有创-无创序贯通气与非序贯无创通气在婴幼儿先天性心脏病外科术后的应用

Invasive-noninvasive sequential ventilation and nonsequential ventilation application in infants patients with complexity congenital heart disease surgery

目的 评估婴幼儿复杂先天性心脏病术后患儿拔管后序贯无创的疗效和无创通气对婴幼儿复杂先天性心脏病术后出现急性呼吸衰竭的疗效.方法 回顾性研究2008年1月至2013年12月间入住我院ICU的951例复杂先天性心脏病术后婴幼儿（年龄≤1岁,体重≤10 kg）,665例患儿顺利脱机拔管,未行无创通气和二次气管插管治疗,286例患儿使用无创通气（NIV）治疗.将286例使用无创通气治疗的患几分为2组,一组为拔除气管插管后给予直接无创通气治疗称为序贯无创组（155例）,另一组为拔管后出现急性呼吸衰竭表现后给予无创通气治疗称为非序贯无创组（131例）.观察非序贯组无创通气治疗前,治疗后1h、2h、3h心率（HR）、呼吸频率（RR）、血压（BP）、血氧饱和度（SpO2）和血气分析（PH、PO2、PCO2）值的变化,比较序贯无创通气组和非序贯无创通气组的并发症、无创通气使用时间、再次使用气管插管的比率、ICU停留时间、住院天数和死亡率.结果 序贯无创组中有12例患儿出现严重呼吸衰竭不能改善,行气管插管机械辅助,其中3例患儿因严重的心功能衰竭死亡,另9例患儿痊愈出院.非序贯组中有20例患儿出现严重呼吸衰竭不能改善,行气管插管机械辅助,其中4例患儿出现严重心功能衰竭死亡,2例患儿出现MODS死亡,余14例痊愈出院.序贯无创组的无创通气相关并发症、无创通气使用时间和死亡率与非序贯组相当,但序贯组的二次插管率、住院时间、ICU停留时间较非序贯组明显缩短,差异具有统计学意义.结论 无创通气可以治疗婴幼儿复杂先天性心脏病术后急性呼吸衰竭,是一种安全有效的方法.序贯无创通气在低龄、低体重婴幼儿复杂先天性心脏病术后能降低二次插管率,缩短ICU停留时间和住院天数,减少费用.

Objective The purpose of this study was to assess the effect of sequential non-invasive ventilator after extubated in infants patients with complexity congenital heart disease surgery, and to assess the effect of non-invasive ventilation in acute respiratory failure after complex congenital heart disease surgery too. Methods A retrospective study of 951 infants with complex congenital heart disease accepted surgery between January 2008 to December 2013 in ICU of our hospital （age≤ 1 year old, weighing≤ 10 kg）, 665 cases pull off tracheal intubation successfully, did not undergo non-invasive ventilation or second intubation treatment, other 286 cases of patients were taken NIV therapy. We divided the 286 cases into two groups, one group was given noninvasive ventilation directly after extubation called sequential noninvasive group, another group were taken non-invasive ventilation when acute respiratory failure occured after extubation, called non-sequential noninvasive group. Sequential groups were 155 cases, and 131 cases were non-sequential group. Observed the changes of heart rate （HR）, respiratory rate（RR ）, blood pressure（BP）, saturation of blood oxygen（SpO2） and blood gas analysis（PH, PO2, PCO2） in the non-sequential group before and after noninvasive ventilation treatment 1 h, 2 h, 3 h. The complications ,the time of use noninvasive ventilation, the ratio of intubation again, detention time of ICU, hospital day and mortality between the sequential noninvasive group and the non-sequential noninvasive ventilation group were compared. Results 12 cases of sequential noninvasive group with severe respiratory failure could not be improved, then be taken tracheal intubation again, 3 patients with severe heart failure and death, and the other 9 patients were recovery and discharged. Non-sequential group had 20 cases with severe respiratory failure and could not be improved, then be given tracheal intubation, 4 cases with severe heart failure and death, 2 cases died in MODS, and 14 cases were recovery and discharged. There had no difference in the complications of noninvasive ventilation related, the time of use noninvasive ventilation and mortality between sequential non-invasive group and non-sequential nonin- vasive ventilation group. But the re-intubation rate, detention time in ICU and hospital day were shorter than the non-sequential group, had a statistically differences. Conclusion Non-invasive ventilation is a safe and effective method to treat acute respiratory failure in infants with complicated congenital heart disease after surgery. Sequential noninvasive ventilation can reduce the rate of second intubation, shorten the ICU stay and hospital stay in younger age, low birth weight infants with complexity congenital heart disease after surgery, and reduce costs.