两种序贯治疗方法在急性左心功能不全患者拔管后的疗效比较

Comparison efficacy of high-flow nasal cannula oxygen therapy and non-invasive positive pressure ventilation after extubation in patients with acute left heart insufficiency undergoing mechanical ventilation

目的观察并比较经鼻高流量湿化氧疗(HFNC)与无创正压通气(NPPV)序贯治疗在急性左心功能不全患者拔管后的临床疗效。方法将华中科技大学协和江北医院重症医学科2017年11月至2018年11月收治的80例急性左心功能不全并行机械通气患者,按照随机数字表法分为停止有创机械通气拔除气管导管后使用HFNC的研究组和NPPV的对照组,每组40例。观察并比较两组患者拔管后2、6、24 h的PaO2、PaCO2、pH值、乳酸值、氧合指数、心率以及呼吸频率;超声检查测定入院时及拔管后48 h的心尖四腔心切面左心室舒张末容积指数(LVEDVI)、左心室射血分数(LVEF)、主动脉血流速度时间积分(AVTI);记录治疗结束时终点事件/合并症(谵妄、腹胀、再插管、拔管后ICU停留时间)的发生情况。结果拔管后2、6、24 h,两组患者PaO2、PaCO2、pH值和乳酸值比较差异均无统计学意义(均P>0.05);研究组氧合指数明显高于对照组,心率和呼吸频率明显优于对照组,差异均有统计学意义(均P<0.05);拔管后48 h,研究组LVEDVI、LVEF、AVTI数值均明显优于对照组,差异均有统计学意义(均P<0.05);研究组谵妄与腹胀发生率明显低于对照组,拔管后ICU停留时间明显短于对照组(均P<0.05);两组患者再插管发生率差异无统计学意义(P>0.05)。结论急性左心功能不全患者停止有创机械通气拔管后给予HFNC与NPPV相比,呼吸状况和心功能改善明显,谵妄和腹胀发生率降低,拔管后ICU停留时间明显减少。

Objective To compare the clinical efficacy of high-flow nasal cannula oxygen therapy(HFNC)and non-invasive positive pressure ventilation(NPPV)after extubation from invasive mechanical ventilation in patients with acute left heart insufficiency.Methods Eighty patients with acute left heart insufficiency receiving invasive mechanical ventilation in Department of Critical Medicine,Union Jiangbei Hospital from November 2017 to November 2018 were enrolled.After extubation from invasive mechanical ventilation,80 patients were divided into HFNC and NPPV groups by random number table with 40 cases in each group.The arterial partial pressure of oxygen(PaO2),arterial partial pressure of carbon dioxide(PaCO2),pH,blood lactic acid,oxygenation index,heart rate(HR)and respiratory rate(RR)were observed at 2,6 and 24h after extubation.Apical four Chamber view of left ventricular end-diastolic volume index(LVEDVI),left ventricular ejection fraction(LVEF),and aorta velocity-time integral(AVTI)with ultrasonography were compared on admission and 48 h after extubation.End-point events/compli-cations(incidence of delirium and abdominal distension,re-intubation rate and length of stay in ICU after extubation)were compared between two groups.Results At 2,6 and 24 h after extubation there were no significant differences in PaO2,PaCO2,pH value and blood lactic acid between two groups(P>0.05).Oxygenation index of the HFNC group was significantly higher than that of the NPPV group,heart rate and respiratory rate of the HFNC group were significantly lower than those of the NPPV group(P<0.05).At 48 h after extubation,the left ventricular end-diastolic volume,left ventricular ejection fraction,and velocity-time integral on ultrasonography in the HFNC group were significantly better than those in the NPPV group(P<0.05).The incidence of delirium and abdominal distension in the HFNC group was significantly lower than that of the NPPV group,and length of stay in ICU after extubation of the HFNC group was significantly shorter than that in the NPPV group(P<0.05).There was no significant difference in the incidence of re-intubation between the two groups(P>0.05).Conclusion After extubation from invasive mechanical ventilation in patients with acute left heart insufficiency,high-flow nasal cannula oxygen therapy is better than noninvasive positive pressure ventilation in respiratory status,oxygenation index and cardiac function,with reduced incidence of delirium and abdominal distension,and reduced length of stay in ICU after extubation.It is worthy of clinical promotion and application.