不同撤机方式在COPD机械通气患者的临床观察

Clinical observation on different ways of weaning from invasive mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease

目的:观察慢性阻塞性肺疾病(COPD)急性加重期接受有创机械通气患者采用2种撤机决策(临床医生经验与自主呼吸试验)的临床疗效。方法:将94例COPD急性加重期且需要有创机械通气的患者,按照PaCO2水平应用分层随机化法分为自主呼吸试验(SBT)组和临床医生经验(DED)组各47例,2组均给予常规基础治疗。每日对2组患者进行撤机筛选试验,完成筛选试验的SBT组患者行SBT后实施撤机;完成筛选试验的DED组患者,由科室呼吸治疗小组根据临床经验决定是否撤机。观察病死率、住ICU时间、有创机械通气时间、脱机成功率、呼吸机相关性肺炎(VAP)发生率、2次插管率、SBT组SBT终止原因等。结果:SBT组患者住ICU时间、有创机械通气时间、病死率及VAP发生率均明显高于DED组患者(均P<0.05)。DED组患者脱机成功率显著高于SBT组(P<0.05)。DED组患者2次插管率略高于SBT组患者,但差异无显著性(P>0.05)。结论:SBT有可能导致撤机延迟,增加有创机械通气时间,应重视COPD加重期有创机械通气撤机决策中医生临床经验的重要性,提高撤机成功率。

Objective ： To observe the clinical therapeutic effect of doctor experience decision （DED） and spontaneous breathing trials （SBT） in patients with acute exacerbation of chronic obstructive pulmonary disease （AECOPD） as different ways of weaning from invasive mechanical ventilation. Methods ： Ninety-four patients with AECOPD who need invasive me- chanical ventilation were stratified randomly divided into SBT group and DED group （47 cases for each group） according to different level of PaCO2 and both received basic therapy. Screening test was conducted in patients of two groups everyday, then patients in SBT group accepted SBT when completed weaning from invasive mechanical ventilation; the respiratory therapy team decided whether to wean of the DED group based on clinical experience. The mortality, days in ICU, time of invasive mechanical ventilation, success ratio of weaning, incidence of ventilator associated pneumonia （VAP） , two times intubation rate, the reason for termination of SBT were observed. Results： Days in ICU, time of invasive mechanical venti- lation, mortality, incidence of VAP in group SBT were obvious higher than those of DED group （ P 〈 0.05 ） , and the suc- cess ratio of weaning was lower （ P 〈 0.05 ）. Two times＇intubation rate in DED group slightly higher than that of SBT group but without significant difference （ P 〉 0.05 ）. Conclusions ： SBT can result in delaying of weaning and increasing the time of invasive mechanical ventilation, we should think highly of doctor experience decision to improve the success ratio of wea- ning.