体外膈神经电刺激对脑损伤术后昏迷的脱机困难患者机械通气时间、膈肌功能及其预后的影响

关键词：脑损伤术后昏迷  机械通气  脱机困难  体外膈神经电刺激  膈肌功能

Keywords:coma after brain injury  mechanical ventilation  difficult offline  external phrenic nerve stimulation  diaphragm function

摘要：

      摘要 目的：探讨体外膈肌起搏器（EDP）对脑损伤术后昏迷的脱机困难患者的机械通气时间、膈肌功能及其预后的影响。 方法：纳入66例脑损伤术后昏迷使用有创呼吸机，并产生脱机困难的患者，按随机数字表法分为对照组（n=33）和试验组（n=33）。对照组接受ICU常规药物和机械通气治疗，试验组在对照组基础上增加EDP治疗，每日2次，每次20mins，连续进行14d。在试验起点（术后上机72—96h内）和试验终点（脱机成功当日，未脱机成功按治疗周期结束后当日算），观察两组患者的机械通气时间和呼吸参数变化。采用超声观察膈肌厚度（diaphragm thickness， DT）、膈肌增厚分数（diaphragm thickening fraction， DTF）及膈肌移动度（diaphragm excursion， DE）的变化，并记录其他预后参数。 结果：两组患者入组时各数据组间无显著性差异（P>0.05）。治疗结束后，在呼吸功能方面，除对照组浅快呼吸指数治疗前后无显著性差异（P＞0.05）外，试验组患者机械通气时间较对照组明显缩短，脱机成功率提高，两组患者潮气量和浅快呼吸指数较治疗前均有改善，对照组治疗后潮气量较前增加有显著性差异（P＜0.05），试验组组间治疗后的潮气量较治疗前增加，试验组浅快呼吸指数治疗后较治疗前减少，均有显著性差异（P＜0.001）。在膈肌功能方面，治疗前两组DT、DTF及DE均无显著性意义（P＞0.05），治疗后两组DT变化的构成比有显著性差异（P<0.001），DTF和DE在两组之间、组内治疗后均有提高，呈显著性差异（P<0.001）。在预后方面，在试验终点试验组复上机率、死亡率及住院周期均比对照组低，但无显著性意义（P＞0.05）。 结论：EDP治疗可以缩短脑损伤术后昏迷脱机困难患者的机械通气时间，提高脱机成功率，改善呼吸参数，同时可提高膈肌功能。但不能减少复上机率、降低死亡率及缩短住院周期。

Abstract:

      Abstract Objective： To investigate the effect of external diaphragm pacemaker （EDP） on the duration of mechanical ventilation， diaphragm function， and other prognosis in coma patients with difficult weaning after brain injury surgery. Method： A total of 66 postoperative coma patients with brain injury were enrolled and divided into control group （n=33） and experimental group （n=33） according to the random number table method. The control group was treated with conventional drugs and mechanical ventilation in ICU， and the experimental group was treated with EDP on the basis of the control group， 20 minutes each time， twice a day for 14 consecutive days. The mechanical ventilation time and respiratory parameters of the two groups were observed at the starting point （within 72—96 hours of mechanical ventilation after operation） and the end point （the day of successful weaning， and the day after the end of treatment cycle if the patients were not successfully weaned）. The changes of diaphragm thickness （DT）， diaphragm thickening fraction （DTF）， and diaphragm excursion （DE） were observed by ultrasound， and other prognostic parameters were recorded. Result： There was no significant difference between the two groups at the time of enrollment（P>0.05）. After treatment， in terms of respiratory function， except for the control group with no statistical difference in shallow rapid respiratory index before and after treatment （P>0.05）， the mechanical ventilation time of the experimental group was significantly shorter than that of the control group， and the success rate of offline was improved. Tidal volume and shallow rapid respiratory index of the two groups were improved compared with that before treatment， and the tidal volume of the control group was increased after treatment with statistical difference （P<0.05）. The tidal volume of experimental group after treatment was increased compared with before treatment， and the shallow rapid respiratory index of experimental group was decreased compared with before treatment， with significant differences （P<0.001）. In terms of diaphragm function， there was no statistical significance in DT， DTF and DE between the two groups before treatment （P>0.05）， and there was a significant difference in the composition ratio of DT changes between the two groups after treatment （P<0.001）. DTF and DE showed significant differences between the two groups and within the two groups after treatment，（P<0.001）.In terms of prognosis， the rate of recovery， mortality and length of hospital stay in the experimental group were lower than those in the control group， but there was no significant difference （P>0.05）. Conclusion： EDP treatment can shorten the mechanical ventilation time of coma patients with difficult weaning after brain injury surgery， improve the success rate of weaning， improve respiratory parameters， and improve diaphragm function. However， it did not reduce the probability of recovery， mortality and length of hospital stay.