【作者】 皮红英；

【导师】 张黎明；

【作者基本信息】 中国人民解放军军医进修学院 ， 护理学， 2004， 硕士

【摘要】 目的：通过动物实验和临床实验，研究更适宜急性呼吸窘迫综合征（ARDS）机械通气患者气管内吸痰的方式及护理方法。方法：1．动物实验部分：采用静脉注射油酸制备犬ARDS模型，随机选择开放式气管内吸痰（OS）和密闭式气管内吸痰（CS）顺序，于吸痰前2min、吸痰后0.5min、5min、10min抽取动脉血及混合静脉血进行血气分析，并记录呼吸力学、血流动力学等监测指标的数据。2．临床研究部分：在外科重症监护病房（SICU）选取诊断ARDS并行机械通气治疗的患者。每名患者使用OS和CS两种吸痰方式，吸痰顺序随机选择。于吸痰前2min、吸痰后0.5min、5min、10min抽取动脉血进行血气分析，并记录吸气峰压（Ppeak）、平台压（Pplat）、心率（HR）、平均动脉压（MAP）、脉搏血氧饱和度（SpO₂）、呼吸末正压（PEEP）、潮气量（V_T）等数据。结果：1．动物实验部分：①吸痰方式对气体交换的影响：OS后，动脉血氧分压（PaO₂）、动脉血氧饱和度（SaO₂）、氧合指数（PaO₂／FiO₂）明显降低，肺泡-动脉血氧分压差（P（A-a）DO₂）明显增大（P＜0.05）；CS前后PaO₂、SaO₂等指标变化无明显差异（P＞0.05）。②吸痰方式对呼吸力学影响：OS和CS后，Ppeak、Pplat、平均气道压力（Pmean）与吸痰前比较均明显上升（P＜0.05）；肺动态解放军总医院军医进修学院硕士学位论文摘要顺应性（Co）、静态顺应性（CS）05后显著下嗽六0.05)。③吸痰方式对血流动力学的影响:05和CS后，平均肺动脉压（NIPAP）与吸疾前比较均明显升高（尸丈0.05）; 05后MAp显著升高任欠0.05)。2.临床研究部分:①吸疾方式对气体交换的影响:05后患者PaOZ、s心、SpQZ与吸疾前比显著喇氏（尸<。.05）; CS前后比较上断旨标无显著性差异沙卜0.05)。②吸痰方式冲呼吸力学影响:05和CS后患者巧姆砍、即lat、Cs、CD增高与吸疾前比较无显著性差异（尸）0.05)。③吸疾方式时1目IR和血压的影响:05和CS后患者HR、动脉收缩压（SBP）、M叭P与吸疾前比较均显著增高（尸<0.05）。结刹狱OS加重患制配氮血症;CS过程中可以保持持续通气，维持PEI护及气道压力，Fiq，PaOZ、SaOZ变化不大沙)0.05)，道岁寸于习豁台疗重点放在肺泡复张和保持肺容积上的ARDS患者非常重要。05、CS均可影响气道压力及血流动力学的稳定。本研究提示我了门，在护理工作中，对ARDS患者应重视吸疾引起的继发损害，加强吸痰前后血气、气道压力、HR、动月和鱼压等监测;对于ARDS患者吸痰时选择CS方式更适宜和安全。更多还原

【Abstract】 Objective: The aim of our study is to find the better ways of endotrachealsuctioning and caring in the ARDS mechanical ventilated patients throughanimal and clinical work.Methods:Part 1 Animal study:Tracheal intubated mongrel dogs were injured by injecting oleic acid to buildup ARDS models. Each dog was suctioned with opened endotrachealsuctioning(OS) and closed endotracheal suctioning(CS) in randomized order.The data of arterial blood gas and mixed venous blood gas were obtained at2min before suction and at 0.5, 5 and 10min after suction, and indexes ofhemocfynamics and respiratory mechanics were attached.Part 2 Clinical study:14 ARDS ventilated patients in SICU were enrolled. Both OS and CS suctiontechniques were performed on each patient in randomized order. Arterialblood gas index was obtained at 2min before suction and at 0.5,5 and 10minafter suction. The data of inspiratory peak pressure (Ppeak), inspiratoryplateau pressure (Pplat), heart rate (HR), mean arterial pressure (MAP),oxygen saturation by pulse oximetry (SpO2), positive end expiratory pressure(PEEP), and tidal volume (VT) were recorded during performing suctiontechniques in ARDS patients.Results:Part 1 Animal study:(1)Gas exchange. After performing OS technique, there showed obviousdecreasing in the data of arterial oxygen partial pressure (PaO2), arterialoxygenation (SaO2) and arterial oxygenation partial pressure/ fractionalinspired oxygen (PaO2/ FiO2), and the data of alveolar-arterial oxygen partialpressure difference [P(A-a)DO2]] got worsen (PO.05). There were notsignificant differences in the indexes of PaQ and SaO2 between before CSand after CS(PX).05).(2)Respiratory Mechanics, There were significant increasing in the data ofPpeak, Pplat and mean airway pressure (Pmean) after suction compared tobefore suction in two suction ways (PO.05). On the contrary, the data ofpulmonary static compliance (Cs) and pulmonary dynamic compliance (CD)got worsen after OS compared to before OS (PO.05).(3)Hemodynamics. In the two suction ways, the data of mean pulmonaryarterial pressure (MPAP) significantly raised after suction (PO.05), but onlymean arterial pressure (MAP) raised after performing OS (PO.05).Part 2 Clinical study(1)Gas exchange and Metabolism. There showed significant decreases in thedata of PaO2, SaO2 and SpO2 after OS (PO.05). There were not statisticaldifferences between after CS and before CS.(2)Respiratory Mechanics. In the two suction ways, there were not significantdifferences in Ppeak, Pplat, CD and Cs between after and before suction.(3)HR and Blood Pressure. Significant increases were found in HR, systolicblood pressure (SBP) and MAP after OS and CS(PO.05).Conclusions: In our experimental and clinical work, we found that theharmful effect of OS is causing deteriorated hypoxemia. Compared to OStechnique, CS technique showed favorable effects in maintaining PEEP effectand confirming continuous ventilation during performing suction ways, and itdid not cause obviously worsen in FiO2, PaO2 and SaO2(P>0.05) duringperforming CS techniques. This is very important for ARDS patients on preventing alveolar recruitment and maintaining lung volume derecruitment In our study, we also found that both OS and CS had obvious influencing on hemodynarnics and airway pressure, and it remind us that we should pay more attention to the potential damages that caused by suction ways and we should intensify monitoring the changes of airway pressure, HR and arterial pressure during performing endotracheal suction ways in clinical nursing practice. In conclusion, compared to OS, we think that CS technique is comparatively safer and more comfortable for ARDS patients.更多还原