【摘要】：第一部分動(dòng)態(tài)調(diào)控氣囊壓力聯(lián)合聲門下吸引預(yù)防呼吸機(jī)相關(guān)性肺炎目的:自動(dòng)調(diào)控氣囊壓力聯(lián)合聲門下吸引預(yù)防呼吸機(jī)相關(guān)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(xué)科收治的90例氣管插管患者,采用隨機(jī)、對(duì)照研究氣囊壓力自動(dòng)控制儀聯(lián)合聲門下吸引預(yù)防呼吸機(jī)相關(guān)性肺炎,比較實(shí)驗(yàn)組和常規(guī)對(duì)照組氣囊壓力監(jiān)測達(dá)標(biāo)率、聲門下引流量、氣囊防分泌物滲漏以及呼吸機(jī)相關(guān)性肺炎、機(jī)械通氣時(shí)間、病死率等。結(jié)果:24小時(shí)內(nèi)氣囊壓力監(jiān)測達(dá)標(biāo)率實(shí)驗(yàn)組顯著高于對(duì)照組(100%vs.59.5%,P0.05);72小時(shí)內(nèi)聲門下引流液總量實(shí)驗(yàn)組明顯高于對(duì)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(jī)械通氣時(shí)間以及ICU住院時(shí)間實(shí)驗(yàn)組顯著低于對(duì)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(shí)驗(yàn)組低于對(duì)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(dú)立預(yù)測因素(OR=0.45,P=0.02)。結(jié)論:自動(dòng)持續(xù)調(diào)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(yīng)用該技術(shù)可降ICU患者住院時(shí)間、機(jī)械通氣時(shí)間和VAP發(fā)病率,但對(duì)患者死亡率無明顯影響。第二部分動(dòng)態(tài)調(diào)控氣囊壓力聯(lián)合聲門下吸引預(yù)防誤吸研究目的:研究自動(dòng)調(diào)控氣囊壓力聯(lián)合聲門下吸引預(yù)防誤吸效果。方法:運(yùn)用雙抗體兩步夾心酶聯(lián)免疫吸附法(ELISA)監(jiān)測實(shí)驗(yàn)組和對(duì)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(jié)果:對(duì)照組和實(shí)驗(yàn)組口腔、鼻腔以及經(jīng)氣囊導(dǎo)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(shí)驗(yàn)組較對(duì)照組明顯降低(23.8%vs.50.0%,P0.05),胃蛋白酶濃度實(shí)驗(yàn)組顯著低于對(duì)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(dú)立預(yù)測因素(OR=1.078,P=0.012)。結(jié)論:氣管插管機(jī)械通氣患者存在較高的誤吸發(fā)生率,自動(dòng)調(diào)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(guān)性。第三部分人工氣道防滲漏以及氣囊壓力影響因素機(jī)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(guān)機(jī)制。方法:運(yùn)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(hù)儀等進(jìn)行體外滲漏模擬試驗(yàn)和動(dòng)態(tài)觀察氣管插管患者氣囊壓力變化以及其影響因素。結(jié)果:8號(hào)組和7.5號(hào)組相比氣管插管氣囊外徑相對(duì)氣管內(nèi)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(duì)氣管內(nèi)徑偏小時(shí),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(shí)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(shí)氣囊壓力會(huì)出現(xiàn)瞬時(shí)升高;PEEP設(shè)置會(huì)導(dǎo)致氣囊壓力增加;運(yùn)用氣囊壓力波形可判斷氣囊封閉氣管實(shí)際效果。結(jié)論:臨床上需根據(jù)患者氣管內(nèi)徑大小選擇相應(yīng)外徑的氣管套管,皺褶通道的形成是導(dǎo)致氣囊上分泌物滲漏的重要原因,需注意患者氣管導(dǎo)管氣囊上引流口水平面以下液體湖的充分引流;患者體內(nèi)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(shè)置需要個(gè)體化,可結(jié)合氣囊壓力波形指導(dǎo)氣囊壓力設(shè)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(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R563.1

【相似文獻(xiàn)】

相關(guān)期刊論文 前10條

1 陳璐;李水莉;;人工氣道氣囊壓力管理研究進(jìn)展[J];齊魯護(hù)理雜志;2009年21期

2 朱艷萍;潘紅;孫艷陽;何靜;錢淑媛;馬璐;;一次性壓力傳感器在人工氣道氣囊壓力監(jiān)測中的應(yīng)用[J];中華護(hù)理雜志;2012年12期

3 盧玉林;范平;陳名睿;楊艷;金其鳳;;人工氣道氣囊壓力管理現(xiàn)狀的調(diào)查研究[J];護(hù)士進(jìn)修雜志;2013年02期

4 顧小紅;王黎梅;;2種人工氣道氣囊壓力測定方法的比較研究[J];中國實(shí)用護(hù)理雜志;2006年29期

5 王國琴;;慢性阻塞性肺病患者人工氣道氣囊壓力監(jiān)測及護(hù)理[J];檢驗(yàn)醫(yī)學(xué)與臨床;2013年03期

6 吳超;沈梅芬;;影響人工氣道氣囊壓力相關(guān)因素的研究進(jìn)展[J];護(hù)士進(jìn)修雜志;2014年04期

7 刁秀芳;;理想氣囊壓力值與氣道密封性不一致的原因分析[J];基層醫(yī)學(xué)論壇;2012年36期

8 王巖,申雪琴,武強(qiáng);對(duì)機(jī)械通氣患者氣管套管氣囊壓力的臨床觀察[J];南方護(hù)理學(xué)報(bào);2004年05期

9 何茹;何潔;黃燕;陶艷玲;;指觸結(jié)合壓力表測壓在人工氣道氣囊壓力維護(hù)中的應(yīng)用[J];護(hù)理學(xué)雜志;2012年17期

10 劉鵬;;人工氣道氣囊壓力管理研究進(jìn)展[J];全科護(hù)理;2012年24期

相關(guān)會(huì)議論文 前2條

1 姜東輝;陸銀春;張燕;羅亮;汪明燈;鮑潔;紀(jì)曉霞;;連續(xù)氣囊壓力監(jiān)測治療儀對(duì)呼吸機(jī)相關(guān)性肺炎治療應(yīng)用的評(píng)價(jià)[A];中華醫(yī)學(xué)會(huì)急診醫(yī)學(xué)分會(huì)第十六次全國急診醫(yī)學(xué)學(xué)術(shù)年會(huì)論文集[C];2013年

2 陳芳;沈炯;;老年危重病人氣囊壓力監(jiān)測及護(hù)理[A];2005年浙江省危重病學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2005年

相關(guān)博士學(xué)位論文 前1條

1 汪明燈;動(dòng)態(tài)調(diào)控氣囊壓力聯(lián)合聲門下吸引預(yù)防呼吸機(jī)相關(guān)性肺炎的臨床、機(jī)理研究[D];蘇州大學(xué);2016年

相關(guān)碩士學(xué)位論文 前2條

1 貢瑞霞;插管后氣管狹窄的臨床研究[D];河北醫(yī)科大學(xué);2015年

2 田卓莎;套管氣囊壓迫對(duì)兔氣管組織形態(tài)結(jié)構(gòu)的影響[D];中國醫(yī)科大學(xué);2008年

，

本文編號(hào)：2179976