

目的探讨早期有创机械通气治疗胸外伤致呼吸窘迫综合征（ARDS）的临床意义。方法回顾性分析93例胸外伤致ARDS有创机械通气患者临床资料，根据有创机械通气情况分为延迟通气组（45例）和及时通气组（48例）。比较两组患者有创机械通气治疗前后血气分析、氧合指数、心率、乳酸、呼吸肌动用评分及两组患者机械通气治疗时间、并发症发生率、病死率、住院时间的差异。结果延迟组与及时组患者在机械通气治疗后各项指标分别为动脉血氧分压（PaO，）（63．2±12．3）、（74．2±12．1）mmHg，动脉血二氧化碳分压（PaC02）（39．4±8．7）、（38．9±7．6）mmHg，氧合指数（Pa02／Fi02）196．2±17．8、、231．4±18．2、，呼吸频率（27．44-3．7）、（21．1±3．4）次／min，心率（117．2±26．8）、（96．0±25．1）次／min，辅助呼吸肌动用评分（2．69±0．15）、（1．67±0．10）分，乳酸（4．23±1．70）、（2．12±0．80）mmol／L，除PaCO：外，其余各项指标差异均具有统计学意义（t值分别为4．346、9．420、3．949、5．436、38．809、7．736，P均〈0．05）；延迟组与及时组机械通气治疗时间分别为（10．21±1．50）、（6．47±1．20）d，住院时间（21．53±1．90）、（16．32±2．10）d，及时组均低于延迟组，差异均有统计学意义（t值分别为12．518、13．318，P均〈0．01）；延迟组与及时组病死率[26．7％（12／45）、14．6％（7／48）]、呼吸机相关性肺炎[46．7％（21／45）、22．9％（11／48）]、急性胃黏膜病变[33．3％（15／45）、12．5％（6／48）]、多器官功能衰竭[40．O％（18／45）、16．7％（8／48）]、气胸发生率[11．1％（5／45）、8．3％（4／48）]，除气胸外，及时组均低于延迟组，差异均有统计学意义（X^2值分别为3．86、5．81、4．49、5．70，P均〈0．05）。结论有创机械通气是治疗胸部外伤所致ARDS的有效方法，早期有创机械通气可以有效降低患者的病死率和并发症发生率，缩短机械通气时间和住院时间。

Objective To explore the clinical significance of early invasive mechanical ventilation for acute respiratory distress syndrome （ARDS） caused by thoracic trauma. Methods We retrospectively analyzed the clinical data of 93 patients of invasive mechanical ventilation in those with ARDS caused by thoracic trauma, and divided them into delayed invasive mechanical ventilation group （ n = 45 ） and timely invasive ventilation group （n = 48 ） by the time of invasive mechanical ventilation. We compared the blood gas analysis, oxygen index, heart rate, lactic acid, muscle use score of the two groups before and after invasive mechanical ventilation and the differences of mechanical ventilation time, incidence of complications, mortality and length of hospital stay between the two groups. Results Each index of the delayed invasive mechanical ventilation group and the timely invasive ventilation group was calculated： PaO2 （63.2 ＋ 12. 3, 74. 2 ± 12. 1 ） mm Hg, PaCO2 （ 39.4 ±8.7, 38. 9 ± 7.6） mm Hg, PaO2/FiO2 （ 196. 2 ＋ 17. 8, 231.4 ± 18.2）, respiratory rate （27.4 ±3.7, 21.1 ±3.4） beats/min, heart rate （ 117.2 ＋ 26. 8, 96.0± 25.1 ） beats/rain, accessory muscle use score （2. 69±0.15,1.67 ±0.10）,lactic acid （4.23 ±1.70,2.12 ±0.80） mmol/L. Except for PaCO2, the differences of each index were statistically significant （t values were respectively 4. 346,9. 420,3. 949,5.436, 38. 809,7. 736 ; P 〈 0.05 ）. The duration of mechanical ventilation treatment （ 10. 21 ± 1.50,6.47 ± 1.20 ） d and the length of hospital stay （21.53± 1.90,16. 32 ±2. 10） d of the delayed group and the timely group were significantly different （t values were respectively 12.518, 13.318; P 〈 0.01 ）.The timely group had significantly lower mortality rate （ 26. 7% （ 12/45 ）, 14. 6% （ 7/48 ） ）, VAP （ 46. 7% （ 21/45 ）, 22. 9% （11/48） ）, acute gastric mucosal lesions （ 33.3% （ 15/45 ）, 12. 5% （ 6/48 ） ）, MODS （40.0% （ 18/45 ）, 16. 7% （8/48）） than the delayed group （ X^2 values were respectively 3.86, 5.81,4. 49,5.70 ; P 〈 0. 05 ）. There is no significant difference on the incidence of pneumothorax between the two groups （ 11.1% （ 5/45 ） , 8.3 % （4/48） ）. Conclusion Invasive mechanical ventilation is an effective treatment of ARDS caused by chest trauma. Early invasive mechanical ventilation can reduce the mortality rate and shorten the duration of mechanical ventilation and hospital stay of the patients with ARDS after severe thoracic trauma.