俯卧位通气治疗在重型颅脑损伤并重度神经源性肺水肿中的应用效果研究

摘要

目的：探究俯卧位通气治疗在重型颅脑损伤并重度神经源性肺水肿（NPE）中的应用效果。方法选取2011年5月—2015年12月柳州市人民医院重症医学科收治的重型颅脑损伤并重度 NPE 患者60例，随机分为对照组和治疗组，每组30例。对照组患者采取常规平卧位机械通气，治疗组患者采取间断俯卧位机械通气。比较两组患者机械通气前及机械通气1 h、12 h、24 h、3 d、5 d 时氧合状况〔包括动脉血氧分压（PaO2）、血氧饱和度（SpO2）、氧合指数〕，机械通气前及机械通气1 h、12 h、24 h 时平均动脉压（MAP）、心率（HR）、中心静脉压（CVP）及颅内压；记录两组患者机械通气时间及 ICU 入住时间，随访3个月比较两组患者预后。结果时间和治疗方法在 PaO2、SpO2、氧合指数上存在交互作用（P ﹤0.05）；治疗方法在 PaO2、SpO2、氧合指数上主效应显著（ P ﹤0.05）；时间在 PaO2、SpO2、氧合指数上主效应显著（P ﹤0.05）；治疗组患者机械通气12 h、24 h、3 d、5 d 时 PaO2、SpO2、氧合指数高于对照组（P ﹤0.05）。时间和治疗方法在 MAP、HR、CVP 及颅内压上不存在交互作用（ P ﹥0.05）；治疗方法在 MAP、HR、CVP 及颅内压上主效应不显著（P ﹥0.05）；时间在 MAP、HR、CVP 及颅内压上主效应不显著（P ﹥0.05）；两组患者机械通气前及机械通气1 h、12 h、24 h 时 MAP、HR、CVP 及颅内压比较，差异均无统计学意义（P ﹥0.05）。治疗组患者机械通气时间和 ICU 入住时间短于对照组（P ﹤0.05）。随访3个月，两组患者预后比较，差异无统计学意义（u =1.605，P =0.108）。治疗组有4例患者出现颜面部皮肤受压红肿，转为仰卧位后症状逐渐消失。两组患者均未出现气胸、明显肝肾功能损伤及血流动力学异常。结论俯卧位通气能有效改善重型颅脑损伤并重度 NPS 患者的氧合状况、缩短机械通气时间及 ICU 入住时间，且对血流动力学、颅内压及预后等无明显影响。%Objective To investigate the clinical effect of prone positioning ventilation in treating severe craniocerebral injury patients complicated with severe neurogenic pulmonary edema. Methods From May 2011 to December 2015,a total of 60 severe craniocerebral injury patients complicated with severe neurogenic pulmonary edema were selected in the Department of Intensive Medicine,the People's Hospital of Liuzhou,and they were randomly divided into control group and treatment group, each of 30 cases. Patients of control group received conventional horizontal positioning mechanical ventilation,while patients of treatment group received discontinuous prone positioning mechanical ventilation. Oxygenation status(including PaO2 ,SpO2 and oxygenation index) before mechanical ventilation,after 1 hour,12 hours,24 hours,3 days and 5 days of mechanical ventilation,MAP,HR,CVP and intracranial pressure before mechanical ventilation,after 1 hour,12 hours and 24 hours of mechanical ventilation were compared between the two groups;duration of mechanical ventilation and ICU stays were recorded, and the prognosis after 3 months of follow up was compared between the two groups. Results There was interaction between time and method in PaO2 ,SpO2 and oxygenation index(P ﹤ 0. 05);the main effects of method and time were significant in PaO2 , SpO2 and oxygenation index;PaO2 ,SpO2 and oxygenation index of treatment group were statistically significantly higher than those of control group after 12 hours,24 hours,3 days and 5 days of mechanical ventilation( P ﹤ 0. 05). There was no interaction between time and method in MAP,HR,CVP or intracranial pressure(P ﹥ 0. 05);the main effects of method and time were not significant in MAP,HR,CVP or intracranial pressure( P ﹥ 0. 05);no statistically significant differences of MAP,HR,CVP or intracranial pressure was found between the two groups before mechanical ventilation or after 1 hour,12 hours,24 hours of mechanical ventilation(P ﹥ 0. 05). Duration of mechanical ventilation and ICU stays of treatment group were statistically significantly shorter than those of control group(P ﹤ 0. 05). After 3 months of follow - up,no statistically significant differences of prognosis was found between the two groups(u = 1. 605,P = 0. 108). During the mechanical ventilation,4 cases of treatment group occurred compression - induced facial skin redness and swelling,but disappeared after change to torizontal positioning mechanical ventilation;no one of the two groups occurred any obvious pneumothorax,liver or kidney function damage,or abnormal hemodynamics. Conclusion Prone positioning ventilation can effectively improve the oxygenation status of severe craniocerebral injury patients complicated with severe neurogenic pulmonary edema,shorten the duration of mechanical ventilation and ICU stays,without obvious impact on haemodynamics,intracranial pressure or prognosis.