慢性咳喘患者食道测压及24小时pH监测的护理配合

对２０例有返流症状的慢性咳嗽、哮喘患者应用多导胃肠功能测定仪及便携式ＰＨ监测记录仪进行食管测压及２４小时ｐＨ监测时，根据患者对检查的认识和接受程度不同，有针对性地进行宣教和心理护理，并通过熟练的操作技术顺利完成了２０例慢性咳嗽、哮喘患者的食道测压及２４小时食管ｐＨ监测。分析了慢性咳嗽、哮喘患者食道测压及２４小时ｐＨ监测的护理配合，认为患者的密切配合和准确、熟练的操作技术是保证检查成功的重要因素。     

慢性咳喘患者食道侧压及24小时pH监测的护理配合

对２０例有返流症状的慢性咳嗽、哮喘患者应用多导胃肠功能测定仪及便携式ＰＨ监测记录仪进行信用这测压及２４小时ＰＨ监测时，根据患者对检查的认识和接受程度不同，有针对性地进行宣教和心理护理，并通过熟练的操作技术顺利完成了２０例慢性 食道测主２４小时食管ＰＨ监测。分析了慢性咳嗽哮患者食道测压是２４小时ＰＨ监测的护理配合，认为２的密切配合和准确，熟练的操作技术是保证检查成功的重要因素。     

跨肺压监测在急性主动脉夹层Stanford A型手术后患者中的应用研究

目的探讨跨肺压监测在急性主动脉夹层Stanford A型手术后患者中的应用。方法选择2015年1-10月收治我院重症医学科经CT确诊"急性主动脉夹层Stanford A型"在急诊全麻深低温体外循环下行"Cabrol加升主动脉及全弓替换加降主动脉支架象鼻手术患者19例,随机分为两组,观察组9例,对照组10例。两组患者入室后,每日均给予肺复张治疗,观察组患者通过食道压监测设定呼气末正压(PEEP)值,维持跨肺压为正值;对照组患者则通过PEEP递增法设定PEEP值,观察两组患者0 h、24 h、48 h、72 h肺顺应性、氧合指数、PEEP值及总机械通气时间、住ICU时间、住院时间。结果两组患者0 h及入室时肺顺应性、氧合指数、PEEP值比较差异无统计学意义(P0.05),入室后观察组患者通过食道压监测维持呼气末跨肺压为正值后24 h、48 h、72 h监测肺顺应性、氧合指数、PEEP值高于对照组,两组比较差异有统计学意义(P0.05),观察组总机械通气时间少于对照组(P0.05),两组患者住ICU时间、住院时间比较差异无统计学意义(P0.05)。结论通过食道压监测设定PEEP值在急性主动脉夹层Stanford A型手术后患者跨肺压维持方面具有指导意义,且在维持跨肺压的过程中更需要护士精心护理,规范护理操作,连续监测、自动调整气囊压力,保持呼吸机管路的密闭性。     

神经调节辅助通气对AECOPD患者呼吸功的影响

目的探讨不同外源性呼气末正压（extrinsic positive end expiratory pressure,PEEPe）条件下,神经调节辅助通气（neurally adjusted ventilatory assist,NAVA）对慢性阻塞性肺疾病急性加重（acute exacerbation of chronicobstructive pulmonary disease,AECOPD）患者呼吸功及触发功的影响。 方法以2012年5月至2013年5月入住东南大学附属中大医院ICU、静态内源性呼气末正压（intrinsic positive end-expiratory pressure,PEEPi）（PEEPi_stat）≥5 cm H2O（1 cm H2O=0.098 kPa）的AECOPD患者为研究对象。本研究方案已通过东南大学附属中大医院伦理委员会批准（批准号：2010ZDLL018.0）,并与患者签署了知情同意书。将控制通气下PEEPe由0升至40%PEEPi_stat,总呼气末正压（total-PEEP）不增加的患者作为呼气流速受限（expiratory flow limitation,EFL）组,增加的患者为呼气阻力（expiratory resistance,Re）增高组。共纳入AECOPD患者12例,其中EFL组6例,Re组6例。患者分组后调节镇静深度至Ramsay3分,在PEEPe设定为0、40%、80%、120%PEEPi_stat条件下,随机进行支持力度相同压力支持通气（pressure support ventilation,PSV）及NAVA通气。通过NAVA压力限定实现NAVA与PSV支持水平的等效性。监测食道内压（esophageal pressure,Pes）、膈肌电活动（electrical activity diaphragm,EAdi）,采集流速、压力波形并计算呼吸功（PTPes_ins）和触发功（PTPes_tri）。测量参数在通气模式和PEEPe水平之间的比较采用两因素的重复测量方差分析。在NAVA或PSV模式下,不同PEEPe水平之间的多重比较采用SNK检验。 结果2组患者年龄与急性生理与慢性健康评分II（acute physidogy and chronic health evaluation,APACHE II）等一般情况无显著差异。① NAVA与PSV支持水平的等效性：NAVA通气时可以获得与PSV通气类似的方波压力-时间曲线,且与PSV相比NAVA通气时呼吸频率、吸气时间、气道峰值压、平均气道压均无显著差异（t=0.720,0.817,0.621,1.579,均P>0.05）。② NAVA对呼吸功影响：在相同PEEPe水平下NAVA通气时呼吸功明显低于PSV通气（t=3.816,3.117,2.758,2.572,均P<0.05）。PEEPe由0逐渐增至120%PEEPi_stat时,在NAVA及PSV模式下,EFL组患者呼吸功均显著下降（t=4.629,4.431,4.165,5.082,均P<0.05）;RE组患者呼吸功无显著变化（F=8.12,7.64,均P>0.05）。③ NAVA对触发功的影响：相同PEEPe水平下,NAVA通气触发功明显低于PSV通气（t=4.624,4.431,4.165,5.082,均P<0.05）。PEEPe由0逐渐增至120%PEEPi_stat时,NAVA模式下EFL组及RE组患者触发功均无显著变化（F=5.71,5.93,均P>0.05）;PSV模式下,EFL组患者触发功显著下降（F=16.21,P<0.05）;RE组患者随着PEEPe增加触发功无明显变化（F=6.12,P>0.05）。 结论与PSV相比,NAVA通气显著降低AECOPD患者的呼吸功及触发功。NAVA通气时触发功不受PEEPe的影响,PSV通气时增加PEEPe可降低呼气流速受限患者的触发功。     

食道压法设置呼气末正压在急性Stanford A型主动脉夹层术后低氧血症中的应用

目的探讨食道压监测调整呼气末正压的方法在改善急性Stanford A型主动脉夹层术后低氧血症中的疗效。 方法将2016年1月至2017年2月南京医科大学附属南京医院重症医学科收住的40例急性Stanford A型主动脉夹层术后低氧血症患者分为食道压监测组和常规治疗组,每组各20例。记录两组患者的一般资料及预后状况,比较两组患者气体交换及呼吸力学指标,包括呼气末正压、氧合指数、呼气末跨肺压、吸气末跨肺压、肺驱动压、肺弹性阻力、胸壁驱动压、胸壁弹性阻力、呼吸系统驱动压及呼吸系统弹性阻力。 结果两组急性Stanford A型主动脉夹层术后低氧血症患者入组时、入组24 h和入组48 h的呼气末正压、动脉血氧合指数、呼气末跨肺压、肺驱动压和肺弹性阻力比较,差异均有统计学意义（F=9.583、9.544、17.806、4.799、6.830,P=0.004、0.004、< 0.001、0.035、0.013）,进一步两两比较发现,食道压监测组患者入组24 h和入组48 h的呼气末正压、动脉血氧合指数及呼气末跨肺压均较常规治疗组显著升高（P均< 0.05）,而肺驱动压和肺弹性阻力均较常规治疗组显著降低（P均< 0.05）。与常规治疗组比较,食道压监测组患者机械通气时间明显降低[（68 ± 20）h vs.（55 ± 16）h,t=2.261,P=0.030]明显缩短;而两组患者住ICU时间[（101 ± 26）h vs.（92 ± 24）h,t=1.226,P=0.228]及和28 d病死率（10% vs. 5%,χ²=0.360,P=0.548）比较,差异均无统计学意义。 结论根据食道压监测调整呼气末正压可以明显改善急性Stanford A型主动脉夹层术后低氧血症患者的氧合指数,降低肺驱动压及肺弹性阻力,缩短患者机械通气时间。     

触发灵敏度对压力支持通气患者肺通气均一性的影响

目的观察呼吸机触发灵敏度对压力支持通气患者肺通气均一性的影响。 方法前瞻性纳入20例使用压力支持模式通气时存在肺不均一性通气的患者,即应用肺电阻抗断层成像监测时重力依赖区通气分布比低于45%。随机使用低和高两种流速触发灵敏度水平通气20 min（采用Servo-i呼吸机流速触发灵敏度的最低和最高限值2 L/min和0.2 L/min）。通过肺电阻抗断层成像评估重力依赖区通气分布和呼气末肺体积,采用食道压监测评估吸气努力和做功。 结果与高触发灵敏度相比,低触发灵敏度增加了患者吸气时重力依赖区通气分布百分比[（33 ± 9）% vs.（36 ± 9）%,t = 3.735,P = 0.001]、食道压变化值[0.8（0.4,1.8）cmH₂O vs. 1.6（1.0,2.1）cmH₂O,Z = 2.722,P = 0.021]、压力时间乘积[29（15,54）cmH₂O·s^-1·min^-1 vs. 48（23,74）cmH₂O·s^-1·min^-1,Z = 3.298,P = 0.044],但跨肺压变化值没有明显变化[（12.6 ± 4.3）cmH₂O vs.（12.8 ± 4.2）cmH₂O,t = 0.906,P = 0.376]。此外,低触发灵敏度的整体呼气末肺容积变化值为78（29,170）mL,且其变化值主要分布于重力依赖区[75（-6,131）mL]。 结论压力支持通气时,降低触发灵敏度可通过增加吸气努力使更多的气体进入肺重力依赖区并改善通气均一性,同时吸气努力和跨肺压仍在可接受范围内。     

呼吸触发B-TFE序列在门静脉成像中的初步应用

目的探讨呼吸触发B-TFE序列在门静脉系统成像的应用价值。方法使用呼吸触发B-TFE序列,对40例病例进行门静脉系统成像,冠状位,使用呼吸触发技术,不使用对比剂。所有病例均在近期进行了双功多普勒超声检查,并和B-TFE门静脉成像结果进行比较。检查的内容包括:门静脉主干、门静脉右支、门静脉左支、肠系膜上静脉和脾静脉以及可能出现的侧支循环情况。结果呼吸触发B-TFE序列门静脉成像准确地显示了本组全部病例的门静脉系统情况;呼吸触发B-TFE门静脉成像结果和双功多普勒超声结果相关性良好,且具有一定的优势。结论呼吸触发B-TFE序列门静脉成像技术可以在不使用对比剂情况下准确地评价门静脉系统情况。     

平均吸气压用于无创性评估预备脱机患者呼吸努力的研究

目的 本研究拟探讨以公式Pi=5×P0.1×Ti为依据,通过测定几腔阻断压(P0.1)以计算预备脱机患者中平均吸气压(Pi)以及无创张力时间指数(TTIi)来无创性评估患者呼吸努力和呼吸负荷/能力比率的可能性及其效率.方法 本研究所有试验对象均来自广州呼吸疾病研究所英东重症监护中心并获得广州医学院第一附属医院临床试验伦理委员会的批准,受试对象知情同意.12例预备脱机患者,COPD 9例,ARDS 2例,重症哮喘1例,通过插入食道囊管监测食道压力(PesoM),经胸壁弹性压的矫正后得到矫正的食道压力(Peso).以常规方法测定P 0.1和气道压力曲线上的最大吸气压(MIPaw)以及食道压力曲线上的最大吸气压(NIPeso).通过方程Pi=5×P0.1×Ti计算Pi;以Pi和MIPaw计算Tni,以Peso和MIPeso计算食道张力时间指数(TTIeso),分别比较Pi与Peso以及TTIi与TTIeso的大小,并分析无创性指标与相应有创性指标之间的相关性与一致性.结果 Pi与Peso之间以及TTIi与TTIeso之间差异无统计学意义(P>0.05),其相关系数分别为0.974和0.957.一致性分析中,Pi与Peso之间以及TTIi与TTIeso之间的平均差值分别小于(Peso+Pi)/2和(TTI+TTIeso)/2中的最小值.结论 本研究表明,Pi与Peso之间以及TTIi与TTIeso之间具有良好的相关性与一致性,这两个无创性指标可用于预备脱机患者呼吸努力以及呼吸负荷/能力比率的无创性评估.     

尿监控系统的研发与临床应用

介绍自主研发的无线网络尿监测控制系统及其临床应用。无线网络尿监测控制系统可自动完成对导尿管留置患者的尿液计量、自动排尿、自动标本采集操作和监测,具有监测尿量灵敏、结果准确、节省护士操作时间、减少标本污染的特点。     

三种血压监测方法在低血容量性休克患者中的应用比较

目的 探讨三种血压监测方法在低血容量性休克患者中的应用比较.方法 分别用手动法、自动无创测量技术及动脉内血压监测对126例低血容量性休克患者进行血压监测,将测得血压值及费用进行比较与分析.结果 (1)手动法、自动无创测量技术法测得血压值接近,差异无统计学意义(P＞0.05);动脉内血压监测测得血压值较前两者明显降低,差异有统计学意义(P＜0.05);(2)手动法、自动无创测量技术费用相对较低,动脉内血压监测费用较高.结论 动脉内血压监测测压准确,更能反映出低血容量性休克患者的真实循环状态.     

Ventilator auto-triggering in a patient with tuberculous bronchopleural fistula

We report a case of ventilator auto-triggering resulting from tuberculous bronchopleural fistula being managed with chest tube suction. Early recognition of bronchopleural fistula-related auto-triggering is extremely important. Auto-triggering can lead to serious adverse effects, including severe hyperventilation and inappropriate escalation of sedatives and/or neuromuscular blockers (administered to reduce spontaneous breathing efforts). Auto-triggering was confirmed in our patient when tachypnea persisted despite pharmacologic neuromuscular paralysis. Auto-triggering can be reduced or eliminated by decreasing ventilator trigger sensitivity or by decreasing the air leak flow by reducing the degree of chest tube suction.     

Esophageal and transpulmonary pressure in the clinical setting: meaning,usefulness and perspectives

Purpose

Esophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only.

Methods

This is a review of the relevant technical, physiological and clinical details that support the clinical utility of Pes.

Results

After appropriately positioning of the esophageal balloon, Pes monitoring allows titration of controlled and assisted mechanical ventilation to achieve personalized protective settings and the desired level of patient effort from the acute phase through to weaning. Moreover, Pes monitoring permits accurate measurement of transmural vascular pressure and intrinsic positive end-expiratory pressure and facilitates detection of patient–ventilator asynchrony, thereby supporting specific diagnoses and interventions. Finally, some Pes-derived measures may also be obtained by monitoring electrical activity of the diaphragm.

Conclusions

Pes monitoring provides unique bedside measures for a better understanding of the pathophysiology of acute respiratory failure patients. Including Pes monitoring in the intensivist’s clinical armamentarium may enhance treatment to improve clinical outcomes.

     

Monitoring of patient-ventilator interaction at the bedside

Monitoring of patient-ventilator interactions at the bedside involves evaluation of patient breathing pattern on ventilator settings. One goal of mechanical ventilation is to have ventilator-assisted breathing coincide with patient breathing. The objectives of this goal are to have patient breath initiation result in ventilator triggering without undue patient effort, to match assisted-breath delivery with patient inspiratory effort, and to have assisted breathing cease when the patient terminates inspiration, thus avoiding ventilator-assisted inspiration during patient exhalation. Asynchrony can occur throughout the respiratory cycle, and this paper describes common asynchronies. The types of asynchronies discussed are trigger asynchrony (ie, breath initiation that may manifest as ineffective triggering, double-triggering, or auto-triggering); flow asynchrony (ie, breath-delivery asynchrony, which may manifest as assisted-breath delivery being faster or slower than what patient desires); and cycling asynchronies (ie, termination of assisted inspiration does not coincide with patient breath termination, which may manifest as delayed cycling or premature cycling). Various waveforms are displayed and graphically demonstrate asynchronies; basic principles of waveform interpretation are discussed.     

Patient-ventilator asynchronies: may the respiratory mechanics play a role?

Introduction

The mechanisms leading to patient/ventilator asynchrony has never been systematically assessed. We studied the possible association between asynchrony and respiratory mechanics in patients ready to be enrolled for a home non-invasive ventilatory program. Secondarily, we looked for possible differences in the amount of asynchronies between obstructive and restrictive patients and a possible role of asynchrony in influencing the tolerance of non-invasive ventilation (NIV).

Methods

The respiratory pattern and mechanics of 69 consecutive patients with chronic respiratory failure were recorded during spontaneous breathing. After that patients underwent non-invasive ventilation for 60 minutes with a "dedicated" NIV platform in a pressure support mode during the day. In the last 15 minutes of this period, asynchrony events were detected and classified as ineffective effort (IE), double triggering (DT) and auto-triggering (AT).

Results

The overall number of asynchronies was not influenced by any variable of respiratory mechanics or by the underlying pathologies (that is, obstructive vs restrictive patients). There was a high prevalence of asynchrony events (58% of patients). IEs were the most frequent asynchronous events (45% of patients) and were associated with a higher level of pressure support. A high incidence of asynchrony events and IE were associated with a poor tolerance of NIV.

Conclusions

Our study suggests that in non-invasively ventilated patients for a chronic respiratory failure, the incidence of patient-ventilator asynchronies was relatively high, but did not correlate with any parameters of respiratory mechanics or underlying disease.     

Intracranial hypertension. Advances in intracranial pressure monitoring

Research is continuing to find improved methods for monitoring intracranial pressure as well as the effect of intracranial hypertension on the patient's recovery. Each of the methods of monitoring has its advantages and disadvantages and the use of one method over others is usually the preference of the neurosurgeon. It is the responsibility of the nurse to be aware of the strengths and weaknesses of each device in order to strengthen patient outcome. Again, the major benefits of the bolt are a low infection rate and easy insertion. Problems associated with its use of which the nurse should be aware are a tendency for a dampened waveform that gives an inaccurate pressure reading requiring irrigation that may or may not clear the catheter, and the inaccurate readings given by the bolt at high pressures. The subdural catheter can be used for long-term monitoring; however, baseline drift has been reported. Ventricular catheters have a mixed bag of results according to research. They are the most accurate of the methods used and enable cerebrospinal fluid to be drained, thereby lowering ICP. However, the catheters appear to have a higher infection rate. This is debatable, however. Some researchers advocate the prophylactic use of antibiotics. A closed drainage system should be used and if the device is used for longer than 4 days, the device should be changed and care should be taken to prevent leakage of cerebrospinal fluid. The devices currently in use have been presented and patient outcomes discussed using medical research, as none was available from the nursing literature.(ABSTRACT TRUNCATED AT 250 WORDS)     

Computer analysis of intraoperative cardiac rhythms using esophageal and surface leads

Esophageal ECG lead and computer as arrhythmia monitor were evaluated in 6 dogs and 23 patients. In dogs arrhythmias were induced by an epinephrine infusion during halothane anesthesia. The computer identified 1858 irregular beats, a cardiologist 2130. Bigeminy was correctly identified 82% of the time, trigeminy 72%, couplets 29%, and ventricular tachycardia 45%. The false positive rate was .03%. In the operating room the monitor identified an average of 44 abnormal beats per patient. In 5 patients junctional rhythm was correctly identified. This study shows the feasibility of using an esophageal ECG lead for computerized ventricular and supraventricular arrhythmia monitoring in the operating room.     

人工气道气囊压力衰减数学模型的建立及应用

目的：连续监测机械通气患者的人工气道气囊压力,建立其压力衰减的数学模型,探讨气囊压力的最佳监测频率。方法选取呼吸重症监护室辅助通气患者158例,根据指南推荐的人工气道气囊压力最高限,调整压力到30 cmH2 O,采用PORTEX压力监测表,每小时监测并记录实际压力,基于测得的压力数据,使用曲线拟合法建立压力衰减数学模型,计算获得人工气道气囊压力监测的合适频率。结果取每小时测取的气囊压力平均值做曲线拟合,建立数学模型,计算得出最佳间隔时间为4．24 h;取每小时测取的气囊压力的下限做曲线拟合,则得出最佳间隔时间为3．06 h。结论建立人工气道呼吸机辅助呼吸的患者,至少间隔4．24 h监测并校正气囊压力一次;若基于更为安全的角度考虑,以防止气囊漏气及相应并发症的发生,应间隔3．06 h监测并校正气囊压力一次。     

不同牵引方法预防留置导尿漏尿的比较研究

目的 探讨预防留置导尿漏尿患者适宜的牵引方法,为临床护理工作提供理论依据。方法 采用方便取样法选取扬州大学医学院附属江都人民医院神经内科及老年科2016年11月—2017年11月留置导尿漏尿患者80例,随机分为A组和B组各40例,A组使用直牵法预防漏尿,B组使用侧牵法预防漏尿,观察两组留置导尿漏尿患者漏尿预防效果、发生尿道粘膜压力性损伤情况及患者舒适度。结果 A组病人预防漏尿有效率(97.5%)高于B组(87.5%),差异有统计学意义(P＜0.05)；A组病人发生尿道粘膜压力性损伤为0, B组为15%(P＜0.05),差异有统计学意义；A组病人中、重度不适发生率为17.5%,低于B组的40%(P＜0.05),差异有统计学意义。结论 直牵法在预防留置导尿漏尿的效果、发生尿道粘膜压力性损伤和患者舒适度方面均优于侧牵法。     

食管癌术后吻合口瘘的预防及护理

吻合口瘘是食管癌根治术后最严重的并发症之一，90年代报道其发生率为2．6％～6．4％，而其死亡率则高达38．1％～53．6。因此，食管癌术前预防及术后针对吻合口瘘的护理至关重要。本文依据多年胸外科护理经验，探讨食管癌术后的护理方法。     

慢性阻塞性肺病患者人工气道气囊压力监测及护理

目的探讨人工气道气囊压力监测在慢性阻塞性肺病（下称慢阻肺）患者气管插管气囊压力监测中的应用价值。方法将60例人工气道的慢阻肺患者随机分为两组。实验组采用专用的PORTEX气囊测压表注气测量压力,对照组采用传统的手估气囊测压注气,用呼吸机监测漏气情况;比较两组患者气囊压力、气囊容积和并发症的发生率。结果实验组气囊压力为（27．50±2．50）cmH2O,气囊容积为（11．0±1．8）mL,呼吸机监测不漏气。对照组气囊压力为（42．74±7．26）cmH2O,气囊容积为（15．0±5．2）mL,呼吸机监测不漏气。实验组发生气管黏膜损伤、气囊破裂的例数明显少于对照组,差异有统计学意义（P〈0．05）,两组发生误吸、气管食管瘘和气囊漏气的例数经比较差异均无统计学意义（P〉0．05）。结论慢阻肺患者人工气道气囊压力采用专用的气囊测压袁注气测量压力并将压力维持在（27．50±2．50）cmH2O,能有效避免气管黏膜损伤、气囊破裂、气囊漏气和误吸的发生。