慢性阻塞性肺疾病急性加重期伴重度呼吸衰竭患者有创机械通气成功撤机拔管的影响因素研究

摘要

目的：探讨慢性阻塞性肺疾病急性加重期（AECOPD）伴重度呼吸衰竭患者有创机械通气成功撤机拔管的影响因素。方法选取2010年3月—2015年3月内蒙古医科大学附属医院收治的 AECOPD 伴重度呼吸衰竭患者74例，均行有创机械通气治疗，其中49例患者成功撤机拔管（成功组），25例患者撤机拔管失败或死亡（失败组）。自制病例资料收集表，收集内容包括一般临床特征（性别、年龄、病程及吸烟史）、实验室检查指标｛插管前动脉血气分析指标〔动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）、血氧饱和度（SaO2）、pH 值〕及插管前和拔管时血常规检查指标〔血红蛋白（Hb）、白细胞计数（WBC）、中性粒细胞分数（NEU%）〕、C 反应蛋白（CRP）、清蛋白（ALB）｝及机械通气指标〔多脏器功能衰竭（ MODS）发生率和通气时间〕，采用多因素 logistic 回归分析筛选AECOPD 伴重度呼吸衰竭患者有创机械通气成功撤机拔管的影响因素。结果74例患者撤机拔管成功率为66.2%，病死率为20.3%。单因素分析结果显示，两组患者性别、病程、吸烟史阳性率和插管前 pH 值、PaO2、PaCO2、SaO2、WBC、NEU%、CRP 及 ALB 水平比较，差异均无统计学意义（P ﹥0.05）；成功组患者年龄小于失败组，插管前 Hb 及拔管时 Hb 和 ALB 水平高于失败组，拔管时 WBC、NEU%、CRP 水平及 MODS 发生率低于失败组，通气时间短于失败组（P ﹤0.05）。多因素 logistic 回归分析结果显示，年龄〔 OR ＝1.733，95% CI（1.043，2.397）〕、插管前 Hb 水平〔OR ＝1.874，95% CI（1.142，3.212）〕、拔管时 NEU%〔OR ＝2.163，95% CI（1.022，3.672）〕、拔管时 ALB 水平〔OR ＝2.730，95% CI（1.374，3.984）〕、MODS〔OR ＝2.032，95% CI（1.123，3.957）〕及通气时间〔 OR ＝1.893，95% CI（1.033，3.163）〕是 AECOPD 伴重度呼吸衰竭患者有创机械通气成功撤机拔管的影响因素（P ﹤0.05）。结论年龄、感染、营养状况、MODS 及通气时间是AECOPD 伴重度呼吸衰竭患者有创机械通气成功撤机拔管的影响因素。%Objective To investigate the influencing factors of successful ventilator weaning and extubation in AECOPD patients complicated with severe respiratory failure undergoing invasive mechanical ventilation. Methods A total of 74 AECOPD patients complicated with severe respiratory failure were selected in the Affiliated Hospital of Inner Mongolia Medical University from March 2010 to March 2015,all of them received invasive mechanical ventilation,thereinto 49 cases with successful ventilator weaning and extubation were served as A group,25 cases with unsuccessful ventilator weaning and extubation were served as B group. Self - made Case Information Collection Table was used to collect the clinical data,including gender, age,disease course,smoking history,PaO2 ,PaCO2 ,SaO2 and pH before intubation,Hb,WBC,NEU% ,CRP and ALB before intubation and at the point of extubation,incidence of MODS and ventilation time,multivariate logistic regression analysis was used to analyze the influencing factors of successful ventilator weaning and extubation. Results The rate of successful ventilator weaning and extubation was 66. 2% ,the fatality rate was 20. 3% . Univariate analysis showed that,no statistically significant differences of age,disease course,positive rate of smoking history,pH,PaO2 ,PaCO2 ,SaO2 ,WBC,NEU% , CRP or ALB before intubation was found between the two groups(P ﹥ 0. 05);age of A group was less than that of B group,Hb before intubation,Hb and ALB at the point of extubation of A group were statistically significantly higher than those of B group, while WBC,NEU% and CRP at the point of extubation and incidence of MODS of A group were statistically significantly lower than those of B group,ventilation time of A group was statistically significantly shorter than that of B group( P ﹤ 0. 05). Multivariate logistic regression analysis showed that,age〔 OR = 1. 733,95% CI(1. 043,2. 397)〕,Hb before intubation〔OR = 1. 874,95% CI(1. 142,3. 212)〕,NEU% at the point of extubation〔 OR = 2. 163,95% CI(1. 022,3. 672)〕, ALB at the point of extubation〔OR = 2. 730,95% CI(1. 374,3. 984)〕,MODS〔OR = 2. 032,95% CI(1. 123,3. 957)〕and ventilation time〔 OR = 1. 893,95% CI(1. 033,3. 163)〕 were influencing factors of successful ventilator weaning and extubation in AECOPD patients complicated with severe respiratory failure undergoing invasive mechanical ventilation( P ﹤0. 05). Conclusion Age,infection,nutritional status,MODS and ventilation time are influencing factors of successful ventilator weaning and extubation in AECOPD patients complicated with severe respiratory failure undergoing invasive mechanical ventilation.