经鼻高流量氧疗对慢性阻塞性肺疾病急性加重患者膈肌功能的影响:一项前瞻性随机对照研究

摘要

Objective To investigate the effect of high-flow nasal cannula oxygen therapy (HFNC) on the clinical efficacy and diaphragm function of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods The patients with mild to moderate AECOPD (clinical classification Ⅰ-Ⅱ) admitted to Huxi Hospital Affiliated to Jining Medical College from January to October in 2018 were enrolled. The patients were divided into HFNC treatment group and routine oxygen therapy control group (each n = 37) by randomly number table method. The two groups were given bronchiectasis drugs, corticosteroids, expectorant, anti-infection treatment, at the same time, the HFNC treatment group was given HFNC with the initial flow rate of 40 L/min. The routine oxygen therapy control group was given low flow oxygen, and the initial flow rate was 3 L/min. General data such as gender, age, clinical grade, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score were recorded. Bedside ultrasound was used to measure the diaphragmatic excursions during quiet breathing (DEq), diaphragmatic excursions during deep breathing (DEd), and diaphragmatic shallow fast breathing index (D-RSBI) before and 2, 24 and 48 hours after treatment in both groups and compared, meanwhile, arterial blood gas analysis was performed, and arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2) were recorded. Results Two patients in the HFNC treatment group withdrew from the study because they could not tolerate HFNC, while other patients were enrolled in the analysis. There was no statistically significant difference in gender, age, proportion of AECOPDⅡ grade or APACHEⅡscore between the two groups, indicating that the general data of the two groups were comparable and balanced. There was no statistically significant difference in DEq, DEd, D-RSBI, PaO2 or PaCO2 before treatment between the two groups. After treatment, DEp in both groups was decreased gradually with time, it was decreased earlier in the HFNC treatment group, and it showed significant difference as compared with that before treatment at 2 hours after treatment (mm: 18.3±3.1 vs. 20.1±4.2, P < 0.01), and it was significantly lower than that in the routine oxygen therapy control group (mm: 18.3±3.1 vs. 20.3±3.7, P < 0.05); DEd was gradually increased in both groups, it was significantly increased in the HFNC treatment group, and it was significantly higher than that in the routine oxygen therapy control group at 24 hours and 48 hours after treatment (mm: 55.2±7.6 vs. 50.8±9.2 at 24 hours, 59.4±7.7 vs. 53.6±9.1 at 48 hours, both P < 0.05); D-RSBI was decreased gradually in both groups, it was decreased earlier and more significant in the HFNC treatment group, and it was significantly lower than that in routine oxygen therapy control group at 24 hours and 48 hours after treatment (times·min-1·mm-1: 0.41±0.13 vs. 0.51±0.20 at 24 hours, 0.31±0.12 vs. 0.43±0.17 at 48 hours, both P < 0.05). After treatment, there was no statistically significant difference in PaO2 or PaCO2 between the two groups. Conclusion HFNC can effectively relieve diaphragm fatigue in patients with mild to moderate AECOPD, but it had no effect on carbon dioxide retention.%目的 探讨经鼻高流量氧疗(HFNC)对慢性阻塞性肺疾病急性加重(AECOPD)患者的临床疗效和膈肌功能的影响.方法 选择2018年1月至10月济宁医学院附属湖西医院收治的轻中度AECOPD(临床分级Ⅰ～Ⅱ级)患者为研究对象,按随机数字表法分为HFNC治疗组和常规氧疗对照组,每组37例.两组均给予支气管扩张药物、糖皮质激素、祛痰、抗感染等治疗.HFNC治疗组同时行HFNC,初始流速40 L/min ;常规氧疗对照组行经鼻导管低流量吸氧,初始流速3 L/min.记录患者的性别、年龄、临床分级、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)等一般资料;分别于治疗前及治疗2、24、48 h采用床旁超声测量患者平静呼吸膈肌移动度(DEq)、深呼吸膈肌移动度(DEd)及膈肌浅快呼吸指数(D-RSBI);同时进行动脉血气分析,记录患者动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2).结果 HFNC治疗组有2例患者因不耐受HFNC而退出研究,其他患者均纳入分析.两组患者性别、年龄、AECOPDⅡ级比例、APACHEⅡ评分比较差异均无统计学意义,说明两组一般资料均衡可比.治疗前两组患者DEq、DEd、D-RSBI、PaO2、PaCO2比较差异均无统计学意义.治疗后,两组DEq均随时间延长逐渐下降,以HFNC治疗组下降更早,治疗2 h即与治疗前出现统计学差异(mm :18.3±3.1比20.1±4.2,P＜0.01),且显著低于常规氧疗对照组(mm :18.3±3.1比20.3±3.7, P＜0.05);DEd均逐渐增加,以HFNC治疗组增加更为显著,治疗24 h、48 h均显著高于常规氧疗对照组(mm :24 h为55.2±7.6比50.8±9.2,48 h为59.4±7.7比53.6±9.1,均P＜0.05);D-RSBI均逐渐下降,以HFNC治疗组下降更早、更显著,治疗24 h、48 h均显著低于常规氧疗对照组(次·min-1·mm-1 :24 h为0.41±0.13比0.51±0.20,48 h为0.31±0.12比0.43±0.17,均P＜0.05).治疗后两组间PaO2、PaCO2比较差异仍无统计学意义.结论 HFNC能有效缓解轻中度AECOPD患者的膈肌疲劳,但对二氧化碳潴留无影响.