支气管肺泡灌洗对行有创—无创序贯机械通气的AECOPD患者的疗效观察

发布时间：2018-05-01 09:01

本文选题：慢性阻塞性肺疾病 + 机械通气　；参考：《郑州大学》2014年硕士论文

【摘要】：目的探讨支气管肺泡灌洗（bronchoalveolar lavage，，BAL）治疗对行有创-无创序贯机械通气的慢性阻塞性肺疾病急性加重（acute exacerbation chronic obstructivepulmonary disease， AECOPD）并严重呼吸衰竭患者的肺部感染窗时间(pulmonary infection control window，PIC window)、机械通气时间、呼吸机相关性肺炎（ventilator-associated pneumonia，VAP）的发生率、拔管后48小时再插管率，病原学检出率以及预后的影响。方法选择因支气管-肺部感染加重导致AECOPD并严重呼吸衰竭行有创机械通气的患者61例，随机分为两组，治疗组32例，对照组29例，两组均以PIC窗为切换点实施有创-无创序贯机械通气，治疗组联合应用BAL。当两组患者出现PIC窗后均拔除气管插管，给予无创正压通气，以后逐渐降低呼吸机支持力度直至撤离无创通气改为文丘里面罩吸氧，期间如果病情恶化并达到重新插管指证，则再次给予气管插管行有创机械通气，以转出呼吸加强治疗病房（respiratory intensivecare unit，RICU）或院内死亡为观察终点，主要观察两组PIC窗出现的时间(即有创通气切换为无创通气的时间)、总的机械通气时间、VAP的发生率、拔管后48小时再插管率、病原学检出率、院内死亡率。结果 1.对照组PIC窗出现的时间(即有创通气切换为无创通气的时间)为(6.2±1.8)d，治疗组PIC窗出现的时间(即有创通气切换为无创通气的时间)为(3.8±1.0)d，和对照组相比，治疗组PIC窗明显提前，有创机械通气时间显著减少(P0．01)。 2..对照组总的机械通气时间为（15.5±5.2）d，治疗组总的机械通气时间为（12.6±5.3）d，和对照组相比，治疗组总的机械通气时间显著减少(P0．05)。 3.对照组VAP发生率为20.69%，治疗组VAP发生率为9.38%，和对照组相比，治疗组VAP发生率明显降低(P0．05)。 4.对照组病原学检出率41.38%，治疗组病原学检出率78.13%，治疗组病原学检出率明显高于对照组(P0．01)。 5.对照组拔管后48小时重新插管率13.793%，治疗组拔管后48小时重新插管率3.125%，治疗组拔管后48小时重新插管率明显低于对照组(PO．05)。 6.对照组院内死亡率13.793%，治疗组院内死亡率3.125%，治疗组死亡率明显低于对照组(P0．05)。 7.治疗组共行床旁支气管肺泡灌洗118例次，在灌洗操作中均出现一过性心律失常、缺氧的表现，其中术后发热6例次，轻微的支气管痉挛2例次，支气管粘膜渗血2例次。结论 1. BAL联合有创-无创序贯机械通气治疗因支气管-肺部感染致AECOPD并呼吸衰竭患者，可以促使PIC窗提前，缩短有创通气时间，降低VAP发生率,提高病原学检出率，降低48小时再插管率，从而改善预后。 2.行BAL可出现一过性心律失常、缺氧、支气管痉挛、支气管粘膜渗血及术后发热等并发症，大多停止操作，给予简单处理，甚至不处理也能缓解或恢复正常，未出现严重并发症，BAL是一项相对安全的治疗措施。
[Abstract]:Purpose To investigate the time of pulmonary infection control window infection and mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and severe respiratory failure after bronchoalveolar lavage with bronchoalveolar lavage (BALL) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and severe respiratory failure. The incidence of ventilator-associated pneumonia (VAP), the rate of re-intubation 48 hours after extubation, the detection rate of etiology and the influence of prognosis. Method Sixty-one patients with AECOPD and severe respiratory failure due to bronchopulmonary infection were randomly divided into two groups: treatment group (n = 32) and control group (n = 29). PIC window was used as switching point in both groups. When PIC window appeared in both groups, tracheal intubation was removed, non-invasive positive pressure ventilation was given, and the support intensity of ventilator was gradually reduced until the withdrawal of non-invasive ventilation was replaced by Venturi mask oxygen inhalation, during which time, if the condition deteriorated and the indication of re-intubation was reached, He was again given tracheal intubation for invasive mechanical ventilation, and the end point was to transfer out of the respiratory intensive care unit (intensivecare unitricu) or to hospital death. The time of emergence of PIC window (that is, the time when invasive ventilation was switched to non-invasive ventilation), the incidence of total mechanical ventilation time, the rate of re-intubation 48 hours after extubation, the detection rate of etiology, and the mortality in hospital were observed. Result 1. The time of PIC window in the control group was 6.2 卤1.8 days, and that of the PIC window in the treatment group was 3.8 卤1.0 days. Compared with the control group, the PIC window in the treatment group was significantly earlier than that in the control group. The time of invasive mechanical ventilation was decreased significantly (P 0.01). 2.. The total mechanical ventilation time of the control group was 15.5 卤5.2 days, and the total mechanical ventilation time of the treatment group was 12.6 卤5.3 days. Compared with the control group, the total mechanical ventilation time of the treatment group was significantly reduced to 0.05%. 3. The incidence of VAP in the control group was 20.69 and the incidence of VAP in the treatment group was 9.38. Compared with the control group, the incidence of VAP in the treatment group was significantly lower than that in the control group (P 0.05). 4. The detection rate of etiology in the control group was 41.38 and that in the treatment group was 78.13. The detection rate of the treatment group was significantly higher than that of the control group (P 0.01). 5. The rate of re-intubation 48 hours after extubation was 13.793 in the control group and 3.125 in the treatment group 48 hours after extubation. The rate of re-intubation 48 hours after extubation in the treatment group was significantly lower than that in the control group. 6. The hospital mortality in the control group was 13.793, and the hospital mortality in the treatment group was 3.125. The mortality in the treatment group was significantly lower than that in the control group (P 0.05). 7. In the treatment group, 118 cases of bronchoalveolar lavage were performed by bedside bronchoalveolar lavage. Transient arrhythmias and anoxia were found in all cases during the lavage operation, including 6 cases of postoperative fever, 2 cases of mild bronchiospasm and 2 cases of osmosis of bronchial mucosa. Conclusion 1. BAL combined with invasive sequential mechanical ventilation in the treatment of patients with AECOPD and respiratory failure caused by bronchopulmonary infection can advance the PIC window, shorten the time of invasive ventilation, reduce the incidence of VAP, and increase the detection rate of etiology. Reduce the rate of 48 hours re-intubation, thereby improving the prognosis. 2. Complications such as transient arrhythmia, anoxia, bronchospasm, blood leakage of bronchial mucosa and postoperative fever can occur after BAL. Most of the complications can be alleviated or returned to normal by simple or even untreated treatment. BAL without severe complications is a relatively safe treatment.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R563.9

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