SC和PSV模式在困难撤机患者中的随机对照研究
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摘要
目的：通过比较Smart Care/PS和压力支持通气(pressure support ventilation,PSV)模式在困难撤机患者中呼吸力学及血流动力学的变化,比较SC撤机模式与PSV撤机模式的效果。方法：满足撤机条件后,将57例中枢神经系统(central nervous system, CNS)疾病术后与肺部感染的困难撤机患者随机分成两组(SC组和PSV组),基础通气模式均为同步间歇指令通气(synchronized intermittent mandatory ventilation, SIMV)+PSV,分别使用SC和PSV模式进行撤机,收集撤机后5min、15min、30min、1h、2h,5个时间点的呼吸力学及血流动力学指标。采用重复测量方差分析进行数据统计。结果：(1)两种撤机方式各时间点的f、P0.1、NIF、HR比较,差异无统计学意义(P>0.05),不同时间点的f、P0.1、NIF、HR比较,差异有统计学意义(P<0.05)。(2)两种撤机方式各时间点的Vt、PetCO2、C、R、MAP、CI比较,差异无统计学意义(P>0.05),不同时间点的Vt、PetCO2、C、R、MAP、CI比较,差异无统计学意义(P>0.05)。结论：对于CNS疾病术后与肺部感染困难撤机患者来说,SC可代替PSV模式,模拟医师对患者机械通气的压力支持(pressure support, PS)水平的调整,进行自动化撤机。
Objective:To compare the variation on hemodynamics and respiratory mechanics of Smart Care/PS and PSV used in difficult weaning patients, in order to evaluate if the Smart Care/PS weaning is superior to PSV weaning. Method:When fifty-seven difficult weaning patients were fitted to the weaning condition, they were randomized into 2 groups:weaning with Smart Care/PS (SC group, n=15)or with pressure support ventilation(PSV group, n=14). The basic ventilation mode was SIMV+PSV before weaning. The two groups used Smart Care/PS and PSV respectively. Parameters of pulmonary mechanics and hemodynamics were measured at 5 min、15 min、30 min、1h and 2h after weaning. The collecting dates were analyzed by repeated measurement analysis of variance. Results:(1) The f、Vt、P0.1、NIF and HR had no significant difference between the two weaning modes (P>0.05); but they had difference at each times (P<0.05). (2) The PetCO2、C、R、MAP and CI had no significant difference between the two weaning modes (P>0.05) and at each times (P>0.05). Conclusion:For those difficult-wean patients caused by postoperative CNS disease and pulmonary infection, Smart Care/PS can take the place of PSV, simulate the doctor judging and dealing with pressure support level according to the patients condition and can be used to automated weaning.
Objective:To compare the variation on hemodynamics and respiratory mechanics of Smart Care/PS and PSV used in difficult weaning patients, in order to evaluate if the Smart Care/PS weaning is superior to PSV weaning. Method:When fifty-seven difficult weaning patients were fitted to the weaning condition, they were randomized into 2 groups:weaning with Smart Care/PS (SC group, n=15)or with pressure support ventilation(PSV group, n=14). The basic ventilation mode was SIMV+PSV before weaning. The two groups used Smart Care/PS and PSV respectively. Parameters of pulmonary mechanics and hemodynamics were measured at 5 min、15 min、30 min、1h and 2h after weaning. The collecting dates were analyzed by repeated measurement analysis of variance. Results:(1) The f、Vt、P0.1、NIF and HR had no significant difference between the two weaning modes (P>0.05); but they had difference at each times (P<0.05). (2) The PetCO2、C、R、MAP and CI had no significant difference between the two weaning modes (P>0.05) and at each times (P>0.05). Conclusion:For those difficult-wean patients caused by postoperative CNS disease and pulmonary infection, Smart Care/PS can take the place of PSV, simulate the doctor judging and dealing with pressure support level according to the patients condition and can be used to automated weaning.
引文
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[15]Burns K, Lellouche F, Lessard M, et al. Automating the weaning process with advanced closed-loop systems[J]. Intensive-Care-Med,2008,34(10):1757-1765.
[16]Tehrani FT, RoumJ. Intelligent decision support systems for mechanical ventilation. Artif Intell Med[J].2008,44(3):171-182.
[17]Francois L, Laurent B. Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare) [J]. Best Pract Res Clin Anaesthesiol,2009,23(1):81-93.
[18]Bums KE, Meade MO, Lessard MR, et al. Wean earier and automatically with new technogy(the WEAN study):a protocol Of a multicenter, pilot randomized controlled trial[J]. Trials,2009,10(1):81.
[19]Rose L, A randomized, controlled trial of conventional versus automated weaning from mechanical ventilation using Smart Care Tm/Ps[J]. Itensive Care Med,2008, 34(10):1788-1795.
[20]成永晖,曹相原Smantcare智能化脱机安全性的临床观察[J]．临床合理用药,2010,3(3),9-10.
[2]Torres A, Serra-batlles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation:the effect of body position[J]. Ann Intern Med,1992,116(7):540-543.
[3]Esteban A, Alia I, Gordo F, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation:the Spanish Lung Failure Collaborative Group[J]. Am J Respir Crit Care Med,1997,156(15):459-465.
[4]Esteban A, Alia I, Tobin MJ, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinued mechanical ventilation:the Spanish Lung Failure Collaborative Group[J]. Am J Respir Crit Care Med,1999; 159(7):512-518.
[5]Vallverdu I, Calaf N, Subirana M, et al. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation[J]. Am J Respir Crit Care Med,2005,158(12):1855-1862.
[6]Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation[J]. Chest,1997,112(10):186-192.
[7]Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation[J]. Am J Respir Crit Care Med,2006,161(5):1912-1916.
[8]Ely EW, Baker AM, Evans GW, et al. The prognostic significance of passing a daily screen of breathing spontaneously[J]. N Engl J Med,2005,25(9):581-587.
[9]Fagon JY, Chastre J, Hance AJ, et al. Nosocomial pneumonia in ventilated patients:a cohort study evaluating atributable mortality and hospital stay[J]. Am J Med,1993, 94(5):281-288.
[10]Esteban A, Anzueto A, Frutos F, et al. Mechanical ventilation international study group, characteristics and outcomes in adult patients receiving mechanical ventilation: a 28 day international study[J]. JAMA,2007,287(12):345-355.
[11]Manthous CA. Summarizing the logistics of liberation from mechanical ventilation: the pathogenesis of respiratory failure[J]. Respir Care Clin N Am,2007,16(3): 443-468.
[12]E Tejerina, F Frutos-Vivar, et al. Incidence,risk factors and outcome of ventilator associated pneumonia[J]. Crit Care,2006,21 (1):56-65.
[13]Hillns. Following protocol weaning difficult-to-wean patients with chronic obstructive pulmonary disease[J]. Am J Resp Cri Care Med,2007,12(3):164-165.
[14]Goldstone J. The pulmonary physician in critical care 10:Difficulty weaning [J]. Thorax,2002,57(11),986-991.
[15]Nozawa E, Azeka E, Ignez M, et al. Factors associated with failure of weaning from long-term mechanical ventilation after cadiac surgery[J]. Int Heart J September,2005, 46(5):819-831.
[16]Quinnell TG, Pilsworth S, Shneerson JM, et al. Prolonged invasive ventilation following acute ventilator failure in COPD[J]. Chest,2006,129(1):133—139.
[17]Ferrer M, Esquians A, Aranclbia F, et al. Noninvasive ventilation during persistent weaning failure[J]. American Journal of Respiratory and Critical Care Medicine,2008, 168(10):70-76.
[18]Rubini F. Factors determining the successful weaning of patients with "difficult weaning"[J]. Minerva Anestesiol,2008,64(11):513-520.
[19]Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation[J]. Eur Respir J,2007,29(5):1033-1056.
[20]Alia I, Esteban A. Weaning from mechanical ventilation[J]. Critical Care,2005,25(4): 72-80.
[21]Goldstone J. The pulmonary physician in critical care:difficule weaning[J]. Thorax, 2005,57(6):986-991.
[22]Bill Prultt. Weaning patients from mechanical ventilation[J]. Nursing,2006,36(9): 36-41.
[23]Perren A, Alia I, Esteban A. Weaning from mechanical ventilation[J]. Crit Care,2005, 15(4):177-184.
[24]O'keefe GE, Hawkins K, Boynton J, et al. Indicator of fatigue and of prolonged weaning from mechanical ventilation in surgical patients[J]. World J Surg,2006,25 (5):98-103.
[25]Bion J, Connors A, Gold stone. The pulmonary physician in critical care[J]. Thorax, 2006,37(6):86-91.
[26]Maramattom BV, Wijdicks EF. Acute neuromuscular weekness in the intensivecare unit[J]. Cri Care Med,2006,34(11):2835-2841.
[27]Amaya Villar R, Garnacho-NionteroJ, Ortiz-LeybaC, et al. Polyneuropathy and discontinuation from mechanical ventilation[J]. Critical Care/Respiratory Care,2006, 13(6):348-352.
[28]Garnacho Montero J, Amqga-Viller R, Garcia-Garmendia JL, et al. Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of staying septic patients[J]. Crit care Med,2005,33(2):349-354.
[29]Chang AT, Bootos RJ, Brown MG, et al. Reduced inspiratory muscle endurance following successful weaning from prolonged mechanical ventilation[J]. Chest,2005, 128(7):553-559.
[30]Sadar N, Dezfulian C, Collard HR, et al. Clinical and economic consequences of ventilator-associated pneumonia:a systematic review[J]. Crit Care Med,2005,33(10): 2184-2198.
[31]中华医学会重症医学分会,机械通气临床应用指南(2006)[M].中国危重病急救医学,2007,19(2)：65-72.
[32]Cohen JD, Shapiro M. Exlubation oulcome following a spontaneous breathing trial with automatic tube compensation versus continuous positivetive airway pressure[J]. Crit Care Med,2006,34(3):682—686.
[33]MaIntyre NB, Cook DJ, Ely EW Jr, et al. Evidence based guidelines for weaning and discontinuing ventilator support:a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine[J]. Chest,2008,120(12):375-386.
[34]罗祖会,詹庆元,孙兵,等.自主呼吸试验的操作与临床应用[J].中国呼吸与危重监护杂志,2006,5(1)：60-68.
[35]Perren A, Domenighetti G, Mauri S, et al. Protocol-directed weaning from mechanical ventilation:clinical outcome in patients randomized for a 30-min or 120-min trial with pressure support ventilation[J]. Intensive Care Med,2008,28(10): 1058-1063.
[36]徐磊,展春,张纳新,等.自主呼吸试验在机械通气撤机过程中的应用[J].中国危重病急救医学,2002,14(3)：144-149.
[37]Boles JM, Bion J, Connors A, et al. Successful weaning from mechancal ventilation[J]. Eur Respir J,2008,20(8):122-148.
[38]Mancebo J, Roum J. Weaning difficult-to-wean patients[J]. Eur Respir J,2007,20(4): 103-108.
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