APACHEⅡ评分在慢性阻塞性肺疾病急性加重患者无创通气治疗时机选择中的应用研究

Application of acute physiology and chronic health evaluationⅡscore in the timing of noninvasive ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease

目的探讨急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)在慢性阻塞性肺疾病急性加重(AECOPD)患者无创通气治疗时机选择及护理中的应用效果。方法选择2018年1月至2019年10月海口市人民医院收治的106例AECOPD患者作为研究对象,按照随机数字表法将患者分为观察组和对照组,每组53例。对照组根据《机械通气》(第2版)中的标准选择无创通气治疗时机,参照《机械通气临床实践》中的标准撤机,并给予重症监护病房(ICU)常规护理,包括营造舒适的室内环境、合理膳食、病情监测、心理护理、并发症护理等;观察组在对照组的基础上,APACHEⅡ评分>10分时给予无创通气治疗,APACHEⅡ评分≤10分时撤机,并按照APACHEⅡ评分<10、10~14、15~19、≥20分4个等级分别给予三级护理、二级护理、一级护理和特级护理。监测两组患者无创通气治疗前及治疗3 d后肺功能,并记录患者机械通气时间、ICU住院时间、气管插管率、呼吸机相关性肺炎(VAP)等并发症发生率和ICU病死率等预后指标。自制护理满意度调查问卷,由患者对本次护理满意度进行评价。结果两组患者性别和年龄等一般资料比较差异无统计学意义。无创通气治疗3 d后,两组患者1秒用力呼气容积(FEV1)、用力肺活量(FVC)及FEV1/FVC比值均治疗前显著升高,以观察组升高更为显著,与对照组比较差异均有统计学意义〔FEV1(L):3.02±0.22比2.54±0.19,FVC(L):3.01±0.32比2.13±0.28,FEV1/FVC比值:0.89±0.08比0.79±0.08,均P<0.05〕。观察组患者机械通气时间和ICU住院时间均较对照组明显缩短〔机械通气时间(d):4.32±0.73比8.42±1.94,ICU住院时间(h):32.23±10.22比38.52±9.85,均P<0.01〕,气管插管率、VAP发生率和ICU病死率均显著低于对照组〔气管插管率:1.9%(1/53)比13.2%(7/53),VAP发生率:1.9%(1/53)比15.1%(8/53),ICU病死率:1.9%(1/53)比13.2%(7/53),均P<0.05〕。观察组患者的护理满意度显著高于对照组〔96.2%(51/53)比75.5%(40/53),P<0.01〕。结论 APACHEⅡ评分用于指导AECOPD患者无创通气治疗时机选择和护理干预措施的制定,能够显著改善患者肺功能,提高治疗效果,降低并发症发生率,并提高患者对护理的满意度,具有较好的临床应用效果。

Objective To explore the application of acute physiology and chronic health evaluationⅡ(APACHEⅡ)score in the timing and nursing of noninvasive ventilation for patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD).Methods 106 AECOPD patients admitted to Haikou People's Hospital from January 2018 to October 2019 were selected as the study objects.According to the method of random number table,the patients were divided into observation group and control group,with 53 patients in each group.The control group selected the timing of noninvasive ventilation treatment according to the standards of Mechanical ventilation(second edition),weaned according to Clinical practice of mechanical ventilation,and received routine nursing in intensive care unit(ICU),including creating comfortable indoor environment,reasonable diet,condition monitoring,psychological nursing and complications nursing.On the basis of the control group,the patients in the observation group were given noninvasive ventilation when APACHEⅡscore was more than 10,and were weaned when APACHEⅡscore was less than or equal to 10.According to APACHEⅡscore<10,10-14,15-19 and≥20,the patients were given level-3 care,level-2 care,level-1 care and intensive care.The pulmonary function before and 3 days after the noninvasive ventilation treatment was monitored,and the duration of mechanical ventilation,the length of ICU stay,endotracheal intubation rate,incidence of complication[ventilator associated pneumonia(VAP)]and ICU mortality were recorded.The self-designed questionnaire of nursing satisfaction was used to evaluate the patients'nursing satisfaction.Results There was no significant difference in general data such as gender or age between the two groups.After 3 days of noninvasive ventilation,the forced expiratory volume in one second(FEV1),forced vital capacity(FVC)and FEV1/FVC ratio of the two groups were increased significantly as compared with those before treatment,especially in the observation group,with statistical significances as compared with the control group[FEV1(L):3.02±0.22 vs.2.54±0.19,FVC(L):3.01±0.32 vs.2.13±0.28,FEV1/FVC ratio:0.89±0.08 vs.0.79±0.08,all P<0.05].Compared with the control group,the duration of mechanical ventilation and length of ICU stay in the observation group were significantly shortened[duration of mechanical ventilation(days):4.32±0.73 vs.8.42±1.94,length of ICU stay(hours):32.23±10.22 vs.38.52±9.85,both P<0.01].The intubation rate,incidence of VAP and ICU mortality in the observation group were significantly lower than those in the control group[intubation rate:1.9%(1/53)vs.13.2%(7/53),incidence of VAP:1.9%(1/53)vs.15.1%(8/53),ICU mortality:1.9%(1/53)vs.13.2%(7/53),all P<0.05].The nursing satisfaction of patients in the observation group was significantly higher than that in the control group[96.2%(51/53)vs.75.5%(40/53),P<0.01].Conclusions APACHEⅡscore can be used to guide the choice of noninvasive ventilation treatment opportunity and nursing intervention measures for AECOPD patients.It can significantly improve the pulmonary function of patients,improve the treatment effect,reduce the incidence of complications,and improve the satisfaction of patients with nursing,which is effective in clinical application.