头盔无创支持通气在小儿先天性心脏病术后应用的安全性和有效性评价

The safety and efficiency of non-invasive pressure support ventilation through a non-invasive ventilationhelmet in children after surgical repair of congenital heart disease

目的通过总结32例应用无创头盔进行无创压力支持通气患儿的临床结果，分析其应用的安全性和显效特点，并为先天性心脏病（congenital heart disease，CHD）术后患儿无创通气（non—invasive ventilation，NIV）适应证的合理选择提出依据。方法2015年7月至2015年12月期间我院心胸外科1岁以上CHD术后患儿，NIV实施后1h临床改善的患儿定义为早期有效组（Group—E），否则为非早期有效组（Group—NE）。记录入选患儿的一般资料、疾病诊断、需要NIV主要原因、ICU停留时间、ICU并发症、病死率以及住院天数。结果共入选使用头盔NIV者32例，18例（56．25％）为Group—E，14例（43．75％）为Group—NE。Group—E中15例避免再次气管插管，持续有效率为83．33％（15／18），而Group—NE中6例避免再次气管插管，持续有效率为42．86％（6／14），差异有统计学意义（P=0．02）。两组NIV1h（NIV—1h）结果显示，心率、呼吸频率和血乳酸水平Group—E明显低于Group—NE，pH值、PaO2／FiO2和舒适度评分Group-E优于Group—NE。结束NIV（NIV·end）时，PaCO2水平Group—E明显低于Group-NE，而两组的氧合指标差异不明显。分析组内变化，Group—E在基线状态（NIV·base）、NIV—1h和NIV—end时各指标基本呈进行性改善趋势，而Group—NE不同时间点差异基本无统计学意义，并且在NIV-end时表现高碳酸血症和镇静过度趋势。两组呼吸机相关性肺炎的发生率分别为33．33％（6／18）和71．43％（10／14），差异有统计学意义（χ2=4．571，P=0．03）。Group—E总体机械通气时间明显少fGroup—NE[（136．72±151．49）h比（252．79±155．33）h，P〈0．05]。结论头盔NIV在CHD术后能够被患儿良好耐受并避免气管插管，早期改善的患儿临床结果更具优势，机械通气时间和相关并发症减少。早期改善可作为是否继续使用NIV有价值的参考指标。

Objective To analyze the safety and effect of non-invasive pressure support ventilation in 32 patients by using a helmet and to give the appropriate way of patients who need non-invasive ventilation （NIV） support after congenital heart disease surgery. Methods Patients over one year old after congential heart disease surgery were admitted in our Department of Cardiovascular Thoracic Surgery from July 2015 to December 2015. Patients who get clinically improved within one hour were divided into the early improved group（ Group-E）, otherwise they were classified to non-early improved group（ Group-NE）. The general infor- mation,diagnosis, indication of NIV, ICU and hospital stay, complications, and mortality were collected. Results Thirty-two patients were engaged in this study,including 18 patients（56. 25% ） in Group-E and 14 patients（43.75% ） in Group-NE. Patients who got improved in the first hour might have a higher incidence of avoiding reintubation[ 83.33% （15/18） vs. 42. 86% （6/14）, P = 0. 023. The heart rate, respiratory rate, pH, PaO2/FiO2 and lactate were improved in Group-E compared with Group-NE after the first hour by using helmet. At the end of NIV, the oxygenation showed no difference but the PaCO2 was lower in Group-E. In Group-E, the values showed a trend of improvement, while the values in Group-NE showed not only no statis- tical significance in different time points but also seemed to have a tendency of hypercapnia and reduced com- fort behavior scale in the end of NIV. There were 6 cases in Group-E and 10 cases in Group-NE developed ventilation associated pneumonia with the incidence of 33.33% （6/18） and 71.43% （10/14） ,respectively,which was significant difference （χ2 = 4. 571, P = 0. 03 ）. The total duration of mechanical ventilation of Group-E was shorter than that of Group-NE [ （ 136. 72 ± 151.49 ） h vs. （ 252. 79 ± 155.33 ） h, P 〈 0. 05 ]. Conclusion NIV through a helmet in children could be well tolerated and avoid re-intubation. Patients who get improved earlier may have more clinical advantages, such as less time of mechanical ventilation and lower incidence of postoperative complications. Early improvement can be considered as a valuable indicator wheth- er the patient needs to use NIV continuously.