摘要
目的通过调查分析重症监护病房(ICU)医护人员对急性呼吸窘迫综合征(ARDS)肺保护通气策略(LPVS)应用的依从性,以改进临床ARDS LPVS的规范实施。方法回顾性调查2021年1月至2022年12月入住江苏省内8家医院ICU进行有创机械通气ARDS患者的临床资料,通过自制的ARDS LPVS实施监测量表,收集患者性别、年龄、身高、理想体质量(IBW),以及机械通气6 h的呼吸机参数〔模式、潮气量(VT)、呼气末正压(PEEP)、吸入氧浓度(FiO2)〕等相关指标。根据ARDS患者机械通气是否按照目标VT≤6 mL/kg(IBW),以及PEEP设置水平是否符合ARDS临床研究网络(ARDSnet)推荐FiO2-PEEP对应量表作为评价ARDS LPVS的标准,评估不同级别医院ICU医护人员对ARDS LPVS临床实施的依从性。结果纳入调查的357例ARDS机械通气患者中,VT设置均值为(6.17±1.02)mL/kg,其中204例患者按照VT≤6 mL/kg(IBW)设置,依从性为57.14%;三级医院VT设置低于二级医院(mL/kg:6.06±1.05比6.33±0.97,P<0.05),三级医院VT设置的依从性较二级医院更好〔61.84%(128/207)比50.67%(76/150),P<0.05〕。PEEP设置区间在3~16 cmH_(2)O(1 cmH_(2)O≈0.098 kPa),PEEP均值为(6.52±2.53)cmH_(2)O,其中199例患者的PEEP设置符合ARDSnet推荐的FiO2-PEEP对应量表,依从性占比为55.74%;三级医院PEEP设置高于二级医院(cmH_(2)O:6.95±2.13比5.94±2.91,P<0.05);三级医院PEEP设置的依从性高于二级医院〔67.63%(140/207)比39.33%(59/150),P<0.05〕。更为明显的是,在PEEP设置<5 cmH_(2)O的38例患者中,二级医院占94.74%(36例),其PEEP设置的不规范程度远高于三级医院〔60.67%(91/150)比32.37%(67/207),P<0.05〕。结论小潮气量(LVT)及合适PEEP的设置是规范实施ARDS LPVS的基础,是预防和减少呼吸机相关肺损伤(VILI)的关键。但从本次调查的情况来看,临床依从性并不乐观,尤其是二级医院在ARDS LPVS临床实施中与三级医院相比存在较大的差距。因此,需要重视ICU医护人员ARDS LPVS的治疗理念,提高整体认知水平,建议采取医护一体化的联合管理模式,建立相应的督查机制,以提高ICU医护人员ARDS LPVS的依从性。
Objective To investigate and analyze the compliance of intensive care unit(ICU)medical staff with acute respiratory distress syndrome(ARDS)lung protective ventilation strategy(LPVS),and improve the standardized implementation of ARDS LPVS in clinical practice.Methods The clinical data of ARDS patients with invasive mechanical ventilation admitted to ICU from 8 hospitals in Jiangsu Province was retrospectivly survey.Gender,age,height,ideal body weight(IBW),and 6-hour mechanical ventilation[mode,tidal volume(VT),positive endexpiratory pressure(PEEP),fraction of inspired oxygen(FiO2)]were collected by a self-made ARDS LPVS monitoring table.According to whether the mechanical ventilation of ARDS patients is based on the target VT≤6 mL/kg(IBW),and whether the level of PEEP was in line with the FiO2-PEEP corresponding scale recommended by ARDS Clinical Research Network(ARDSnet)as the standard for evaluating ARDS LPVS,to evaluate the compliance of ICU medical staff with the clinical implementation of ARDS LPVS in different levels of hospitals.Results Among 357 ARDS mechanical ventilation patients included,mean VT setting was(6.17±1.02)mL/kg,of which 204 patients were set with VT≤6 mL/kg(IBW),with compliance of 57.14%.The VT setting was lower in tertiary hospitals than that in secondary hospitals(mL/kg:6.06±1.05 vs.6.33±0.97,P<0.05),and the compliance of VT setting in tertiary hospitals was better than that in secondary hospitals[61.84%(128/207)vs.50.67%(76/150),P<0.05].The PEEP setting ranged from 3-16 cmH_(2)O(1 cmH_(2)O≈0.098 kPa),and the mean value was(6.52±2.53)cmH_(2)O.The PEEP settings of 199 patients complied with the FiO2-PEEP scale recommended by ARDSnet,and the corresponding compliance rate was 55.74%.The PEEP setting was higher in tertiary hospitals than that in secondary hospitals(cmH_(2)O:6.95±2.13 vs.5.94±2.91,P<0.05).The compliance of PEEP setting was better in tertiary hospitals than that in secondary hospitals[67.63%(140/207)vs.39.33%(59/150),P<0.05].It is worth noting that the PEEP settings of 38 patients were<5 cmH_(2)O,of which 36 patients were found in secondary hospitals(94.74%).The non-standard level of PEEP settings in secondary hospitals was much higher than that that in tertiary hospitals[60.67%(91/150)vs.32.37%(67/207),P<0.05].Conclusions Low VT(LVT)and appropriate PEEP settings were the basis for the standardized implementation of ARDS LPVS,and the key to prevent and reduce ventilator-induced lung injury(VILI).However,this study indicated that clinical compliance is not optimistic,especially there was a significant gap in the clinical implementation of ARDS LPVS between secondary and tertiary hospitals.Therefore,it is necessary to pay attention to the treatment concept of ARDS LPVS for ICU medical staff,and improve the overall cognitive level.A joint management model of medical and nursing integration,and corresponding supervision mechanisms were needed to improve the compliance of ICU medical staff with ARDS LPVS.
作者
陈小潍
史加海
徐梦瑶
许惠芬
董洪利
翟怀香
李晶
王小丹
顾晓成
陆相君
吴春娟
Chen Xiaowei;Shi Jiahai;Xu Mengyao;Xu Huifen;Dong Hongli;Zhai Huaixiang;Li Jing;Wang Xiaodan;Gu Xiaocheng;Lu Xiangjun;Wu Chunjuan(Nantong University,Nantong 226001,Jiangsu,China;Affiliated Maternity&Child Health Care Hospital of Nantong University,Nantong 226007,Jiangsu,China;Department of Intensive Care Unit,Affiliated Hospital of Nantong University,Nantong 226006,Jiangsu,China;Department of Intensive Care Unit,the First People's Hospital of Lianyungang,Lianyungang 222001,Jiangsu,China;Department of Intensive Care Unit,Xuzhou Mining Group General Hospital,Xuzhou 221000,Jiangsu,China;Department of Intensive Care Unit,the Second People's Hospital of Nantong,Nantong 226002,Jiangsu,China;Department of Intensive Care Unit,Zhenjiang First People's Hospital,Zhenjiang 212002,Jiangsu,China;Department of Intensive Care Unit,the Sixth People's Hospital of Nantong,Nantong 226002,Jiangsu,China;Department of Intensive Care Unit,Taixing People's Hospital,Taizhou 225400,Jiangsu,China)
出处
《中国中西医结合急救杂志》
CAS
CSCD
北大核心
2023年第3期267-270,共4页
Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care
基金
江苏省南通市科技计划项目(MSZ20081)。
关键词
急性呼吸窘迫综合征
肺保护通气策略
依从性
小潮气量
呼气末正压
Acute respiratory distress syndrome
Lung protective ventilation strategy
Compliance
Low tidal volume
Positive end-expiratory pressure
