摘要
目的比较不同营养支持方式对慢性阻塞性肺疾病急性加重(AECOPD)并呼吸衰竭患者营养状态、肺功能及炎性因子的影响。方法选取2016年10月-2018年10月北京市顺义区医院呼吸与危重症医学科收治的AECOPD并呼吸衰竭患者135例,采用随机区组法分为A、B、C 3组,每组45例。在常规治疗及有创呼吸机辅助通气治疗基础上,A组患者单独给予肠内营养支持,B组患者单独给予肠外营养支持,C组患者给予序贯肠内外营养支持。比较3组患者营养支持前及营养支持1周、2周营养指标〔包括白蛋白(ALB)、前白蛋白(PA)、血红蛋白(Hb)、转铁蛋白(TRF)、上臂三头肌肌围(AMC)〕、肺功能指标〔包括第1秒用力呼气容积(FEV1)、第1秒用力呼气容积占预计值百分比(FEV1%pred)及第1秒用力呼气容积与用力肺活量比值(FEV1/FVC)〕、炎性因子〔包括肿瘤坏死因子α(TNF-α)、超敏C反应蛋白(hs-CRP)、降钙素原(PCT)、白介素10(IL-10)〕,机械通气时间、ICU入住时间,住院期间并发症发生率、病死率。结果(1)时间与方法在血清ALB、PA、Hb、TRF水平上存在交互作用(P<0.05);时间、方法在血清ALB、PA、Hb、TRF水平上主效应显著(P<0.05)。营养支持1、2周,B、C组患者血清ALB、PA、Hb、TRF水平高于A组,C组患者血清ALB、PA、Hb、TRF水平高于B组(P<0.05)。营养支持前3组患者AMC比较,差异无统计学意义(P>0.05)。营养支持1、2周,B、C组患者AMC长于A组,C组患者AMC长于B组(P<0.05)。(2)时间与方法在FEV1、FEV1%pred、FEV1/FVC上存在交互作用(P<0.05);时间、方法在FEV1、FEV1%pred、FEV1/FVC上主效应显著(P<0.05)。营养支持1、2周,C组患者FEV1大于A、B组,FEV1%pred、FEV1/FVC高于A、B组(P<0.05)。(3)时间与方法在血清TNF-α、hs-CRP、PCT、IL-10水平上存在交互作用(P<0.05);时间、方法在血清TNF-α、hs-CRP、PCT、IL-10水平上主效应显著(P<0.05)。营养支持1、2周,C组患者血清TNF-α、hs-CRP、PCT、IL-10水平低于A、B组(P<0.05)。(4)C组患者机械通气时间、ICU入住时间短于A、B组(P<0.05)。(5)住院期间B组患者腹胀、应激性溃疡发生率高于A、C组,C组患者呼吸机相关性肺炎(VAP)、心力衰竭发生率及病死率低于A、B组(P<0.05)。结论与单独肠内/肠外营养支持相比,序贯肠内外营养支持能更有效地改善AECOPD并呼吸衰竭患者营养状态、肺功能,降低炎性因子水平并减轻炎性反应,缩短机械通气时间、ICU入住时间,降低住院期间并发症发生率及死亡风险,可作为AECOPD并呼吸衰竭患者首选营养支持方式。
Objective To compare the impact of different nutritional support modes on nutritional status,pulmonary function and inflammatory cytokines in AECOPD patients complicated with respiratory failure. Methods From October 2016 to October 2018,a total of 135 AECOPD patients complicated with respiratory failure were selected in the Department of Respiratory and Critical Care Medicine,Shunyi District Hospital of Beijing,and they were divided into groups A,B,and C according to randomized block method,with 45 cases in each group. Based on conventional treatment and invasive ventilator assisted ventilation,patients in A group received enteral nutrition support only,patients in B group received parenteral nutrition support only,while patients in C group received sequential enteral and parenteral nutrition support. Nutritional indicators〔including ALB,PA,Hb,TRF and arm muscle circumference(AMC)〕,pulmonary function indicators(including FEV1,FEV1%pred and FEV1/FVC)and inflammatory cytokines(including TNF-α,hs-CRP,PCT and IL-10)before and after 1 and 2 weeks of nutritional support,duration of mechanical ventilation,ICU stays,incidence of complications and fatality rate during hospitalization were compared between the two groups. Results(1)There was statistically significant interaction between time and method in serum levels of ALB,PA,Hb and TRF(P<0.05);main effects of time and method were statistically significant in serum levels of ALB,PA,Hb and TRF(P<0.05). After 1 and 2 weeks of nutrition support,serum levels of ALB,PA,Hb and TRF in groups B and C were statistically significantly higher than those in A group,meanwhile serum levels of ALB,PA,Hb and TRF in C group were statistically significantly higher than those in B group(P<0.05). There was no statistically significant difference in AMC in three groups before nutritional support(P>0.05);after 1 and 2 weeks of nutritional support,AMC in groups B and C were statistically significantly longer than those in A group,respectively,meanwhile AMC in C group was statistically significantly longer than that in B group(P<0.05).(2)There was statistically significant interaction between time and method in FEV1,FEV1%pred and FEV1/FVC(P<0.05);main effects of time and method were statistically significant in FEV1,FEV1%pred and FEV1/FVC(P<0.05). After 1 and 2 weeks of nutritional support,FEV1,FEV1%pred and FEV1/FVC in C group were statistically significantly higher than those in groups A and B(P<0.05).(3)There was statistically significant interaction between time and methods in serum levels of TNF-α,hs-CRP,PCT and IL-10(P<0.05). Main effects of time and method were statistically significant in serum levels of TNF-α,hs-CRP,PCT and IL-10(P<0.05). After 1 and 2 weeks of nutritional support,serum levels of TNF-α,hs-CRP,PCT and IL-10 in C group were statistically significantly lower than those in groups A and B(P<0.05).(4)Duration of mechanical ventilation and ICU stays in C group were statistically significantly shorter than those in groups A and B(P<0.05).(5)During hospitalization,incidence of abdominal distension and stress ulcer in B group was statistically significantly higher than that in groups A and C,respectively,while incidence of ventilator-associated pneumonia(VAP)and heart failure,and fatality rate in C group were statistically significantly lower than those in groups A and B(P<0.05). Conclusion Compared with enteral/parenteral nutrition support only,sequential enteral and parenteral nutrition support can more effectively improve the nutritional status and pulmonary function in AECOPD patients with respiratory failure,reduce the inflammatory cytokines and relieve the inflammatory reaction,shorten the duration of mechanical ventilation and ICU stays,reduce the risk of complications and death during hospitalization,which may be the preferred nutritional support mode in AECOPD patients with respiratory failure.
作者
赵辉
ZHAO Hui(Department of Respiratory and Critical Care Medicine,Shunyi District Hospital of Beijing,Beijing 101300,China)
出处
《实用心脑肺血管病杂志》
2019年第4期77-82,共6页
Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease
基金
北京市科技计划项目(Z171100001017244)
关键词
慢性阻塞性肺疾病
呼吸衰竭
肠内营养
肠外营养
营养状态
肺功能
炎性因子
疗效比较研究
Chronic obstructive pulmonary disease
Respiratory failure
Enteral nutrition
Parenteral nutrition
Nutritional status
Pulmonary function
Inflammatory cytokines
Comparative effectiveness research
