CAJ | 학술논문

目的探讨以改良格拉斯哥昏迷评分(GCS)15分为切换点指导慢性阻塞性肺疾病(COPD)合并呼吸衰竭(呼衰)患者早期拔管改换无创机械通气的可行性,并评价其治疗效果.方法选择接受气管插管和机械通气的COPD并呼衰患者,采用前瞻性对照研究方法,以2007年3月至2009年11月收治的20例患者为治疗组,采用同步间歇指令通气+压力支持通气(SIMV+PSV)方式行机械通气,待改良GCS评分达15分并稳定2 h的窗口期拔除气管导管,改用经鼻面罩PSV+呼气末正压(PEEP)通气,以后逐渐减小压力支持(PS)水平直至脱机;以2005年3月至2007年3月收治的19例患者为对照组,按常规机械通气及传统脱机方式脱机.动态观察两组患者机械通气前通气及氧合指标,接受有创机械通气时间、总机械通气时间、总住院时间、再插管及呼吸机相关性肺炎(VAP)发生例数.结果两组机械通气前通气及氧合指标均无明显差异.治疗组较对照组有创通气时间(d:3.2±1.1比10.5±3.2)、总机械通气时间(d:4.8±2.5比10.5±3.2)、总住院时间(d:17±3比22±7)均明显缩短(均P＜0.01);VAP发生数减少(例:0比5,P＜0.01),再插管数稍增加,但无统计学意义(例:3比1,P＞0.05).结论对COPD合并呼衰的机械通气患者,以改良GCS评分达15分稳定2 h窗口期为时机早期拔管改用经鼻面罩无创通气,可以显著改善患者的治疗效果.
목적 탐토이개량격랍사가혼미평분(GCS)15분위절환점지도만성조새성폐질병(COPD)합병호흡쇠갈(호쇠)환자조기발관개환무창궤계통기적가행성,병평개기치료효과.방법 선택접수기관삽관화궤계통기적COPD병호쇠환자,채용전첨성대조연구방법,이2007년3월지2009년11월수치적20례환자위치료조,채용동보간헐지령통기+압력지지통기(SIMV+PSV)방식행궤계통기,대개량GCS평분체15분병은정2 h적창구기발제기관도관,개용경비면조PSV+호기말정압(PEEP)통기,이후축점감소압력지지(PS)수평직지탈궤;이2005년3월지2007년3월수치적19례환자위대조조,안상규궤계통기급전통탈궤방식탈궤.동태관찰량조환자궤계통기전통기급양합지표,접수유창궤계통기시간、총궤계통기시간、총주원시간、재삽관급호흡궤상관성폐염(VAP)발생례수.결과 량조궤계통기전통기급양합지표균무명현차이.치료조교대조조유창통기시간(d:3.2±1.1비10.5±3.2)、총궤계통기시간(d:4.8±2.5비10.5±3.2)、총주원시간(d:17±3비22±7)균명현축단(균P＜0.01);VAP발생수감소(례:0비5,P＜0.01),재삽관수초증가,단무통계학의의(례:3비1,P＞0.05).결론 대COPD합병호쇠적궤계통기환자,이개량GCS평분체15분은정2 h창구기위시궤조기발관개용경비면조무창통기,가이현저개선환자적치료효과.
Objective To estimate the feasibility and the efficacy of early extubation and the sequential non-invasive mechanical ventilation (MV) in severe respiratory failure of chronic obstructive pulmonary disease (COPD) with the improved Glasgow coma scale (GCS) score of 15 as the switching point. Methods By a prospective control study, 20 patients with COPD and respiratory failure who had undergone endotracheal intubation and MV from March 2007 to November 2009 were enrolled as treatment group.Invasive MV with synchronous intermittent mandatory ventilation and pressure support ventilation (SIMV+PSV) pattern were given to these patients. When the period of "improved GCS score of 15 standard" window period appeared and being kept for 2 hours, endotracheal tube was extubated, and nasal mask with PSV±positive end-expiratory pressure (PEEP) was used, followed by gradual decrease of the level of pressure support till weaning of MV. Nineteen patients who were treated with MV with ordinary way of weaning from March 2005 to March 2007 served as the control group. Prior to the MV, the ventilation and oxygenation index, the length of invasive MV, total MV time, total hospital stay, re-intubation and ventilator-associated pneumonia (VAP) occurred in the number of cases were observed and compared between two groups. Results There was no significant difference in the ventilation and oxygenation index prior to the MV. Compared with control group, in treatment group, the length of invasive ventilation (days: 3. 2±1.1 vs. 10. 5± 3. 2),the total duration of MV (days: 4. 8±2. 5 vs. 10. 5±3. 2), the length of hospital stay (days:17±3 vs. 22±7) were significantly shorter (all P＜0.01), and the incidence of VAP was significantly lower (cases: 0 vs.5, P＜ 0. 01), while the number of re-intubation was slightly higher but without statistical significance (cases:3 vs. 1, P＞0. 05). Conclusion The application of improved GCS score of 15 as the switching point with 2 hours as window period for early extubation and non-invasive nasal mask ventilation can significantly improve the therapeutic effect in patients with severe respiratory failure in COPD.