不同机械通气模式治疗重度肺爆震伤致顽固性低氧血症的效果  

Effect of different mechanical ventilation in the treatment of refractory hypoxemia following severe lung explosive injuries

作　　者：卢国妹 易云峰 陈检明 钟京 陈松林 Lu Guomei;Yi Yunfeng;Chen Jianming;Zhong Jing;Chen Songlin(Department of Cardiothoracic Surgery,909th Hospital of Joint Logistics Support Force(Affiliated Dongnan Hospital of Xiamen University Medical College),Cardiothoracic Surgery Medical Center of Eastern War Zone,Zhangzhou,Fujian363000,China)

机构地区：[1]联勤保障部队第九○九医院(厦门大学医学院附属东南医院)心胸外科,东部战区心胸外科医学中心,福建漳州363000

出　　处：《创伤外科杂志》2023年第4期280-286,共7页Journal of Traumatic Surgery

基　　金：军队后勤科研项目(CNJ14C007 CWH17J030)。

摘　　要：目的评估不同机械通气模式治疗重度肺爆震伤致顽固性低氧血症的效果,为重度肺爆震伤的救治提供科学依据。方法回顾性分析2010年8月—2018年7月联勤保障部队第九〇九医院心胸外科符合纳入标准的36例重度肺爆震伤致顽固性低氧血症患者,男性24例,女性12例;年龄15~65岁,平均36.5岁;致伤原因:锅炉爆震伤9例,化工厂爆震伤8例,粉尘爆震伤1例,煤气罐爆震伤15例,地下矿井瓦斯爆震伤2例,炮弹爆震伤1例。按机械通气模式分为辅助/控制模式组(A/C通气模式组)20例、辅助/控制并逐渐改为间歇辅助通气(SIMV)和压力支持通气(PSV)模式组(A/C→SIMV→PSV通气模式组)16例。分析对比两组患者的肺动脉压(PAP)、肺动脉楔压(PAWP)、心输出量(CO)、心脏指数(CI)、外周循环阻力(SVR)、肺循环阻力(PVR)、动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2))、动脉血pH值(pH)、混合静脉血氧分压(PvO_(2))、混合静脉血二氧化碳分压(PvCO_(2))、氧供给(DO_(2))、氧消耗(VO_(2))、氧摄取率(O_(2)ER)、氧合指数(PaO_(2)/FiO_(2))、肺静态顺应性(Cst)、气道峰值压(PIP)和相关并发症发生情况。结果A/C通气模式组呼气末正压通气(PEEP)在5~10cmH_(2)O范围内,PaO_(2)、PaO_(2)/FiO_(2)、DO_(2)和Cst随着PEEP的增高而逐渐增加(P<0.05)。PEEP增加到15cmH_(2)O时CO和Cst下降,SVR、PVR和PIP增加(P<0.05)。A/C→SIMV→PSV通气模式组SIMV与A/C模式组相比可增加DO_(2)(P<0.05),PSV与A/C相比可降低PIP并使Cst增加(P<0.05)。SIMV和PSV方式均可降低SVR。两组相关并发症发生率比较差异无统计学意义(P>0.05)。结论重度肺爆震伤致顽固性低氧血症患者早期采用A/C模式通气治疗,PaO_(2)稳定后改为SIMV或PSV模式,可提高机体氧合,减少对呼吸、血流动力学的影响。Objective To explore the clinical value of different mechanical ventilation in the treatment of refractory hypoxemia following severe lung explosive injuries and to provide scientific basis for its future manage-ment.Methods Retrospective analysis was performed on the clinical data of 36 patients with refractory hypoxemia caused by severe lung explosive injuries,who were admitted to the 909th Hospital of Joint Logistic Support of PLA from Aug.2010 to Jul.2018.There were 24 males and 12 females aged 15-65 years,mean 36.5 years,including 9 boiler blast injuries,8 chemical blast injuries,1 dust explosion blasting,15 gas tank blast injuries,2 underground mine blast injuries and 1 shell blast injury.Twenty patients were treated with assist control(A/C)ventilation(A/C ventilation group);the other 16 patients were treated with initial A/C ventilation and gradual change to intermittent assisted ventilation(SIMV)and pressure support ventilation(PSV)(A/C→SIMV→PSV group).Analysis and comparison was conducted on the changes of pulmonary artery pressure(PAP),pulmonary artery wedge pressure(PAWP),cardiac output(CO),cardiac index(CI),peripheral circulation resistance(SVR),pulmonary vascular resistance(PVR),partial pressure of oxygen in artery(PaO_(2)),partial pressure of carbon dioxide in artery(PaCO_(2)),hydrogen ion concentration in artery(pH),partial pressure of oxygen in mixed venous blood(PvO_(2)),partial pressure of carbon dioxide in mixed venous blood(PvCO_(2)),oxygen delivery(DO_(2)),global oxygen consump-tion(VO_(2)),oxygen extraction ratio(O_(2)ER),arterial oxygen tension/inspired oxygen fraction(PaO_(2)/FiO_(2)),static lung compliance(Cst),peak airway pressure(PIP)and related complications.Results In the A/C ventilation group,when the positive end expiratory pressure(PEEP)was between 5-10 cmH_(2)O,the PaO_(2),PaO_(2)/FiO_(2),DO_(2)and Cst increased with the rise of PEEP(all P<0.05).When PEEP increased to 15 cmH_(2)O,CO and Cst decreased while SVR,PVR and PIP increased(all P<0.05).In the A/C→SIMV→PSV group,SIM

关 键 词：爆震伤 肺损伤 顽固性低氧血症 

分 类 号：R642[医药卫生—外科学]