【摘要】：目的:通過動(dòng)物實(shí)驗(yàn)探討聲門下吸引方式的安全性和有效性,尋找聲門下吸引最安全有效的吸引負(fù)壓和間歇吸引時(shí)間,為臨床應(yīng)用提供理論依據(jù)。方法:采用前瞻性隨機(jī)對照基礎(chǔ)實(shí)驗(yàn)研究方法將32只健康大耳白兔隨機(jī)分組:持續(xù)聲門下引流組(實(shí)驗(yàn)A組)和間歇聲門下引流組(實(shí)驗(yàn)B組)。實(shí)驗(yàn)A組和實(shí)驗(yàn)B組根據(jù)不同的吸引負(fù)壓和間歇吸引時(shí)間隨機(jī)分成:A1組:恒定40-60 mmHg負(fù)壓聲門下吸引結(jié)合間斷聲門下沖洗;A2組:恒定60-80mmHg負(fù)壓聲門下吸引結(jié)合間斷聲門下沖洗;B1組:60-80mmHg負(fù)壓間歇2h聲門下吸引結(jié)合間斷聲門下沖洗;B2組:60-80mmHg負(fù)壓間歇4h聲門下吸引結(jié)合間斷聲門下沖洗;B3組:60-80mmHg負(fù)壓間歇6h聲門下吸引結(jié)合間斷聲門下沖洗;B4組:80-100mmHg負(fù)壓間歇2h聲門下吸引結(jié)合間斷聲門下沖洗;B5組:80-100mmHg負(fù)壓間歇4h聲門下吸引結(jié)合間斷聲門下沖洗;B6組:80-100mmHg負(fù)壓間歇6h聲門下吸引結(jié)合間斷聲門下沖洗,實(shí)驗(yàn)B組下各組每次吸引時(shí)間均為1h。每組動(dòng)物數(shù)4只。效應(yīng)指標(biāo):觀察并記錄各組機(jī)械通氣1周內(nèi)聲門下-氣囊上滯留物引流量和痰液量;機(jī)械通氣第4d和實(shí)驗(yàn)結(jié)束時(shí)引流物顏色(有無肉眼可見血性液體),未出現(xiàn)肉眼可見血性液體情況的組別則分別在機(jī)械通氣第4d和試驗(yàn)結(jié)束時(shí)留取每組引流物2ml待檢,行滯留物隱血實(shí)驗(yàn);機(jī)械通氣第4d和試驗(yàn)結(jié)束時(shí)分別處死各組兔子2只,并留取氣管粘膜組織制作病理標(biāo)本,常規(guī)HE染色,顯微鏡下觀察氣道粘膜組織的形態(tài)學(xué)改變。所有數(shù)據(jù)統(tǒng)計(jì)均采用SPSS17.0統(tǒng)計(jì)軟件,計(jì)數(shù)資料懫用頻數(shù)、構(gòu)成比進(jìn)行描述,懫用X2檢驗(yàn)進(jìn)行定性比較;連續(xù)性計(jì)量資料符合正態(tài)分布的懫用單因素方差分析(One-way ANOVA),以均數(shù)±標(biāo)準(zhǔn)差(?x±s)表示,根據(jù)方差齊性結(jié)果,組間差異比較采用S-N-K(q)檢驗(yàn),P㩳0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果:(1)痰液量:機(jī)械通氣1周內(nèi)各組間痰液量差異無統(tǒng)計(jì)學(xué)意義(p均㧐0.05);(2)聲門下-氣囊上滯留物引流量:實(shí)驗(yàn)A1組、A2組、B4組、B5組和B6組滯留物引流量分別是13.94±1.82、14.02±1.34、13.52±0.61、13.09±1.88和12.98±1.29 ml/d,差異無統(tǒng)計(jì)學(xué)意義(p=0.601);實(shí)驗(yàn)B1組、B2組和B3組滯留物引流量分別是10.89±0.54、10.40±1.39和10.69±1.43 ml/d,差異無統(tǒng)計(jì)學(xué)意義(p=0.765),但實(shí)驗(yàn)A1組、A2組、B4組、B5組、B6組和實(shí)驗(yàn)B1組、B2組、B3組之間有顯著差異(p均0.05);(3)肉眼可見血性液體情況結(jié)果:機(jī)械通氣第4d,所有實(shí)驗(yàn)組別均未出現(xiàn)肉眼可見血性液體情況;直至實(shí)驗(yàn)結(jié)束時(shí),除實(shí)驗(yàn)A2組出現(xiàn)1例肉眼可見血性液體情況,其余各組均未出現(xiàn)肉眼可見血性液體情況。提示A2組隨機(jī)械通氣時(shí)間的延長損傷加重,存在氣道粘膜出血的風(fēng)險(xiǎn);(4)滯留物潛血實(shí)驗(yàn)陽性情況結(jié)果:機(jī)械通氣第4d,除a2組出現(xiàn)1例陽性,其余各組均為陰性;實(shí)驗(yàn)結(jié)束時(shí),a2組(2例,67%)b4組(2例,50%)b1組=b2組=b5組(1例,25%)b3組=b6組=a1組(0,0%)。a2組(第4d)與其他各組組間兩兩比較,雙側(cè)檢驗(yàn)p=0.429,p0.05,差異無統(tǒng)計(jì)學(xué)意義;實(shí)驗(yàn)結(jié)束時(shí):a2組與a1組、b3組和b6組兩兩比較,p=0.033,p0.05,差異有統(tǒng)計(jì)學(xué)意義;a2組與b1組、b2組和b5組兩兩比較,雙側(cè)檢驗(yàn)p=0.371,p0.05,差異無統(tǒng)計(jì)學(xué)意義。a2組與b4組兩兩比較,雙側(cè)檢驗(yàn)p=0.143,p0.05,差異無統(tǒng)計(jì)學(xué)意義;(5)氣管粘膜組織he染色病理結(jié)果:將各組實(shí)驗(yàn)動(dòng)物氣管黏膜損傷情況進(jìn)行分級后并加以對比發(fā)現(xiàn),在各時(shí)間段內(nèi),各組氣道粘膜受損嚴(yán)重程度排列如下:機(jī)械通氣第4d:a2組(Ⅳ度)b4組(Ⅲ度)b1組(Ⅱ度)b2組=b5組=b6組=a1組(Ⅰ度)b3組(0度)。第7d:a2組(Ⅴ度)b4組(Ⅳ度)b1組(Ⅲ度)b2組=b5組(Ⅱ度)b3組=b6組=a1組(Ⅰ度)。除a1組和b6組外,其余各組均表現(xiàn)為機(jī)械通氣時(shí)間越長,氣道黏膜損傷程度越重。結(jié)論:目前臨床上對于聲門下吸引方式的選擇沒有形成統(tǒng)一的標(biāo)準(zhǔn),具體實(shí)踐方案臨床差異性較大,本實(shí)驗(yàn)通過對各種吸引方式下的吸引效果和吸引的安全性進(jìn)行對比研究,根據(jù)以上研究結(jié)果可得到如下結(jié)論:1.有效性方面:(1)持續(xù)聲門下吸引結(jié)合間斷聲門下沖洗,恒定40-60mmhg負(fù)壓和60-80mmhg負(fù)壓,吸引效果相似;(2)間歇聲門下吸引結(jié)合間斷聲門下沖洗,在同一時(shí)間下,吸引負(fù)壓80-100mmhg下的吸引效果優(yōu)于吸引負(fù)壓60-80mmhg下的吸引效果;(3)間歇聲門下吸引結(jié)合間斷聲門下沖洗,同一負(fù)壓下,間歇2h、4h和6h聲門下吸引,吸引效果無差別,即不同的間歇吸引時(shí)間對吸引效果沒有影響;(4)持續(xù)聲門下不同吸引負(fù)壓(40-60mmhg、60-80mmhg)的吸引效果優(yōu)于吸引負(fù)壓為60-80mmhg的間歇聲門下吸引;(5)持續(xù)聲門下不同吸引負(fù)壓(40-60mmhg、60-80mmhg)與吸引負(fù)壓80-100mmhg的間歇聲門下吸引比較,吸引效果相似,均能保證最大限度引流。2.安全性方面:(1)持續(xù)聲門下吸引結(jié)合間斷聲門下沖洗,恒定40-60mmhg負(fù)壓和60-80mmhg負(fù)壓吸引,各組出現(xiàn)肉眼可見血性液體和滯留物潛血實(shí)驗(yàn)陽性情況相似,但顯微鏡下觀察各組實(shí)驗(yàn)家兔氣道粘膜組織形態(tài)學(xué)改變,持續(xù)聲門下吸引選擇的壓力值與損傷呈正相關(guān)。即60-80mmhg負(fù)壓持續(xù)吸引損傷嚴(yán)重,40-60mmhg負(fù)壓持續(xù)吸引損傷程度輕,家兔耐受情況較好;(2)間歇聲門下吸引結(jié)合間斷聲門下沖洗,在同一負(fù)壓下,間歇2h、4h、6h聲門下吸引,出現(xiàn)肉眼可見血性液體和滯留物潛血實(shí)驗(yàn)陽性情況相似,但間歇6h聲門下吸引一次,對氣道粘膜的損傷程度最輕;且整個(gè)實(shí)驗(yàn)過程中,氣道粘膜損傷程度沒有隨著機(jī)械通氣時(shí)間的延長加重。提示:間斷聲門下吸引在壓力相同情況下,時(shí)間與氣管損傷呈負(fù)相關(guān),間斷時(shí)間越長,氣道損傷越小;(3)間歇聲門下吸引結(jié)合間斷聲門下沖洗,在同一時(shí)間下,如果間歇時(shí)間短(2h),壓力與損傷成正比,若間歇時(shí)間長(4h或6h),壓力的大小與氣道損傷無關(guān)聯(lián);(4)恒定40-60mmHg負(fù)壓持續(xù)聲門下吸引和吸引負(fù)壓80-100mmHg,間歇6h聲門下吸引一次相比,兩組出現(xiàn)肉眼可見血性液體和滯留物潛血實(shí)驗(yàn)陽性情況的結(jié)果無差別,且對氣道粘膜組織的損傷情況相似,損傷程度均最輕。綜上所述,短時(shí)間內(nèi)(1周內(nèi)),持續(xù)聲門下吸引在研究采用的負(fù)壓范圍內(nèi),其負(fù)壓大小不影響吸引效果;但負(fù)壓為40-60mmHg時(shí)對氣道損傷最小,建議臨床使用。間歇聲門下吸引,在負(fù)壓相同的情況下,間歇時(shí)間與吸引效果無關(guān)聯(lián),其中間歇6h聲門下吸引一次,對氣道粘膜的損傷程度最輕;在時(shí)間相同的情況下,壓力越大效果越好,間歇時(shí)間大于4h時(shí),其吸引負(fù)壓值對氣道損傷無影響。因此,間歇6h,在負(fù)壓80-100mmHg下行聲門下吸引既能保證患者的安全,又能保證吸引達(dá)到最大化,值得推薦。在相同壓力下,持續(xù)吸引與間斷吸引相比較,雖然持續(xù)吸引的效果好于間斷吸引,但對氣道的損傷更嚴(yán)重,所以,在今后的臨床應(yīng)用中,治療條件允許的情況下,建議采用間斷聲門下吸引。
[Abstract]:Objective: To explore the safety and effectiveness of subglottic suction in rabbits, and to find the most safe and effective suction negative pressure and intermittent suction time for subglottic suction, so as to provide theoretical basis for clinical application. Group A and group B were randomly divided into two groups according to different suction negative pressure and intermittent suction time: group A1: constant 40-60 mmHg subglottic suction combined with intermittent subglottic flushing; group A2: constant 60-80 mmHg subglottic suction combined with intermittent subglottic flushing; group B1: 60-80 mmHg subglottic suction combined with intermittent subglottic flushing. Subglottic suction with intermittent subglottic flushing at 2 h interval of negative pressure; subglottic suction with intermittent subglottic flushing at 60-80 mmHg interval of negative pressure for 4 h in group B2; subglottic suction with intermittent subglottic flushing at 60-80 mmHg interval of negative pressure for 6 h in group B3; subglottic suction with intermittent subglottic flushing at 80-100 mmHg interval of negative pressure for 2 h in group B4; subglottic suction with intermittent subglottic flushing at 80-100 mmHg interval of negative pressure for 4 h in group B5 Subglottic suction with intermittent subglottic flushing for 4 hours; subglottic suction with intermittent subglottic flushing for 6 hours in group B6; subglottic suction with intermittent subglottic flushing for 6 hours in group B; each suction time was 1 hour in group B. The number of animals in each group was 4. On the 4th day of ventilation and at the end of the experiment, the color of the drainage (with or without blood visible to the naked eye) and the 2 ml of the drainage in each group were retained at the 4th day of mechanical ventilation and at the end of the experiment, respectively, for occult blood test; on the 4th day of Mechanical ventilation and at the end of the experiment, 2 rabbits in each group were sacrificed and retained. Histopathological specimens of tracheal mucosa were made and stained with routine HE. Morphological changes of airway mucosa were observed under microscope. All data were analyzed by SPSS17.0 statistical software. The counting data were described by frequency and composition ratio, and were not qualitatively compared by X2 test. Results: (1) Sputum volume: There was no significant difference in sputum volume between groups within 1 week of mechanical ventilation (all P? 0.05); (2) Subglottic-supracapsular retention drainage volume: Experimental A1 group Retention drainage in group A2, group B4, group B5, and group B6 were 13.94 (+ 1.82), 14.02 (+ 1.34), 13.52 (+ 0.61), 13.09 (+ 1.88) and 12.98 (+ 1.29) ml/d, respectively, with no significant difference (p = 0.601); in group B1, group B2 and group B3, retention drainage was 10.89 (+ 0.54), 10.40 (+ 1.39) and 10.69 (+ 1.43 ml/d), respectively (p = 0.765). There was a significant difference between group B 4, group B 5, group B 6, group B 1, group B 2, and group B 3 (all P 0.05); (3) Visible blood fluids to the naked eye: on the 4th day of mechanical ventilation, no visible blood fluids to the naked eye were found in all the experimental groups; until the end of the experiment, except one visible blood fluids to the naked eye in group A2, all the other groups did not appear. The results showed that the prolonged mechanical ventilation time in group A2 was worse and there was a risk of airway mucosal bleeding. (4) Positive results of occult blood test in group A2 were negative on the 4th day of mechanical ventilation except one case in group a2. At the end of the experiment, group A2 (2 cases, 67%) in group B4 (2 cases, 50%) in group B1 = group B5 (1). There was no significant difference between group A2 and other groups (p = 0.429, P 0.05). at the end of the experiment: group A2 was compared with group a1, group B3 and group b6, P = 0.033, P 0.05, the difference was statistically significant; group A2 was compared with group b1, group B2 and group b5, the difference was not significant (p = 0.371, P 0.05). There was no significant difference between A2 group and B4 group (p = 0.143, P 0.05). (5) pathological results of HE staining of tracheal mucosa: the severity of tracheal mucosa injury in each group was classified and compared. the severity of each group was arranged as follows: mechanical ventilation. 4th day: group A2 (Grade IV) group B4 (Grade III) group B1 (Grade II) group B2 = group B5 = group B6 = group A1 (Grade I) group B3 (Grade 0). 7th day: group A2 (Grade V) group B4 (Grade IV) group B2 (Grade IV) group B2 = group B5 (Grade II) group B3 = group B6 = group A1 (Grade I). Except group A1 and group b6, the longer the mechanical ventilation time, the more severe the airway mucosal damage. There is no uniform standard for the selection of subglottic suction, and there is a great difference in the clinical practice. Through the comparative study of the suction effect and the safety of subglottic suction under various suction methods, the following conclusions can be drawn from the above results: 1. Effectiveness: (1) Continuous subglottic suction combination Intermittent subglottic suction combined with intermittent subglottic flushing at the same time, the suction effect under the suction pressure of 80-100 mmHg is better than that under the suction pressure of 60-80 mmhg. (3) Intermittent subglottic suction combined with intermittent subglottic flushing under the same negative pressure. There was no difference in attraction effect between intermittent subglottic suction for 2, 4 and 6 hours, that is, different intermittent suction time had no effect on the attraction effect; (4) the suction effect of different suction negative pressure under continuous glottis (40-60 mmhg, 60-80 mmhg) was better than that under intermittent subglottic suction with negative pressure of 60-80 mmhg; (5) different suction negative pressure under continuous glottis (40-60 mmhg, 60-80 mmhg). Compared with the intermittent subglottic suction with negative pressure of 80-100 mmhg, the suction effect was similar, and the maximum drainage was guaranteed. 2. Safety aspects: (1) Continuous subglottic suction combined with intermittent subglottic flushing, constant 40-60 mmHg negative pressure and 60-80 mmHg negative pressure suction, all groups showed positive results of occult blood test with visible blood fluids and retained substances. Similarly, the morphological changes of airway mucosa were observed under microscope, and the pressure of continuous subglottic suction was positively correlated with the injury. Under the same negative pressure, intermittent subglottic suction for 2 hours, 4 hours and 6 hours showed similar positive results for visible blood fluids and occult blood retained by naked eyes, but subglottic suction for 6 hours had the least damage to the airway mucosa, and the degree of airway mucosa damage did not increase with the prolongation of mechanical ventilation. Intermittent subglottic suction under the same pressure, time and tracheal injury was negatively correlated, the longer the intermittence time, the smaller the airway injury; (3) Intermittent subglottic suction combined with intermittent subglottic flushing, at the same time, if the intermittence time is short (2h), pressure and injury is proportional, if the intermittence time is long (4h or 6h), the size of pressure and airway injury. There was no correlation between the two groups. (4) There was no difference in the results of occult blood test between the two groups, and the damage to airway mucosa was similar and the degree of injury was the least. Within one week, continuous subglottic suction was used within the range of the negative pressure used in the study, and the negative pressure did not affect the suction effect; however, when the negative pressure was 40-60 mmHg, the damage to the airway was the smallest. Intermittent subglottic suction was recommended for clinical use. In the same time, the greater the pressure is, the better the effect is. When the interval time is longer than 4 hours, the negative pressure of aspiration has no effect on the airway damage. In comparison with intermittent suction, continuous suction is more effective than intermittent suction, but the damage to airway is more serious. Therefore, intermittent subglottic suction is recommended in the future clinical application when the treatment conditions permit.
【學(xué)位授予單位】：長江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R459.7

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