动态调控气囊压力联合声门下吸引预防呼吸机相关性肺炎的临床、机理研究

发布时间：2018-08-12 18:50

【摘要】：第一部分动态调控气囊压力联合声门下吸引预防呼吸机相关性肺炎目的:自动调控气囊压力联合声门下吸引预防呼吸机相关性肺炎。方法:前瞻性入选2013年10月至2014年12月无锡市第二人民医院重症医学科收治的90例气管插管患者,采用随机、对照研究气囊压力自动控制仪联合声门下吸引预防呼吸机相关性肺炎,比较实验组和常规对照组气囊压力监测达标率、声门下引流量、气囊防分泌物渗漏以及呼吸机相关性肺炎、机械通气时间、病死率等。结果:24小时内气囊压力监测达标率实验组显著高于对照组(100%vs.59.5%,P0.05);72小时内声门下引流液总量实验组明显高于对照组(50±5 mL vs.31±3 mL,60±8 mLvs.42±5mL,45±7mL vs.32±64 mL;P0.05);VAP发生率、机械通气时间以及ICU住院时间实验组显著低于对照组(22.9%vs.47.6%;7.3±3.2d vs.12.3±4.0d;10.3±2.2d vs.15.1±3.0d;P0.05),两组病死率无明显差异;VAP患者痰培养革兰氏阳性菌比例实验组低于对照组(22.9%vs.47.6%,P0.05);多因素Logistic回归分析显示气囊压力监测方法为气管插管患者发生VAP的独立预测因素(OR=0.45,P=0.02)。结论:自动持续调控气囊压力联合声门下吸引可有效降低声门下分泌物渗漏量,应用该技术可降ICU患者住院时间、机械通气时间和VAP发病率,但对患者死亡率无明显影响。第二部分动态调控气囊压力联合声门下吸引预防误吸研究目的:研究自动调控气囊压力联合声门下吸引预防误吸效果。方法:运用双抗体两步夹心酶联免疫吸附法(ELISA)监测实验组和对照组上呼吸道、下呼吸道分泌物胃蛋白酶阳性率、浓度并比较两组患者误吸发生率。结果:对照组和实验组口腔、鼻腔以及经气囊导管吸引声门下分泌物中胃蛋白酶阳性率、浓度均无明显差异;下呼吸道分泌物胃蛋白酶阳性率实验组较对照组明显降低(23.8%vs.50.0%,P0.05),胃蛋白酶浓度实验组显著低于对照组(20.1±4.2 ng/mL vs.28.1±3.1 ng/mL,P0.05);下呼吸道分泌物胃蛋白酶阳性较阴性患者VAP发生率明显增高(73.5%vs.10.7%,P0.05);多因素Logistic回归分析显示气囊压力监测方法为气管插管患者发生误吸的独立预测因素(OR=1.078,P=0.012)。结论:气管插管机械通气患者存在较高的误吸发生率,自动调控气囊压力联合声门下吸引可有效降低误吸的发生率,VAP的发生与误吸有明显相关性。第三部分人工气道防渗漏以及气囊压力影响因素机制研究目的:研究人工气道气囊防渗漏以及气囊压力影响因素的相关机制。方法:运用医用气管插管、医用注射器、压力传感器及其附件、VBM气囊压力表、PHLIPS心电监护仪等进行体外渗漏模拟试验和动态观察气管插管患者气囊压力变化以及其影响因素。结果:8号组和7.5号组相比气管插管气囊外径相对气管内径差增大,皱褶增多,皱褶管径增大,分泌物向下渗漏显著增加(P0.05);气管插管气囊外径相对气管内径偏小时,气囊上方液体沿气囊壁周呈袖套状渗漏;气管插管保持水平面30~45度时气囊上吸引口平面以下液体不易被吸引出。气管插管患者套囊压力随呼吸周期呈近似正弦波形变化;吸痰、咳嗽时气囊压力会出现瞬时升高;PEEP设置会导致气囊压力增加;运用气囊压力波形可判断气囊封闭气管实际效果。结论:临床上需根据患者气管内径大小选择相应外径的气管套管,皱褶通道的形成是导致气囊上分泌物渗漏的重要原因,需注意患者气管导管气囊上引流口水平面以下液体湖的充分引流;患者体内气囊压力受呼吸周期、PEEP、咳嗽、吸痰等因素影响而变化;气囊压力的设置需要个体化,可结合气囊压力波形指导气囊压力设置。
[Abstract]:Objective: To prevent ventilator-associated pneumonia by automatically regulating airbag pressure and subglottic suction. Methods: 90 patients with endotracheal intubation were prospectively enrolled in the Department of Critical Care Medicine of the Second People's Hospital of Wuxi from October 2013 to December 2014. A randomized, controlled study was conducted to compare the compliance rate of balloon pressure monitoring, subglottic drainage, balloon anti-secretion leakage, ventilator-associated pneumonia, mechanical ventilation time and mortality between the experimental group and the conventional control group. The total volume of subglottic drainage fluid in the experimental group was significantly higher than that in the control group (50 There was no significant difference in mortality between the two groups; the proportion of Gram-positive bacteria in sputum culture of VAP patients was lower than that of the control group (22.9% vs. 47.6%, P 0.05); multivariate logistic regression analysis showed that balloon pressure monitoring was an independent predictor of VAP in patients with tracheal intubation (OR = 0.45, P = 0.02). CONCLUSIONS: Auto-continuous control of balloon pressure combined with subglottic suction can effectively reduce the amount of subglottic secretion leakage, which can reduce the length of stay in ICU, the duration of mechanical ventilation and the incidence of VAP, but has no significant effect on mortality. Methods: The positive rate of pepsin in upper respiratory tract and lower respiratory tract secretions of the experimental group and the control group were monitored by double antibody sandwich enzyme linked immunosorbent assay (ELISA). The concentration of pepsin in upper respiratory tract and lower respiratory tract secretions and the incidence of aspiration were compared between the control group and the experimental group. The positive rate of pepsin in the lower respiratory tract secretion was significantly lower in the experimental group than in the control group (23.8% vs. 50.0%, P 0.05), and the pepsin concentration in the experimental group was significantly lower than that in the control group (20.1 + 4.2 ng / mL vs. 28.1 + 3.1 ng / mL, P 0.05). The incidence of VAP in patients with positive pepsin secretion was significantly higher than that in patients with negative pepsin secretion (73.5% vs. 10.7%, P 0.05). Multivariate logistic regression analysis showed that balloon pressure monitoring was an independent predictor of aspiration in patients with endotracheal intubation (OR = 1.078, P = 0.012). Conclusion: Patients with mechanical ventilation for endotracheal intubation had a higher incidence of aspiration errors and automatic control. The incidence of aspiration mistake can be effectively reduced by balloon pressure combined with subglottic suction. The occurrence of VAP is significantly related to aspiration mistake. Results: Compared with group 8 and 7.5, the balloon diameter of tracheal intubation increased, the wrinkles increased, the balloon diameter of tracheal intubation increased, and the balloon pressure of tracheal intubation increased. With the increase of the diameter, the secretion leakage increased significantly (P Similar sinusoidal waveform changes; suction, cough balloon pressure will appear instantaneous increase; PEEP settings will lead to increased balloon pressure; the use of balloon pressure waveform can judge the actual effect of balloon airway closure. Conclusion: The clinical need to choose the appropriate diameter of the patient's trachea according to the size of the inner diameter of the tube, the formation of folded channel is leading to the upper part of the balloon. The important reason of secretion leakage is to pay attention to the sufficient drainage of the liquid lake below the level of the upper drainage outlet of the airbag of the tracheal tube; the pressure of the airbag in the patient is affected by the respiratory cycle, PEEP, cough, sputum suction and other factors; the setting of the pressure of the airbag needs to be individualized, which can be combined with the pressure waveform of the airbag to guide the setting of the pressure of the airbag.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R563.1

【相似文献】