纤维支气管镜肺泡灌洗联合振动排痰治疗重症肺炎机械通气患者的效果观察：一项286例患者前瞻性随机对照研究被引量：160

Effect of bronchoalveolar lavage with fiberoptic bronchoscopy combined with vibration sputum drainage on mechanically ventilated patients with severe pneumonia： a prospective randomized controlled trial in 286 patients

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摘要目的探讨纤维支气管镜（纤支镜）肺泡灌洗联合振动排痰对重症肺炎机械通气（MV）患者的疗效。方法采用前瞻性随机对照临床研究方法，选择2014年1月至2016年7月湖南省人民医院重症加强治疗病房（ICU）收治的286例重症肺炎MV患者，按随机数字表法分为对照组和观察组，每组143例。两组患者均给予敏感抗菌药物抗感染、原发病治疗及温湿化治疗；对照组采用纤支镜肺泡灌洗治疗，观察组在对照组基础上联合振动排痰治疗。比较两组患者治疗前后呼吸功能指标、炎症指标及疗效和预后指标。结果①治疗前两组呼吸功能指标无明显差异；治疗2h后各指标均明显改善，且观察组氧合指数（PaO2／FiO2）明显高于对照组[mmHg（1mmHg=0．133kPa）：379．1±20．2比351．8±24．7]，动脉血二氧化碳分压（PaCO2）及气道阻力（Raw）均明显低于对照组[PaCO2（mmHg）：36．5±5．8比453±6．9，Raw（cmH2O，1cmH2O=0．098kPa）：12．9±0．6比13．1±0．8，均P〈0．01]。②治疗前两组炎症指标无明显差异；治疗24h后各指标均明显下降，且观察组白细胞计数（WBC）、降钙素原（PCT）、C-反应蛋白（CRP）较对照组降低更为显著[WBC（×10^9／L）：8．2±1．7比12．8±3．7，PCT（μg／L）：15．4±2．4比21．8±3．1，CRP（mg/L）：37．1±6．1比67．2±7．2，均P〈0．01]。③与对照组比较，观察组总有效率明显提高[95．1％（136／143）比87．4％（125／143）]，排痰量明显增多（mL：49．2±12．5比36．9±11．0），MV时间和ICU住院时间明显缩短（d：6．4±3．6比9．4±2．1，8．6±5．7比12．4±4．6，均P〈0．01）；但对照组与观察组28d病死率差异无统计学意义[2．8％（4／143）比2．1％（3／143），P〉0．05]。结论与单纯纤支镜肺泡灌洗比较，联合振动排痰治疗重症肺炎MV患者可通过有效排痰改善呼吸功能，减轻炎症反应，缩短MV时间及ICU住院时间，提高疗效，促进患者康复。 Objective To investigate the curative effect of bronchoalveolar lavage with fiberoptic bronchoscopy combined with vibration sputum drainage in the treatment of severe pneumonia patients undergoing mechanical ventilation （MV）. Methods A prospective randomized controlled trial was conducted. 286 severe pneumonia patients undergoing MY admitted to intensive care unit （ICU） of Hunan People＇s Hospital from January 2014 to July 2016 were enrolled, and they were divided into control group and observation group according to random number table, with 143 patients in each group. Patients in both groups received sensitive antibiotics for anti-infection, etiological treatment, and calefacient and humidifying treatment. The patients in the control group received bronchoalveolar lavage with fiberoptic bronchoscopy, and those in the observation group received bronchoalveolar lavage combined with vibration sputum drainage. The parameters of respiratory function and inflammation before and after treatment, curative effect, and prognosis were compared between the two groups. Results （1） There were no significant differences in respiratory function parameters between the two groups before treatment, 2 hours after treatment, the parameters were improved in both groups. Moreover, oxygenation index （PaO2/FiO2） in observation group was significantly higher than that of control group [mmHg （1 mmHg = 0.133 kPa）： 379.1 ±20.2 vs. 351.8±24.7], and arterial partial pressure of carbon dioxide （PaCO2） and airway resistance （Raw） were significantly lower than those of the control group [PaCO2 （mmHg）： 36.5 ± 5.8 vs. 45.3 ±6.9, Raw （cmH2O, 1 cmH2O = 0.098 kPa）： 12.9±0.6 vs. 13.1 ±0.8, all P 〈 0.01]. （2） There were no significant differences in inflammation parameters between the two groups before treatment, 24 hours after intervention, which were significantly decreased in both groups. Moreover, white blood cell count （WBC）, procalcitonin （PCT） and C-reactive protein （CRP） in the observation group were significantly lower than those of the control group [WBC （ × 10^9/L）： 8.2 ± 1.7 vs. 12.8±3.7, PCT （μg/L）： 15.4±2.4 vs. 21.8±3.1, CRP （mg/L）： 37.1 ±6.1 vs. 67.2±7.2, all P 〈 0.01]. （3） Compared with the control group, the treatment efficiency of observation group was improved [95.1% （136/143） vs. 87.4% （125/143）], the quantity of sputum excretion was increased （mL： 49.2 ± 12.5 vs. 36.9 ± 11.0）, duration of MV and length of ICU stay were significantly shortened （days： 6.4±3.6 vs. 9.4±2.1, 8.6±5.7 vs. 12.4±4.6, both P 〈 0.01）, however, there was no significantly statistical difference in 28-clay mortality between control group and observation group [2.8% （4/143） vs. 2.1% （3/143）, P 〉 0.05]. Conclusion Compared with bronehoalveolar lavage with fiberoptie bronehoscopy alone, the treatment of bronehoalveolar lavage combined with vibration sputum drainage is more effective in sputum excretion for severe pneumonia patients undergoing MV, which could improve the respiratory function, reduce infection, shorten the duration of MV and the length of ICU stay, and improve the recovery.