危重型新型冠状病毒肺炎采用体外膜肺氧合支持下的机械通气策略探讨:附1例分析  

Strategic approach on mechanical ventilation under application of extracorporeal membrane oxygenation support for treatment of one patient with critical coronavirus disease 2019

作　　者：支永乐[1] 胡晓旻[2] 李建国[3] 吴鹏[2] 稂与恒[2] 王志勇[1] 徐磊[1] Zhi Yongle;Hu Xiaomin;Li Jianguo;Wu Peng;Lang Yuheng;Wang Zhiyong;Xu Lei(Department of Intensive Care Unit,Tianjin Third Central Hospital,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases,Tianjin Arificial Cell Engineering Technology Research Center,Tianjin Institute of Hepatobiliary Disease,Tianjin 300170,China;Department of Cardiac Surgery,Tianjin Third Central Hoaspital,Tianjin 300170,China;Depurtment of Respiratory and Critical Care Medicine,Haihe Hospial,Tianjin 300350,China)

机构地区：[1]天津市第三中心医院重症医学科,天津市重症疾病体外生命支持重点实验室,天津市人工细胞工程技术研究中心,天津市肝胆疾病研究所,天津300170 [2]天津市第三中心医院心外科,天津300170 [3]天津市海河医院呼吸与危重病医学科,天津300350

出　　处：《中国中西医结合急救杂志》2020年第5期528-531,共4页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：天津市科技计划项目(18ZXDBSY00100);天津市卫生健康科技项目(2O2OXKZO3)。

摘　　要：目的 探讨体外膜肺氧合(ECMO)支持下治疗危重型新型冠状病毒肺炎(简称新冠肺炎)的机械通气策略.方法 天津市新冠肺炎定点医院截至2020年3月23日对收治的2例机械通气失败危重型新冠肺炎患者实施静脉-静脉(VV)-ECMO支持,后成功撤除ECMO.笔者作为支援天津市新冠肺炎定点医院医疗队成员时参与了此2例患者的救治,现总结其中1例的救治经过,分享经验教训.结果 患者男性,53岁,于入院前1d出现发热、干咳,胸部CT显示右肺上叶斑片状高密度影;咽拭子新型冠状病毒(2019-nCoV)核酸检测呈阳性,确诊为新冠肺炎.患者于入院后第7天氧合指数下降,转为危重型,给予紧急经口气管插管接呼吸机辅助呼吸,胸部影像学检查显示双肺斑片状实变影,氧合指数<60mmHg(1mmHg≈0.133kPa)持续5h,立即行VV-ECMO支持,同时行连续性静脉-静脉血液滤过(CVVH)调整容量.ECMO支持期间采用肺休息策略,根据影像学变化及血气分析结果调整参数.经治疗患者病情改善,ECMO支持11d后成功撤除.结论 危重型新冠肺炎患者的机械通气策略应充分考虑保护性通气,避免进一步肺损伤.Objeetive To discuss the strategy of mecbanical ventilation under extracorporeal membrane oxygenation(ECMO)in trealment of critical coronavirus disease 2019(COVID-19).Methods Two patients with critical COVID-19 were admitted into a COVID-19 designated hospital in Tianjin,and they had failed twice in treatment of mechanical ventilation until March 23,2020,venous-venous extracorporeal membrane oxygenation(V V-ECMO)support was implemented,and afterwards ECMO was succssfully evacuated.As a member of medical team of Tianjin C0VID-19 designated hospital,the author paricipated in the treatment of these two patients.The rescue and treatment process in one of them was summarized,and the lessons and experiences we had obtained could be shared.Results A patient male 53 year old complained that he had fever and dry cough one day before admission,chest CT showed high density patchy shadow in the upper lobe of the right lung;novel coronavirus(2019-nCoV)nucleic acid was detected by swab showing test result positive,then the diagnosis of COVID-19 was confirmed.On day 7 after admission,the patient's oxygenation index decreased and turned to severe type.The patient was given emergency endotracheal intubation via mouth to receive ventilator assisted respiration.Chest X ray showed patchy consolidation shadows in both lungs and oxygenation index was<60 mmHg(1 mmHg≈0.133 kPa)for 5 hours.The patient was immediately supported by V V-ECMO,and the volume was adjusted by continuous venous-venous hemofiltration(CVVH).During ECMO,the lung rest strategy was adopted,and the parameters were adjusted accoding 1o the imaging changes and blood gas analysis results.After treatment,the patient's condition was improved anc the ECMO support was removed successfully after using it for 11 days.Conclusion The mechanical ventilation strategy in treatment of critical COVID-19 patients should take full consideration of protective ventilation lo avoid further lung injury.

关 键 词：新型冠状病毒肺炎 危重型 体外膜肺氧合 机械通气 

分 类 号：R47[医药卫生—护理学]