人工氣道套囊壓力管理的研究進(jìn)展

郭曉偉，段培蓓

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人工氣道套囊壓力管理的研究進(jìn)展

郭曉偉，段培蓓

綜述建立人工氣道病人套囊壓力監(jiān)測(cè)的必要性、套囊壓力值的變化及套囊壓力監(jiān)測(cè)間隔時(shí)間，得出正常機(jī)械通氣必須要保證正常的套囊壓力，但是套囊壓力會(huì)隨著時(shí)間的延長(zhǎng)而降低，最適宜的監(jiān)測(cè)套囊壓力的間隔時(shí)間還未有定論，需要更多的研究來(lái)得出監(jiān)測(cè)套囊壓力的具體頻次。

人工氣道;呼吸衰竭;機(jī)械通氣;套囊;壓力監(jiān)測(cè)

在急性呼吸衰竭治療領(lǐng)域中,大部分重癥病人需要建立人工氣道,接受氣管插管機(jī)械通氣治療。機(jī)械通氣時(shí),套囊的作用是保持聲門(mén)下的氣道封閉,防止漏氣,從而保障機(jī)械通氣時(shí)潮氣量的供給等,以保證正壓通氣的有效完成。因此,要正常地進(jìn)行機(jī)械通氣,必須要保證正常的套囊壓力。Nseir等[1]研究顯示：對(duì)于行腸內(nèi)營(yíng)養(yǎng)的病人,為防止胃內(nèi)容物的微量吸入及口咽部分泌物流入下呼吸道,套囊需要始終保持充氣。

1 套囊壓力監(jiān)測(cè)的必要性

在我國(guó),呼吸機(jī)相關(guān)肺炎(ventilator-associated pneumonia,VAP)發(fā)生率為4.7%～55.8%,或(8.4～49.3)例/1 000機(jī)械通氣日,盡管目前的治療有了很大進(jìn)展,但VAP病死率仍為19.4%～51.6%[2-4]。若病原菌是多重耐藥菌或泛耐藥菌,病死率可高達(dá)76%,情況極為嚴(yán)峻[5-6]。在國(guó)內(nèi)外研究中,VAP均會(huì)使機(jī)械通氣時(shí)間、病人ICU滯留時(shí)間、住院時(shí)間延長(zhǎng),抗菌藥物使用增加[7-9]。因此,預(yù)防VAP的發(fā)生顯得尤為重要。關(guān)于VAP發(fā)生的危險(xiǎn)因素包括病人的基本情況、實(shí)施于病人身上的相關(guān)診療操作及藥物治療等[2,7,10-11]。氣管插管與VAP的關(guān)系極為密切,建立人工氣道后,病人的吞咽功能受限,口腔分泌物和胃內(nèi)容物的微量吸入因膨脹的套囊阻隔而滯留于套囊上方,從而形成套囊上滯留物。研究顯示：套囊上滯留物進(jìn)入下呼吸道,下呼吸道細(xì)菌定殖可能會(huì)發(fā)展為VAP[12-14]。Rello等[15]研究顯示：在插管的前8 d內(nèi),套囊壓力<20 cmH2O(1 cmH2O=0.098 kPa)是導(dǎo)致VAP發(fā)生的獨(dú)立危險(xiǎn)因素(相對(duì)風(fēng)險(xiǎn)4.23,95%CI為1.12～15.92);且發(fā)現(xiàn)對(duì)機(jī)械通氣病人4 h監(jiān)測(cè)1次套囊壓力與不監(jiān)測(cè)相比，VAP的發(fā)生率有所降低。因此,管理好套囊且控制好套囊壓力是預(yù)防VAP發(fā)生的重要前提之一。為減少套囊壓力降低所導(dǎo)致的諸如增加VAP的發(fā)生率等不良后果,護(hù)理干預(yù)顯得越來(lái)越有意義,即有必要定時(shí)監(jiān)測(cè)套囊壓力。

2 套囊壓力

2.1 目標(biāo)值 關(guān)于套囊壓力的目標(biāo)值,國(guó)內(nèi)外研究均已成定論。國(guó)外文獻(xiàn)建議套囊壓力直接測(cè)量且壓力值保持在20 cmH2O～30 cmH2O[16]。國(guó)內(nèi)的《VAP的診斷、預(yù)防和治療指南(2013)》[6]中也明確提出其壓力值。

2.2 套囊壓力值的變化 Sole等[17]多次提出氣管導(dǎo)管套囊壓力并不是恒定不變的,把氣囊壓力初始值調(diào)成至少20 cmH2O,使套囊與一種換能器及壓力監(jiān)測(cè)器相連,每12 h分別以0.008 s及1 min記錄套囊壓力值,結(jié)果只有54%的套囊壓力為正常范圍20 cmH2O～30 cmH2O，壓力值<20 cmH2O的達(dá)30%。Sridermma等[18]研究表明,套囊壓力初始值調(diào)成25 cmH2O,4 h～5 h后下降至20 cmH2O。Nseir等[19]從最初調(diào)節(jié)套囊壓力為25 cmH2O,8 h測(cè)量1次套囊壓力,其套囊壓力隨著時(shí)間的推移下降得更多。綜上所述,研究證明套囊壓力會(huì)隨著時(shí)間的延長(zhǎng)而降低。

3 套囊壓力監(jiān)測(cè)間隔時(shí)間

對(duì)于氣管導(dǎo)管套囊壓力監(jiān)測(cè)的頻次,國(guó)外2006年相關(guān)《VAP的診斷、治療及預(yù)防》[20]中未提及,《2015更新的呼吸機(jī)相關(guān)肺炎:對(duì)防治、診斷和治療的新見(jiàn)解》[21]中提到持續(xù)監(jiān)測(cè)及間斷手動(dòng)監(jiān)測(cè)套囊壓力均可以減少口咽部分泌物的誤吸,從而降低VAP的發(fā)生。國(guó)內(nèi)最新的《VAP的診斷、預(yù)防和治療指南(2013)》[6]中也未明確相關(guān)的測(cè)量頻次。

3.1 4 h調(diào)節(jié)1次 最適宜的監(jiān)測(cè)套囊壓力的間隔時(shí)間,各學(xué)者的見(jiàn)解不一。Sole等[22]指出,調(diào)整套囊壓力至20 cmH2O,在調(diào)整后的4 h～12 h內(nèi),氣管導(dǎo)管套囊壓力是降低的。Sridermma等[18]報(bào)道,從最初調(diào)節(jié)套囊壓力為25 cmH2O,4 h～5 h后套囊壓力下降至20 cmH2O。Rello等[15]明確指出,對(duì)機(jī)械通氣病人,與不監(jiān)測(cè)套囊壓力相比,每4 h監(jiān)測(cè)1次套囊壓力可降低VAP的發(fā)生率是肯定的。但是從理想上講,在保證VAP的發(fā)生率不上升的前提下,希望能最大限度地減少護(hù)理人員的工作量,更優(yōu)化地選擇間歇測(cè)量套囊壓力的間隔時(shí)間。

3.2 8 h調(diào)節(jié)1次 研究結(jié)果表明:套囊壓力一般至少每8 h調(diào)節(jié)1次[22-23]。一篇?dú)獾拦芾韺?shí)踐的文章指出：大多數(shù)策略指定呼吸治療是8 h～12 h測(cè)量和記錄1次氣管導(dǎo)管套囊壓力(81%),即確定最佳的套囊壓力的變化方法[22]。付優(yōu)等[23]對(duì)機(jī)械通氣時(shí)間≥48 h的氣管插管成年病人為研究對(duì)象,分析機(jī)械通氣病人低氣囊壓力的影響因素中,采用的是8 h測(cè)量1次氣管插管套囊壓力。有研究發(fā)現(xiàn)：53%的病人氣囊壓力<20 cmH2O[24]，這與另一項(xiàng)研究8 h手動(dòng)測(cè)量1次套囊壓力的常規(guī)護(hù)理,壓力值<20 cmH2O的病人占45.3%相一致[25]。Koeman等[26]關(guān)于氯己定進(jìn)行口腔護(hù)理可降低VAP的發(fā)生率研究中,采用的是6 h進(jìn)行1次口腔護(hù)理,較其他學(xué)者的研究中采用每天3次的口腔護(hù)理[27]或?qū)嶒?yàn)中采用每天2次的口腔護(hù)理[28-31],6 h 1次的口腔護(hù)理最為頻繁。Berry等[32]在標(biāo)準(zhǔn)口腔護(hù)理中明確指出,對(duì)于氣管插管病人,口腔護(hù)理前需保證充足正常的套囊壓力。因此,對(duì)于氣管插管的機(jī)械通氣病人,建議6 h進(jìn)行1次口腔護(hù)理,即需要6 h校正1次氣管導(dǎo)管套囊壓力。因此,8 h測(cè)量1次套囊壓力在臨床上已不可取。

3.3 套囊壓力的持續(xù)監(jiān)測(cè) Nseir等[1]另一項(xiàng)隨機(jī)對(duì)照試驗(yàn)研究顯示:與8 h監(jiān)測(cè)1次氣管導(dǎo)管套囊壓力相比,在套囊壓力控制在25 cmH2O的前提下,持續(xù)監(jiān)測(cè)套囊壓力可有效降低VAP的發(fā)生率。又有研究得出持續(xù)監(jiān)測(cè)套囊壓力可降低VAP的發(fā)生率[33-34],但與Alzahrani等[24-25]研究結(jié)果卻是矛盾的,且國(guó)內(nèi)目前沒(méi)有一種可直接使用的持續(xù)監(jiān)測(cè)套囊壓力的設(shè)備。

3.4 國(guó)內(nèi)采用的測(cè)量套囊壓力裝置及方法 控制套囊壓力的設(shè)備可分為電子類(lèi)型及氣動(dòng)類(lèi)型。有報(bào)道稱(chēng)電子類(lèi)型的控壓設(shè)備氣囊膨脹不足問(wèn)題出現(xiàn)得更為頻繁[35]。國(guó)外的研究中大部分提及并使用氣動(dòng)類(lèi)型的控壓設(shè)備,如Nseir等[1]研究中所采用的持續(xù)測(cè)量氣囊壓力的裝置為氣動(dòng)裝置;Duguet等[36]測(cè)試9例行機(jī)械通氣的病人均采用氣動(dòng)裝置;Nseir等[37]用氣動(dòng)裝置對(duì)12頭仔豬進(jìn)行了實(shí)驗(yàn)性研究。因此,控制套囊壓力的設(shè)備宜采用氣動(dòng)類(lèi)型。目前國(guó)內(nèi)采用的是德國(guó)產(chǎn)VBM專(zhuān)用套囊壓力測(cè)壓表(VMB Medizintechnik GMBH,Germany),屬于氣動(dòng)類(lèi)型。若設(shè)定套囊初始?jí)毫?0 cmH2O或25 cmH2O,1 h測(cè)定1次現(xiàn)有的套囊壓力值,觀(guān)察從設(shè)定初始值后多長(zhǎng)時(shí)間現(xiàn)有的套囊壓力會(huì)<20 cmH2O(正常范圍低限值)。此種方法從理論上講切實(shí)可行,但是林艷俠等[38]經(jīng)過(guò)214次測(cè)量發(fā)現(xiàn),使用氣囊壓力表進(jìn)行間斷測(cè)量套囊壓力時(shí),充氣管線(xiàn)單向閥在與壓力表斷開(kāi)和連接的過(guò)程中會(huì)造成套囊壓力下降。因此,從實(shí)踐上講此種方法不可行。綜上所述,需要更多的研究來(lái)得出監(jiān)測(cè)套囊壓力的具體頻次。

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(本文編輯蘇琳)

Research progress on the management of artificial airway cuff pressure

Guo Xiaowei,Duan Peibei
(Jiangsu Province Hospital of Traditional Chinese Medicine,Nanjing University of Chinese Medicine,Jiangsu 210029 China)

郭曉偉，主管護(hù)師，本科，單位：210029，南京中醫(yī)藥大學(xué)附屬江蘇省中醫(yī)院；段培蓓(通訊作者)單位：210029，南京中醫(yī)藥大學(xué)附屬江蘇省中醫(yī)院。

R472

A

10.3969/j.issn.1009-6493.2017.15.006

1009-6493(2017)15-1810-03

2016-07-16;

2017-04-28)

引用信息 郭曉偉，段培蓓.人工氣道套囊壓力管理的研究進(jìn)展[J].護(hù)理研究，2017，31(15)：1810-1812.