呼吸阶梯化管理在感染性休克合并急性肺损伤患者中的应用分析

Application effect of respiratory stepwise management in patients with septic shock combined with acute lung injury

目的观察呼吸阶梯化管理在感染性休克合并急性肺损伤(ALI)患者的应用效果。方法选择2018年1月至2020年6月在中南大学湘雅医学院附属海口医院就诊的感染性休克合并ALI的100例患者作为研究对象。50例患者在常规治疗基础上进行了气管插管或有创通气(常规治疗组);50例患者根据呼吸衰竭和血气情况按照由简单到复杂的原则进行系统化呼吸支持阶梯性治疗,按照从徒手到器械到机械的顺序给予患者恰当、科学的呼吸支持(呼吸阶梯化管理组)。比较两组患者治疗前后心肺功能指标心排血指数(CI)、中心静脉压(CVP)、平均动脉压(MAP)、血管外肺水指数(EVLWI)、动脉血二氧化碳分压(PaCO_(2))、动脉血氧分压(PaO_(2))、氧合指数(PaO_(2)/FiO_(2))的差异,并评价两组患者治疗效果,同时记录两组患者复苏效果、并发症发生率、气管切开率和有创呼吸机使用率。结果两组患者治疗后CI、CVP、EVLWI、PaO_(2)、PaO_(2)/FiO_(2)水平均较治疗前明显升高,MAP、PaCO_(2)水平均较治疗前明显降低;且呼吸阶梯化管理组治疗后MAP、PaCO_(2)均明显低于常规治疗组〔MAP(mmHg,1 mmHg=0.133 kPa):68.2±7.0比74.4±6.8,PaCO_(2)(mmHg):37.82±4.05比41.76±4.59〕,EVLWI、PaO_(2)、PaO_(2)/FiO_(2)水平均明显高于常规治疗组〔EVLWI(mL/kg):15.34±3.03比13.64±3.32,PaO_(2)(mmHg):84.44±4.83比79.03±5.54,PaO_(2)/FiO_(2)(mmHg):452.42±51.32比431.73±50.03,均P<0.05〕;呼吸阶梯化管理组和常规治疗组治疗后CI、CVP水平比较差异均无统计学意义〔CI(mL·s^(-1)·m^(-2)):70.01±21.67比66.68±18.34,CVP(mmHg):11.1±3.2比12.3±3.2,均P>0.05〕。与常规治疗组比较,呼吸阶梯化管理组患者平均复苏时间提前(h:2.04±0.54比4.29±0.20,P<0.05),呼吸平稳时间缩短(h:3.07±0.22比5.36±0.35,P<0.05),总有效率和复苏成功率均显著提高〔86.0%(43/50)比60.0%(30/50),94.0%(47/50)比74.0%(37/50),均P<0.05〕,呼吸机相关性肺炎(VAP)和气道并发症发生率明显减少〔14.0%(7/50)比32.0%(16/50),12.0%(6/50)比40.0%(20/50),均P<0.05〕,气管切开率和有创呼吸机使用率均明显降低〔8.0%(4/50)比28.0%(14/50),30.0%(15/50)比60.0%(30/50),均P<0.05〕。结论呼吸阶梯化管理能有效提高感染性休克合并ALI患者的复苏效果,改善心肺功能和血气指标,提高治疗有效率,同时可有效降低医源性创伤及并发症发生率。

Objective To observe the application effect of respiratory stepwise management in patients with septic shock combined with acute lung injury(ALI).Methods 100 patients with septic shock combined with ALI were selected as the research objects in Haikou Hospital Affiliated to Xiangya Medical College of Central South University from January 2018 to June 2020.Fifty patients were given endotracheal intubation or invasive ventilation on the basis of conventional treatment(conventional treatment group).According to the respiratory situation and blood gas,50 patients were given systematic respiratory support step-by-step treatment according to the principle of simple to complex,and appropriate and scientific respiratory support was given according to the sequence from unarmed to mechanical(respiratory stepwise management group).The differences of cardiac index(CI),central venous pressure(CVP),mean arterial pressure(MAP),extravascular lung water index(EVLWI),arterial partial pressure of carbon dioxide(PaCO_(2)),arterial partial pressure of oxygen(PaO_(2)),oxygenation index(PaO_(2)/FiO_(2))before and after treatment were compared between the two groups,the therapeutic effects of the two groups were evaluated,and the resuscitation effect,postoperative complications rate,tracheotomy rate,utilization rate of invasive ventilator of the two groups were recorded.Results After treatment,CI,CVP,EVLWI,PaO_(2),PaO_(2)/FiO_(2) levels of the two groups were significantly higher than before treatment,MAP and PaCO_(2) levels were significantly lower than before treatment;MAP and PaCO_(2) levels after treatment of the respiratory stepwise management group were significantly lower than those of the conventional treatment group[MAP(mmHg,1 mmHg=0.133 kPa):68.2±7.0 vs.74.4±6.8,PaCO_(2)(mmHg):37.82±4.05 vs.41.76±4.59],the levels of EVLWI,PaO_(2) and PaO_(2)/FiO_(2) in the respiratory stepwise management group were significantly higher than those in the conventional treatment group[EVLWI(mL/kg):15.34±3.03 vs.13.64±3.32,PaO_(2)(mmHg):84.44±4.83 vs.79.03±5.54,PaO_(2)/FiO_(2)(mmHg):452.42±51.32 vs.431.73±50.03,all P<0.05].There was no significant difference in CI or CVP after treatment between respiratory stepwise management group and conventional treatment group[CI(mL·s^(-1)·m^(-2)):70.01±21.67 vs.66.68±18.34,CVP(mmHg):11.1±3.2 vs.12.3±3.2,both P>0.05].Compared with the conventional treatment group,the average recovery time of the respiratory stepwise management group was earlier(hours:2.04±0.54 vs.4.29±0.20,P<0.05),the stable breathing time was shorter(hours:3.07±0.22 vs.5.36±0.35,P<0.05),the total effective rate and the success rate of recovery were significantly improved[86.0%(43/50)vs.60.0%(30/50),94.0%(47/50)vs.74.0%(37/50),both P<0.05],the incidence of ventilator associated pneumonia(VAP)and airway complications were significantly reduced[14.0%(7/50)vs.32.0%(16/50),12.0%(6/50)vs.40.0%(20/50),both P<0.05],and the tracheotomy rate and the utilization rate of invasive ventilator were significantly reduced[8.0%(4/50)vs.28.0%(14/50),30.0%(15/50)vs.60.0%(30/50),both P<0.05].Conclusion Respiratory stepwise management can effectively improve the resuscitation effect of septic shock patients with ALI,improve cardiopulmonary function,blood gas index and the treatment efficiency,effectively reduce the incidence of iatrogenic trauma and complications.