高强度间歇性吸气肌训练联合体外膈肌起搏对慢阻肺急性加重期机械通气患者呼吸功能和运动能力的影响

Intermittent inspiratory muscle training with an external diaphragm pacer can improve the respiration and the exercise capacity of mechanically-ventilated patients with chronic obstructive pulmonary disease

目的观察高强度间歇性吸气肌训练(HII-IMT)联合体外膈肌起搏(EDP)对慢阻肺急性加重期(AECOPD)机械通气(MV)患者呼吸和运动功能的影响。方法选取AECOPD患者120例, 按随机数字表法分为观察组1、观察组2、观察组3和对照组, 每组30例。对照组给予常规康复, 观察组1给予常规康复、高强度间歇性吸气肌训练(HII-IMT)和EDP治疗, 观察组2给予常规康复、低-中等强度持续性吸气肌训练(L-MIS-IMT)和EDP治疗, 观察组3给予常规康复和EDP治疗。4组患者均每日训练2次, 每周6 d, 连续治疗2周。治疗前和治疗2周后(治疗后)检测4组患者的膈肌和外周骨骼肌功能指标, 并采用医学研究委员会(MRC)评分和莫顿活动指数(DEMMI)分别评估其运动功能和活动能力, 同时记录4组患者的动脉血气指标、MV和ICU入住时间。采用Spearman相关性和分位数回归分析吸气肌与外周肌肉功能、运动功能和活动能力的相关性。结果治疗2周后, 4组患者膈肌活动度(DE)、膈肌增厚分数(DTF)、最大吸气压力(MIP)、动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2))、肱二头肌厚度(BRT)、股四头肌厚度(QMT)、MRC、DEMMI较组内治疗前均显著改善(P<0.05)。观察组1治疗后的DE、DTF、MIP、PaO_(2)、PaCO_(2)、BRT、QMT、MRC、DEMMI均显著优于观察组2、观察组3和对照组治疗后(P<0.05)。观察组1的MV时间为(9.2±0.4)d, 显著短于其他3组, 差异均有统计学意义(P<0.05);观察组1的ICU入住时间为12(10.2~13.7)d, 显著短于其他3组, 差异均有统计学意义(P<0.05)。Spearman相关性分析显示, BRT、QMT、MRC、DEMMI的提高与DE、DTF、MIP的提高呈正相关(P<0.05)。以DE、DTF、MIP为因变量的分位数回归显示, BRT受DE、DTF、MIP的正影响(P<0.05), QMT受MIP的正影响(P<0.05), MRC和DEMMI均受DE和DTF的正影响(P<0.05)。结论 HII-IMT联合EDP可显著改善AECOPD机械通气患者的吸气肌和外周骨骼肌功能、运动功能和活动能力, 且DE、DTF、MIP的提高可不同程度地改善患者的BRT、QMT、MRC和DEMMI。

ObjectiveTo observe any effect of combining high-intensity intermittent inspiratory muscle training(HII-IMT)with an external diaphragm pacer(EDP)on the respiration and exercise capacity of mechanically-ventilated(MV)patients during an acute exacerbation of chronic obstructive pulmonary disease(AECOPD).MethodsA total of 120 AECOPD patients were randomly divided into a control group,and 3 observation groups,each of 30.The control group was given conventional rehabilitation.The observation groups also received an EDP.In addition,the observation group 1 underwent HII-IMT twice a day,6 days a week for 2 weeks,and the observation group 2 did low-to-moderate intensity sustained inspiratory muscle training(L-MIS-IMT)on the same schedule.Before and after the treatment,the functioning of the diaphragm and peripheral skeletal muscles was evaluated.Their motor functioning was measured using Medical Research Council(MRC)scoring and mobility was measured using the de Morton mobility index(DEMMI).Arterial blood gases and the durations of MV and ICU stay were recorded.Inspiratory muscle and peripheral muscle functioning were correlated with motor functioning and mobility using Spearman correlation analysis and quantile regression analysis.ResultsSignificant improvements were observed in the average diaphragm excursion(DE),diaphragm thickening fraction(DTF),maximum inspiratory pressure(MIP),arterial partial pressure of oxygen(PaO_(2)),arterial partial pressure of carbon dioxide(PaCO_(2)),biceps thickness(BRT),quadriceps thickness(QMT),MRC scores and DEMMI values in all 4 groups.Those of observation group 1 were significantly better than the observation group 2 and 3 results,on average.The MV time of observation group 1 averaged(9.2±0.4)days and with an average ICU stay of 12 days(a range of 10.2-13.7).Both were significantly shorter than the other 3 groups′averages.BRT,QMT,MRC score and DEMMI values were positively correlated with the increases in DE,DTF and MIP.ConclusionsHII-IMT combined with EDP can significantly improve the breathing and mobility of AECOPD patients on mechanical ventilation.The improvements in MIP,DE and DTF can better their BRT,QMT,MRC score and DEMMI values to varying degrees.