侧俯卧位在ICU老年患者HAP综合防控中的效果观察

Observation on the effect of lateral prostrate position in comprehensive prevention and control of HAP in elderly ICU patients

目的探讨侧俯卧位在重症监护病房(ICU)老年患者医院获得性肺炎(HAP)综合防控中的临床效果。方法采用前瞻性随机对照临床研究方法,选择2016年1月至2017年12月江苏附属金坛医院重症医学科收治的入住院期间没有气管插管且未处于病原感染潜伏期或拔除人工气道48 h内未出现肺炎的41例老年患者为研究对象,其中男性24例,女性17例;年龄67～93岁,平均年龄(79. 90±6. 65)岁。患者按随机数字表法分为半卧位组(21例)和侧俯卧位组(20例)。两组患者的性别、年龄、急性生理与慢性健康评分(APACHEⅡ)、意识障碍程度[格拉斯哥昏迷评分(GCS)]、制酸药物及镇静药物使用率的差异均无统计学意义(P> 0. 05)。两组患者均给予鼻肠管营养、口腔护理(q6 h)、受压处使用减压贴、胸部物理治疗及气道温湿化并在体位改变前按需吸痰。半卧位组:床头保持抬高30°～45°,每1～2 h视局部受压情况调整身体横轴与床面的角度。侧俯卧位组:在放平床头后,患者取侧卧位,颜面部、胸部俯向床面,与床面的夹角≤90°,每1～2h左右侧交替。比较两组患者在每班护士第一次翻身后5 min的安静状态下的呼吸指标[呼吸频率、脉搏血氧饱和度(Sp O2)、氧合指数、平均每日吸痰次数、循环指标(心率、平均动脉压)]和总体HAP发生率、皮肤压疮发生率。结果侧俯卧位组与半卧位组比较平均每日吸痰次数[(3±3. 2)次/d:(6±3. 3)次/d],Sp O2[(92%±7. 3%):(88%±6. 5%)]和氧合指数[(321±23) mm Hg:(280±33) mm Hg],差异有统计学意义(P均<0. 05)。但两组患者心率差异无统计学差异(P> 0. 05)。侧俯卧位组患者的HAP发生率为10. 00%(2/20),低于半卧位组[38. 09%(8/21)](P <0. 05)。但两组患者的皮肤压疮发生率差异无统计学意义[10. 00%(2/20):14. 28%(3/21)](P> 0. 05)。结论侧俯卧位较半卧位更有利于降低ICU老年患者的HAP发生率、改善患者呼吸功能和减轻病痛。

Objective To study the clinical effect of lateral prone position in the comprehensive prevention and control of hospital-acquired pneumonia(HAP) in elderly patients in ICU. Methods Using prospective randomized controlled clinical research methods, 41 elderly patients, including 24 males, 17 females, age 67-93 years old, average age (79.90±6.65) years old, who were admitted to our hospital from January 2016 to December 2017, had no trachea intubation during hospitalization and were not in the incubation period of pathogenic infections or had no pneumonia within the artificial airway 48 h were selected. All patients were divided into a semi-horizontal group (21 cases) and a side-prone group (20 cases) according to the random number table method. There were no statistically significant differences in gender, age, acute physiology and chronic health score (APACHEⅡ), degree of consciousness disorder [GCS score] and the use of acid and sedative drugs in the two groups (P>0.05). Both groups of patients were given nasal enteric nutrition, oral care (q6h), decompression stickers at pressure, chest physiotherapy, and airway temperature humidification, and they were required to suck sputum before changing body position. Semi-horizontal group: The head of the bed is kept elevated by 30 °- 45 °, and the angle between the horizontal axis and the bed surface is adjusted depending on the local pressure situation of every 1~2 h; Side prone position group: After leveling the head of the bed, the patient takes the side lying position, the face and chest are bent toward the bed surface, and the angle between the face and the bed surface≤90 °, alternating between the left and right sides of every 1~2 h. The respiratory indicators of the two groups of patients in the quiet state of 5 min after each class of nurses turned over for the first time were compared, including breathing frequency, pulse oxygen saturation(SpO2), oxygenation index, average daily phlegm intake, circulation index(heart rate, average arterial pressure) and overall HAP incidence, skin pressure sore incidence. Results The average number of sputum aspiration per day in the patients with lateral prone position was lower than that in the semi-horizontal group [(3±3.2) times/day vs (6±3.3) times/day], SpO2[(92%±7.3%) vs (88%±6.5%)] and oxygenation index [(321±23) mmHg vs (280±33) mmHg] were higher than that in the semi-horizontal group, which were statistically significant (P<0.05). However, there was no significant difference in heart rate between the two groups (P>0.05). The incidence of HAP was 10.00% (2/20) in the lateral prone group, which was lower than that in the semi-lying group [38.09% (8/21)], and the difference was statistically significant (P<0.05). However, there was no statistical difference in the incidence of pressure ulcers between the two groups [10.00% (2/20) vs. 14.28% (3/21), P>0.05]. Conclusion Compared with half decubitus position, lateral prone position is more favorable for reducing the incidence of HAP, improving respiratory function and alleviating pain in elderly ICU patients.