中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2014年
12期
855-859
,共5页
刘晓青%黎毅敏%何为群%徐永昊%桑岭
劉曉青%黎毅敏%何為群%徐永昊%桑嶺
류효청%려의민%하위군%서영호%상령
肺疾病,阻塞性,慢性%急性加重期%纤维支气管镜%机械通气%咳嗽峰流速%拔管
肺疾病,阻塞性,慢性%急性加重期%纖維支氣管鏡%機械通氣%咳嗽峰流速%拔管
폐질병,조새성,만성%급성가중기%섬유지기관경%궤계통기%해수봉류속%발관
Chronic obstructive pulmonary disease%Acute exacerbation%Fibrobronchoscopy%Mechanical ventilation%Cough peak expiratory flow%Extubation
目的：探讨纤维支气管镜（纤支镜）在低咳嗽峰流速（CPEF）慢性阻塞性肺疾病急性加重期（AECOPD）患者拔管后的应用价值。方法采用单中心前瞻性对照研究方法，选择2009年6月至2014年5月广州医科大学广州呼吸疾病研究所重症医学科收治的AECOPD需要行气管插管机械通气的患者，在顺利通过自主呼吸试验（SBT）2 h后嘱患者用力咳嗽，测定CPEF，完成测量后拔除气管插管。根据CPEF值将患者分为≥60 L/min组（高CPEF组）和＜60 L/min组（低CPEF组）。高CPEF组患者按病情需要给予纤支镜气道引流；低CPEF组每日主动给予一次纤支镜气道引流，并根据临床情况增加使用次数。如果患者拔管后48 h内不需要重新插管，则视为拔管成功。比较两组患者性别、年龄、拔管前急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、机械通气时间、重症监护病房（ICU）住院时间、ICU病死率、再插管率、拔管后咳嗽能力和拔管48 h内纤支镜操作次数。结果共入选102例AECOPD患者，其中高CPEF组58例，低CPEF组44例。与高CPEF组比较，低CPEF组患者年龄较大（岁：74.3±15.2比69.5±11.4，t＝2.164，P＝0.041），ICU住院时间明显延长（d：20.1±11.2比17.4±7.3，t＝2.274，P＝0.030），但性别分布〔男/女（例）：35/9比45/13，χ2＝0.057，P＝0.812〕、APACHEⅡ评分（分：11.9±1.9比10.3±4.2，t＝1.290，P＝0.200）、机械通气时间（d：14.8±10.8比13.3±9.6，t＝0.677，P＝0.501）、再插管率〔18.18%（8/44）比12.07%（7/58），χ2＝1.412，P＝0.235〕比较差异均无统计学意义。高CPEF组患者咳嗽能力以“强”为主（52例），而低CPEF组患者咳嗽能力以“中”（14例）、“弱”（26例）为主。低CPEF组患者拔管后48 h内纤支镜气道引流次数明显多于高CPEF组（次：4.1±1.8比1.3±0.9，t＝2.626，P＝0.011）。所有患者均成功撤机，无死亡。结论低CPEF的AECOPD患者拔管后主动应用纤支镜引流可以降低再插管率，避免通气时间延长，但未能缩短ICU住院时间。
目的：探討纖維支氣管鏡（纖支鏡）在低咳嗽峰流速（CPEF）慢性阻塞性肺疾病急性加重期（AECOPD）患者拔管後的應用價值。方法採用單中心前瞻性對照研究方法，選擇2009年6月至2014年5月廣州醫科大學廣州呼吸疾病研究所重癥醫學科收治的AECOPD需要行氣管插管機械通氣的患者，在順利通過自主呼吸試驗（SBT）2 h後囑患者用力咳嗽，測定CPEF，完成測量後拔除氣管插管。根據CPEF值將患者分為≥60 L/min組（高CPEF組）和＜60 L/min組（低CPEF組）。高CPEF組患者按病情需要給予纖支鏡氣道引流；低CPEF組每日主動給予一次纖支鏡氣道引流，併根據臨床情況增加使用次數。如果患者拔管後48 h內不需要重新插管，則視為拔管成功。比較兩組患者性彆、年齡、拔管前急性生理學與慢性健康狀況評分繫統Ⅱ（APACHEⅡ）評分、機械通氣時間、重癥鑑護病房（ICU）住院時間、ICU病死率、再插管率、拔管後咳嗽能力和拔管48 h內纖支鏡操作次數。結果共入選102例AECOPD患者，其中高CPEF組58例，低CPEF組44例。與高CPEF組比較，低CPEF組患者年齡較大（歲：74.3±15.2比69.5±11.4，t＝2.164，P＝0.041），ICU住院時間明顯延長（d：20.1±11.2比17.4±7.3，t＝2.274，P＝0.030），但性彆分佈〔男/女（例）：35/9比45/13，χ2＝0.057，P＝0.812〕、APACHEⅡ評分（分：11.9±1.9比10.3±4.2，t＝1.290，P＝0.200）、機械通氣時間（d：14.8±10.8比13.3±9.6，t＝0.677，P＝0.501）、再插管率〔18.18%（8/44）比12.07%（7/58），χ2＝1.412，P＝0.235〕比較差異均無統計學意義。高CPEF組患者咳嗽能力以“彊”為主（52例），而低CPEF組患者咳嗽能力以“中”（14例）、“弱”（26例）為主。低CPEF組患者拔管後48 h內纖支鏡氣道引流次數明顯多于高CPEF組（次：4.1±1.8比1.3±0.9，t＝2.626，P＝0.011）。所有患者均成功撤機，無死亡。結論低CPEF的AECOPD患者拔管後主動應用纖支鏡引流可以降低再插管率，避免通氣時間延長，但未能縮短ICU住院時間。
목적：탐토섬유지기관경（섬지경）재저해수봉류속（CPEF）만성조새성폐질병급성가중기（AECOPD）환자발관후적응용개치。방법채용단중심전첨성대조연구방법，선택2009년6월지2014년5월엄주의과대학엄주호흡질병연구소중증의학과수치적AECOPD수요행기관삽관궤계통기적환자，재순리통과자주호흡시험（SBT）2 h후촉환자용력해수，측정CPEF，완성측량후발제기관삽관。근거CPEF치장환자분위≥60 L/min조（고CPEF조）화＜60 L/min조（저CPEF조）。고CPEF조환자안병정수요급여섬지경기도인류；저CPEF조매일주동급여일차섬지경기도인류，병근거림상정황증가사용차수。여과환자발관후48 h내불수요중신삽관，칙시위발관성공。비교량조환자성별、년령、발관전급성생이학여만성건강상황평분계통Ⅱ（APACHEⅡ）평분、궤계통기시간、중증감호병방（ICU）주원시간、ICU병사솔、재삽관솔、발관후해수능력화발관48 h내섬지경조작차수。결과공입선102례AECOPD환자，기중고CPEF조58례，저CPEF조44례。여고CPEF조비교，저CPEF조환자년령교대（세：74.3±15.2비69.5±11.4，t＝2.164，P＝0.041），ICU주원시간명현연장（d：20.1±11.2비17.4±7.3，t＝2.274，P＝0.030），단성별분포〔남/녀（례）：35/9비45/13，χ2＝0.057，P＝0.812〕、APACHEⅡ평분（분：11.9±1.9비10.3±4.2，t＝1.290，P＝0.200）、궤계통기시간（d：14.8±10.8비13.3±9.6，t＝0.677，P＝0.501）、재삽관솔〔18.18%（8/44）비12.07%（7/58），χ2＝1.412，P＝0.235〕비교차이균무통계학의의。고CPEF조환자해수능력이“강”위주（52례），이저CPEF조환자해수능력이“중”（14례）、“약”（26례）위주。저CPEF조환자발관후48 h내섬지경기도인류차수명현다우고CPEF조（차：4.1±1.8비1.3±0.9，t＝2.626，P＝0.011）。소유환자균성공철궤，무사망。결론저CPEF적AECOPD환자발관후주동응용섬지경인류가이강저재삽관솔，피면통기시간연장，단미능축단ICU주원시간。
Objective To investigate the value of the application of fibrobronchoscopy in extubation for patients suffering from acute exacerbation of chronic obstructive pulmonary disease(AECOPD)with low cough peak expiratory flow(CPEF). Methods A single-center prospective controlled study was conducted. The ventilated AECOPD patients who were cooperative at the time of extubation in Department of Critical Care Medicine of Guangzhou Institute of Respiratory Disease of Guangzhou Medical University from June 2009 to May 2014 were enrolled. All patients successfully passed the spontaneous breathing trial(SBT). Extubation was performed after determination of CPEF following energetic coughing. According to the CPEF,the patients were divided into CPEF≥60 L/min group (high CPEF group)and CPEF<60 L/min group(low CPEF group). After extubation,fibrobronchoscopic drainage was given to the patients in high CPEF group when necessary. Fibrobronchoscopic drainage was given to the patients in low CPEF group at least once a day,and the frequency of such treatment could be increased according to the patient's condition. If the patients did not require re-intubation within 48 hours,extubation was recorded as successful. The gender,age,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score before extubation,ventilation time,the time of intensive care unit(ICU)stay,the mortality in ICU,the rate of re-intubation,the ability to cough and the frequency of application of fibrobronchoscopy after extubation were recorded. Results A total of 102 patients with AECOPD were enrolled,58 patients in high CPEF group and 44 in low CPEF group. Compared with high CPEF group,the mean age in low CPEF group was older(years:74.3±15.2 vs. 69.5±11.4,t=2.164,P=0.041),the time of ICU stay was significantly longer(days:20.1±11.2 vs. 17.4±7.3,t=2.274,P=0.030), but there was no significant difference in gender〔male/female(cases):35/9 vs. 45/13,χ2=0.057,P=0.812〕, APACHEⅡscore(11.9±1.9 vs. 10.3±4.2,t=1.290,P=0.200),mechanical ventilation time(days:14.8±10.8 vs. 13.3±9.6,t=0.677,P=0.501)and the rate of re-intubation〔18.18%(8/44)vs. 12.07%(7/58),χ2=1.412, P=0.235〕between low CPEF group and high CPEF group. The cough strength of patients in high CPEF group was almost always"strong"(52 cases),and in the low CPEF group,most of them was"moderate"(14 cases)or"weak"(26 cases). The frequency of application of fibrobronchoscopy in low CPEF group was higher than that in high CPEF group(times:4.1±1.8 vs. 1.3±0.9,t=2.626,P=0.011). All patients underwent weaning successfully,and no death occurred. Conclusion The application of fibrobronchoscopy in the extubated AECOPD patients with low CPEF can reduce the rate of re-intubation,avoid the prolonged ventilation,but cannot reduce the time of ICU stay.
