无创通气下纤维支气管镜检查在危重患者中的应用探讨

Application of fiberoptic bronchoscopy assisted by noninvasive ventilation in critical patients

目的探讨危重症患者在无创通气下行纤维支气管镜检查的安全性及有效性。方法将30例氧合指数<200mmHg且具有气管镜检查适应证的患者纳入研究,根据病情需要进行支气管肺泡灌洗、保护性毛刷刷检、活检等操作。采用随机对照方法分为2组:无创通气组(15例)和常规氧疗组(15例)。主要观察终点是气管镜检查过程中患者氧合指数、生命体征的变化及检查完成后1h及24h内气管插管率的比较。结果2组患者在性别、年龄、生命体征、急性生理和慢性健康评分(APACHEⅡ评分)方面差异无统计学意义。在气管镜检查过程中,无创通气组的氧合指数增加,由从(151.20±21.63)mmHg上升至(177.67±18.46)mmHg(t=-3.605,P=0.001),而常规氧疗组氧合指数下降了15.7%,从(158.53±21.37)mmHg下降至(133.60±17.79)mmHg(t=3.473,P=0.002)。操作过程中常规氧疗组患者心率更快。常规氧疗组中1例患者需要行气管插管。3例肿瘤患者均得到确诊。病原学结果主要是铜绿假单胞菌和肺炎克雷伯杆菌。结论对于严重呼吸衰竭患者,无创通气支持下行支气管镜检查要比常规氧疗情况下更能维持氧合指数及生命体征的稳定,具有更好的安全性。

Objective To discuss the safety and effectiveness of fiberoptic bronchoscopy assisted by noninvasive ventilation in critical patients. Methods Thirty patients with oxygenation index<200 mmHg who required bronchoscopy were entered into the study.Procedures including bronchoalveolar lavage, protective cell brushing, endobronchial biopsy and others were performed if needed.The patients were randomly divided into noninvasive ventilation group (n=15) and venturi mask group (n=15). The primary end points were changes in the oxygenation index, vital signs during bronchoscopy, and the intubation rate within the one hour and 24 hours after terminating the procedure. Results There was no statistical significance in sex, age, vital signs, APACHEⅡ score between the two groups.During bronchoscopy, oxygenation index increased from (151.20±21.63) mmHg to (177.67±18.46) mmHg (t=-3.605, P=0.001) in the noninvasive ventilation group, and decreased by 15.7% in the venturi mask group, from (158.53±21.37) mmHg to (133.60±17.79) mmHg (t=3.473, P=0.002). The heart rate in the venturi mask group was faster.One patient in the venturi mask group needed endotracheal intubation.All the three patients with cancer were definitely diagnosed.Major bacteria isolated included Pseudomonas aeruginosa and Klebsiella pneumoniae. Conclusions In patients with severe respiratory failure, fiberoptic bronchoscopy assisted by noninvasive ventilation is superior to conventional oxygen supplementation with more stable oxygenation index, vital signs, and better security.