發(fā)布時間：2018-05-01 09:01

  本文選題：慢性阻塞性肺疾病 + 機械通氣　； 參考：《鄭州大學》2014年碩士論文

【摘要】：目的 探討支氣管肺泡灌洗（bronchoalveolar lavage，，BAL）治療對行有創(chuàng)-無創(chuàng)序貫機械通氣的慢性阻塞性肺疾病急性加重（acute exacerbation chronic obstructivepulmonary disease， AECOPD）并嚴重呼吸衰竭患者的肺部感染窗時間(pulmonary infection control window，PIC window)、機械通氣時間、呼吸機相關性肺炎（ventilator-associated pneumonia，VAP）的發(fā)生率、拔管后48小時再插管率，病原學檢出率以及預后的影響。 方法 選擇因支氣管-肺部感染加重導致AECOPD并嚴重呼吸衰竭行有創(chuàng)機械通氣的患者61例，隨機分為兩組，治療組32例，對照組29例，兩組均以PIC窗為切換點實施有創(chuàng)-無創(chuàng)序貫機械通氣，治療組聯(lián)合應用BAL。當兩組患者出現(xiàn)PIC窗后均拔除氣管插管，給予無創(chuàng)正壓通氣，以后逐漸降低呼吸機支持力度直至撤離無創(chuàng)通氣改為文丘里面罩吸氧，期間如果病情惡化并達到重新插管指證，則再次給予氣管插管行有創(chuàng)機械通氣，以轉(zhuǎn)出呼吸加強治療病房（respiratory intensivecare unit，RICU）或院內(nèi)死亡為觀察終點，主要觀察兩組PIC窗出現(xiàn)的時間(即有創(chuàng)通氣切換為無創(chuàng)通氣的時間)、總的機械通氣時間、VAP的發(fā)生率、拔管后48小時再插管率、病原學檢出率、院內(nèi)死亡率。 結(jié)果 1.對照組PIC窗出現(xiàn)的時間(即有創(chuàng)通氣切換為無創(chuàng)通氣的時間)為(6.2±1.8)d，治療組PIC窗出現(xiàn)的時間(即有創(chuàng)通氣切換為無創(chuàng)通氣的時間)為(3.8±1.0)d，和對照組相比，治療組PIC窗明顯提前，有創(chuàng)機械通氣時間顯著減少(P0．01)。 2..對照組總的機械通氣時間為（15.5±5.2）d，治療組總的機械通氣時間為（12.6±5.3）d，和對照組相比，治療組總的機械通氣時間顯著減少(P0．05)。 3.對照組VAP發(fā)生率為20.69%，治療組VAP發(fā)生率為9.38%，和對照組相比，治療組VAP發(fā)生率明顯降低(P0．05)。 4.對照組病原學檢出率41.38%，治療組病原學檢出率78.13%，治療組病原學檢出率明顯高于對照組(P0．01)。 5.對照組拔管后48小時重新插管率13.793%，治療組拔管后48小時重新插管率3.125%，治療組拔管后48小時重新插管率明顯低于對照組(PO．05)。 6.對照組院內(nèi)死亡率13.793%，治療組院內(nèi)死亡率3.125%，治療組死亡率明顯低于對照組(P0．05)。 7.治療組共行床旁支氣管肺泡灌洗118例次，在灌洗操作中均出現(xiàn)一過性心律失常、缺氧的表現(xiàn)，其中術后發(fā)熱6例次，輕微的支氣管痙攣2例次，支氣管粘膜滲血2例次。 結(jié)論 1. BAL聯(lián)合有創(chuàng)-無創(chuàng)序貫機械通氣治療因支氣管-肺部感染致AECOPD并呼吸衰竭患者，可以促使PIC窗提前，縮短有創(chuàng)通氣時間，降低VAP發(fā)生率,提高病原學檢出率，降低48小時再插管率，從而改善預后。 2.行BAL可出現(xiàn)一過性心律失常、缺氧、支氣管痙攣、支氣管粘膜滲血及術后發(fā)熱等并發(fā)癥，大多停止操作，給予簡單處理，甚至不處理也能緩解或恢復正常，未出現(xiàn)嚴重并發(fā)癥，BAL是一項相對安全的治療措施。
[Abstract]:Purpose To investigate the time of pulmonary infection control window infection and mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and severe respiratory failure after bronchoalveolar lavage with bronchoalveolar lavage (BALL) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and severe respiratory failure. The incidence of ventilator-associated pneumonia (VAP), the rate of re-intubation 48 hours after extubation, the detection rate of etiology and the influence of prognosis. Method Sixty-one patients with AECOPD and severe respiratory failure due to bronchopulmonary infection were randomly divided into two groups: treatment group (n = 32) and control group (n = 29). PIC window was used as switching point in both groups. When PIC window appeared in both groups, tracheal intubation was removed, non-invasive positive pressure ventilation was given, and the support intensity of ventilator was gradually reduced until the withdrawal of non-invasive ventilation was replaced by Venturi mask oxygen inhalation, during which time, if the condition deteriorated and the indication of re-intubation was reached, He was again given tracheal intubation for invasive mechanical ventilation, and the end point was to transfer out of the respiratory intensive care unit (intensivecare unitricu) or to hospital death. The time of emergence of PIC window (that is, the time when invasive ventilation was switched to non-invasive ventilation), the incidence of total mechanical ventilation time, the rate of re-intubation 48 hours after extubation, the detection rate of etiology, and the mortality in hospital were observed. Result 1. The time of PIC window in the control group was 6.2 鹵1.8 days, and that of the PIC window in the treatment group was 3.8 鹵1.0 days. Compared with the control group, the PIC window in the treatment group was significantly earlier than that in the control group. The time of invasive mechanical ventilation was decreased significantly (P 0.01). 2.. The total mechanical ventilation time of the control group was 15.5 鹵5.2 days, and the total mechanical ventilation time of the treatment group was 12.6 鹵5.3 days. Compared with the control group, the total mechanical ventilation time of the treatment group was significantly reduced to 0.05%. 3. The incidence of VAP in the control group was 20.69 and the incidence of VAP in the treatment group was 9.38. Compared with the control group, the incidence of VAP in the treatment group was significantly lower than that in the control group (P 0.05). 4. The detection rate of etiology in the control group was 41.38 and that in the treatment group was 78.13. The detection rate of the treatment group was significantly higher than that of the control group (P 0.01). 5. The rate of re-intubation 48 hours after extubation was 13.793 in the control group and 3.125 in the treatment group 48 hours after extubation. The rate of re-intubation 48 hours after extubation in the treatment group was significantly lower than that in the control group. 6. The hospital mortality in the control group was 13.793, and the hospital mortality in the treatment group was 3.125. The mortality in the treatment group was significantly lower than that in the control group (P 0.05). 7. In the treatment group, 118 cases of bronchoalveolar lavage were performed by bedside bronchoalveolar lavage. Transient arrhythmias and anoxia were found in all cases during the lavage operation, including 6 cases of postoperative fever, 2 cases of mild bronchiospasm and 2 cases of osmosis of bronchial mucosa. Conclusion 1. BAL combined with invasive sequential mechanical ventilation in the treatment of patients with AECOPD and respiratory failure caused by bronchopulmonary infection can advance the PIC window, shorten the time of invasive ventilation, reduce the incidence of VAP, and increase the detection rate of etiology. Reduce the rate of 48 hours re-intubation, thereby improving the prognosis. 2. Complications such as transient arrhythmia, anoxia, bronchospasm, blood leakage of bronchial mucosa and postoperative fever can occur after BAL. Most of the complications can be alleviated or returned to normal by simple or even untreated treatment. BAL without severe complications is a relatively safe treatment.
【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R563.9

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