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Implementation of A Real-time Compliance Dashboard to Help Reduce Ventilator-Associated Pneumonia with Ventilator Bundle

Objective To investigate the effect of a real-time compliance dashboard to help reduce ventilator-associated pneumonia ( VAP) with ventilator bundle. Methods 240 patients who were admitted into the intensive care unit ( ICU) of Shougang Hospital of Peking University and had received mechanical ventilation ( MV) for over 48 hours, between January 2010 and November 2011, were studied prospectively. The patients were divided into two groups by random number table, ie. a dashboard group ( n = 120) with implementation of a real-time compliance dashboard to help reduce VAP with ventilator bundle, and a control group ( n=120) with implementation of usually routine order to help reduce VAP with ventilator bundle. The success rate of ventilator bundle implementation, incidence of VAP, duration of MV, duration within ICU, mortality within 28 days, cost within ICU were compared between two groups. Results Compared with the control group, the success rate of ventilator bundle implementation obviously increased ( 81.6% vs. 52.5%) , incidence of VAP ( 14. 5/1000 days of MV vs. 36.2 /1000 days of MV) , duration of MV [ 5( 4,7) days vs. 8( 6,11) days] , duration within ICU [ 8( 6,12) days vs. 13( 8,16) days] , mortality of 28 days ( 12.6% vs. 28.6% ) , and cost within ICU ( 36,437 vs. 58,942) in the dashboard group obviously reduced ( Plt;0.05) . Conclusions Implementation of a real time compliance dashboard to help reduce VAP with ventilator bundle can obviously improve medical personnel compliance and reduce incidence of VAP, duration of MV, duration within ICU, mortality and cost in ICU than those of routine medical order to help reduce VAP with ventilator bundle.

Clinical Analysis of 34 Patients with Severe H1N1 Influenza

Objective To analyze the clinical features and treatment of severe H1N1 influenza.Methods The clinical data of 34 patients with severe H1N1 influenza admitted to intensive care unit from October to December 2009 were reviewed. Results The patients aged 3 months to 60 years with an average of ( 13. 9 ±4. 5) years, of which 24 patients were younger than 7 years old. Fever( 30 cases) , cough( 32 cases) , progressive shortness of breath( 19 cases) were the main symptoms. White blood cell count was normal in 21 cases, increased in 6 cases, and decreased in 7 cases. Lymphocyte count was normal in 16 cases, increased in 12 cases, and decreased in6 cases. Chest X-ray films showed bilateral or unilateral patchy pulmonary fuzzy shadows in28 cases. Chest CT showed diffuse interstitial lesion in1 case, pleural effusion in 2 cases, and bronchiectasis in 1 case. The hepatic and myocardial enzymogramparameters were all abnormal.30 cases were treated by oseltamivir and ribavirin, 4 cases by methyllprednisolone, and 6 cases by gamma globulin. 8 cases underwent routine intubation and mechanical ventilation, and 5 cases received non-invasive mechanical ventilation. All 34 patients were cured. Conclusions Lung, heart, and liver are the major target organs in severe H1N1 influenza. Mechanical ventilatory support is an important treatment for severe H1N1influenza.

Application of BiLevel Positive Airway Pressure Mechanical Ventilation on Cardiac Surgery Patients in Intensive Care Unit

【摘要】 目的 探讨双水平无创正压通气(BiPAP)对心脏外科术后需要二次机械辅助通气患者的治疗效果。方法 2008年9月—2009年9月，收集心脏外科手术后成功脱离呼吸机辅助通气后心功能衰竭或呼吸功能衰竭需要二次机械通气的患者,符合纳入及排除标准者共53例，进行回顾性分析,根据治疗方案分为无创通气组(32例)和有创通气组(21例),在需要机械通气时(T1),机械通气后30 min(T2),机械通气后2 h(T3)及预计脱离机械通气时(T4),分别统计患者心率、血气分析等情况,比较氧分压、ICU停留时间及术后至出院时间。结果 给予辅助通气前,两组患者的心率及PO2无统计学差异(Pgt;0.05)。给予辅助通气后,无创通气组患者的心率由T1(130.8±21.10)次/min,下降到T2(125.60±21.36)次/min,T3(101.70±13.73)次/min,T4(87.40±9.35)次/min；PO2由T1(64.70±14.12) mm Hg,上升到T2 (121.40±30.19) mm Hg，T3 (140.40±25.29) mm Hg，T4 (132.90±16.33) mm Hg。有创通气组患者的心率由T1 (138.27±21. 39)次/min,下降到T2(118.18±18.03)次/min，T3(100.00±11.73)次/min，T4(87.00±10.70)次/min；PO2由T1 (61.45±13.56) mm Hg上升到T2(122.55±29.50) mm Hg，T3(138.91±24.77) mm Hg，T4(133.55±18.00) mm Hg。两组患者心率及PO2均较辅助通气前降低(Plt;0.05)。两组患者之间各时间点心率及PO2比较无差异(Pgt;0.05)。无创通气组的ICU停留时间及术后至出院时间分别为(1.75±2.97) d及(9.14±4.11) d，均低于有创通气组的(4.38±5.13) d及(14.00±0.82) d,有统计学意义(Plt;005)。结论 双水平无创正压通气可用于心脏外科术后需要二次机械通气的患者。

无创通气辅助困难撤机气管切开患者成功撤机一例

有创-无创序贯性机械通气在肺挫伤致急性呼吸窘迫综合征中的应用价值

目的 观察有创-无创序贯机械通气在肺挫伤致急性呼吸窘迫综合征( ARDS) 中的应用价值。方法 选择肺挫伤致ARDS 患者44 例, 随机分为序贯治疗组和对照组, 每组22 例。所有病例均气管插管行机械通气, 通气模式为同步间歇指令通气( SIMV) + 压力支持通气( PSV) + 呼气末正压( PEEP) 。当ARDS 控制窗出现时, 序贯治疗组依次选择双水平正压通气( BiPAP) 至停机通气模式, 对照组选择SIMV + PSV + PEEP 至停机通气模式。结果 序贯治疗组有创通气时间[ ( 4.5 ±2.5) d 比( 13.1 ±4.9) d] 、总机械通气时间[ ( 14±2) d 比( 19±1) d] 、呼吸机相关性肺炎( VAP) 发生率 ( 9.1%比40.9% ) 、ICU住院时间[ ( 17±3) d 比( 22±4) d] 、病死率( 13.6% 比31.8% ) 与对照组比较差异均有统计学意义( Plt;0.05) 。结论 有创-无创序贯机械通气是治疗肺挫伤致ARDS 的安全、有效的方法, 能明显缩短有创通气时间和总机械通气时间, 降低VAP发生率, 缩短ICU住院时间, 降低病死率。

有创机械通气患者人工气道的选择: 经鼻还是经口插管? 是否要早做气管切开?

一、经鼻或经口气管插管的优劣有创机械通气患者需建立人工气道( 气管插管或气管切开) , 气管插管经鼻或经口途径何者优越的问题, 国内外始终存在争论。20 世纪80 年代前, 我们和国内大多数医院一样, 较多采用经口插管, 理由是经口比较容易插入, 可用较大管径的导管, 气流阻力较小; 便于吸痰, 清除气道内分泌物。但缺点是容易移位, 脱出, 如果脱出后重插, 将增加患者危险和呼吸机相关肺炎( VAP) 发生率; 患者不能闭口, 不能进行有效的口腔清洁护理, 且使不少患者口咽分泌物增加,口咽部定植菌的增加和分泌物经过气管导管气囊的微误吸, 也增加VAP发生的危险。由于那时还没有使用高容低压气囊, 使用的高压低容气囊的橡胶插管只能短时间保留, 故患者插管后1～3 d 均行气管切开。

Effects of Different Inspiratory Flow Waveforms on the Respiratory Function of Patients with Severe Exacerbation of Asthma During Mechanical Ventilation

Objective To evaluate the effects of different inspiratory flow waveforms on the respiratory function of patients with severe exacerbation of asthma during mechanical ventilation. Methods Twenty-one patients with severe exacerbation of asthma were ventilated with square waveform and decelerating waveform respectively for 30 minutes when the tidal volume was set at 6 mL/ kg, 8 mL/ kg and 10 mL/ kg in ICUof Zhejiang Hospital of Integrated Traditional Chinese and Western Medicine fromJanuary 2006 to December 2007. Meanwhile shunt fraction ( Q·S /Q·T ) , dead space value ( VD/VT ) , airway peak pressure ( Ppeak ) , plateau pressure ( Pplat) ,intrinsic positive end-expiratory pressure( PEEPi) and arterial blood gas analysis were measured. Results The Q ·S /Q·T in the decelerating waveformgroup was less than that of the square waveform group( P lt;0. 05) when tidal volume was set at 6 mL/ kg. When tidal volume was set at 10 mL/ kg, PEEPi and VD /VT in the decelerating waveform group were higher than those of the square waveform group. On the contrary, the Ppeak was lower than that of square waveform group( P lt; 0. 05) . Conclusion For patients with severe exacerbation of asthma treated with mechanical ventilation, decelerating waveform is preferable at low tidal volume( 6 mL/ kg) , and square waveform is preferable at high tidal volume( 10 mL/kg) .

Establishment and Evaluation of Rabbit Model of Ventilator-Induced Lung Injury

Objective To establish a rabbit model of ventilator-induced lung injury. Methods Fourty healthy New Zealand rabbits were randomly divided into 3 groups: ie. a routine 8 mL/kg tidal volume group( VT8 group) , 25 mL/kg large tidal volume group( VT25 group) , and 40 mL/kg large tidal volume group( VT40 group) . VT25 and VT40 group were further divided into 2 hours and 4 hours ventilation subgroups. Arterial blood gas, lung mechanical force and hemodynamic parameters were monitored. Lungtissue was sampled for evaluate lung wet/dry ratio and lung injury by HE stain. Bronchoalveolar lavage fluid ( BALF) was collected for measurement of protein concentration, total and differential cell counts. Results Compared with VT8 group, lung injury score in both VT40 and VT25 groups were elevated significantly, ofwhich 4 hour VT40 subgroup was the highest. Lung pathology examination of VT40 group revealed apparent alveolar deformation, interstitial and alveolar space exudation, inflammatory cells infiltration, pulmonary consolidation and alveolar hemorrhage. Lung pathology examination of VT25 group showed pulmonary intervalthickening, inflammatory cells infiltration, while alveolar intravasation was mild. Blood gas analysis showed that PaO2 /FiO2 was deteriorated with time in VT25 and VT40 groups, and PaO2 /FiO2 at the 3 hours in VT40 group( lt; 300 mm Hg) had met the acute lung injury standard, while which in VVT25 group was above 300 mmHg. Lung wet/dry ratio, BALF protein concentration, total nucleated cell and neutrophilic leukocyte were elevated in both VT25 and VT40 groups, of which 4 hours VT40 group was the highest. Conclusion Using 4 hours ventilation at a tidal volume of 40 mL/kg can successfully establish the rabbit model of ventilator-induced lung injury.

机械通气在胸部肿瘤术后急性呼吸衰竭治疗中的应用

目的 总结胸部肿瘤患者术后发生急性呼吸衰竭（ARF）行机械通气治疗的经验。 方法 根据64例胸部肿瘤患者术后发生ARF的情况，如原发病、手术后的肺疾病、呼吸肌力和手术并发症等进行不同的机械通气治疗，其中61例进行有创通气治疗，3例进行无创性正压通气。对12例肺不张或严重肺部感染者进行床旁纤维支气管镜吸痰、支气管肺泡灌洗（BAL）。 结果 64例ARF中 54例治愈，10例死亡。12例肺不张或严重肺部感染者经纤维支气管镜治疗均有效；随访54例，随访时间2个月，无ARF复发。 结论 胸部肿瘤患者术后发生ARF应选择恰当的通气模式，进行个性化机械通气治疗，良好的机械通气有利于治疗术后并发症；对有肺不张或严重肺部感染者进行纤维支气管镜吸痰和BAL治疗效果良好。

PAV在新生儿机械通气中的研究进展

【摘要】 〖HT5”SS〗比例辅助通气(proportional assist ventilation,PAV)是近年来呼吸生理学和计算机智能分析技术结合的产物,国外研究结果显示PAV具有良好的临床应用前景。本文综合相关研究报道，简要介绍PAV在新生儿机械通气中的应用进展。