关于需长期机械通气患者气管切开时机研究

Study on the timing of tracheotomy in patients with long-term mechanical ventilation

目的评价气管切开时机对需长期机械通气患者的影响。方法 167例日照市中医医院急诊科重症监护室(ICU)收治的进行经皮扩张气管切开术(PDT)的急危重症患者作为研究对象,依据经口气管插管机械通气时间将患者分成两组,其中≤7 d行PDT的患者81例为早期气切组,>7 d行PDT的患者86例为晚期气切组,对两组经口气管插管机械通气时间、PDT时间、PDT后机械通气时间、总机械通气时间、在PDT后住ICU时间、ICU住院时间、总住院时间以及病死率进行比较,并进行相关分析。结果早期气切组经口气管插管机械通气时间为(5.16±1.33)d、PDT时间为(5.16±1.33)d、PDT后机械通气时间为(15.16±1.05)d、总机械通气时间为(18.02±2.03)d、在PDT后住ICU时间为(16.05±1.25)d、ICU住院时间为(21.13±0.25)d优于晚期气切组的(11.64±4.25)、(11.64±4.25)、(17.18±1.23)、(26.02±3.03)、(21.08±1.55)、(32.25±1.35)d,差异均有统计学意义(P<0.05)。两组患者总住院时间、ICU住院病死率以及住院病死率比较,差异均无统计学意义(P>0.05)。单因素回归分析显示,总机械通气时间与PDT时间呈正相关(r=0.552,t=8.495,P=0.000<0.05)。损伤严重度评分、PDT后机械通气时间、总机械通气时间与延长ICU住院时间均具有相关性(P<0.05);年龄、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和格拉斯哥昏迷评分(GCS)与延长ICU住院时间无明显相关性(P>0.05)。多因素方差分析显示,总机械通气时间是ICU住院时间延长的独立危险因素[OR=4.700,95%置信区间=(0.990,2.614),F=106.200,P=0.000<0.05]。结论急危重症患者行早期气切可缩短机械通气时间和ICU住院时间,但不影响患者的预后,对需长期机械通气患者气管切开时机宜采用7 d内进行。

Objective To evaluate the effect of timing of tracheotomy on patients with long-term mechanical ventilation. Methods A total of 167 critically ill patients with percutaneous dilatation tracheotomy（PDT） admitted to the intensive care unit（ICU） of Rizhao Traditional Chinese Medicine Hospital as study subjects were divided by oral tracheal intubation mechanical ventilation time into two groups, with 81 patients undergoing PDT less 7 d as early tracheostomy group, and 86 patients undergoing PDT more than 7 d as late tracheostomy group. Comparison were made on oral tracheal intubation mechanical ventilation time, PDT time, mechanical ventilation time after PDT, total mechanical ventilation time, ICU stay time after PDT, ICU hospitalization time, total hospitalization time and fatality rate in two groups for correlation analysis. Results The early tracheostomy group had oral tracheal intubation mechanical ventilation time as（5.16±1.33） d, PDT time as（5.16±1.33） d, mechanical ventilation time after PDT as（15.16±1.05） d, total mechanical ventilation time as（18.02±2.03） d, ICU stay time after PDT as（16.05±1.25） d, ICU hospitalization time as（21.13±0.25） d, which were all better than（11.64±4.25）,（11.64±4.25）,（17.18±1.23）,（26.02±3.03）,（21.08±1.55） and（32.25±1.35） d in the late tracheostomy group, and their difference had statistical significance（P〈0.05）. Both groups had no statistically significant difference in total hospitalization time, ICU hospital fatality rate and hospital fatality rate（P〉0.05）.Single factor regression analysis showed that the total mechanical ventilation time was positively correlated with PDT time（r=0.552, t=8.495, P=0.000〈0.05）. The injury severity score, mechanical ventilation time after PDT, total mechanical ventilation time were correlated with prolonged ICU hospitalization time（P〈0.05）. Age, acute physiology and chronic health evaluation（APACHE Ⅱ） score and Glasgow coma scale（GCS） were not significantly associated with prolonged ICU hospitalization（P〉0.05）. Multivariate analysis of variance showed that the total mechanical ventilation time was an independent risk factor for prolonged ICU hospitalization time [OR=4.700, 95%CI=（0.990, 2.614）, F=106.200, P=0.000〈0.05]. Conclusion Early tracheostomy for critically ill patients can shorten mechanical ventilation time and ICU hospitalization time, and it does not affect the prognosis of patients. Tracheotomy should be performed with 7 d for patients with long-term mechanical ventilation.