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目的比较智能监护(SmartCare)脱机模式和间断停用呼吸机两种脱机方法,探讨智能监护脱机模式是否可以提高老年慢性阻塞性肺疾病(COPD)患者的脱机成功率。方法2003年1月至2005年4月解放军总医院老年呼吸科收治的男性呼吸衰竭机械通气患者38例,为机械通气时间均超过3 d的COPD患者,年龄70～91岁,平均(83．3±4．3)岁;随机分为智能监护脱机组(SC组,13例)和间断停用呼吸机组(SBT组,25例)进行脱机治疗。所有患者病情稳定,准备脱机。SC组在吸入气氧浓度(FiO2)≤45％,调节吸气压力(IPAP)水平,使动脉血pH值≥7．35,动脉血氧饱和度(SaO2)≥90％,呼吸频率(RR)在10～30次／min。SBT组每天逐渐延长停机时间。记录每位患者脱机开始时的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分,血气分析,血钙、镁、磷,脱机前机械通气时间,脱机时间。脱机成功标准为停用呼吸机48 h以上未再进行机械通气,脱机失败为在脱机过程中患者死亡或者脱机40 d后仍然需要机械通气。结果在脱机开始时,两组患者的机械通气时间,APACHEⅡ评分,血浆白蛋白含量,血清磷、镁、钙含量以及动脉血二氧化碳分压(PaCO2)比较差异均无统计学意义(t分别为0．834,0．696,1．384,0．682、0．467、0．816,0．384,P均>0．05);脱机前SBT组pH值(7．45±0．05)显著高于SC组(7．40±0．04,t=3．263,P<0．05)。SC组脱机时间[(8．54±2．09)d]短于SBT组[(13．32±2．19)d],但差异无统计学意义(t=1．320,P=0．251)。SC组第7天时脱机成功率(77％)显著高于SBT组(40％,X2=4．677,P=0．031);但第14天时两组的脱机成功率比较差异无统计学意义(77％、64％,X2=0．661,P=0．416)。SC组的血气分析次数[(3．5±3．1)次]显著少于SBT组[(6．6±3．7)次,t=2．710,P=0．011]。结论智能监护脱机模式在7 d内的脱机成功率要优于间断停用呼吸机的脱机方法。
Objective To compare two offline methods, SmartCare Off-line Mode and Discontinuation of Respiratory Ventilator, to investigate whether Smart-Monitor Off-line Mode can improve the off-line success rate in elderly patients with chronic obstructive pulmonary disease (COPD). Methods From January 2003 to April 2005, 38 patients with respiratory failure in male respiratory failure admitted to Department of Geriatrics, General Hospital of Chinese PLA were COPD patients aged from 70 to 91 with an average duration of mechanical ventilation of more than 3 days (mean, 83.3 ± 4.3) years old were randomly divided into two groups: the intensive care off-line group (SC group, 13 cases) and the discontinued respiration group (SBT group, 25 cases). All patients in stable condition, ready to go offline. In group SC, the arterial blood pH value ≥7.35, arterial oxygen saturation (SaO2) ≥90%, respiratory rate (RR) In 10 ~ 30 times / min. The SBT group gradually extended downtime every day. Acute Physiology and Chronic Health Score II (APACHE II) score, blood gas analysis, serum calcium, magnesium, phosphorus, mechanical ventilation before off-line and off-time were recorded at the beginning of each patient’s off-line. Success criteria for off-line resuscitation No ventilation was resumed for more than 48 h after the patient was either offline or mechanically ventilated after 40 days of off-line. Results There was no significant difference in mechanical ventilation time, APACHEⅡscore, plasma albumin, serum phosphorus, magnesium, calcium content and arterial carbon dioxide partial pressure (PaCO2) between the two groups at the beginning of off-line (t = 0.834,0.696,1.384,0.682,0.467,0.816,0.384, P> 0.05); SBT group before off-line pH (7.45 ± 0. 05) was significantly higher than SC group (7.40 ± 0.04, t = 3.263, P <0.05). The offline time in SC group [(8.54 ± 2.09) d] was shorter than that in SBT group [(13.32 ± 2.19) d], but the difference was not statistically significant (t = 1.320, P = 0 .251). The success rate of off-line on day 7 in SC group (77%) was significantly higher than that in SBT group (40%, X2 = 4.677, P = 0.031) Significance (77%, 64%, X2 = 0.661, P = 0.416). The frequency of blood gas analysis in SC group [(3.5 ± 3.1) times] was significantly lower than that in SBT group (6.6 ± 3.7 times, t = 2.710, P = 0.011). Conclusion The off-line success rate of intelligent monitoring off-line model in 7 days is better than off-line method of discontinuing ventilator.