摘要
目的分析机械通气辅助治疗老龄患者急性左心衰竭(acute left ventricular failure,ALVF)并发急性呼吸衰竭(acute respiratory failure,ARF)的临床效果及相关问题。方法 75例符合研究标准的ALVF并发ARF患者根据入科时情况给予无创正压(noninvasive positive pressure ventilation,NIPPV)或有创-无创正压(invasive positive pressure ventilation-NIPPV,IPPV-NIPPV)序贯机械通气辅助治疗,按入科时血气分析结果将患者分为I型呼吸衰竭(ALVF+ARF-I)组和II型呼吸衰竭(ALVF+ARF-II)组,回顾性对二组患者机械通气辅助治疗方式和治疗效果进行统计学比较。结果 ALVF+ARF-I组首选NIPPV治疗明显多于ALVF+ARF-II组,差异有统计学意义(70.3%vs.57.9%,P<0.05);但两组治疗成功率比较,差异无统计学意义(70.0%vs.68.2%,P<0.05);ALVF+ARF-I组需要IPPV-NIPPV序贯通气患者比例和撤机失败率明显少于ALVF+ARF-II组,差异有统计学意义(59.5%vs.86.8%,P<0.05;31.8%vs.60.6%,P<0.05)。ALVF+ARF-II组比ALVF+ARF-I组血压低,差异有统计学意义[平均动脉压:(61±17)mm Hg vs.(69±18)mm Hg,P<0.05;1 mm Hg=0.133 k Pa];ALVF+ARF-I组比ALVF+ARF-II组氧合指数低,差异有统计学意义(122.9±17.5 vs.246.3±29.4,P<0.05);通气2 h后,ALVF+ARF-I组与ALVF+ARF-II组心律失常(54.1%vs.76.3%,P<0.05)、低血压(29.7%vs.60.5%,P<0.05)、呼吸机相关性肺炎发生率(21.6%vs.42.1%,P<0.05)比较,差异均有统计学意义,ALVF+ARF-II组比ALVF+ARF-I组高。ALVF+ARF-II组上消化道出血发生率较高,但与ALVF+ARF-I组比较,差异无统计学意义(5.4%vs.18.4%,P>0.05);ALVF+ARF-I组病死率比ALVF+ARF-II低,差异有统计学意义(18.9%vs.28.9%,P<0.05)。ALVF+ARF-I组病情好转时间[(13±7)d vs.(18±14)d,P<0.05]、机械通气时间[(48.7±7.4)h vs.(62.9±9.6)h,P<0.05]、重症监护病房停留时间[(16.8±4.9)d vs.(21.7±6.8)d,P<0.05]短于ALVF+ARF-II组,差异有统计学意义。结论机械通气是辅助治疗老年ALVF+ARF患者的有效方法,不必强调呼吸衰竭分型,尽早采用NIPPV后根据治疗情况再改变通气模式可能更合理。临床上应积极电复律,慎用镇静、镇痛、利尿药,注意气道管理与尽早拔管结束IPPV,预防并发症。
Objectives To analyze the associated effect of mechanical ventilation in elderly patients with acute left ventricular failure（ALVF） combined with acute respiratory failure（ARF）. Methods Totally 75 patients aged（74.2 ±10.6） years old with ALVF＋ARF were given noninvasive positive pressure ventilation（NIPPV） or sequential ventilation of NIPPV following invasive positive pressure ventilation（IPPV） according to the status at admission. These patients were divided into ALVF ＋ARF-I（hypoxemia） group and ALVF ＋ARF-II（hypoxemia plus hypercarbia） group based on the results of blood gas analysis（BGA）. Clinical data were analyzed and compared between the two groups. Results Percentage of patients firstly treated with NIPPV in ALVF ＋ARF-I group was greater than that in ALVF ＋ARF-II group（70.3% vs. 57.9%, P〈0.05）, but therapeutic effects of the two groups were similar（70.0% vs. 68.2%, P〈0.05）.Percentage of patients treated with sequential ventilation of IPPV to NIPPV in ALVF＋ARF-I group was less than that in ALVF ＋ARF-II group（59.5% vs. 86.8%,P〈0.05）; percentage of defeating weaning from ventilator in ALVF ＋ARF-I group was less than that in ALVF ＋ARF-II group（31.8% vs. 60.6%,P〈0.05）. Blood pressure was lower and oxygenation index was higher in ALVF＋ARF-II group than in ALVF＋ARF-I group [mean blood pressure：（61±17） mm Hg vs.（69 ±18） mm Hg, P〈0.05; 1 mm Hg =0.133 k Pa; oxygenation index ： 122.9 ±17.5 vs. 246.3 ±29.4, P〈0.05 ].Incidences of arrhythmia, hypotension and ventilator-associated pneumonia（VAP） were higher in ALVF＋ARF-II group than in ALVF＋ARF-I group（54.1% vs. 76.3%, P〈0.05; 29.7% vs. 60.5%,P〈0.05; 21.6% vs. 42.1%, P〈0.05）.but incidence of gastrointestinal tract bleeding had no statistic significance between the two groups（5.4% vs. 18.4%,P〈0.05）. Mortality of the whole cohort was 24.0% and that of ALVF ＋ARF-II group was higher than that of ALVF ＋ARF-I group（18.9% vs. 28.9%, P〈0.05）. Duration of clinical improvement, ventilation and intensive care unit stay of ALVF ＋ARF-II group were longer than those of ALVF ＋ARF-I group [（13 ±7） d vs.（18 ±14） d, P〈0.05;（48.7 ±7.4） h vs.（62.9±9.6） h, P〈0.05;（16.8±4.9） d vs.（21.7±6.8） d, P〈0.05 ]. Conclusions Mechanical ventilation is effective in elderly patients with ALVF ＋ARF, and NIPPV should be applied as early as possible regardless of the type of respiratory failure. Electroversion, careful use of anesthetics, analgesia and diuretics, airway management,early extubation should be performed for preventing complications.
出处
《岭南心血管病杂志》
2015年第5期650-654,699,共6页
South China Journal of Cardiovascular Diseases
关键词
心力衰竭
急性呼吸衰竭
机械通气
治疗
分析
heart failure
acute respiratory failure
mechanical ventilation
treatment
analysis
