不同状态下经气管压力对重症气管切开患者说话瓣膜应用的影响

The effects of transtracheal pressure on the utility of speaking valves in critically ill patients after tracheostomy

目的观察不同状态下经气管压力(TTP)对重症气管切开(简称气切)患者说话瓣膜应用的影响。方法回顾性分析2019年6月至2021年4月期间在东南大学附属中大医院重症医学科佩戴说话瓣膜的50例气切患者相关资料,根据患者佩戴说话瓣膜耐受时长是否≥30 min将其分为耐受组和非耐受组。检测2组患者平静呼吸、用力呼气及发音时TTP,并探讨不同状态下TTP对患者佩戴说话瓣膜耐受情况的预测价值;采用线性回归模型分析影响患者说话瓣膜佩戴时长的相关因素,并采用超声评估患者佩戴说话瓣膜前、后呼吸肌收缩变化,同时记录患者对说话瓣膜应用的满意度。结果发音时TTP对患者佩戴说话瓣膜的耐受性具有预测价值(Cut off值为11 cmH_(2)O,敏感度为83.78%,特异性为61.54%)。对说话瓣膜佩戴时长的正性影响因素包括基线膈肌增厚分数和身体功能评分,负性影响因素为急性生理与慢性健康-Ⅱ评分(APACHE-Ⅱ)。佩戴说话瓣膜后2组患者腹直肌、腹外斜肌、腹内斜肌及腹横肌收缩幅度均较佩戴说话瓣膜前明显增加(P<0.05),2组患者对应用说话瓣膜的整体满意度评分[分别为(7.11±1.71)分和(5.00±1.63)分]均较高。结论发音时TTP可帮助预测重症气切患者佩戴说话瓣膜的耐受性,同时APACHE-Ⅱ评分、基线膈肌增厚分数及身体功能评分也可影响气切患者说话瓣膜佩戴时长。

Objective To analyze the effect of transtracheal pressure(TTP)on the application of a speaking valve in critically ill patients after tracheostomy.Methods A retrospective analysis was conducted of 50 patients wearing a speaking valve after tracheostomy.Patients who had been wearing a speaking valve for 30min or more were the tolerance group,while those with less than 30min were the intolerance group.Transtracheal pressure was monitored during resting breathing,forced expiration and speaking.Linear regression models were evaluated to isolate the factors best predicting tolerance.The changes in respiratory muscle contraction before and after wearing a speaking valvs were evaluated using ultrasound.The patients′satisfaction with wearing a speaking valve was also recorded.Results TTP during speaking significantly predicted tolerance.The baseline values of diaphragmatic thickening fraction and physical functioning also positively predicted tolerance.Acute physiology and chronic health(APACHE II)score was a significant negative predictor.After wearing the speaking valve,the average contraction of the rectus abdominis,external oblique,internal oblique and transverse abdominis muscles increased significantly.Both groups expressed high satisfaction with the speaking valves.Conclusions Transtracheal pressure during speaking can help predict the tolerance for wearing a speaking valve among critically ill patients after a tracheostomy.Baseline diaphragmatic thickening fraction,physical functioning and APACHE II score can predict the duration of speaking valve tolerance.