-
在急性呼吸窘迫综合征(ARDS)病人的治疗中,改善通气的同时需预防继发性肺损伤[1]。俯卧位通气可促进塌陷肺泡复张,增加胸肺顺应性,减少肺内分流,改善V/Q比例, 增加氧合,是重度ARDS治疗的一种重要手段[2-4]。然而研究[5]发现,长时间且不间断的俯卧位通气,病人头部垫俯卧位枕,胸部垫枕抬高可增加机械通气病人发生压疮、呕吐等风险。压力性损伤的出现会导致病人住院时间延长及住院费用增加等。因此,我科对传统俯卧位通气方式进行了改进,采用基于力学分布的改良俯卧位护理策略,使用翻身垫进行俯卧位翻身,病人头胸腹部不垫枕抬高,避免局部皮肤受力面积减少压强增大的发生,从而降低压力性损伤发生率。本研究比较改良俯卧位与传统俯卧位机械通气时并发症、血流动力学及呼吸力学方面的差异,以探讨改良俯卧位护理策略在ARDS病人中的应用效果,为临床进行合理的机械通气提供参考。
-
2组病人一般资料比较差异无统计学意义(P>0.05)(见表 1)。
分组 n 年龄/岁 男 女 体质量指数/
(kg/m2)俯卧位
时间/hAPACHEⅡ
评分/分首次俯卧位前
PaO2/FiO2观察组 20 61.45±14.98 15 5 19.59±2.31 15.08±3.04 19.70±1.72 137.70±29.10 对照组 27 58.22±19.58 15 12 20.0±1.44 14.71±2.53 19.26±2.1 150.93±28.90 t — 0.62 1.13* 0.70 0.45 0.77 1.55 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组病人一般资料比较(x±s)
-
观察组压力性损伤发生率低于对照组(P < 0.05)。2组病人呕吐和意外脱管发生率差异无统计学意义(P>0.05)(见表 2)。
分组 n 并发症 压力性损伤 呕吐 意外脱管 观察组 20 3(15.00) 4(4.80) 0(0.00) 对照组 27 12(44.44) 11(16.20) 4(3.00) χ2 — 4.58 2.27 1.62* P — < 0.05 >0.05 >0.05 *示χ2矫正法 表 2 2组病人并发症的比较[n;百分率(%)]
-
2组病人在俯卧位前和俯卧位1h、2h、4h的HR、CVP比较,差异均无统计学意义(P>0.05);观察组病人在俯卧位前的MAP高于对照组(P < 0.05), 2组在俯卧位1h、2h、4h的MAP比较差异均无统计学意义(P>0.05)(见表 3)。
分组 n 俯卧位前 俯卧位1h 俯卧位2h 俯卧位4h HR/(次/分) 观察组 20 86.27±11.65 89.86±8.87 92.5±7.98 91.40±6.05 对照组 27 89.71±12.64 91.6±10.57 93.0±7.14 92.35±5.83 t — 1.74 1.10 0.40 0.98 P — >0.05 >0.05 >0.05 >0.05 MAP/mmHg 观察组 20 79.27±7.62 78.61±7.22 73.5±7.57 78.52±6.89 对照组 27 76.79±7.09 76.29±7.26 74.5±7.56 77.90±7.85 t — 2.05 1.96 0.81 0.52 P — < 0.05 >0.05 >0.05 >0.05 CVP/mmHg 观察组 20 8.59±2.71 9.46±2.82 9.34±2.69 9.13±2.83 对照组 27 9.07±2.80 9.76±2.17 8.84±2.9 9.49±2.6 t — 1.07 0.74 1.10 0.81 P — >0.05 >0.05 >0.05 >0.05 表 3 2组病人血流动力学指标比较(x±s)
-
观察组病人在俯卧位前和俯卧位1 h的R高于对照组(P < 0.05和P < 0.01),而在俯卧位2 h和4 h比较,2组R差异无统计学意义(P>0.05)。2组病人在俯卧位前和俯卧位1 h、2 h、4 h的Cst比较差异均无统计学意义(P>0.05)(见表 4)。
分组 n 俯卧位前 俯卧位1 h 俯卧位2 h 俯卧位4 h R/[cmH2O/(L·s)] 观察组 20 18.7±3.20 19.12±2.51 19.5±2.55 19.46±2.63 对照组 27 17.4±3.19 17.94±2.81 18.6±2.99 18.75±3.60 t — 2.49 2.72 1.95 1.36 P — < 0.05 < 0.01 >0.05 >0.05 Cst/(mL/cmH2O) 观察组 20 22.8±6.44 23.17±2.99 33.4±3.42 40.36±6.59 对照组 27 24.0±6.02 22.94±3.10 33.3±3.51 38.68±7.35 t — 1.17 0.46 0.18 1.48 P — >0.05 >0.05 >0.05 >0.05 表 4 2组病人呼吸力学指标的比较(x±s)
急性呼吸窘迫综合征病人不同俯卧位护理策略的效果评价
Application effects of different prone positions nursing strategies in patients with acute respiratory distress syndrome
-
摘要:
目的探讨改良式与传统俯卧位护理策略在急性呼吸窘迫综合征(ARDS)病人中的应用效果。 方法选择2017年6月至2019年5月行俯卧位通气治疗的ARDS病人47例,对照组(27例)采用头胸部垫俯卧位枕抬高的传统俯卧位护理方式;观察组(20例)病人采用基于力学分布的改良俯卧位护理策略。比较2组病人并发症(压力性损伤、呕吐)的发生情况、俯卧位前后血流动力学[心率(HR)、平均动脉压(MAP)、中心静脉压(CVP))的变化及呼吸力学[气道阻力(R)、胸肺顺应性(Cst)]的变化。 结果观察组压力性损伤发生率低于对照组(P < 0.05)。2组病人呕吐和意外脱管发生率差异无统计学意义(P>0.05)。2组病人在俯卧位前和俯卧位1 h、2 h、4 h的HR、CVP比较差异均无统计学意义(P>0.05);观察组病人在俯卧位前的MAP高于对照组(P < 0.05),2组在俯卧位1 h、2 h、4 h的MAP比较差异均无统计学意义(P>0.05)。观察组病人在俯卧位前和俯卧位1h的R高于对照组(P < 0.05和P < 0.01),而在俯卧位2 h和4 h比较,2组R差异无统计学意义(P>0.05)。2组病人在俯卧位前、俯卧位1 h、2 h、4 h的Cst比较,差异均无统计学意义(P>0.05)。 结论改良式俯卧位通气护理策略较传统俯卧位方式可降低ARDS病人并发症发生率,值得在临床推广。 Abstract:ObjectiveTo explore the application effects of improved and traditional prone position nursing strategies in patients with acute respiratory distress syndrome(ARDS). MethodsFrom June 2017 to May 2019, 47 ARDS patients with prone position were divided into the control group(27 cases) and observation group(20 cases).The control group and observation group were nursed with traditional prone position(head and chest pad prone position and pillow elevation) and improved prone position nursing strategy based on mechanical distribution, respectively.The occurrence of complications(pressure injury and vomiting), changes of hemodynamics[heart rate(HR), mean arterial pressure(MAP) and central venous pressure(CVP)] and changes of respiratory mechanics[airway resistance(R), chest and lung compliance(Cst)] before and after prone position were compared between two groups. ResultsThe incidence rate of stress injury in observation group was lower than that in control group(P < 0.05).There was no statistical significance in the incidence of vomiting and accidental detubation between two groups(P>0.05).The differences of the HR and CVP between two groups were not statistically significant before prone position and after 1h, 2h and 4h of prone position(P>0.05).The MAP in observation group before prone position was higher than that in control group(P < 0.05), and the differences of MAP between two groups were not statistically significant after 1h, 2h and 4h of prone position(P>0.05).The R in observation group before and after 1 h of prone position were higher than that in control group(P < 0.05 and P < 0.01), while there was no statistical significance in R between two groups after 2 h and 4 h of prone position(P>0.05).The differences of the Cst between two groups were not statistically significant before and after 1h, 2h and 4h of prone position(P>0.05). ConclusionsCompared with the traditional prone position nursing strategy, the improved prone position ventilation nursing strategy can reduce the incidence of complications in ARDS patients, which is worthy of clinical promotion. -
表 1 2组病人一般资料比较(x±s)
分组 n 年龄/岁 男 女 体质量指数/
(kg/m2)俯卧位
时间/hAPACHEⅡ
评分/分首次俯卧位前
PaO2/FiO2观察组 20 61.45±14.98 15 5 19.59±2.31 15.08±3.04 19.70±1.72 137.70±29.10 对照组 27 58.22±19.58 15 12 20.0±1.44 14.71±2.53 19.26±2.1 150.93±28.90 t — 0.62 1.13* 0.70 0.45 0.77 1.55 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组病人并发症的比较[n;百分率(%)]
分组 n 并发症 压力性损伤 呕吐 意外脱管 观察组 20 3(15.00) 4(4.80) 0(0.00) 对照组 27 12(44.44) 11(16.20) 4(3.00) χ2 — 4.58 2.27 1.62* P — < 0.05 >0.05 >0.05 *示χ2矫正法 表 3 2组病人血流动力学指标比较(x±s)
分组 n 俯卧位前 俯卧位1h 俯卧位2h 俯卧位4h HR/(次/分) 观察组 20 86.27±11.65 89.86±8.87 92.5±7.98 91.40±6.05 对照组 27 89.71±12.64 91.6±10.57 93.0±7.14 92.35±5.83 t — 1.74 1.10 0.40 0.98 P — >0.05 >0.05 >0.05 >0.05 MAP/mmHg 观察组 20 79.27±7.62 78.61±7.22 73.5±7.57 78.52±6.89 对照组 27 76.79±7.09 76.29±7.26 74.5±7.56 77.90±7.85 t — 2.05 1.96 0.81 0.52 P — < 0.05 >0.05 >0.05 >0.05 CVP/mmHg 观察组 20 8.59±2.71 9.46±2.82 9.34±2.69 9.13±2.83 对照组 27 9.07±2.80 9.76±2.17 8.84±2.9 9.49±2.6 t — 1.07 0.74 1.10 0.81 P — >0.05 >0.05 >0.05 >0.05 表 4 2组病人呼吸力学指标的比较(x±s)
分组 n 俯卧位前 俯卧位1 h 俯卧位2 h 俯卧位4 h R/[cmH2O/(L·s)] 观察组 20 18.7±3.20 19.12±2.51 19.5±2.55 19.46±2.63 对照组 27 17.4±3.19 17.94±2.81 18.6±2.99 18.75±3.60 t — 2.49 2.72 1.95 1.36 P — < 0.05 < 0.01 >0.05 >0.05 Cst/(mL/cmH2O) 观察组 20 22.8±6.44 23.17±2.99 33.4±3.42 40.36±6.59 对照组 27 24.0±6.02 22.94±3.10 33.3±3.51 38.68±7.35 t — 1.17 0.46 0.18 1.48 P — >0.05 >0.05 >0.05 >0.05 -
[1] RUSTE M, BITKER L, YONIS H, et al.Hemodynamic effects of extended prone position sessions in ARDS[J].Ann In Care, 2018, 8(1):120. [2] CHARRON C, BOUFERRACHE K, CAILLE V, et al.Routine prone positioning in patients with severe ARDS:feasibility and impact on prognosis[J].Intensive Care Med, 2011, 37(5):785. doi: 10.1007/s00134-011-2180-x [3] 穆根华, 邓义军, 卢仲谦, 等.俯卧位通气对急性呼吸窘迫综合征病人呼吸力学的影响[J].中国急救复苏与灾害医学杂志, 2017, 12(9):845. [4] GILL R, WONG T, JOHNSTON A.Prone positioning in severe acute respiratory distress syndrome (ARDS)[J].New Engl J Med, 2013, 369(10):979. doi: 10.1056/NEJMc1308895 [5] 肖媛媛.急性呼吸窘迫综合征病人俯卧位通气的护理[J].华北理工大学学报(医学版), 2012, 14(5):702. [6] 梅亚凡, 米元元, 黄海燕, 等.危重症俯卧位通气病人压疮预防及管理研究进展[J].中国临床护理, 2019, 11(1):96. [7] LUCCHINI A, BONETTI I, BORRELLI G, et al.Enteral nutrition during prone positioning in mechanically ventilated patients[J].Assistenza Infermieristica E Ricerca, 2017, 36(2):76. [8] KOR DJ, WARNER DO, CARTER RE, et al.Extravascular lung water and pulmonary vascular permeability index as markers predictive of postoperative acute respiratory distress syndrome:a prospective cohort investigation.[J].Crit Care Med, 2015, 43(3):665. [9] GUÉRIN C, REIGNIER J, RICHARD JC, et al.Prone positioning in severe acute respiratory distress syndrome[J].N Engl J Med, 2013, 368(23):2159. doi: 10.1056/NEJMoa1214103 [10] 许启霞, 詹庆元, 王辰, 等.俯卧位通气加肺复张对急性呼吸窘迫综合征的作用[J].中华危重病急救医学, 2008, 20(10):592. doi: 10.3321/j.issn:1003-0603.2008.10.006