急性Stanford A型主动脉夹层术后膈肌功能障碍的临床研究  

Clinical Study of Diaphragmatic Dysfunction After Surgical Treatment of Acute Stanford Type A Aortic Dissection

作　　者：李静[1] 沈骁 孙加奎[1] 孙芳[1] 薛寅莹 章文豪[1] 章淬[1] LI Jing;SHEN Xiao;SUN Jiakui;SUN Fang;XUE Yinying;ZHANG Wenhao;ZHANG Cui(Department of Intensive Care Unit,Nanjing First Hospital,Nanjing Medical University,Nanjing 210006,Jiangsu,China)

机构地区：[1]南京医科大学附属南京医院(南京市第一医院)重症医学科,江苏南京210006

出　　处：《心血管病学进展》2022年第7期657-661,共5页Advances in Cardiovascular Diseases

基　　金：南京市科技发展计划项目(201611002)。

摘　　要：目的明确急性Stanford A型主动脉夹层(ATAAD)术后合并心功能不全的患者中膈肌功能障碍的发生情况及其对呼吸机撤机的影响。方法采用前瞻性研究,入选2019年1月—2021年9月入住南京医科大学附属南京医院行孙氏手术且合并心功能不全(左室射血分数<55%)的ATAAD患者43例,术后应用床旁超声测定膈肌增厚率(DTF)及膈肌移动度,根据DTF分为膈肌功能正常组及障碍组,观察对比两组患者基线资料、手术相关指标及机械通气相关临床预后等指标。结果纳入研究的ATAAD患者中膈肌功能障碍(DTF<20%)29例,发生率为67.4%(29/43)。与正常组相比,障碍组平均DTF明显小于正常组(P<0.001),平静呼气末移动度及最大呼气末移动度均小于正常组(P<0.001)。两组患者术后左室射血分数及正性肌力药物的应用情况均无统计学差异。与膈肌功能正常组相比,障碍组主动脉阻断时间(P=0.001)及体外循环时间(P=0.002)更长,而两组之间的手术时间无明显差异,膈肌功能障碍组的机械通气时间较正常组延长(P<0.001),且住ICU时间也明显延长(P=0.011)。拔管后无创辅助通气的比例、再次气管插管的比例及行气管切开术的比例,两组之间均无统计学差异。结论膈肌功能障碍在ATAAD术后合并左心功能不全的患者中发生普遍,且与机械通气时间、住ICU时间相关,以超声评价其膈肌功能简便可行,并对术后撤机具有预测及指导价值。Objective To investigate the occurrence of diaphragmatic dysfunction in patients with cardiac insufficiency after acute Stanford type A aortic dissection(ATAAD)and its impact on ventilator weaning.Methods In this prospective study,43 ATAAD patients with cardiac insufficiency(left ventricular ejection fraction<55%)who were admitted to Nanjing First Hospital from January 2019 to September 2021 underwent Sun’s surgery were enrolled.Diaphragmatic thickening fraction(DTF)and diaphragmatic mobility were measured by bedside ultrasound.According to DTF,the patients were divided into normal diaphragmatic function group and diaphragmatic dysfunction group.The baseline data,surgical indicators and clinical prognostic indicators related to mechanical ventilation were observed and compared between the two groups.Results A total of 43 ATAAD patients were included in the study,including 29 patients with diaphragmatic dysfunction(DTF<20%),the incidence was 67.4%(29/43).Compared with normal diaphragm function group,the mean DTF of diaphragmatic dysfunction group was significantly lower than normal group(P<0.001),and calm end-expiratory mobility and the maximum end-expiratory mobility were both significantly lower than normal group(P<0.001).There was no statistical difference in the left ventricular ejection fraction and the application of positive inotropic drugs between the two groups.Compared with normal diaphragm function group,the time to aorta occlusion(P=0.001)and the time to cardiopulmonary bypass(P=0.002)were longer,but there was no significant difference in the operation time between the two groups.The duration of mechanical ventilation was longer in the diaphragmatic dysfunction group than in the normal group(P<0.001).The ICU length of stay in the diaphragmatic dysfunction group was also longer than that in normal diaphragm function group(P=0.011).There was no statistical difference between the two groups in the proportion of non-invasive ventilation,reintubation and tracheotomy after extubation.Conclusion Diaphragmat

关 键 词：膈肌 急性Stanford A型主动脉夹层 超声 

分 类 号：R654.2[医药卫生—外科学]