声门下吸引方式的安全有效性的实验室研究
发布时间：2018-08-26 19:55
【摘要】：目的:通过动物实验探讨声门下吸引方式的安全性和有效性,寻找声门下吸引最安全有效的吸引负压和间歇吸引时间,为临床应用提供理论依据。方法:采用前瞻性随机对照基础实验研究方法将32只健康大耳白兔随机分组:持续声门下引流组(实验A组)和间歇声门下引流组(实验B组)。实验A组和实验B组根据不同的吸引负压和间歇吸引时间随机分成:A1组:恒定40-60 mmHg负压声门下吸引结合间断声门下冲洗;A2组:恒定60-80mmHg负压声门下吸引结合间断声门下冲洗;B1组:60-80mmHg负压间歇2h声门下吸引结合间断声门下冲洗;B2组:60-80mmHg负压间歇4h声门下吸引结合间断声门下冲洗;B3组:60-80mmHg负压间歇6h声门下吸引结合间断声门下冲洗;B4组:80-100mmHg负压间歇2h声门下吸引结合间断声门下冲洗;B5组:80-100mmHg负压间歇4h声门下吸引结合间断声门下冲洗;B6组:80-100mmHg负压间歇6h声门下吸引结合间断声门下冲洗,实验B组下各组每次吸引时间均为1h。每组动物数4只。效应指标:观察并记录各组机械通气1周内声门下-气囊上滞留物引流量和痰液量;机械通气第4d和实验结束时引流物颜色(有无肉眼可见血性液体),未出现肉眼可见血性液体情况的组别则分别在机械通气第4d和试验结束时留取每组引流物2ml待检,行滞留物隐血实验;机械通气第4d和试验结束时分别处死各组兔子2只,并留取气管粘膜组织制作病理标本,常规HE染色,显微镜下观察气道粘膜组织的形态学改变。所有数据统计均采用SPSS17.0统计软件,计数资料懫用频数、构成比进行描述,懫用X2检验进行定性比较;连续性计量资料符合正态分布的懫用单因素方差分析(One-way ANOVA),以均数±标准差(?x±s)表示,根据方差齐性结果,组间差异比较采用S-N-K(q)检验,P㩳0.05为差异有统计学意义。结果:(1)痰液量:机械通气1周内各组间痰液量差异无统计学意义(p均㧐0.05);(2)声门下-气囊上滞留物引流量:实验A1组、A2组、B4组、B5组和B6组滞留物引流量分别是13.94±1.82、14.02±1.34、13.52±0.61、13.09±1.88和12.98±1.29 ml/d,差异无统计学意义(p=0.601);实验B1组、B2组和B3组滞留物引流量分别是10.89±0.54、10.40±1.39和10.69±1.43 ml/d,差异无统计学意义(p=0.765),但实验A1组、A2组、B4组、B5组、B6组和实验B1组、B2组、B3组之间有显著差异(p均0.05);(3)肉眼可见血性液体情况结果:机械通气第4d,所有实验组别均未出现肉眼可见血性液体情况;直至实验结束时,除实验A2组出现1例肉眼可见血性液体情况,其余各组均未出现肉眼可见血性液体情况。提示A2组随机械通气时间的延长损伤加重,存在气道粘膜出血的风险;(4)滞留物潜血实验阳性情况结果:机械通气第4d,除a2组出现1例阳性,其余各组均为阴性;实验结束时,a2组(2例,67%)b4组(2例,50%)b1组=b2组=b5组(1例,25%)b3组=b6组=a1组(0,0%)。a2组(第4d)与其他各组组间两两比较,双侧检验p=0.429,p0.05,差异无统计学意义;实验结束时:a2组与a1组、b3组和b6组两两比较,p=0.033,p0.05,差异有统计学意义;a2组与b1组、b2组和b5组两两比较,双侧检验p=0.371,p0.05,差异无统计学意义。a2组与b4组两两比较,双侧检验p=0.143,p0.05,差异无统计学意义;(5)气管粘膜组织he染色病理结果:将各组实验动物气管黏膜损伤情况进行分级后并加以对比发现,在各时间段内,各组气道粘膜受损严重程度排列如下:机械通气第4d:a2组(Ⅳ度)b4组(Ⅲ度)b1组(Ⅱ度)b2组=b5组=b6组=a1组(Ⅰ度)b3组(0度)。第7d:a2组(Ⅴ度)b4组(Ⅳ度)b1组(Ⅲ度)b2组=b5组(Ⅱ度)b3组=b6组=a1组(Ⅰ度)。除a1组和b6组外,其余各组均表现为机械通气时间越长,气道黏膜损伤程度越重。结论:目前临床上对于声门下吸引方式的选择没有形成统一的标准,具体实践方案临床差异性较大,本实验通过对各种吸引方式下的吸引效果和吸引的安全性进行对比研究,根据以上研究结果可得到如下结论:1.有效性方面:(1)持续声门下吸引结合间断声门下冲洗,恒定40-60mmhg负压和60-80mmhg负压,吸引效果相似;(2)间歇声门下吸引结合间断声门下冲洗,在同一时间下,吸引负压80-100mmhg下的吸引效果优于吸引负压60-80mmhg下的吸引效果;(3)间歇声门下吸引结合间断声门下冲洗,同一负压下,间歇2h、4h和6h声门下吸引,吸引效果无差别,即不同的间歇吸引时间对吸引效果没有影响;(4)持续声门下不同吸引负压(40-60mmhg、60-80mmhg)的吸引效果优于吸引负压为60-80mmhg的间歇声门下吸引;(5)持续声门下不同吸引负压(40-60mmhg、60-80mmhg)与吸引负压80-100mmhg的间歇声门下吸引比较,吸引效果相似,均能保证最大限度引流。2.安全性方面:(1)持续声门下吸引结合间断声门下冲洗,恒定40-60mmhg负压和60-80mmhg负压吸引,各组出现肉眼可见血性液体和滞留物潜血实验阳性情况相似,但显微镜下观察各组实验家兔气道粘膜组织形态学改变,持续声门下吸引选择的压力值与损伤呈正相关。即60-80mmhg负压持续吸引损伤严重,40-60mmhg负压持续吸引损伤程度轻,家兔耐受情况较好;(2)间歇声门下吸引结合间断声门下冲洗,在同一负压下,间歇2h、4h、6h声门下吸引,出现肉眼可见血性液体和滞留物潜血实验阳性情况相似,但间歇6h声门下吸引一次,对气道粘膜的损伤程度最轻;且整个实验过程中,气道粘膜损伤程度没有随着机械通气时间的延长加重。提示:间断声门下吸引在压力相同情况下,时间与气管损伤呈负相关,间断时间越长,气道损伤越小;(3)间歇声门下吸引结合间断声门下冲洗,在同一时间下,如果间歇时间短(2h),压力与损伤成正比,若间歇时间长(4h或6h),压力的大小与气道损伤无关联;(4)恒定40-60mmHg负压持续声门下吸引和吸引负压80-100mmHg,间歇6h声门下吸引一次相比,两组出现肉眼可见血性液体和滞留物潜血实验阳性情况的结果无差别,且对气道粘膜组织的损伤情况相似,损伤程度均最轻。综上所述,短时间内(1周内),持续声门下吸引在研究采用的负压范围内,其负压大小不影响吸引效果;但负压为40-60mmHg时对气道损伤最小,建议临床使用。间歇声门下吸引,在负压相同的情况下,间歇时间与吸引效果无关联,其中间歇6h声门下吸引一次,对气道粘膜的损伤程度最轻;在时间相同的情况下,压力越大效果越好,间歇时间大于4h时,其吸引负压值对气道损伤无影响。因此,间歇6h,在负压80-100mmHg下行声门下吸引既能保证患者的安全,又能保证吸引达到最大化,值得推荐。在相同压力下,持续吸引与间断吸引相比较,虽然持续吸引的效果好于间断吸引,但对气道的损伤更严重,所以,在今后的临床应用中,治疗条件允许的情况下,建议采用间断声门下吸引。
[Abstract]:Objective: To explore the safety and effectiveness of subglottic suction in rabbits, and to find the most safe and effective suction negative pressure and intermittent suction time for subglottic suction, so as to provide theoretical basis for clinical application. Group A and group B were randomly divided into two groups according to different suction negative pressure and intermittent suction time: group A1: constant 40-60 mmHg subglottic suction combined with intermittent subglottic flushing; group A2: constant 60-80 mmHg subglottic suction combined with intermittent subglottic flushing; group B1: 60-80 mmHg subglottic suction combined with intermittent subglottic flushing. Subglottic suction with intermittent subglottic flushing at 2 h interval of negative pressure; subglottic suction with intermittent subglottic flushing at 60-80 mmHg interval of negative pressure for 4 h in group B2; subglottic suction with intermittent subglottic flushing at 60-80 mmHg interval of negative pressure for 6 h in group B3; subglottic suction with intermittent subglottic flushing at 80-100 mmHg interval of negative pressure for 2 h in group B4; subglottic suction with intermittent subglottic flushing at 80-100 mmHg interval of negative pressure for 4 h in group B5 Subglottic suction with intermittent subglottic flushing for 4 hours; subglottic suction with intermittent subglottic flushing for 6 hours in group B6; subglottic suction with intermittent subglottic flushing for 6 hours in group B; each suction time was 1 hour in group B. The number of animals in each group was 4. On the 4th day of ventilation and at the end of the experiment, the color of the drainage (with or without blood visible to the naked eye) and the 2 ml of the drainage in each group were retained at the 4th day of mechanical ventilation and at the end of the experiment, respectively, for occult blood test; on the 4th day of Mechanical ventilation and at the end of the experiment, 2 rabbits in each group were sacrificed and retained. Histopathological specimens of tracheal mucosa were made and stained with routine HE. Morphological changes of airway mucosa were observed under microscope. All data were analyzed by SPSS17.0 statistical software. The counting data were described by frequency and composition ratio, and were not qualitatively compared by X2 test. Results: (1) Sputum volume: There was no significant difference in sputum volume between groups within 1 week of mechanical ventilation (all P? 0.05); (2) Subglottic-supracapsular retention drainage volume: Experimental A1 group Retention drainage in group A2, group B4, group B5, and group B6 were 13.94 (+ 1.82), 14.02 (+ 1.34), 13.52 (+ 0.61), 13.09 (+ 1.88) and 12.98 (+ 1.29) ml/d, respectively, with no significant difference (p = 0.601); in group B1, group B2 and group B3, retention drainage was 10.89 (+ 0.54), 10.40 (+ 1.39) and 10.69 (+ 1.43 ml/d), respectively (p = 0.765). There was a significant difference between group B 4, group B 5, group B 6, group B 1, group B 2, and group B 3 (all P 0.05); (3) Visible blood fluids to the naked eye: on the 4th day of mechanical ventilation, no visible blood fluids to the naked eye were found in all the experimental groups; until the end of the experiment, except one visible blood fluids to the naked eye in group A2, all the other groups did not appear. The results showed that the prolonged mechanical ventilation time in group A2 was worse and there was a risk of airway mucosal bleeding. (4) Positive results of occult blood test in group A2 were negative on the 4th day of mechanical ventilation except one case in group a2. At the end of the experiment, group A2 (2 cases, 67%) in group B4 (2 cases, 50%) in group B1 = group B5 (1). There was no significant difference between group A2 and other groups (p = 0.429, P 0.05). at the end of the experiment: group A2 was compared with group a1, group B3 and group b6, P = 0.033, P 0.05, the difference was statistically significant; group A2 was compared with group b1, group B2 and group b5, the difference was not significant (p = 0.371, P 0.05). There was no significant difference between A2 group and B4 group (p = 0.143, P 0.05). (5) pathological results of HE staining of tracheal mucosa: the severity of tracheal mucosa injury in each group was classified and compared. the severity of each group was arranged as follows: mechanical ventilation. 4th day: group A2 (Grade IV) group B4 (Grade III) group B1 (Grade II) group B2 = group B5 = group B6 = group A1 (Grade I) group B3 (Grade 0). 7th day: group A2 (Grade V) group B4 (Grade IV) group B2 (Grade IV) group B2 = group B5 (Grade II) group B3 = group B6 = group A1 (Grade I). Except group A1 and group b6, the longer the mechanical ventilation time, the more severe the airway mucosal damage. There is no uniform standard for the selection of subglottic suction, and there is a great difference in the clinical practice. Through the comparative study of the suction effect and the safety of subglottic suction under various suction methods, the following conclusions can be drawn from the above results: 1. Effectiveness: (1) Continuous subglottic suction combination Intermittent subglottic suction combined with intermittent subglottic flushing at the same time, the suction effect under the suction pressure of 80-100 mmHg is better than that under the suction pressure of 60-80 mmhg. (3) Intermittent subglottic suction combined with intermittent subglottic flushing under the same negative pressure. There was no difference in attraction effect between intermittent subglottic suction for 2, 4 and 6 hours, that is, different intermittent suction time had no effect on the attraction effect; (4) the suction effect of different suction negative pressure under continuous glottis (40-60 mmhg, 60-80 mmhg) was better than that under intermittent subglottic suction with negative pressure of 60-80 mmhg; (5) different suction negative pressure under continuous glottis (40-60 mmhg, 60-80 mmhg). Compared with the intermittent subglottic suction with negative pressure of 80-100 mmhg, the suction effect was similar, and the maximum drainage was guaranteed. 2. Safety aspects: (1) Continuous subglottic suction combined with intermittent subglottic flushing, constant 40-60 mmHg negative pressure and 60-80 mmHg negative pressure suction, all groups showed positive results of occult blood test with visible blood fluids and retained substances. Similarly, the morphological changes of airway mucosa were observed under microscope, and the pressure of continuous subglottic suction was positively correlated with the injury. Under the same negative pressure, intermittent subglottic suction for 2 hours, 4 hours and 6 hours showed similar positive results for visible blood fluids and occult blood retained by naked eyes, but subglottic suction for 6 hours had the least damage to the airway mucosa, and the degree of airway mucosa damage did not increase with the prolongation of mechanical ventilation. Intermittent subglottic suction under the same pressure, time and tracheal injury was negatively correlated, the longer the intermittence time, the smaller the airway injury; (3) Intermittent subglottic suction combined with intermittent subglottic flushing, at the same time, if the intermittence time is short (2h), pressure and injury is proportional, if the intermittence time is long (4h or 6h), the size of pressure and airway injury. There was no correlation between the two groups. (4) There was no difference in the results of occult blood test between the two groups, and the damage to airway mucosa was similar and the degree of injury was the least. Within one week, continuous subglottic suction was used within the range of the negative pressure used in the study, and the negative pressure did not affect the suction effect; however, when the negative pressure was 40-60 mmHg, the damage to the airway was the smallest. Intermittent subglottic suction was recommended for clinical use. In the same time, the greater the pressure is, the better the effect is. When the interval time is longer than 4 hours, the negative pressure of aspiration has no effect on the airway damage. In comparison with intermittent suction, continuous suction is more effective than intermittent suction, but the damage to airway is more serious. Therefore, intermittent subglottic suction is recommended in the future clinical application when the treatment conditions permit.
【学位授予单位】：长江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7
本文编号：2205992
[Abstract]:Objective: To explore the safety and effectiveness of subglottic suction in rabbits, and to find the most safe and effective suction negative pressure and intermittent suction time for subglottic suction, so as to provide theoretical basis for clinical application. Group A and group B were randomly divided into two groups according to different suction negative pressure and intermittent suction time: group A1: constant 40-60 mmHg subglottic suction combined with intermittent subglottic flushing; group A2: constant 60-80 mmHg subglottic suction combined with intermittent subglottic flushing; group B1: 60-80 mmHg subglottic suction combined with intermittent subglottic flushing. Subglottic suction with intermittent subglottic flushing at 2 h interval of negative pressure; subglottic suction with intermittent subglottic flushing at 60-80 mmHg interval of negative pressure for 4 h in group B2; subglottic suction with intermittent subglottic flushing at 60-80 mmHg interval of negative pressure for 6 h in group B3; subglottic suction with intermittent subglottic flushing at 80-100 mmHg interval of negative pressure for 2 h in group B4; subglottic suction with intermittent subglottic flushing at 80-100 mmHg interval of negative pressure for 4 h in group B5 Subglottic suction with intermittent subglottic flushing for 4 hours; subglottic suction with intermittent subglottic flushing for 6 hours in group B6; subglottic suction with intermittent subglottic flushing for 6 hours in group B; each suction time was 1 hour in group B. The number of animals in each group was 4. On the 4th day of ventilation and at the end of the experiment, the color of the drainage (with or without blood visible to the naked eye) and the 2 ml of the drainage in each group were retained at the 4th day of mechanical ventilation and at the end of the experiment, respectively, for occult blood test; on the 4th day of Mechanical ventilation and at the end of the experiment, 2 rabbits in each group were sacrificed and retained. Histopathological specimens of tracheal mucosa were made and stained with routine HE. Morphological changes of airway mucosa were observed under microscope. All data were analyzed by SPSS17.0 statistical software. The counting data were described by frequency and composition ratio, and were not qualitatively compared by X2 test. Results: (1) Sputum volume: There was no significant difference in sputum volume between groups within 1 week of mechanical ventilation (all P? 0.05); (2) Subglottic-supracapsular retention drainage volume: Experimental A1 group Retention drainage in group A2, group B4, group B5, and group B6 were 13.94 (+ 1.82), 14.02 (+ 1.34), 13.52 (+ 0.61), 13.09 (+ 1.88) and 12.98 (+ 1.29) ml/d, respectively, with no significant difference (p = 0.601); in group B1, group B2 and group B3, retention drainage was 10.89 (+ 0.54), 10.40 (+ 1.39) and 10.69 (+ 1.43 ml/d), respectively (p = 0.765). There was a significant difference between group B 4, group B 5, group B 6, group B 1, group B 2, and group B 3 (all P 0.05); (3) Visible blood fluids to the naked eye: on the 4th day of mechanical ventilation, no visible blood fluids to the naked eye were found in all the experimental groups; until the end of the experiment, except one visible blood fluids to the naked eye in group A2, all the other groups did not appear. The results showed that the prolonged mechanical ventilation time in group A2 was worse and there was a risk of airway mucosal bleeding. (4) Positive results of occult blood test in group A2 were negative on the 4th day of mechanical ventilation except one case in group a2. At the end of the experiment, group A2 (2 cases, 67%) in group B4 (2 cases, 50%) in group B1 = group B5 (1). There was no significant difference between group A2 and other groups (p = 0.429, P 0.05). at the end of the experiment: group A2 was compared with group a1, group B3 and group b6, P = 0.033, P 0.05, the difference was statistically significant; group A2 was compared with group b1, group B2 and group b5, the difference was not significant (p = 0.371, P 0.05). There was no significant difference between A2 group and B4 group (p = 0.143, P 0.05). (5) pathological results of HE staining of tracheal mucosa: the severity of tracheal mucosa injury in each group was classified and compared. the severity of each group was arranged as follows: mechanical ventilation. 4th day: group A2 (Grade IV) group B4 (Grade III) group B1 (Grade II) group B2 = group B5 = group B6 = group A1 (Grade I) group B3 (Grade 0). 7th day: group A2 (Grade V) group B4 (Grade IV) group B2 (Grade IV) group B2 = group B5 (Grade II) group B3 = group B6 = group A1 (Grade I). Except group A1 and group b6, the longer the mechanical ventilation time, the more severe the airway mucosal damage. There is no uniform standard for the selection of subglottic suction, and there is a great difference in the clinical practice. Through the comparative study of the suction effect and the safety of subglottic suction under various suction methods, the following conclusions can be drawn from the above results: 1. Effectiveness: (1) Continuous subglottic suction combination Intermittent subglottic suction combined with intermittent subglottic flushing at the same time, the suction effect under the suction pressure of 80-100 mmHg is better than that under the suction pressure of 60-80 mmhg. (3) Intermittent subglottic suction combined with intermittent subglottic flushing under the same negative pressure. There was no difference in attraction effect between intermittent subglottic suction for 2, 4 and 6 hours, that is, different intermittent suction time had no effect on the attraction effect; (4) the suction effect of different suction negative pressure under continuous glottis (40-60 mmhg, 60-80 mmhg) was better than that under intermittent subglottic suction with negative pressure of 60-80 mmhg; (5) different suction negative pressure under continuous glottis (40-60 mmhg, 60-80 mmhg). Compared with the intermittent subglottic suction with negative pressure of 80-100 mmhg, the suction effect was similar, and the maximum drainage was guaranteed. 2. Safety aspects: (1) Continuous subglottic suction combined with intermittent subglottic flushing, constant 40-60 mmHg negative pressure and 60-80 mmHg negative pressure suction, all groups showed positive results of occult blood test with visible blood fluids and retained substances. Similarly, the morphological changes of airway mucosa were observed under microscope, and the pressure of continuous subglottic suction was positively correlated with the injury. Under the same negative pressure, intermittent subglottic suction for 2 hours, 4 hours and 6 hours showed similar positive results for visible blood fluids and occult blood retained by naked eyes, but subglottic suction for 6 hours had the least damage to the airway mucosa, and the degree of airway mucosa damage did not increase with the prolongation of mechanical ventilation. Intermittent subglottic suction under the same pressure, time and tracheal injury was negatively correlated, the longer the intermittence time, the smaller the airway injury; (3) Intermittent subglottic suction combined with intermittent subglottic flushing, at the same time, if the intermittence time is short (2h), pressure and injury is proportional, if the intermittence time is long (4h or 6h), the size of pressure and airway injury. There was no correlation between the two groups. (4) There was no difference in the results of occult blood test between the two groups, and the damage to airway mucosa was similar and the degree of injury was the least. Within one week, continuous subglottic suction was used within the range of the negative pressure used in the study, and the negative pressure did not affect the suction effect; however, when the negative pressure was 40-60 mmHg, the damage to the airway was the smallest. Intermittent subglottic suction was recommended for clinical use. In the same time, the greater the pressure is, the better the effect is. When the interval time is longer than 4 hours, the negative pressure of aspiration has no effect on the airway damage. In comparison with intermittent suction, continuous suction is more effective than intermittent suction, but the damage to airway is more serious. Therefore, intermittent subglottic suction is recommended in the future clinical application when the treatment conditions permit.
【学位授予单位】：长江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7
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