肺部感染控制窗结合无创序贯通气在支气管扩张合并呼吸衰竭患者脱机中的临床应用

Application of noninvasive ventilation in patients with bronchiectasis and acute respiratory failure for early extubation at the time of pulmonary infection control window

目的探讨肺部感染控制(PIC)窗结合无创序贯通气在支气管扩张合并呼吸衰竭早期脱机中的临床应用。方法收集2013~2016年2家综合性医院ICU/RICU中支气管扩张并呼吸衰竭行气管插管有创呼吸机治疗患者90例,随机分为对照组及序贯治疗组,两组达到PIC窗时,对照组按常规方法降低呼吸机参数后撤机,序贯治疗组采用无创呼吸机序贯通气治疗。比较两组呼吸机相关性肺炎(VAP)发生率、第一次脱机拔管成功率、撤机10 d内达到再插管标准率、有创通气时间、住ICU/RICU时间、总住院时间及住院费用。结果最终85例患者完成研究并进行统计学分析(对照组45例,序贯治疗组40例)。两组患者插管前一般情况及PIC窗出现时间差异无统计学意义。对照组和序贯治疗组的VAP发生率分别为22.22%(10/45)、5.00%(2/40),差异有统计学意义(P=0.02);住院病死率分别为11.11%(5/45)、0.00%(0/40),差异有统计学意义(P=0.04);有创通气时间分别为(6.89±1.82)d、(4.85±3.23)d,两组差异有统计学意义(P=0.01);住ICU/RICU平均时间分别为(9.44±2.98)d、(6.38±2.58)d,差异有统计学意义(P=0.00);第一次脱机拔管成功率分别为88.89%(40/45)、95.00%(38/40),两组差异无统计学意义(P=0.44);再插管率分别为13.33%(6/45)、5.00%(2/40),两组差异无统计学意义(P=0.27);平均总住院时间分别为(15.78±6.32)d、(17.00±8.59)d,差异无统计学意义(P=0.45);平均住院费用分别为(39273.55±17086.92)元、(37095.31±15306.62)元,差异无统计学意义(P=0.54)。结论以PIC窗为时机结合无创呼吸机序贯治疗用于支气管扩展合并呼吸衰竭患者脱机可显著降低患者VAP发生率、住院病死率,缩短患者有创通气时间及住ICU/RICU时间。该方法用于支气管扩展合并呼吸衰竭患者早期脱机有效、可行。

Objective To explore the application of noninvasive ventilation（non-IV） for weaning from invasive ventilation（IV） in patients with bronchiectasis and acute respiratory failure（ARF） for early extubation at the time of pulmonary infection control（PIC） window. Methods 90 bronchiectasis patients were collected from 2 general hospitals in Longyan city, southeast China during January 2014 and December 2016, who all received IV in ICU/RICU because of AFR due to severe pulmonary infection. The patients were randomly divided into two groups（control group and treatment group）. When the PIC window appeared, control group（n=45） continued to use the SIMV＋PSV mode for weaning. Treatment group（n=45） was supposed to extubate immediately at the PIC window, and accepted non-IV treatment continuously. 5 of the 45 patients in treatment group withdrew the study halfway. Indices（including the length of IV, ICU stay and total hospital stay, the average costs of hospitalization, the occurrence of VAP, the in-hospital mortality, the success rate of weaning from IV for the first time and the rate of re-ventilation） were observed and compared between the two groups. Results 85 patients were enrolled finally. No significant differences in the demographic, respiratory, hemodynamic characteristic and PIC window occurrence were indicated between the two groups. The incidence of VAP was 22.22%（10/45） in control group and 5.00%（2/40） in treatment group（P=0.02）. The in-hospital mortality was 11.11%（5/45） in control group and 0%（0/40） in treatment group（P=0.04）. The duration of IV was （6.89±1.82） d in control group and （4.85±3.23）d in treatment group（P=0.01）. The RICU/ICU stay was （9.44±2.98）d in control group and （6.38±2.58）d in treatment group（P=0.00）. The total hospital stay was （15.78±6.32）d in control group and （17.00±8.59）d in treatment group（P=0.45）. The success rate of weaning from IV for the first time was 88.89%（40/45） in control group and 95.00%（38/40） in treatment group（P=0.44）. The rate of re-ventilation was 13.33%（6/45） in control group and 5.00%（2/40） in treatment group（P=0.27）. The average costs of hospitalization were （39273.55±17086.92）YAN（RMB） in control group and （37095.31±15306.62）Yan（RMB） in treatment group（P=0.54）. Conclusion The application of non-IV in the patients with bronchiectasis and ARF at the time of PIC window can significantly decrease the duration of IV, the ICU/RICU stay, the occurrence of VAP and the in-hospital mortality. It is an effective and feasible method for clinicians to try early extubation in the patients with bronchiectasis and ARF.