早期活动对机械通气患者膈肌功能的影响：一项前瞻陛随机对照研究

Effect of early mobilization on diaphragmatic function in patients with mechanical ventilation： a prospective randomized controlled study

目的探讨早期活动对机械通气（MV）患者膈肌功能的影响。方法选择2016年1月至2017年1月济宁医学院附属湖西医院重症医学科（ICU）收治的行有创MV治疗的60例慢性阻塞性肺疾病急性加重期（AECOPD）呼吸衰竭（呼衰）患者。按随机数字表法将患者分为治疗组和对照组，每组30例。两组均给予镇痛镇静、MV、抗感染、营养支持等治疗；治疗组在此基础上参照ICU成人患者疼痛、烦躁和谵妄临床实践（PAD）指南实施早期活动（如关节活动、床旁站立等，每日3次）。两组分别于治疗前及治疗24 h、48 h、3 d、5 d行床旁超声检查，测量呼气末膈肌厚度（DTee）、吸气末膈肌厚度（DTei）、膈肌增厚分数（DTF）。结果两组患者治疗前DTee、DTei、DTF等膈肌参数比较差异均无统计学意义。对照组治疗后DTee逐渐减小，5 d时明显小于治疗前（cm：0.26±0.06比0.28±0.08，t＝3.045，P＝0.005），而治疗组治疗前后DTee无显著变化；两组治疗后各时间点DTee比较差异无统计学意义。两组治疗后DTei和DTF均显著增加，并均于48 h时达峰值；随MV时间延长，对照组3 d和5 d时DTei、DTF均显著低于48 h时〔DTei（cm）：0.35±0.07、0.34±0.07比0.36±0.08，DTF：（29.29±11.01）%、（28.62±11.97）%比（32.48±15.63）%，均P〈0.01〕，而治疗组3 d和5 d的DTei、DTF与48 h时比较无明显变化；但治疗组3 d和5 d时DTF均明显高于对照组〔（38.53±11.39）%比（29.29±11.01）%，（37.27±11.26）%比（28.62±11.97）%，均P〈0.01〕。结论MV可导致膈肌功能障碍，早期活动能够延缓MV患者的膈肌萎缩和收缩功能障碍。

ObjectiveTo investigate the effect of early mobilization on diaphragmatic function in patients with mechanical ventilation （MV）.Methods Sixty chronic obstructive pulmonary disease with acute exacerbation （AECOPD） patients with respiratory failure （RF） and underwent MV admitted to intensive care unit （ICU） of Huxi Affiliated Hospital of Jining Medical College from January 2016 to January 2017 were enrolled. The patients were divided into treatment group （n = 30） and control group （n = 30） by randomly number table method. The two groups were given analgesia, sedation, MV, antibiotics, nutritional support and other treatments. An implementation plan was developed based on the clinical practice of pain, irritability and delirium in adult patients （PAD） with ICU, while the treatment group was given early mobilization （such as joint activity, stand to the bed, 3 times a day）. The diaphragmatic thickness at the end of expiration （DTee）, diaphragmatic thickness at the end of inspiration （DTei） and diaphragmatic thickening fraction （DTF） were measured by bedside ultrasonography before and 24 hours, 48 hours, 3 days and 5 days after treatment respectively.ResultsThere were no significant differences in the parameters of the diaphragm before treatment between the two groups. In the control group, DTee was gradually decreased at 5 days after treatment and was significantly lower than that before treatment （cm： 0.26±0.06 vs. 0.28±0.08, t = 3.045, P = 0.005）. While there was no significant change in DTee in the treatment group. There was no significant difference in DTee between the two groups at different time points after treatment. DTei and DTF were significantly increased in the two groups after treatment, and reached the peak value at 48 hours; with the prolonged of MV time, DTei and DTF in the control group at 3 days and 5 days were significantly lower than those at 48 hours [DTei （cm）： 0.35±0.07, 0.34±0.07 vs. 0.36±0.08; DTF： （29.29±11.01）%, （28.62±11.97）% vs. （32.48±15.63）%, all P 〈 0.01]; there were no significant changes in the treatment group. DTF in the treatment group at 3 days and 5 days was significantly higher than that in the control groups [（38.53±11.39）% vs. （29.29±11.01）%, （37.27±11.26）% vs. （28.62±11.97）%, both P 〈 0.01].ConclusionMV can lead to diaphragmatic dysfunction, while early mobilization can delay diaphragmatic atrophy and systolic dysfunction in MV patients.