左心功能不全对AECOPD机械通气患者脱机困难影响研究

目的探讨左心功能不全对慢性阻塞性肺病急性加重（AECOPD）呼吸衰竭机械通气患者脱机困难的影响.方法选取上海市松江区中心医院重症监护室（ICU）2012年1月至2015年2月55例AECOPD 呼吸衰竭有创机械通气患者进行前瞻性队列研究,根据治疗一周后是否脱离呼吸机分为脱机组43例,未脱机组12例,以脉搏指示的连续心输出量监测技术（PiCCO）监测患者治疗前及治疗一周的血流动力学指标：血管外肺水（EVLWI）、肺血管通透性指数（PVPI）、心排量指数（CI）、全心舒张末期容积指数（GEDVI）、心功能指数（CFI）、全心射血分数（GEF）、左心室收缩力指数（dP/dtmax）变化,对影响脱机相关因素进行 Logistic 多因素回归分析.结果①脱机组治疗后与治疗前相比,EVLWI、GEDVI 降低,CI、CFI、GEF、dP/dtmax 升高,差异有统计学意义（P〈0.05）,PVPI 在治疗前后差异无统计学意义;②未脱机组治疗后与治疗前相比 EVLWI、PVPI、CI、GEDVI、CFI、GEF、dP/dtmax 差异无统计学意义（P〉0.05）;③脱机组治疗后与未脱机组治疗后比较 EVLWI、GEDVI 更低,CI、CFI、GEF、dP/dtmax 更高,差异有统计学意义（P〈0.05）;④经多因素 Logistic 回归分析显示治疗后EVLWI、CFI、GEF 是 AECOPD 有创机械通气患者一周脱机困难的独立危险因素.结论左心功能不全及伴随的肺水肿是影响 AECOPD 机械通气患者脱机困难的一个重要原因,PICCO 技术提供的 EVLWI、CFI、GEF 治疗后指标可监测此类患者的左心功能状态并预测困难脱机,对 AECOPD 呼吸衰竭患者机械通气治疗有指导意义.

Objective To investigate the left ventricular dysfunction affects weaning of mechanical ventilation （MV） in patients with acute exacerbation of chronic obstructive pulmonary disease （AECOPD）.Methods We selected 55 AECOPD patients of respiratory failure with mechanical ventilation from January 2012 to February 2015 of GICU in Central Hospital of Songjiang District, and were analyzed with retrospective cohort study. According to weaning or not after one week mechanical ventilation treatment is divided into two groups： weaning group of 43 cases and difficulty in withdrawing the mechanical ventilation of 12 cases. Monitoring hemodynamic index such as EVLWI, PVPI, CI, GEDVI, CFI, GEF, dP/dtmax of patients with PiCCO before treatment and after one week. Then take a multivariate regression analysis to study the factors of Mechanical ventilation weaning. Results The weaning group after treatment compared with before treatment,EVLWI, CI, CFI, GEDVI decreased, GEF, dPmx increased, the difference was statistically significant （P〈0.05）, There was no significant difference of PVPI with treatment. In the difficulty weaning group, showed no significant difference of EVLWI, PVPI, CI, GEDVI, CFI, GEF, dPmx before treated with MV compared to after treatment （P〉0.05）. After one week treatment, the index of EVLWI and GEDVI were lower, while the index of CI, CFI, GEF and dP/dtmax were higher in weaning group. The difference was statistically significant （P〈0.05）. The outcomings of Logistic regression analysis shows that EVLWI, CFI, GEF are the independent risk factors of difficulty weaning in AECOPD patients with MV after one week. Conclusion Left ventricular dysfunction and concomitant pulmonary edema is important factors of difficult weaning in respiratory failure of AECOPD patients. PICCO provided the technology to monitor the index of EVLWI,CFI,GEF which can detect left ventricular function of patients and predict difficulty weaning. It could guild mechanical ventilation in AECOPD patients with respiratory failure.