呼吸力学导向的镇静策略对慢性阻塞性肺疾病机械通气患者膈肌功能的影响  

Effect of respiratory mechanics-guided sedation strategy on diaphragm function in mechanical ventilated patients with chronic obstructive pulmonary disease

作　　者：刘贞[1] 孟素秋[2] 吴杨 梁茂玲 时启标[3] 杨圣强[2] Liu Zhen;Meng Suqiu;Wu Yang;Liang Maoling;Shi Qibiao;Yang Shengqiang(Department of Pulmonary Medicine,Huxi Hospital Affiliated to Jining Medical College(Shanxian Central Hospital),Heze 274300,Shandong,China;Department of Intensive Care Unit,Huxi Hospital Affiliated to Jining Medical College(Shanxian Central Hospital),Heze 274300,Shandong,China;Department of Emergency,Huxi Hospital Affiliated to Jining Medical College(Shanxian Central Hospital),Heze 274300,Shandong,China)

机构地区：[1]济宁医学院附属湖西医院(单县中心医院)呼吸科,山东菏泽274300 [2]济宁医学院附属湖西医院(单县中心医院)重症医学科,山东菏泽274300 [3]济宁医学院附属湖西医院(单县中心医院)急诊科,山东菏泽274300

出　　处：《中华危重病急救医学》2022年第7期699-703,共5页Chinese Critical Care Medicine

基　　金：山东省医药卫生科技发展计划项目(202017010398)。

摘　　要：目的探讨呼吸力学导向的镇静策略对慢性阻塞性肺疾病(COPD)机械通气(MV)患者膈肌功能的影响。方法采用前瞻性研究方法, 选择2020年5月至2021年5月济宁医学院附属湖西医院收治的行有创MV治疗的慢性阻塞性肺疾病急性加重(AECOPD)患者为研究对象。按照随机数字表法将入选患者分为观察组和对照组。所有患者均经口气管插管行MV, 并给予支气管扩张药物、糖皮质激素、抗感染、祛痰、营养支持、镇痛镇静等治疗;两组镇静药物均为右美托咪定联合丙泊酚, 镇痛药物均为舒芬太尼。观察组每6 h行呼吸力学监测, 根据患者呼吸力学状态调整镇静深度:气道阻力(Raw)>20 cmH_(2)O·L^(-1)·s^(-1)时, 给予深镇静, 维持Richmond躁动-镇静评分(RASS)≤-3分;Raw为10~20 cmH_(2)O·L^(-1)·s^(-1)时, 初始镇静深度维持RASS评分-2~0分;Raw<10 cmH_(2)O·L^(-1)·s^(-1)时, 停止镇静, 或给予浅镇静, 维持RASS评分-2~0分。对照组初始即给予浅镇静, 维持RASS评分-2~0分。两组均于镇静过程中调整镇静深度, 以维持人机同步, 保证患者安全。床旁超声测量患者膈肌移动度(DE), 同时记录潮气量(VT)、呼吸频率(RR), 计算膈肌浅快呼吸指数(D-RSBI, D-RSBI=RR/DE)和膈肌运动效能(DEE, DEE=VT/DE)。比较两组患者治疗前及治疗3 d、5 d时DE、D-RSBI、DEE的差异;比较两组镇静3 d内RASS评分的差异;比较两组MV时间及28 d病死率的差异。结果共入选96例患者, 因谵妄、MV时间<3 d等原因剔除6例, 最终入组90例, 观察组46例, 对照组44例。治疗前两组DE、D-RSBI、DEE差异均无统计学意义;治疗后两组D-RSBI均随时间延长逐渐降低, DEE则均随时间延长逐渐升高, 且观察组3 d、5 d D-RSBI均显著低于对照组(次·min^(-1)·mm^(-1):3 d为1.73±0.48比1.96±0.35, 5 d为1.45±0.64比1.72±0.40, 均P<0.05), DEE则均显著高于对照组(mL/mm:3 d为19.7±4.3比17.1±3.9, 5 d为25.8±5.6比22.9±5.4, 均P<0.05);两组Objective To investigate the effects of respiratory mechanics-guided sedation strategy on diaphragm function in chronic obstructive pulmonary disease(COPD)patients treated with mechanical ventilation(MV).Methods A prospective study was conducted.Patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD)received invasive MV who were admitted to the Affiliated Huxi Hospital of Jining Medical University from May 2020 to May 2021 were enrolled.The patients were divided into observational group and control group by random number table method.All patients were intubated for MV,and received bronchodilators,glucocorticoid,anti-infectives,expectorant,nutritional support,analgesia and sedation.The sedatives were dexmedetomidine combined with propofol,and the analgesics were sufentanil in both groups.Respiratory mechanics monitoring was performed every 6 hours in the observational group,and the depth of sedation was adjusted according to the parameters of respiratory mechanics:when airway resistance(Raw)>20 cmH_(2)O·L^(-1)·s^(-1),deep sedation was given to maintain Richmond agitation-sedation scale(RASS)≤-3;when the Raw was 10-20 cmH_(2)O·L^(-1)·s^(-1),the initial depth of sedation maintained to reach the RASS score of-2-0;when Raw<10 cmH_(2)O·L^(-1)·s^(-1),withdrawn the sedation,or given light sedation,and maintained the RASS score of-2-0.While the control group received light sedation.The patients'diaphragmatic excursions(DE)was measured by bedside ultrasound,tidal volume(VT)and respiratory rate(RR)were recorded,and the diaphragmatic rapid shallow breathing index(D-RSBI,D-RSBI=RR/DE)and diaphragmatic excursion efficiency(DEE,DEE=VT/DE)were calculated.The differences in DE,D-RSBI,and DEE before and 3 days and 5 days of treatment between the two groups were compared.The difference in the RASS score within 3 days of sedation between the two groups was compared.The differences in the duration of MV and 28-day mortality between the two groups were compared.Results A total of 96 patients were sele

关 键 词：慢性阻塞性肺疾病 机械通气 膈肌功能障碍 镇静 呼吸力学 

分 类 号：R563.9[医药卫生—呼吸系统]