早期活动对慢性阻塞性肺疾病急性加重机械通气患者谵妄及呼吸力学影响的前瞻性研究

Influence of Early Mobilization on Delirium and Respiratory Dynamics in Mechanically Ventilated Patients with Acute Excerbation of COPD: A Prospective Study

目的探讨慢性阻塞性肺疾病(简称慢阻肺)急性加重机械通气患者的谵妄发生情况以及早期活动对其呼吸力学、谵妄及预后的影响。方法纳入2014年1月至2015年6月单县中心医院收治的107例血流动力学稳定、接受机械通气治疗的慢阻肺急性加重患者,随机分为治疗组54例和对照组53例。在相同常规治疗基础上,治疗组予以进行早期活动,对照组予以常规镇静镇痛。观察两组患者谵妄的发生率、谵妄持续时间、机械通气时间、ICU病死率的差异,两组患者治疗前以及治疗后3 d和5 d呼吸力学参数[内源性呼气末正压(PEEPi)、气道阻力(Raw)、静态顺应性(Cs)、动态顺应性(Cd)]的差异。结果治疗组谵妄发生率较对照组患者下降(59.3%比77.4%),谵妄持续时间缩短[(1.8±1.1)d比(2.6±1.3)d],机械通气时间减少[(6.2±3.4)d比(7.9±4.2)d],差异有统计学意义(P<0.05)。两组患者治疗前各项呼吸力学参数差异均无统计学意义(P>0.05),组间有可比性。治疗组与对照组比较,PEEPi治疗后3 d[(6.23±2.83)cm H_2O比(7.42±2.62)cm H_2O]、5 d[(4.46±2.20)cm H_2O比(5.92±2.51)cm H_2O]均下降;Raw治疗后3 d[(20.35±7.15)cm H_2O·L-1·s-1比(23.23±6.64)cm H_2O·L-1·s-1]、5 d[(16.00±5.41)cm H_2O·L-1·s-1比(19.02±6.37)cm H_2O·L-1·s-1]均缩小;Cd治疗后3 d[(25.20±9.37)m L/cm H_2O比(21.75±7.38)m L/cm H_2O]、5 d[(27.46±5.45)m L/cm H_2O比(24.40±6.68)m L/cm H_2O]均增大,差异有统计学意义(P<0.05);两组治疗后3 d和5 d时的Cs差异无统计学意义(P>0.05)。两组患者均未发生管道滑脱、肢体损伤、恶性心律失常等并发症。治疗组较对照组患者病死率下降(5.6%比11.3%),但差异无统计学意义(P>0.05)。结论慢阻肺急性加重机械通气患者谵妄的发生率高。早期活动能够减少其谵妄的发生率和持续时间,能够降低其气道阻力,增加肺Cd,改善动态肺过度充气状态,降低PEEPi,改善呼吸功能,缩短机械通气时间,安全有效,值得临床推广。

Objective To evaluate the influence of early mobilization on delirium and respiratory dynamics in mechanically ventilated patients with acute exacerbation of chronic obstructive pulmonary disease（AECOPD）. Methods The study prospectively recruited 107 AECOPD patients who admitted between January 2014 and June 2015 and underwent mechanical ventilation. On basis of same routine treatment,the patients were randomly divided into a treatment group（54 cases） receiving regime of early mobilization,and a control group（ 53 cases） receiving routine sedation and analgesia treatment. The incidence of delirium,duration of delirium,time of mechanical ventilation,and ICU mortality were compared between two groups.The respiratory mechanical parameters including endogenous positive end expiratory pressure（ PEEPi）,airway resistance（ Raw）,static compliance（ Cs）,and dynamic compliance（ Cd） before treatment,3 days and5 days after treatment were also compared between two groups. Results Compared with the control group,the incidence of delirium decreased（ 59. 3% vs. 77. 4%）,the duration of delirium [（ 1. 8 ± 1. 1） d vs.（2. 6 ± 1. 3）d] and mechanical ventilation[（6. 2 ± 3. 4） d vs.（7. 9 ± 4. 2） d] reduced in the treatment group with significant difference（ P 〈 0. 05）. There was no significant difference in respiratory mechanical parameters before treatment between two groups（ P 〉 0. 05）. While at 3 days and 5 days after treatment,PEEPi decreased [（6. 23 ± 2. 83） cm H2 O vs.（7. 42 ± 2. 62） cm H2 O,（4. 46 ± 2. 20） cm H2 O vs.（5. 92 ±2. 51）cm H2O],Raw decreased [（20. 35 ± 7. 15） cm H2O·L- 1·s- 1vs.（23. 23 ± 6. 64） cm H2O·L- 1·s- 1,（16. 00 ± 5. 41）cm H2O·L- 1·s- 1vs.（19. 02 ± 6. 37） cm H2O·L- 1·s- 1],Cd increased [（25. 20 ±9. 37） m L / cm H2 O vs（ 21. 75 ± 7. 38） m L / cm H2 O,（ 27. 46 ± 5. 45） m L / cm H2 O vs.（ 24. 40 ±6. 68） m L / cm H2O] in the treatment group compared with the control group（ P 〈 0. 05）,and the difference in Cs was not significant（ P 〉 0. 05）. No complications such as slippage,physical injury,or malignant arrhythmia occurred in two groups. The mortality slightly decreased in the treatment group compared with the control group（ 5. 6% vs 11. 3%）,but the difference was not statistically significant（ P 〉 0. 05）.Conclusions The incidence of delirium is high in mechanically ventilated patients with AECOPD. Early mobilization can reduce the incidence and duration of delirium,decrease the airway resistance,increase the dynamic lung compliance,relieve dynamic pulmonary hyperinflation and reduce PEEPi,so as to improve the respiratory function and shorten the time of mechanical ventilation. Therefore,early mobilization is an effective and safe regime for AECOPD patients underwent mechanical ventilation.