功能残气量监测联合呼气末正压滴定在慢阻肺急性加重伴呼吸衰竭患者中的临床应用

The clinical application of functional residual capacity monitoring combined with positive end-expiratory pressure titration in patients with acute exacerbation of chronic obstructive pulmonary disease with respiratory failure

目的探讨功能残气量监测联合呼气末正压滴定在慢性阻塞性肺疾病急性加重伴呼吸衰竭患者中的临床应用。方法纳入2020年5月至2021年5月锦州医科大学附属第一医院重症医学科收治的慢性阻塞性肺疾病急性加重伴呼吸衰竭的患者54例为研究对象。记录患者一般资料,给予气管插管正压通气,首先测定无外源性呼气末正压(PEEPe)下呼气末肺泡内正压(PEEPi)、功能残气量(FRC)、潮气量(VT)、呼吸频率(f)、呼吸功(WOBimp)、气道峰压(PIP)、平台压(Pplat)、二氧化碳分压(PaCO_(2))、氧分压(PaO_(2))、PH、平均动脉压(MAP);再给予常规推荐水平PEEPe(60%~80%PEEPi),分别监测入室插管后、机械通气6h、20h及拔管前的以上指标,并按照拔管前功能残气量改善水平(FRC改善量/FRC改善前)分组,本研究以5%FRC改善水平分组(以下称改善量在5%及5%以上的组为A组,改善量不足5%组为B组),观察两组患者的病情及预后(治疗过程中FRC未见明显好转的,PEEP滴定调整以能将FRC尽量降低再进行分析)。结果与B组相比,A组机械通气20h及拔管前FRC、PIP、Pplat、VT、f、WOBimp均明显好转(P<0.05),各时段两组PEEPi相比差异均无统计学意义(P>0.05)。与B组相比,A组机械通气20h及拔管前的MAP有显著差异(P<0.05)。两组的再插管率、28天死亡率、ICU住院时长均有显著差异(P<0.05)。两组各时段PH、PaCO_(2)、PaO_(2)相比,差异无统计学意义(P>0.05)。结论AECOPD在机械通气治疗过程中监测FRC可帮助判断患者病情并指导治疗,且FRC的降低可改善患者预后。

Objective To investigate the clinical application of functional residual capacity monitoring combined with positive end-expiratory pressure titration in patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD)with respiratory failure.Methods From February 2020 to February 2021,forty patients with AECOPD with respiratory failure treated in intensive care department(ICU)of the first affiliated Hospital of Jinzhou Medical University was included.Record the general data of the patients, and they were all given tracheal intubation and positive pressure ventilation.Intrinsic positive end-expiratory pressure(PEEPi),functional residual capacity(FRC),tidal volume(VT),respiratory rate(f),work of breathing(WOBimp),peak inspiratory pressure(PIP),plateau pressure(Pplat),arterial partial pressure of carbon dioxide(PaCO_(2)),arterial partial pressure of oxygen(PaO_(2)),PH,mean arterial pressure(MAP)were first measured without extrinsic positive end-expiratory pressure(PEEPe),and then the routine recommended level PEEPe(60%~80%PEEPi)was given.The above indexes were measured at the moment after intubation, mechanical ventilation for 6 hours, mechanical ventilation for 20 hours and before extubation, then, we divided groups according to the decrease level of functional residual capacity before extubation(the decrease of FRC/FRC).In this study, all the patients were divided into two groups according to the level of 5% decrease(hereinafter referred to as the group A with the decrease of 5% and more than 5%,and the decrease less than 5% group was group B).The condition and prognosis of the two groups were observed(If FRC did not decrease significantly during treatment, PEEP titration will be adjusted to reduce FRC as much as possible before analysis).Results Compared with group B,the indexes of group A,FRC,PIP,Pplat, VT, f and WOBimp were significantly improved, at the moment of mechanical ventilation for 20 hours and before extubation, but the PEEPi of the two groups was not significant in each period.There was significant difference in MAP at mechanical ventilation for 20 hours and before extubation in group A and B(P<0.05).And there were also significant differences in re-intubation rate, 28-day mortality and length of ICU hospitalization between the two groups.But there was no significant difference in segment PH,PaCO_(2) and PaO_(2).Conclusion When AECOPD treated by mechanical ventilation, monitoring FRC during the process can help to judge the patient’s condition and guide the treatment, and FRC has value for the prognosis of patients.