慢性阻塞性肺疾病急性加重患者机械通气后期应用俯卧位通气呼吸和循环的临床评价

Assessment and Research to Applying Prone Position Ventilation Oxygenation and Circulation to Acute Exacerbation of Chronic Obstructive Pulmonary Disease Patients in Pro-Intrusive Ventilation Phase

目的观察俯卧位通气对改善慢性阻塞性肺疾病急性加重(AECOPD)有创通气后期患者氧合、血流动力学、拔管时间和住ICU时间的情况,评价俯卧位通气对AECOPD患者的临床疗效.方法将80名AECOPD有创正压通气后期的患者随机分成实验组(俯卧位机械通气组)和对照组(仰卧位机械通气组)每组40人,实验组和对照组均严格按照慢性阻塞性肺疾病指南(中国2011版)进行治疗,实验组所有患者均行俯卧位通气,记录并比较2组患者入院时和治疗1 h、8 h、24 h中心静脉压(CVP)、心率(HR)、平均动脉压(MAP)、心排量(CO)、心排指数(CI)、每搏量(SV)和每搏量变异率(SVV)监测,血氧饱和度(Sp O2)、血氧分压(Pa O2)、氧合指数(Pa O2/Fi O2),治疗后1 d、7 d、14 d血氧饱和度(Sp O2)、血氧分压(Pa O2)、氧合指数(Pa O2/Fi O2)、胸部CT变化及记录并比较住ICU时间和住院时间、患者年龄、患病时间、住院次数、入院时1s用力呼气容积(FEV1)和APACHEⅡ评分情况.结果 (1)实验组和对照组血气监测比较:Pa O2、Sp O2、Pa O2/Fi O2在1 h时开始有改善,而实验组8、24 h时Pa O2、Pa O2/Fi O2均较对照组高,差异有统计学意义(P<0.05);Pa O2、Sp O2、Pa O2/Fi O2在1 d时开始有改善,而实验组7、15 d时Pa O2、Pa O2/Fi O2均较对照组高,差异有统计学意义(P<0.05);(2)实验组和对照组血流动力学比较:实验组与对照组HR、MBP、CVP、CO、CI、SV、SVV在l、8、24 h时点差异无统计学意义(P>0.05);(3)实验组和对照组拔管时间和住ICU时间:实验组拔管中位时间19.04 d,对照组拔管时间(20.83)d,差异有统计学意义(P<0.05),实验组和对照组住ICU时间:实验组住ICU中位时间8.85 d,对照组住ICU时间10.46 d,差异有统计学意义(P<0.05).结论俯卧位通气较仰卧位通气能明显改善AECOPD有创正压通气后期的患者的氧合状态、减少气管插管时间和住ICU时间,对血流动力学影响不明显.

Objective To investigate the improvement of oxygenation, hemodynamics, extubation time and time in ICU of patients of AECOPD in their Pro-Intrusive Ventilation Phase, as well as to evaluate the overall treatment effectiveness of Prone Position Ventilation to AECOPD patients; and to hopefully provide advices to the application of Prone Position Ventilation as a clinic practice. Method 80 pro-intrusive ventilation patients with AECOPD were evenly and randomly divided into two groups： forty patients each in experimental and control groups.Patients in both experimental and control groups are treated strictly according to The Treatment Guideline to Chronic Obstructive Lung Diseases China 2011 Edition）, while patients in experimental group were given treatment of Prone Position Ventilation PPV） . Central venous pressure CVP） , heart rate HR） , mean arterial pressure MAP） , cardiac output CO） , cardiac index CI） , stroke volume SV） and stroke volume variation rate SVV） monitoring, oxygen saturation SpO2）, blood oxygen pressure PaO2）, oxygenation index PaOz/FiO2） of the all patients in both groups were recorded before hospitalization and lhour, 8 hours, 24 hours. Their oxygen saturation SpO2） , blood oxygen pressure PaO2） , oxygenation index PaO2/FiO2） , chest CT changes were also recorded 1 day, 7 days, 14 days after PPV, and their duration in ICU and days of hospitalization, patients＇ age, frequency of hospitalization, FEV1 and APACHE Ⅱ evaluations were also compared. Results （1） Comparison of blood and oxygenation monitoring： arterial oxygen tension PaO2）, oxygen saturation SpO2）, oxygenation index PaO2/FiO2） were improved in 1 hour; while oxygen saturation SpO2） , oxygenation index PaO2/ FiO2） in 8 and 24 hours of the experimental group were higher than those of control groups with statistic significance P〈0.05） ; arterial oxygen tension PaO2） , oxygen saturation SpO2） , oxygenation index PaO2/FiO2） were improved from day 1, while the oxygen saturation SpO2） and oxygenation index PaO2/FiO2） of the experimental group were higher than those of control groups with statistic significanceP〈0.005） . （2） Comparison ofhemodynamics：theHR, MBP, CVP, CO, CI, SV, SVV of both experimental and control groups in 1, 8, and 24 hours had no statistically significant difference P〉0.05） （3） Extubation time and ICU stay-time： there is a statistically significant difference in extubation time between experimental and control groups： the median extubation time of the experimental groups 19.04） days： control group 20.83） days; there is also statistically significant difference in ICU stay-time between experimental and control groups： the median ICU stay-time of the experimental groups 8.85） days： control group 10.46） days P〈0.05） Conclusion Comparing to Spine Position Ventilation, Prone Position Ventilation remarkably improves the oxygenation, reduces the extubation time and decreases the ICU stay-time of the patients with AECOPD in their pro-intrusive positive pressure ventilation phase; while PPV does not show influence on hemodynamics changes.