多学科诊疗模式对儿童长期机械通气过渡为家庭机械通气的质量改进研究  

The transition from pediatric prolonged mechanical ventilation to home mechanical ventilation by a multidisciplinary approach:A quality improvement study

作　　者：杜俐佳 秦妍 杜岩 柳宇鑫 刘盼 陶金好 陈超[2] 王素娟 高萱[4] 陆国平 张铮铮 陈伟明 DU Lijia;QIN Yan;DU Yan;LIU Yuxin;LIU Pan;TAO Jinhao;CHEN Chao;WANG Sujuan;GAO Xuan;LU Guoping;ZHANG Zhengzheng;CHEN Weiming(Children's Hospital of Fudan University Department of Critical Care Medicine,Shanghai 201102,China;Children's Hospital of Fudan University Department of Otorhinolaryngology,Shanghai 201102,China;Children's Hospital of Fudan University Department of Rehabilitation,Shanghai 201102,China;Children's Hospital of Fudan University Department of Nutrition,Shanghai 201102,China)

机构地区：[1]复旦大学附属儿科医院重症医学科,上海201102 [2]复旦大学附属儿科医院耳鼻喉科,上海201102 [3]复旦大学附属儿科医院康复科,上海201102 [4]复旦大学附属儿科医院营养科,上海201102

出　　处：《中国循证儿科杂志》2023年第2期91-95,共5页Chinese Journal of Evidence Based Pediatrics

基　　金：国家重点研发计划:2021YFC2701800,2021YFC2701805;上海申康医院发展中心促进市级医院临床技能与临床创新能力三年行动计划重大临床研究项目:SHDC2020CR4092。

摘　　要：背景对于危重症医疗团队而言,长期机械通气(PMV)患者的撤机管理和后续向家庭机械通气(HMV)治疗模式转变一直是复杂的挑战。目的探索多学科诊疗模式(MDT)在PICU呼吸机依赖患儿诊治中的应用,分析其对于实施个体化撤机方案和指导从PMV过渡为HMV的临床价值以及推广意义。设计质量改进研究。方法以PICU中呼吸机依赖的PMV病例为观察对象,以2020年7月时点前后各18个月的PMV病例分为对照组和干预组。我院PMV诊疗措施主要包括:呼吸机相关肺炎预防,镇静、镇痛,液体管理,营养支持,早期康复,个体化撤机方案,PMV过渡为HMV的宣教,随访。对照组以PICU中不同医生或团队经验性的采用PMV诊疗措施,干预组以PMV-MDT团队采用PMV诊疗措施,以重症医学科为平台,PMV-MDT团队包括兼职联络员、核心团队成员(呼吸治疗师、康复科医生、五官科医生、营养科医生等)和原发病专科医生,并建立HMV专病随访门、急诊。主要结局指标①PMV过渡为HMV的情况,②个体化撤机方案的应用情况。结果干预组和对照组PMV患儿分别纳入124例和101例,两组性别、年龄、体重和导致PMV的原发疾病等差异无统计学意义。对照组院内死亡36例,遵医嘱出院67例(成功拔管撤离呼吸机44例,仍依赖机械通气14例,仍依赖人工气道无需机械通气7例),放弃治疗出院21例。干预组院内死亡26例,遵医嘱出院64例(成功拔管撤离呼吸机38例,仍依赖机械通气19例,依赖人工气道无需机械通气7例),放弃治疗出院11例(死亡9例,仍需机械通气1例,成功拔管脱离呼吸机1例)。干预组较对照组实施膈肌超声(97.0%vs 12.7%)、膈肌电活动监测(5%vs 0)和体外膈肌起搏技术(26.7%vs 0)差异均有统计学意义;两组纤维支气管镜检查例数差异无统计学意义,食道压监测、神经调节辅助通气在干预组首次开展。干预组HMV 19例,其中3例因病情加重(气道廓清不规范导�Background Weaning management of patients with prolonged mechanical ventilation(PMV)and subsequent transition to home mechanical ventilation have been complex challenges for critical care teams.Objective To explore the application of multidisciplinary treatment(MDT)model in the diagnosis and treatment of pediatric PMV and to analyze its clinical value and the significance of promotion for individualized weaning plan and transition from PMV to HMV.Design Quality improvement.Methods Patients with PMV in PICU were observed,and were divided into control group and intervention group according to 18 months before and after July 2020.The diagnosis and treatment measures of PMV in our hospital mainly include:prevention of ventilator-associated pneumonia,sedation,analgesia,fluid management,nutritional support,early rehabilitation,individualized weaning program,education and follow-up of PMV transition to HMV,and establishment of outpatient and emergency follow-up for HMV specific diseases.The control group was empirically treated by different doctors or teams in the PICU.In the intervention group,the PMV-MDT team led the treatment.Taking the PICU as the platform,PMV-MDT part-time liaisons and core team members(respiratory therapists,rehabilitation physicians,ent physicians,nutrition physicians,etc.)were set up.The HMV special follow-up and emergency clinics were established.Main outcome measures PMV transition to HMV and the application of individualized weaning technology.Results There were 101 cases of PMV in the intervention group and 124 cases in the control group.There was no statistical difference in gender,age,weight and the primary disease causing PMV between the two groups.In the control group,36 cases died in hospital,67 cases were improved and discharged(44 cases discharged after weaning and extubation,14 cases still dependent on mechanical ventilation,and 7 cases still dependent on artificial airway without mechanical ventilation),and 21 patients gave up treatment.In the intervention group,26 cases died in hos

关 键 词：长期机械通气 儿童 多学科诊疗 纤维支气管镜检查 膈肌超声 家庭机械通气 

分 类 号：R725.6[医药卫生—儿科]