密闭式气管内吸痰对急性呼吸窘迫综合征影响的实验与临床研究
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摘要
目的：通过动物实验和临床实验，研究更适宜急性呼吸窘迫综合征(ARDS)机械通气患者气管内吸痰的方式及护理方法。方法：1．动物实验部分：采用静脉注射油酸制备犬ARDS模型，随机选择开放式气管内吸痰(OS)和密闭式气管内吸痰(CS)顺序，于吸痰前2min、吸痰后0.5min、5min、10min抽取动脉血及混合静脉血进行血气分析，并记录呼吸力学、血流动力学等监测指标的数据。2．临床研究部分：在外科重症监护病房(SICU)选取诊断ARDS并行机械通气治疗的患者。每名患者使用OS和CS两种吸痰方式，吸痰顺序随机选择。于吸痰前2min、吸痰后0.5min、5min、10min抽取动脉血进行血气分析，并记录吸气峰压(Ppeak)、平台压(Pplat)、心率(HR)、平均动脉压(MAP)、脉搏血氧饱和度(SpO_2)、呼吸末正压(PEEP)、潮气量(V_T)等数据。结果：1．动物实验部分：①吸痰方式对气体交换的影响：OS后，动脉血氧分压(PaO_2)、动脉血氧饱和度(SaO_2)、氧合指数(PaO_2／FiO_2)明显降低，肺泡-动脉血氧分压差(P(A-a)DO_2)明显增大(P＜0.05)；CS前后PaO_2、SaO_2等指标变化无明显差异(P＞0.05)。②吸痰方式对呼吸力学影响：OS和CS后，Ppeak、Pplat、平均气道压力(Pmean)与吸痰前比较均明显上升(P＜0.05)；肺动态
解放军总医院军医进修学院硕士学位论文
摘要
顺应性(Co)、静态顺应性(CS)05后显著下嗽六0.05)。③吸痰方
式对血流动力学的影响:05和CS后，平均肺动脉压(NIPAP)与
吸疾前比较均明显升高(尸丈0.05); 05后MAp显著升高任欠0.05)。
2.临床研究部分:①吸疾方式对气体交换的影响:05后患者PaOZ、
s心、SpQZ与吸疾前比显著喇氏(尸<。.05); CS前后比较上断旨标
无显著性差异沙卜0.05)。②吸痰方式冲呼吸力学影响:05和CS后
患者巧姆砍、即lat、Cs、CD增高与吸疾前比较无显著性差异(尸)0.05)。
③吸疾方式时1目IR和血压的影响:05和CS后患者HR、动脉收缩压
(SBP)、M叭P与吸疾前比较均显著增高(尸<0.05)。结刹狱OS加重
患制配氮血症;CS过程中可以保持持续通气，维持PEI护及气道压
力，Fiq，PaOZ、SaOZ变化不大沙)0.05)，道岁寸于习豁台疗重点放在
肺泡复张和保持肺容积上的ARDS患者非常重要。05、CS均可影响
气道压力及血流动力学的稳定。本研究提示我了门，在护理工作中，对
ARDS患者应重视吸疾引起的继发损害，加强吸痰前后血气、气道
压力、HR、动月和鱼压等监测;对于ARDS患者吸痰时选择CS方式
更适宜和安全。
Objective: The aim of our study is to find the better ways of endotracheal
suctioning and caring in the ARDS mechanical ventilated patients through
animal and clinical work.
Methods:
Part 1 Animal study:
Tracheal intubated mongrel dogs were injured by injecting oleic acid to build
up ARDS models. Each dog was suctioned with opened endotracheal
suctioning(OS) and closed endotracheal suctioning(CS) in randomized order.
The data of arterial blood gas and mixed venous blood gas were obtained at
2min before suction and at 0.5, 5 and 10min after suction, and indexes of
hemocfynamics and respiratory mechanics were attached.
Part 2 Clinical study:
14 ARDS ventilated patients in SICU were enrolled. Both OS and CS suction
techniques were performed on each patient in randomized order. Arterial
blood gas index was obtained at 2min before suction and at 0.5,5 and 10min
after suction. The data of inspiratory peak pressure (Ppeak), inspiratory
plateau pressure (Pplat), heart rate (HR), mean arterial pressure (MAP),
oxygen saturation by pulse oximetry (SpO2), positive end expiratory pressure
(PEEP), and tidal volume (VT) were recorded during performing suction
techniques in ARDS patients.
Results:
Part 1 Animal study:
(1)Gas exchange. After performing OS technique, there showed obvious
decreasing in the data of arterial oxygen partial pressure (PaO2), arterial
oxygenation (SaO2) and arterial oxygenation partial pressure/ fractional
inspired oxygen (PaO2/ FiO2), and the data of alveolar-arterial oxygen partial
pressure difference [P(A-a)DO2]] got worsen (PO.05). There were not
significant differences in the indexes of PaQ and SaO2 between before CS
and after CS(PX).05).
(2)Respiratory Mechanics, There were significant increasing in the data of
Ppeak, Pplat and mean airway pressure (Pmean) after suction compared to
before suction in two suction ways (PO.05). On the contrary, the data of
pulmonary static compliance (Cs) and pulmonary dynamic compliance (CD)
got worsen after OS compared to before OS (PO.05).
(3)Hemodynamics. In the two suction ways, the data of mean pulmonary
arterial pressure (MPAP) significantly raised after suction (PO.05), but only
mean arterial pressure (MAP) raised after performing OS (PO.05).
Part 2 Clinical study
(1)Gas exchange and Metabolism. There showed significant decreases in the
data of PaO2, SaO2 and SpO2 after OS (PO.05). There were not statistical
differences between after CS and before CS.
(2)Respiratory Mechanics. In the two suction ways, there were not significant
differences in Ppeak, Pplat, CD and Cs between after and before suction.
(3)HR and Blood Pressure. Significant increases were found in HR, systolic
blood pressure (SBP) and MAP after OS and CS(PO.05).
Conclusions: In our experimental and clinical work, we found that the
harmful effect of OS is causing deteriorated hypoxemia. Compared to OS
technique, CS technique showed favorable effects in maintaining PEEP effect
and confirming continuous ventilation during performing suction ways, and it
did not cause obviously worsen in FiO2, PaO2 and SaO2(P>0.05) during
performing CS techniques. This is very important for ARDS patients on preventing alveolar recruitment and maintaining lung volume derecruitment In our study, we also found that both OS and CS had obvious influencing on hemodynarnics and airway pressure, and it remind us that we should pay more attention to the potential damages that caused by suction ways and we should intensify monitoring the changes of airway pressure, HR and arterial pressure during performing endotracheal suction ways in clinical nursing practice. In conclusion, compared to OS, we think that CS technique is comparatively safer and more comfortable for ARDS patients.
解放军总医院军医进修学院硕士学位论文
摘要
顺应性(Co)、静态顺应性(CS)05后显著下嗽六0.05)。③吸痰方
式对血流动力学的影响:05和CS后，平均肺动脉压(NIPAP)与
吸疾前比较均明显升高(尸丈0.05); 05后MAp显著升高任欠0.05)。
2.临床研究部分:①吸疾方式对气体交换的影响:05后患者PaOZ、
s心、SpQZ与吸疾前比显著喇氏(尸<。.05); CS前后比较上断旨标
无显著性差异沙卜0.05)。②吸痰方式冲呼吸力学影响:05和CS后
患者巧姆砍、即lat、Cs、CD增高与吸疾前比较无显著性差异(尸)0.05)。
③吸疾方式时1目IR和血压的影响:05和CS后患者HR、动脉收缩压
(SBP)、M叭P与吸疾前比较均显著增高(尸<0.05)。结刹狱OS加重
患制配氮血症;CS过程中可以保持持续通气，维持PEI护及气道压
力，Fiq，PaOZ、SaOZ变化不大沙)0.05)，道岁寸于习豁台疗重点放在
肺泡复张和保持肺容积上的ARDS患者非常重要。05、CS均可影响
气道压力及血流动力学的稳定。本研究提示我了门，在护理工作中，对
ARDS患者应重视吸疾引起的继发损害，加强吸痰前后血气、气道
压力、HR、动月和鱼压等监测;对于ARDS患者吸痰时选择CS方式
更适宜和安全。
Objective: The aim of our study is to find the better ways of endotracheal
suctioning and caring in the ARDS mechanical ventilated patients through
animal and clinical work.
Methods:
Part 1 Animal study:
Tracheal intubated mongrel dogs were injured by injecting oleic acid to build
up ARDS models. Each dog was suctioned with opened endotracheal
suctioning(OS) and closed endotracheal suctioning(CS) in randomized order.
The data of arterial blood gas and mixed venous blood gas were obtained at
2min before suction and at 0.5, 5 and 10min after suction, and indexes of
hemocfynamics and respiratory mechanics were attached.
Part 2 Clinical study:
14 ARDS ventilated patients in SICU were enrolled. Both OS and CS suction
techniques were performed on each patient in randomized order. Arterial
blood gas index was obtained at 2min before suction and at 0.5,5 and 10min
after suction. The data of inspiratory peak pressure (Ppeak), inspiratory
plateau pressure (Pplat), heart rate (HR), mean arterial pressure (MAP),
oxygen saturation by pulse oximetry (SpO2), positive end expiratory pressure
(PEEP), and tidal volume (VT) were recorded during performing suction
techniques in ARDS patients.
Results:
Part 1 Animal study:
(1)Gas exchange. After performing OS technique, there showed obvious
decreasing in the data of arterial oxygen partial pressure (PaO2), arterial
oxygenation (SaO2) and arterial oxygenation partial pressure/ fractional
inspired oxygen (PaO2/ FiO2), and the data of alveolar-arterial oxygen partial
pressure difference [P(A-a)DO2]] got worsen (PO.05). There were not
significant differences in the indexes of PaQ and SaO2 between before CS
and after CS(PX).05).
(2)Respiratory Mechanics, There were significant increasing in the data of
Ppeak, Pplat and mean airway pressure (Pmean) after suction compared to
before suction in two suction ways (PO.05). On the contrary, the data of
pulmonary static compliance (Cs) and pulmonary dynamic compliance (CD)
got worsen after OS compared to before OS (PO.05).
(3)Hemodynamics. In the two suction ways, the data of mean pulmonary
arterial pressure (MPAP) significantly raised after suction (PO.05), but only
mean arterial pressure (MAP) raised after performing OS (PO.05).
Part 2 Clinical study
(1)Gas exchange and Metabolism. There showed significant decreases in the
data of PaO2, SaO2 and SpO2 after OS (PO.05). There were not statistical
differences between after CS and before CS.
(2)Respiratory Mechanics. In the two suction ways, there were not significant
differences in Ppeak, Pplat, CD and Cs between after and before suction.
(3)HR and Blood Pressure. Significant increases were found in HR, systolic
blood pressure (SBP) and MAP after OS and CS(PO.05).
Conclusions: In our experimental and clinical work, we found that the
harmful effect of OS is causing deteriorated hypoxemia. Compared to OS
technique, CS technique showed favorable effects in maintaining PEEP effect
and confirming continuous ventilation during performing suction ways, and it
did not cause obviously worsen in FiO2, PaO2 and SaO2(P>0.05) during
performing CS techniques. This is very important for ARDS patients on preventing alveolar recruitment and maintaining lung volume derecruitment In our study, we also found that both OS and CS had obvious influencing on hemodynarnics and airway pressure, and it remind us that we should pay more attention to the potential damages that caused by suction ways and we should intensify monitoring the changes of airway pressure, HR and arterial pressure during performing endotracheal suction ways in clinical nursing practice. In conclusion, compared to OS, we think that CS technique is comparatively safer and more comfortable for ARDS patients.
引文
1．俞森洋，主编．现代机械通气的监护和临床应用．北京：中国协和医科大学出版社，2000：398-406．
2. Patroniti N, Foti G, Cortinovis B, et al. Sigh improves gas exchange and lung volume in patients with acute respiratory distress syndrome undergoing pressure support ventilation. Anesthesiology, 2002, 96(4): 788-794.
3. Wickerts CJ, Blomqvist H, Baehrendtz S, et al. Clinical application of differential ventilation with selective positive end-expiratory pressure in adult respiratory distress syndrome. Acta Anaesthesiol Scand, 1995 39(3): 307-11.
4．刘又宁，主编．机械通气与治疗(第二版)．北京：科学出版社，1998：79，211-225．
5．王茹，冯玉英．急性呼吸窘迫综合征的监测及呼吸道管理．张家口医学院学报，2003，17(1)：93-94．
6．韩淑贞，王立祥，韦中余等．ARDS病人吸痰前后不同氧供方法对SPO2的影响．护理学杂志，2002，17(9)：643-646．
7. McIntosh D, Baun MM, Rogge J. Effects of lung hyperinflation and presence of positive end-expiratory pressure on arterial and tissue oxygenation during endotracheal suctioning. Am J Crit Care. 1993, 2(4): 317-25.
8．朱艳萍，杨言诚，刘夕珍等．预充氧对减少吸痰导致组织缺氧的临床观察．中华护理杂志，1999，34(12)：714-7165．
9．王建荣，王洋，刘喜梅．高度氧合、过度通气对心脏手术患者吸痰后动脉血氧的影响．军医进修学院学报，1996，17(6)：277-279．
10. Carlon GC, Fox SJ, Ackerman NJ. Evaluation of a closed-tracheal suction system. Crit Care Med, 1987, 15(5): 522-525.
11. Stenqvist O, Lindgren S, Karason S, et al. Warning! Suctioning. A lung model evaluation of closed suctioning systems. Acta Anaesthesiol Scand, 2001,45(2): 167-72.
12. June AT, Nancy LD, James SS. Airway Pressures during closed system suctioning. Heart-Lung, 1988, 17(5): 536-542.
13. Noll ML, Hix CD, Scott G. Closed tracheal suction systems: effectiveness and nursing implications. Aacn Clin Issues Crit Care Nurs, 1990, 1(2): 318-28.
14. Crimlisk JT, Paris R, McGonagle EG, et al. The closed tracheal suction system: implications for critical care nursing. Dimens Crit Care Nurs, 1994, 13(6): 292-300.
15. Webb CH, Hogg GM. Contamination of multi-use closed tracheal suction catheters: an in-vitro study. J Hosp Infect, 1995, 31(3): 219-224.
16．张为华，倪为东．密闭吸痰管的临床应用．重庆医科大学学报，2003，28(1)：109．
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2. Patroniti N, Foti G, Cortinovis B, et al. Sigh improves gas exchange and lung volume in patients with acute respiratory distress syndrome undergoing pressure support ventilation. Anesthesiology, 2002, 96(4): 788-794.
3. Wickerts CJ, Blomqvist H, Baehrendtz S, et al. Clinical application of differential ventilation with selective positive end-expiratory pressure in adult respiratory distress syndrome. Acta Anaesthesiol Scand, 1995 39(3): 307-11.
4．刘又宁，主编．机械通气与治疗(第二版)．北京：科学出版社，1998：79，211-225．
5．王茹，冯玉英．急性呼吸窘迫综合征的监测及呼吸道管理．张家口医学院学报，2003，17(1)：93-94．
6．韩淑贞，王立祥，韦中余等．ARDS病人吸痰前后不同氧供方法对SPO2的影响．护理学杂志，2002，17(9)：643-646．
7. McIntosh D, Baun MM, Rogge J. Effects of lung hyperinflation and presence of positive end-expiratory pressure on arterial and tissue oxygenation during endotracheal suctioning. Am J Crit Care. 1993, 2(4): 317-25.
8．朱艳萍，杨言诚，刘夕珍等．预充氧对减少吸痰导致组织缺氧的临床观察．中华护理杂志，1999，34(12)：714-7165．
9．王建荣，王洋，刘喜梅．高度氧合、过度通气对心脏手术患者吸痰后动脉血氧的影响．军医进修学院学报，1996，17(6)：277-279．
10. Carlon GC, Fox SJ, Ackerman NJ. Evaluation of a closed-tracheal suction system. Crit Care Med, 1987, 15(5): 522-525.
11. Stenqvist O, Lindgren S, Karason S, et al. Warning! Suctioning. A lung model evaluation of closed suctioning systems. Acta Anaesthesiol Scand, 2001,45(2): 167-72.
12. June AT, Nancy LD, James SS. Airway Pressures during closed system suctioning. Heart-Lung, 1988, 17(5): 536-542.
13. Noll ML, Hix CD, Scott G. Closed tracheal suction systems: effectiveness and nursing implications. Aacn Clin Issues Crit Care Nurs, 1990, 1(2): 318-28.
14. Crimlisk JT, Paris R, McGonagle EG, et al. The closed tracheal suction system: implications for critical care nursing. Dimens Crit Care Nurs, 1994, 13(6): 292-300.
15. Webb CH, Hogg GM. Contamination of multi-use closed tracheal suction catheters: an in-vitro study. J Hosp Infect, 1995, 31(3): 219-224.
16．张为华，倪为东．密闭吸痰管的临床应用．重庆医科大学学报，2003，28(1)：109．
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