【摘要】：第一部分動態(tài)調控氣囊壓力聯(lián)合聲門下吸引預防呼吸機相關性肺炎目的:自動調控氣囊壓力聯(lián)合聲門下吸引預防呼吸機相關性肺炎。方法:前瞻性入選2013年10月至2014年12月無錫市第二人民醫(yī)院重癥醫(yī)學科收治的90例氣管插管患者,采用隨機、對照研究氣囊壓力自動控制儀聯(lián)合聲門下吸引預防呼吸機相關性肺炎,比較實驗組和常規(guī)對照組氣囊壓力監(jiān)測達標率、聲門下引流量、氣囊防分泌物滲漏以及呼吸機相關性肺炎、機械通氣時間、病死率等。結果:24小時內氣囊壓力監(jiān)測達標率實驗組顯著高于對照組(100%vs.59.5%,P0.05);72小時內聲門下引流液總量實驗組明顯高于對照組(50±5 mL vs.31±3 mL,60±8 mLvs.42±5mL,45±7mL vs.32±64 mL;P0.05);VAP發(fā)生率、機械通氣時間以及ICU住院時間實驗組顯著低于對照組(22.9%vs.47.6%;7.3±3.2d vs.12.3±4.0d;10.3±2.2d vs.15.1±3.0d;P0.05),兩組病死率無明顯差異;VAP患者痰培養(yǎng)革蘭氏陽性菌比例實驗組低于對照組(22.9%vs.47.6%,P0.05);多因素Logistic回歸分析顯示氣囊壓力監(jiān)測方法為氣管插管患者發(fā)生VAP的獨立預測因素(OR=0.45,P=0.02)。結論:自動持續(xù)調控氣囊壓力聯(lián)合聲門下吸引可有效降低聲門下分泌物滲漏量,應用該技術可降ICU患者住院時間、機械通氣時間和VAP發(fā)病率,但對患者死亡率無明顯影響。第二部分動態(tài)調控氣囊壓力聯(lián)合聲門下吸引預防誤吸研究目的:研究自動調控氣囊壓力聯(lián)合聲門下吸引預防誤吸效果。方法:運用雙抗體兩步夾心酶聯(lián)免疫吸附法(ELISA)監(jiān)測實驗組和對照組上呼吸道、下呼吸道分泌物胃蛋白酶陽性率、濃度并比較兩組患者誤吸發(fā)生率。結果:對照組和實驗組口腔、鼻腔以及經氣囊導管吸引聲門下分泌物中胃蛋白酶陽性率、濃度均無明顯差異;下呼吸道分泌物胃蛋白酶陽性率實驗組較對照組明顯降低(23.8%vs.50.0%,P0.05),胃蛋白酶濃度實驗組顯著低于對照組(20.1±4.2 ng/mL vs.28.1±3.1 ng/mL,P0.05);下呼吸道分泌物胃蛋白酶陽性較陰性患者VAP發(fā)生率明顯增高(73.5%vs.10.7%,P0.05);多因素Logistic回歸分析顯示氣囊壓力監(jiān)測方法為氣管插管患者發(fā)生誤吸的獨立預測因素(OR=1.078,P=0.012)。結論:氣管插管機械通氣患者存在較高的誤吸發(fā)生率,自動調控氣囊壓力聯(lián)合聲門下吸引可有效降低誤吸的發(fā)生率,VAP的發(fā)生與誤吸有明顯相關性。第三部分人工氣道防滲漏以及氣囊壓力影響因素機制研究目的:研究人工氣道氣囊防滲漏以及氣囊壓力影響因素的相關機制。方法:運用醫(yī)用氣管插管、醫(yī)用注射器、壓力傳感器及其附件、VBM氣囊壓力表、PHLIPS心電監(jiān)護儀等進行體外滲漏模擬試驗和動態(tài)觀察氣管插管患者氣囊壓力變化以及其影響因素。結果:8號組和7.5號組相比氣管插管氣囊外徑相對氣管內徑差增大,皺褶增多,皺褶管徑增大,分泌物向下滲漏顯著增加(P0.05);氣管插管氣囊外徑相對氣管內徑偏小時,氣囊上方液體沿氣囊壁周呈袖套狀滲漏;氣管插管保持水平面30~45度時氣囊上吸引口平面以下液體不易被吸引出。氣管插管患者套囊壓力隨呼吸周期呈近似正弦波形變化;吸痰、咳嗽時氣囊壓力會出現(xiàn)瞬時升高;PEEP設置會導致氣囊壓力增加;運用氣囊壓力波形可判斷氣囊封閉氣管實際效果。結論:臨床上需根據(jù)患者氣管內徑大小選擇相應外徑的氣管套管,皺褶通道的形成是導致氣囊上分泌物滲漏的重要原因,需注意患者氣管導管氣囊上引流口水平面以下液體湖的充分引流;患者體內氣囊壓力受呼吸周期、PEEP、咳嗽、吸痰等因素影響而變化;氣囊壓力的設置需要個體化,可結合氣囊壓力波形指導氣囊壓力設置。
[Abstract]:Objective: To prevent ventilator-associated pneumonia by automatically regulating airbag pressure and subglottic suction. Methods: 90 patients with endotracheal intubation were prospectively enrolled in the Department of Critical Care Medicine of the Second People's Hospital of Wuxi from October 2013 to December 2014. A randomized, controlled study was conducted to compare the compliance rate of balloon pressure monitoring, subglottic drainage, balloon anti-secretion leakage, ventilator-associated pneumonia, mechanical ventilation time and mortality between the experimental group and the conventional control group. The total volume of subglottic drainage fluid in the experimental group was significantly higher than that in the control group (50 There was no significant difference in mortality between the two groups; the proportion of Gram-positive bacteria in sputum culture of VAP patients was lower than that of the control group (22.9% vs. 47.6%, P 0.05); multivariate logistic regression analysis showed that balloon pressure monitoring was an independent predictor of VAP in patients with tracheal intubation (OR = 0.45, P = 0.02). CONCLUSIONS: Auto-continuous control of balloon pressure combined with subglottic suction can effectively reduce the amount of subglottic secretion leakage, which can reduce the length of stay in ICU, the duration of mechanical ventilation and the incidence of VAP, but has no significant effect on mortality. Methods: The positive rate of pepsin in upper respiratory tract and lower respiratory tract secretions of the experimental group and the control group were monitored by double antibody sandwich enzyme linked immunosorbent assay (ELISA). The concentration of pepsin in upper respiratory tract and lower respiratory tract secretions and the incidence of aspiration were compared between the control group and the experimental group. The positive rate of pepsin in the lower respiratory tract secretion was significantly lower in the experimental group than in the control group (23.8% vs. 50.0%, P 0.05), and the pepsin concentration in the experimental group was significantly lower than that in the control group (20.1 + 4.2 ng / mL vs. 28.1 + 3.1 ng / mL, P 0.05). The incidence of VAP in patients with positive pepsin secretion was significantly higher than that in patients with negative pepsin secretion (73.5% vs. 10.7%, P 0.05). Multivariate logistic regression analysis showed that balloon pressure monitoring was an independent predictor of aspiration in patients with endotracheal intubation (OR = 1.078, P = 0.012). Conclusion: Patients with mechanical ventilation for endotracheal intubation had a higher incidence of aspiration errors and automatic control. The incidence of aspiration mistake can be effectively reduced by balloon pressure combined with subglottic suction. The occurrence of VAP is significantly related to aspiration mistake. Results: Compared with group 8 and 7.5, the balloon diameter of tracheal intubation increased, the wrinkles increased, the balloon diameter of tracheal intubation increased, and the balloon pressure of tracheal intubation increased. With the increase of the diameter, the secretion leakage increased significantly (P Similar sinusoidal waveform changes; suction, cough balloon pressure will appear instantaneous increase; PEEP settings will lead to increased balloon pressure; the use of balloon pressure waveform can judge the actual effect of balloon airway closure. Conclusion: The clinical need to choose the appropriate diameter of the patient's trachea according to the size of the inner diameter of the tube, the formation of folded channel is leading to the upper part of the balloon. The important reason of secretion leakage is to pay attention to the sufficient drainage of the liquid lake below the level of the upper drainage outlet of the airbag of the tracheal tube; the pressure of the airbag in the patient is affected by the respiratory cycle, PEEP, cough, sputum suction and other factors; the setting of the pressure of the airbag needs to be individualized, which can be combined with the pressure waveform of the airbag to guide the setting of the pressure of the airbag.
【學位授予單位】：蘇州大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R563.1

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