安福成

·論著·

綜合治療對(duì)老年慢性阻塞性肺疾病所致急性呼吸衰竭患者的臨床療效研究

安福成

目的 觀察綜合治療對(duì)老年慢性阻塞性肺疾病(COPD)所致急性呼吸衰竭患者的臨床療效。方法 選取2011年7月—2013年8月北京市門頭溝區(qū)醫(yī)院收治的90例老年COPD所致急性呼吸衰竭患者。按照隨機(jī)數(shù)字表法將患者分為3組，即無(wú)創(chuàng)組、序貫組、綜合治療組，各30例。3組患者在常規(guī)治療的基礎(chǔ)上分別給予無(wú)創(chuàng)通氣治療、有創(chuàng)-無(wú)創(chuàng)序貫通氣治療和綜合治療。檢測(cè)3組患者治療前和治療后4 h、2 d、12 d的急性生理與慢性健康評(píng)分Ⅱ(APACHEⅡ)評(píng)分、克里斯(CRIS)評(píng)分、呼吸頻率(RR)、心率(HR)、平均動(dòng)脈壓(MAP)、動(dòng)脈血?dú)夥治觥矂?dòng)脈血氧分壓(PaO2)、動(dòng)脈血二氧化碳分壓(PaCO2)〕、白細(xì)胞計(jì)數(shù)(WBC)。治療后記錄3組患者肺部感染控制(PIC)窗出現(xiàn)時(shí)間、有創(chuàng)通氣時(shí)間、總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、呼吸機(jī)相關(guān)肺炎(VAP)發(fā)生率及住院病死率。檢測(cè)患者入院時(shí)及治療后30 d日間自主呼吸狀態(tài)下第1秒末用力呼氣容積(FEV1)、最大呼氣容積(FVC)，比較患者肺通氣功能〔FEV1占預(yù)計(jì)值百分比(FEV1%)、FEV1/FVC〕。結(jié)果 序貫組、綜合治療組治療后2 d和治療后12 d RR、HR、PaCO2、WBC低于無(wú)創(chuàng)組，序貫組、綜合治療組治療后2 d PaO2高于無(wú)創(chuàng)組，綜合治療組治療后12 d PaO2高于無(wú)創(chuàng)組(P<0.05)；綜合治療組治療后2 d和治療后12 d RR、PaCO2、WBC低于序貫組，PaO2高于序貫組，綜合治療組治療后2 d HR低于序貫組(P<0.05)。3組治療后2 d和治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、PaCO2、WBC分別低于本組治療前，PaO2分別高于本組治療前，序貫組、綜合治療組治療后4 h WBC分別低于本組治療前(P<0.05)；3組治療后2 d和治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、PaCO2分別低于本組治療后4 h，PaO2分別高于本組治療后4 h，3組治療后12 d RR、HR、WBC分別低于本組治療后4 h，序貫組、綜合治療組治療后2 d HR、WBC分別低于本組治療后4 h(P<0.05)；3組治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、PaCO2、WBC分別低于本組治療后2 d，PaO2分別高于本組治療后2 d(P<0.05)。序貫組有創(chuàng)通氣時(shí)間、VAP發(fā)生率大于無(wú)創(chuàng)組，總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間小于無(wú)創(chuàng)組(P<0.05)；綜合治療組有創(chuàng)通氣時(shí)間、VAP發(fā)生率大于無(wú)創(chuàng)組，總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間小于無(wú)創(chuàng)組(P<0.05)；綜合治療組有創(chuàng)通氣時(shí)間、總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、VAP發(fā)生率小于序貫組(P<0.05)。序貫組、綜合治療組治療后30 d FEV1%、FEV1/FVC大于無(wú)創(chuàng)組(P<0.05)；綜合治療組治療后30 d FEV1%、FEV1/FVC大于序貫組(P<0.05)。3組治療后30 d FEV1%、FEV1/FVC均大于本組入院時(shí)(P<0.05)。結(jié)論 綜合治療對(duì)老年COPD所致急性呼吸衰竭患者的臨床療效優(yōu)于無(wú)創(chuàng)通氣治療、有創(chuàng)-無(wú)創(chuàng)序貫通氣治療方式，其有助于改善患者肺功能，縮短機(jī)械通氣時(shí)間、住院時(shí)間，進(jìn)而降低患者的病死率。

肺疾病,慢性阻塞性；呼吸功能不全；無(wú)創(chuàng)通氣治療；有創(chuàng)-無(wú)創(chuàng)序貫通氣治療；綜合治療

安福成.綜合治療對(duì)老年慢性阻塞性肺疾病所致急性呼吸衰竭患者的臨床療效研究[J].中國(guó)全科醫(yī)學(xué)，2017，20(9)：1049-1054.[www.chinagp.net]

AN F C.Clinical efficacy observation of comprehensive therapy on patients with acute respiratory failure induced by chronic obstructive pulmonary disease[J].Chinese General Practice，2017，20(9)：1049-1054.

慢性阻塞性肺疾病(COPD)屬于慢性呼吸系統(tǒng)疾病的一種，是以氣流受限為主要特征的肺部疾病，同時(shí)伴有對(duì)有害氣體或者顆粒物的異常炎性反應(yīng)。當(dāng)前，COPD發(fā)病率高，且患者肺功能進(jìn)行性下降，其生活質(zhì)量及壽命受到嚴(yán)重影響[1]。近年來(lái)國(guó)內(nèi)外已將有創(chuàng)通氣治療、無(wú)創(chuàng)通氣治療、有創(chuàng)-無(wú)創(chuàng)序貫通氣治療、綜合治療(包括纖維支氣管鏡吸痰，聯(lián)合霧化吸入異丙托溴銨、沙丁胺醇和布地奈德)等治療方式應(yīng)用于COPD所致急性呼吸衰竭患者的治療[2]。研究顯示，長(zhǎng)期家庭無(wú)創(chuàng)通氣治療穩(wěn)定期COPD合并Ⅱ型呼吸衰竭療效良好，減少了患者COPD急性發(fā)作[3]。但對(duì)綜合治療與無(wú)創(chuàng)通氣治療和有創(chuàng)-無(wú)創(chuàng)序貫通氣治療療效的比較鮮有報(bào)道。因此，本研究采用前瞻性隊(duì)列研究方法對(duì)無(wú)創(chuàng)通氣治療、有創(chuàng)-無(wú)創(chuàng)序貫通氣治療、綜合治療的療效進(jìn)行比較，評(píng)價(jià)綜合治療在COPD所致急性呼吸衰竭患者中的治療價(jià)值，為臨床治療提供依據(jù)。

1 資料與方法

1.1 納入標(biāo)準(zhǔn) 滿足中華醫(yī)學(xué)會(huì)呼吸病學(xué)會(huì)慢性阻塞性肺疾病學(xué)組制定的COPD急性加重和呼吸衰竭的診斷標(biāo)準(zhǔn)[4]。

1.2 排除標(biāo)準(zhǔn) (1)肝腎功能不全的患者；(2)患有原發(fā)性心臟疾病者；(3)有機(jī)械通氣禁忌證的患者；(4)頭面部有創(chuàng)傷或者鼻咽部異常而無(wú)法進(jìn)行無(wú)創(chuàng)通氣治療的患者；(5)患有中樞神經(jīng)系統(tǒng)疾病而無(wú)法配合治療的患者。

1.3 一般資料 選取2011年7月—2013年8月北京市門頭溝區(qū)醫(yī)院收治的90例老年COPD所致急性呼吸衰竭患者。按照隨機(jī)數(shù)字表法將患者分為3組，即無(wú)創(chuàng)組、序貫組、綜合治療組，各30例。其中無(wú)創(chuàng)組男17例、女13例，平均年齡(69.2±6.0)歲，平均體質(zhì)量(63.0±14.2)kg，平均COPD病程(7.6±3.2)年；序貫組男19例、女11例，平均年齡(71.5±5.3)歲，平均體質(zhì)量(67.0±12.5)kg，平均COPD病程(7.5±4.1)年；綜合治療組男16例、女14例，平均年齡(70.8±4.4)歲，平均體質(zhì)量(64.6±13.1)kg，平均COPD病程(7.8±3.9)年。各組患者性別、年齡、體質(zhì)量、COPD病程比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(χ2=0.638，P=0.727；F=1.500，P=0.229；F=0.690，P=0.505；F=0.050，P=0.952)。

1.4 治療方法 3組患者均給予抗感染、解痙平喘、支氣管擴(kuò)張藥物、糖皮質(zhì)激素、維持水電解質(zhì)平衡等常規(guī)治療，并預(yù)防或治療肺動(dòng)脈高壓。無(wú)創(chuàng)組：在常規(guī)治療的基礎(chǔ)上，采用凱迪泰無(wú)創(chuàng)呼吸機(jī)進(jìn)行輔助通氣，通氣模式為壓力支持通氣(PSV)加呼氣末正壓通氣(PEEP)。根據(jù)患者的病情設(shè)置各項(xiàng)參數(shù)：PSV從8～10 cm H2O(1 cm H2O=0.098 kPa)逐漸增加到15～20 cm H2O，PEEP從4 cm H2O逐漸增加到6～7 cm H2O，呼吸頻率(RR)為8～14次/min，待患者病情好轉(zhuǎn)后逐漸下調(diào)壓力和減少使用時(shí)間，直到終止無(wú)創(chuàng)通氣。序貫組：在常規(guī)治療的基礎(chǔ)上實(shí)施氣管插管機(jī)械通氣，模式為同步間歇指令通氣(SIMV)+PSV+PEEP。當(dāng)出現(xiàn)肺部感染控制(PIC)窗時(shí)給予拔管處理，再繼續(xù)使用無(wú)創(chuàng)呼吸機(jī)輔助通氣，直至脫機(jī)。綜合治療組：在常規(guī)治療的基礎(chǔ)上，進(jìn)行有創(chuàng)-無(wú)創(chuàng)序貫通氣治療，并在氣管插管12 h內(nèi)利用纖維支氣管鏡對(duì)患者進(jìn)行吸痰處理，另外利用超聲聯(lián)合霧化吸入異丙托溴銨、沙丁胺醇及布地奈德等藥物。

1.5 觀察指標(biāo)

1.5.1 治療前后各臨床指標(biāo) 檢測(cè)3組患者治療前和治療后4 h、2 d、12 d的急性生理與慢性健康評(píng)分Ⅱ(APACHEⅡ)評(píng)分、克里斯(CRIS)評(píng)分、RR、心率(HR)、平均動(dòng)脈壓(MAP)、動(dòng)脈血?dú)夥治觥矂?dòng)脈血氧分壓(PaO2)、動(dòng)脈血二氧化碳分壓(PaCO2)〕、白細(xì)胞計(jì)數(shù)(WBC)。

1.5.2 治療后有關(guān)指標(biāo) 治療后記錄3組患者PIC窗出現(xiàn)時(shí)間、有創(chuàng)通氣時(shí)間、總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、呼吸機(jī)相關(guān)肺炎(VAP)發(fā)生率及住院病死率。

1.5.3 肺通氣功能 檢測(cè)患者入院時(shí)及治療后30 d日間自主呼吸狀態(tài)下第1秒末用力呼氣容積(FEV1)、最大呼氣容積(FVC)，比較患者肺通氣功能〔FEV1占預(yù)計(jì)值百分比(FEV1%)、FEV1/FVC〕。

2 結(jié)果

2.1 治療前后各臨床指標(biāo)比較 不同治療方法與時(shí)間間存在交互作用(P<0.05)。組間APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、MAP、PaO2、PaCO2、WBC比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。序貫組、綜合治療組治療后2 d和治療后12 d RR、HR、PaCO2、WBC低于無(wú)創(chuàng)組，序貫組、綜合治療組治療后2 d PaO2高于無(wú)創(chuàng)組，綜合治療組治療后12 d PaO2高于無(wú)創(chuàng)組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；綜合治療組治療后2 d和治療后12 d RR、PaCO2、WBC低于序貫組，PaO2高于序貫組，綜合治療組治療后2 d HR低于序貫組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。不同時(shí)間間APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、MAP、PaO2、PaCO2、WBC比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。3組治療后2 d和治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、PaCO2、WBC分別低于本組治療前，PaO2分別高于本組治療前，序貫組、綜合治療組治療后4 h WBC分別低于本組治療前，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；3組治療后2 d和治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、PaCO2分別低于本組治療后4 h，PaO2分別高于本組治療后4 h，3組治療后12 d RR、HR、WBC分別低于本組治療后4 h，序貫組、綜合治療組治療后2 d HR、WBC分別低于本組治療后4 h，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；3組治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、PaCO2、WBC分別低于本組治療后2 d，PaO2分別高于本組治療后2 d，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表1)。

2.2 治療后有關(guān)指標(biāo)比較 3組PIC窗出現(xiàn)時(shí)間、住院病死率比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)；3組有創(chuàng)通氣時(shí)間、總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、VAP發(fā)生率比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。序貫組有創(chuàng)通氣時(shí)間、VAP發(fā)生率大于無(wú)創(chuàng)組，總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間小于無(wú)創(chuàng)組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；綜合治療組有創(chuàng)通氣時(shí)間、VAP發(fā)生率大于無(wú)創(chuàng)組，總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間小于無(wú)創(chuàng)組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；綜合治療組有創(chuàng)通氣時(shí)間、總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、VAP發(fā)生率小于序貫組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表2)。

表1 3組治療前后各臨床指標(biāo)比較

注：與無(wú)創(chuàng)組比較，aP<0.05；與序貫組比較，bP<0.05；與治療前比較，cP<0.05；與治療后4 h比較，dP<0.05；與治療后2 d比較，eP<0.05；APACHEⅡ=急性生理與慢性健康評(píng)分Ⅱ，CRIS評(píng)分=克里斯評(píng)分，RR=呼吸頻率，HR=心率，MAP=平均動(dòng)脈壓，PaO2=動(dòng)脈血氧分壓，PaCO2=動(dòng)脈血二氧化碳分壓，WBC=白細(xì)胞計(jì)數(shù)

表2 3組治療后有關(guān)指標(biāo)比較

注：a為χ2值；與無(wú)創(chuàng)組比較，bP<0.05；與序貫組比較，cP<0.05；PIC窗=肺部感染控制窗，VAP=呼吸機(jī)相關(guān)肺炎

2.3 肺通氣功能比較 3組入院時(shí)FEV1%、FEV1/FVC比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)；3組治療后30 d FEV1%、FEV1/FVC比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。序貫組、綜合治療組治療后30 d FEV1%、FEV1/FVC大于無(wú)創(chuàng)組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；綜合治療組治療后30 d FEV1%、FEV1/FVC大于序貫組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。3組治療后30 d FEV1%、FEV1/FVC均大于本組入院時(shí)，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表3)。

表3 3組肺通氣功能比較

注：與無(wú)創(chuàng)組比較，aP<0.05；與序貫組比較，bP<0.05；與入院時(shí)比較，cP<0.05；FEV1%=第1秒末用力呼氣容積占預(yù)計(jì)值百分比，F(xiàn)EV1=第1秒末用力呼氣容積，F(xiàn)VC=最大呼氣容積

3 討論

COPD是以氣流受限為特征的慢性呼吸系統(tǒng)疾病，COPD并發(fā)呼吸衰竭時(shí)，患者氣道阻力增高，內(nèi)源性呼氣末正壓形成，使呼吸耗能增加進(jìn)而呼吸肌疲勞，致使機(jī)體缺氧，機(jī)體PaO2下降，PaCO2升高，并出現(xiàn)意識(shí)障礙，嚴(yán)重時(shí)會(huì)危及生命[5]。近年來(lái)，無(wú)創(chuàng)通氣治療在呼吸衰竭方面表現(xiàn)出了良好的效果，引起人們的廣泛關(guān)注[6]。然而，無(wú)創(chuàng)通氣治療仍有一些缺點(diǎn)及不足，如不能解決痰栓問(wèn)題，不能保證有效通氣量，無(wú)法完全代替自主呼吸，無(wú)法保證較高的吸氧濃度等[7]。

本研究結(jié)果顯示，3組治療后2 d和治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、PaCO2、WBC分別低于本組治療前，PaO2分別高于本組治療前，序貫組、綜合治療組治療后4 h WBC分別低于本組治療前，3組治療后2 d和治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、PaCO2分別低于本組治療后4 h，PaO2分別高于本組治療后4 h，3組治療后12 d RR、HR、WBC分別低于本組治療后4 h，序貫組、綜合治療組治療后2 d HR、WBC分別低于本組治療后4 h，3組治療后12 d APACHEⅡ評(píng)分、CRIS評(píng)分、RR、HR、PaCO2、WBC分別低于本組治療后2 d，PaO2分別高于本組治療后2 d。表明3種治療方法均可改善患者臨床指標(biāo)，而有創(chuàng)-無(wú)創(chuàng)序貫通氣治療改善患者臨床指標(biāo)的時(shí)間較無(wú)創(chuàng)治療短，綜合治療又較有創(chuàng)-無(wú)創(chuàng)序貫通氣治療短。

有研究表明，有創(chuàng)-無(wú)創(chuàng)序貫通氣治療會(huì)減少有創(chuàng)通氣治療的相關(guān)并發(fā)癥及時(shí)間[8]，但有創(chuàng)-無(wú)創(chuàng)序貫通氣治療是否優(yōu)于無(wú)創(chuàng)通氣治療，尚未見(jiàn)相關(guān)報(bào)道。因此，本研究對(duì)比了有創(chuàng)-無(wú)創(chuàng)序貫通氣治療與無(wú)創(chuàng)通氣治療對(duì)COPD的作用，結(jié)果顯示，序貫組治療后2 d和治療后12 d RR、HR、PaCO2、WBC低于無(wú)創(chuàng)組，治療后2 d PaO2高于無(wú)創(chuàng)組；序貫組總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、VAP發(fā)生率小于無(wú)創(chuàng)組；序貫組治療后30 d FEV1、FEV1/FVC大于無(wú)創(chuàng)組。表明有創(chuàng)-無(wú)創(chuàng)序貫通氣治療在臨床療效、患者預(yù)后方面優(yōu)于無(wú)創(chuàng)通氣治療。序貫組VAP發(fā)生率高于無(wú)創(chuàng)組。而周澤云等[9]研究表明，序貫機(jī)械通氣組的VAP發(fā)生率(5.1%)明顯低于無(wú)創(chuàng)通氣組(23.5%)，可能與有創(chuàng)-無(wú)創(chuàng)序貫通氣治療的機(jī)械通氣時(shí)間不一致有關(guān)。

COPD在臨床中經(jīng)常存在電解質(zhì)紊亂、營(yíng)養(yǎng)不良、循環(huán)功能障礙及低氧血癥等，容易引起呼吸衰竭，且病死率高[10]。尤其是老年COPD患者，中樞神經(jīng)系統(tǒng)抑制和呼吸肌疲勞等導(dǎo)致痰無(wú)法咳出，易在肺部形成痰栓而引起肺部感染，而引流通暢可控制肺部感染。有研究表明，纖維支氣管鏡吸痰會(huì)縮短使用抗生素的時(shí)間，可以促進(jìn)炎癥陰影的消退；其次，霧化吸入激素(布地奈德)可以產(chǎn)生局部抗炎作用，β2受體激動(dòng)劑(沙丁胺醇)可松弛支氣管平滑肌，改善黏液纖毛功能，具有一定的抗炎作用，抗膽堿藥物(異丙托溴銨)可以減少黏液分泌，具有平喘的效果?？鼓憠A藥物(異丙托溴銨)聯(lián)合應(yīng)用短效β2受體激動(dòng)劑(沙丁胺醇)及糖皮質(zhì)激素(布地奈德)可以明顯改善肺功能，且降低治療成本[11]。因此，本研究采用綜合治療方法來(lái)治療老年COPD患者，結(jié)果顯示，綜合治療組治療后2 d和治療后12 d RR、PaCO2、WBC低于序貫組，PaO2高于序貫組，治療后2 d HR低于序貫組；綜合治療組有創(chuàng)通氣時(shí)間、總機(jī)械通氣時(shí)間、ICU住院時(shí)間、總住院時(shí)間、VAP發(fā)生率小于序貫組；綜合治療組治療后30 d FEV1%、FEV1/FVC大于序貫組。表明綜合治療的療效優(yōu)于有創(chuàng)-無(wú)創(chuàng)序貫通氣治療，其可改善患者預(yù)后，且在一定程度上降低治療成本。

綜上所述，綜合治療對(duì)老年COPD所致急性呼吸衰竭患者的臨床療效優(yōu)于無(wú)創(chuàng)通氣治療、有創(chuàng)-無(wú)創(chuàng)序貫通氣治療，值得臨床推薦。本研究局限性在于樣本例數(shù)較少，治療后觀察時(shí)間不長(zhǎng)，缺乏隨訪調(diào)查研究，具體的治療機(jī)制效果尚不清楚，將在下一步研究中深入分析。

本文無(wú)利益沖突。

[1]魏亮.無(wú)創(chuàng)正壓通氣治療老年慢性阻塞性肺疾病并發(fā)急性呼吸衰竭58例臨床分析[J].醫(yī)學(xué)理論與實(shí)踐,2015,28(6):754-756. WEI L.Clinical analysis of noninvasive positive pressure ventilation in the treatment of 58 elderly patients with chronic obstructive pulmonary disease complicated with acute respiratory failure[J].The Journal of Medical Theory and Practice,2015,28(6):754-756.

[2]CALVERLEY P,VLIES B.New pharmacotherapeutic approaches for chronic obstructive pulmonary disease[J].Semin Respir Crit Care Med,2015,36(4):523-542.

[3]金玉女.無(wú)創(chuàng)呼吸機(jī)治療慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭的臨床療效[J].中國(guó)老年學(xué)雜志,2014(21):6020-6022.DOI:10.3969/j.issn.1005-9202.2014.21.036. JIN Y N.Clinical efficacy of noninvasive ventilation in the treatment of chronic obstructive pulmonary disease complicated with type Ⅱ respiratory failure[J].Chinese Journal of Gerontology,2014(21):6020-6022.DOI:10.3969/j.issn.1005-9202.2014.21.036.

[4]中華醫(yī)學(xué)會(huì)呼吸病學(xué)分會(huì)慢性阻塞性肺疾病學(xué)組.慢性阻塞性肺疾病診治指南[J].中華結(jié)核和呼吸雜志,2002,25(8):453-460. Chronic Obstructive Pulmonary Disease,Chinese Academy of Medical Sciences.Guidelines for diagnosis and treatment of chronic obstructive pulmonary disease[J].Chinese Journal of Internal Medicine,2002,25(8):453-460.

[5]朱勤瑞,周政敏.沙美特羅替卡松粉吸入劑對(duì)慢性阻塞性肺疾病合并呼吸衰竭患者超敏C反應(yīng)蛋白和腦鈉肽的影響[J].醫(yī)學(xué)綜述,2014,20(6):1106-1108. ZHU Q R,ZHOU Z M.Impact of salmeterol and fluticasone propionate powder on brain natriuretic peptide and high sensitivity C-reactive protein of COPD patients with respiratory failure[J].Medical Recapitulate,2014,20(6):1106-1108.

[6]童國(guó)強(qiáng),熊小明,羅于琳.無(wú)創(chuàng)正壓通氣治療慢性阻塞性肺疾病合并呼吸衰竭療效觀察[J].實(shí)用心腦肺血管病雜志,2014,22(3):69-70.DOI:10.3969/j.issn.1008-5971.2014.03.036. TONG G Q,XIONG X M,LUO Y L.Curative effect of noninvasive positive pressure ventilation in the treatment of chronic obstructive pulmonary disease complicated with respiratory failure[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2014,22(3):69-70.DOI:10.3969/j.issn.1008-5971.2014.03.036.

[7]鄧清軍,蔡云剛,曾紅玉.無(wú)創(chuàng)正壓通氣治療AECOPD并Ⅱ型呼吸衰竭的臨床療效分析[J].臨床肺科雜志,2008,13(3):286-287. DENG Q J,CAI Y G,ZENG H Y.Clinic effect of non-invssive positive pressure ventilation in treatment for patients with a cute exacerbation of chronic obstructive pulmonary disease and type Ⅱ respiratory failure[J].Journal of Clinical Pulmonary Medicine,2008,13(3):286-287.

[8]甘斌.序貫機(jī)械通氣治療慢性慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭32例[J].廣西醫(yī)學(xué),2010,32(6):683-685.DOI:10.3969/j.issn.0253-4304.2010.06.020. GAN B.Sequential mechanical ventilation in the treatment of 32 patients with chronic obstructive pulmonary disease complicated with type Ⅱ respiratory failure[J].Guangxi Medical Journal,2010,32(6):683-685.DOI:10.3969/j.issn.0253-4304.2010.06.020.

[9]周澤云,吳紅梅.序貫機(jī)械通氣治療慢性阻塞性肺疾病急性加重合并嚴(yán)重Ⅱ型呼吸衰竭的臨床效果與護(hù)理[J].重慶醫(yī)學(xué),2012,41(22):2336-2337.DOI:10.3969/j.issn.1671-8348.2012.22.047. ZHOU Z Y,WU H M.Sequential mechanical ventilation in the treatment of acute exacerbation of chronic obstructive pulmonary disease with severe type Ⅱ respiratory failure[J].Chongqing Medicine,2012,41(22):2336-2337.DOI:10.3969/j.issn.1671-8348.2012.22.047.

[10]楊敏,熊劍飛.無(wú)創(chuàng)通氣治療慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭的療效探討[J].臨床肺科雜志,2009,14(5):577-578. YANG M,XIONG J F.The discussion on curative effect of non-invasive ventilation therapy to COPD patients with type Ⅱ respiratory failure[J].Journal of Clinical Pulmonary Medicine,2009,14(5):577-578.

[11]劉麗平,石斌,王琳,等.老年COPD合并呼吸衰竭患者綜合治療的臨床研究[J].中國(guó)呼吸與危重監(jiān)護(hù)雜志,2010,9(5):476-480. LIU L P,SHI B,WANG L,et al.Integrated treatment in elderly patients with COPD complicated with respiratory failure[J].Chinese Journal of Respiratory and Critical Care Medicine,2010,9(5):476-480.

(本文編輯：崔麗紅)

Clinical Efficacy Observation of Comprehensive Therapy on Patients with Acute Respiratory Failure Induced by Chronic Obstructive Pulmonary Disease

ANFu-cheng

DepartmentofPneumology,BeijingMentougouDistrictHospital,Beijing102300,China

Objective To investigate the clinical efficacy of comprehensive therapy on patients with acute respiratory failure induced by chronic obstructive pulmonary disease (COPD).Methods Ninety patients with acute respiratory failure induced by COPD who were admitted into Beijing Mentougou District Hospital from July 2011 to August 2013 were enrolled in the study.Using random number table,the patients were divided into non-invasive therapy group,sequential therapy group and comprehensive therapy group,with 30 patients in each group.The three groups were given non-invasive ventilation therapy,invasive and non-invasive ventilation sequential therapy and comprehensive therapy respectively based on conventional treatment.Before treatment,and 4 h,2 d and 12 d after treatment,APACHEⅡ score,CRIS score,RR,HR,MAP,results of arterial blood gas analysis (PaO2and PaCO2) and WBC of the three groups were recorded.After treatment,the occurrence time of pulmonary infection control (PIC) window,the occurrence time of ventilator-associated pneumonia (VAP),duration of invasive ventilation,total duration of mechanical ventilation,length of stay in ICU,total length of hospitalization,the incidence of VAP and the case fatality rate during hospitalization were recorded.Before admission and 30 days after treatment,FEV1and FVC of the patients in spontaneous breathing state were measured,and comparison was made among the three groups in FEV1% and FEV1/FVC.Results On 2 d and 12 d after treatment,sequential therapy group and comprehensive therapy group were lower in RR,HR,PaCO2and WBC than non-invasive therapy group (P<0.05);on 2 d after treatment,sequential therapy group and comprehensive therapy group were higher in PaO2than non-invasive therapy group (P<0.05);on 12 d after treatment,comprehensive therapy group was higher in PaO2than non-invasive therapy group (P<0.05);on 2 d and 12 d after treatment,comprehensive therapy group was lower in RR,PaCO2and WBC and higher in PaO2than sequential therapy group (P<0.05);on 2 d after treatment,comprehensive therapy group was lower than sequential therapy group in HR (P<0.05).On 2 d and 12 d after treatment,APACHEⅡ score,CRIS score,RR,HR,PaCO2and WBC of the three groups were lower than those before treatment,and PaO2of the three groups was higher than that before treatment (P<0.05);at 4 h after treatment,WBC of sequential therapy group and comprehensive therapy group was lower than that before treatment (P<0.05);on 2 d and 12 d after treatment,APACHEⅡ score,CRIS score and PaCO2of the three groups were lower than those at 4 h after treatment,and PaO2of the three groups was higher than that at 4 h after treatment (P<0.05);on 12 d after treatment,RR,HR and WBC of the three groups were lower than those at 4 h after treatment (P<0.05);on 2 d after treatment,HR and WBC of sequential therapy group and comprehensive group were lower than those at 4 h after treatment (P<0.05);on 12 d after treatment,APACHEⅡ score,CRIS score,RR,HR,PaCO2and WBC of the three groups were lower than those on 2 d after treatment (P<0.05);on 12 d after treatment,PaO2of the three groups was higher than that on 2 d after treatment (P<0.05).Duration of invasive ventilation,and the incidence of VAP of sequential therapy group were higher than those of non-invasive therapy group (P<0.05);total duration of mechanical ventilation,length of stay in ICU,and total length of hospitalization of sequential therapy group were lower than those of non-invasive therapy group (P<0.05).Duration of invasive ventilation,and the incidence of VAP of comprehensive group were higher than those of non-invasive therapy group (P<0.05);total duration of mechanical ventilation,length of stay in ICU,and total length of hospitalization of comprehensive group were lower than those of non-invasive therapy group (P<0.05).Duration of invasive ventilation,total duration of mechanical ventilation,length of stay in ICU,total length of hospitalization,and the incidence of VAP of comprehensive group were lower than those of sequential therapy group (P<0.05).On 30 d after treatment,FEV1% and FEV1/FVC of sequential therapy group and comprehensive therapy group were higher than those of non-invasive therapy group (P<0.05).On 30 d after treatment,FEV1% and FEV1/FVC of comprehensive therapy group were higher than those of sequential therapy group (P<0.05).On 30 d after treatment,FEV1% and FEV1/FVC of the three groups were higher than those before treatment (P<0.05).Conclusion The clinical efficacy of comprehensive therapy on acute respiratory failure induced by COPD is better than non-invasive therapy and invasive and non-invasive ventilation sequential therapy.The comprehensive therapy could improve the lung function,shorten the duration of mechanical ventilation and hospitalization,thus reducing mortality.

Pulmonary disease,chronic obstructive;Respiratory insufficiency;Non-invasive therapy;Invasive and non-invasive sequential therapy;Comprehensive therapy

R 563 R 563.8

A

10.3969/j.issn.1007-9572.2017.09.006

2016-07-29；

2017-01-04)

102300 北京市門頭溝區(qū)醫(yī)院呼吸科