改良式俯卧位通气对ARDS患儿治疗的有效性和安全性系统评价

陈娟娟; 李莉; 孙琦; 张茜; 李冬梅

doi:10.16766/j.cnki.issn.1674-4152.003140

改良式俯卧位通气对ARDS患儿治疗的有效性和安全性系统评价

doi: 10.16766/j.cnki.issn.1674-4152.003140

蚌埠医学院第一附属医院儿童重症医学科，安徽蚌埠 233004

基金项目:

安徽省高校人文社会科学研究项目 SK2021A0425

蚌埠医学院人文社会科学类项目 BYKY2019205skZD

详细信息

通讯作者:
陈娟娟，E-mail：812475105@qq.com

中图分类号: R473.72 R725.6
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出版历程
- 收稿日期: 2022-07-18
- 网络出版日期: 2023-09-13

Systematic evaluation of the efficacy and safety of modified prone position ventilation in the treatment of children with ARDS

Department of Pediatric Intensive Care Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China

摘要

摘要: 目的观察改良式俯卧位通气对儿童急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)治疗的有效性和安全性，为临床ARDS的治疗和护理提供标准化流程。方法采用便利抽样法，选取2020年1月—2021年12月于蚌埠医学院第一附属医院儿童重症医学科住院的50例急性呼吸窘迫综合征患儿，采用随机数字表法随机分为对照组及观察组，各25例。对照组给予传统俯卧位通气方法，观察组给予改良式俯卧位通气方法，比较2组干预前后呼吸力学指标(氧合指数、胸肺顺应性)以及血流动力学指标(心率、平均动脉压)的改善及并发症发生情况。结果 2组俯卧位干预前呼吸力学指标以及血流动力学指标监测得分对比，差异无统计学意义(P＞0.05)；2组俯卧位通气后，血流动力学指标无明显改变，差异均无统计学意义(P＞0.05)；采取俯卧位通气后，观察组氧合指数、胸肺顺应性监测得分优于对照组，差异有统计学意义(均P＜0.05)。观察组并发症(压力性损伤，呕吐，意外脱管，颜面部水肿)的发生率为4.0%，对照组并发症发生率为48.0%，2组比较，差异有统计学意义(P＜0.05)。结论改良式俯卧位通气策略可促进ARDS患儿呼吸运动恢复，维持患儿血液动力学稳定，且减少了传统俯卧位造成的皮肤损伤、呕吐等并发症的发生，同时因改良俯卧位给予头面部有效支撑，缓解常规俯卧位引起的面部、眼睑或结膜水肿，减少并发症的发生，值得临床推广。
- 改良式俯卧位通气 /
- 早期 /
- 急性呼吸窘迫综合征 /
- 儿童
Abstract: Objective To observe the efficacy and safety of modified prone position ventilation in the treatment of children with acute respiratory distress syndrome (ARDS), to provide a standardized process for the treatment and care of clinical ARDS. Methods Fifty children with ARDS hospitalized in the Department of Intensive Care Medicine, the First Affiliated Hospital of Bengbu Medical College from January 2020 to December 2021 were conveniently selected and randomly divided into control group and observation group by using a radom number table method, with 25 cases in each group. The control group was given the traditional prone position ventilation method, and the observation group was given the modified prone position ventilation method. The improvement of respiratory mechanical indexes (oxygenation index, thoracic and pulmonary compliance) and hemodynamic indexes (heart rate, mean arterial pressure) and the occurrence of complications before and after intervention were compared between the two groups. Results There was no significant difference in the scores of respiratory mechanics index and hemodynamic index between the two groups before intervention (P>0.05). After prone position ventilation, there were no significant changes in hemodynamic indexes between the two groups (P>0.05). The oxygenation index and chest and lung compliance monitoring scores of the observation group were better than those of the control group, and the differences were statistically significant (all P < 0.05). The incidence of complications (stress injury, vomiting, accidental extubation, facial edema) was 4.0% in the observation group and 28.0% in the control group, and the difference was statistically significant between the two groups (P < 0.05). Conclusion The modified prone position ventilation strategy can promote the recovery of respiratory movement, maintain the hemodynamic stability of children with ARDS, and reduce the occurrence of complications such as skin injury and vomiting caused by traditional prone position. Meanwhile, the modified prone position provides effective head and face support, alleviates the edema of face, eyelid or conjunctival caused by conventional prone position, and reduces the occurrence of complications. It is worthy of clinical promotion.
- Modified prone position ventilation /
- Early stage /
- Acute respiratory distress syndrome /
- Children

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图 1 改良式俯卧位通气垫“趴趴乐”

Figure 1. Modified prone position air cushion "Pake Ke Le"

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表 1 2组急性呼吸窘迫综合征患儿一般资料比较

Table 1. Comparison of general data of two groups of children with acute respiratory distress syndrome

组别	例数	性别[例(%)]		体重 [M(P₂₅, P₇₅)，kg]	年龄 [M(P₂₅, P₇₅)，岁]
组别	例数	男	女	体重 [M(P₂₅, P₇₅)，kg]	年龄 [M(P₂₅, P₇₅)，岁]
观察组	25	14(56.0)	11(44.0)	(7.75, 10.10)	(0.29, 2.00)
对照组	25	12(48.0)	13(52.0)	(8.45, 12.00)	(0.46, 2.50)
统计量		0.321^a		-1.175^b	-0.759^b
P值		0.571		0.240	0.448
注：^a为χ²值，^b为Z值。

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表 2 2组急性呼吸窘迫综合征患儿HR、MAP比较

Table 2. Comparison of HR and MAP between the two groups of ARDS children

组别	例数	HR(x±s，次/min)		t值	P值	MAP[M(P₂₅, P₇₅)，mmHg]		Z值	P值
组别	例数	俯卧位干预前	俯卧位干预后	t值	P值	俯卧位干预前	俯卧位干预后	Z值	P值
对照组	25	114.94±17.21	115.04±17.56	0.204	0.604	72.00(68.17, 83.17)	74.00(68.17, 84.67)	-1.429	0.153
观察组	25	115.54±16.40	115.80±16.00	0.049	0.961	72.00(68.50, 83.00)	74.00(67.17, 84.67)	-0.229	0.819
统计量		-0.111^a	0.160^a			-1.034^b	-1.848^b
P值		0.912	0.873			0.301	0.065
注：^a为t值，^b为Z值。

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表 3 2组急性呼吸窘迫综合征患儿PaO₂/FiO₂、Cst比较[M(P₂₅, P₇₅)]

Table 3. Comparison of PaO₂/FiO₂ and Cst in ARDS children between the two groups[M(P₂₅, P₇₅)]

组别	例数	PaO₂/FiO₂(mmHg)		Z值	P值	Cst(mL/cmH₂O)		Z值	P值
组别	例数	俯卧位干预前	俯卧位干预后	Z值	P值	俯卧位干预前	俯卧位干预后	Z值	P值
对照组	25	160.55(142.27, 171.66)	166.00(146.70, 199.11)	-2.247	0.025	37.20(32.55, 39.65)	38.10(34.50, 40.50)	-3.419	0.001
观察组	25	159.20(142.45, 168.65)	180.60(168.41, 194.89)	-4.049	＜0.001	36.40(32.80, 39.00)	41.50(39.95, 46.10)	-4.373	＜0.001
Z值		-1.546	-1.736			-1.816	-4.381
P值		0.122	0.043			0.069	＜0.001

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表 4 2组急性呼吸窘迫综合征患儿并发症发生情况比较

Table 4. Comparison of complications between the two groups of ARDS children [cases(%)]

组别	例数	呕吐	意外脱管	压力性损伤	颜面部水肿	合计
对照组	25	5(20.0)	3(12.0)	2(8.0)	2(8.0)	12(48.0)
观察组	25	1(4.0)	0	0	0	1(4.0)
注：2组并发症发生率比较，χ²=12.578，P＜0.001。

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参考文献(20)

[1]	杨琴, 马红玲, 王卫, 等. 儿童下呼吸道流感病毒感染危重症临床特征分析[J]. 中国小儿急救医学, 2020, 27(7): 502-506. doi: 10.3760/cma.j.issn.1673-4912.2020.07.006 ANG Q, MA H L, WANG W, et al. Analysis of the clinical characteristics of lower respiratory tract infection of influenza virus-related critical illness in children[J]. Chinese Pediatric Emergency Medicine, 2020, 27(7): 502-506. doi: 10.3760/cma.j.issn.1673-4912.2020.07.006
[2]	DOWELL J C, PARVATHANENI K, THOMAS N J, et al. Epidemiology of cause of death in pediatric acute respiratory distress syndrome[J]. Crit Care Med, 2018, 46(11): 1811-1819. doi: 10.1097/CCM.0000000000003371
[3]	陈思, 顾君君, 冯玉兰, 等. 早期活动干预法预防ICU获得性衰弱的应用效果[J]. 解放军护理杂志, 2018, 35(17): 50-53. https://www.cnki.com.cn/Article/CJFDTOTAL-JFHL201817014.htm CHEN S, GU J J, FENG Y L, et al. Application of Early Activity Intervention to Prevent Acquired ICU Weakness[J]. Nursing Journal of Chinese People's Liberation Army, 2018, 35(17): 50-53. https://www.cnki.com.cn/Article/CJFDTOTAL-JFHL201817014.htm
[4]	余敏敏, 钟剑峰, 龚晓莉, 等. 小儿脓毒症合并急性呼吸窘迫综合征的早期俯卧位通气应用效果及护理体会[J]. 中华全科医学, 2020, 18(11): 1957-1960. doi: 10.16766/j.cnki.issn.1674-4152.001663 YU M M, ZHONG J F, GONG X L, et al. Effect of early prone position ventilation on children with sepsis complicated with ARDS and nursing experience[J]. Chinese Journal of General Practice, 2020, 18(11): 1957-1960. doi: 10.16766/j.cnki.issn.1674-4152.001663
[5]	全胜利, 陈焕, 李奇, 等. 改良俯卧位通气护理策略在重症新型冠状病毒肺炎中应用的单中心回顾性研究[J]. 中国医刊, 2020, 55(8): 878-882. doi: 10.3969/j.issn.1008-1070.2020.08.019 QUAN S L, CHEN H, LI Q, et al. Single-center retrospective study on the application of modified prone position ventilation nursing strategy in severe COVID-19 pneumonia[J]. Chinese Journal of Medicine, 2020, 55(8): 878-882. doi: 10.3969/j.issn.1008-1070.2020.08.019
[6]	侯锦, 李奇, 李尊柱, 等. 俯卧位通气患者肠内营养安全性和有效性的Meta分析[J]. 中华护理杂志, 2022, 57(17): 2149-2155. doi: 10.3761/j.issn.0254-1769.2022.17.017 HOU J, LI Q, LI Z Z, et al. Efficacy and safety of enteral nutrition in patients with prone position ventilation: a meta-analysis[J]. Chinese Journal of Nursing, 2022, 57(17): 2149-2155. doi: 10.3761/j.issn.0254-1769.2022.17.017
[7]	胡美玲, 戴书华, 于世勇. 心源性肺水肿的影像学特征与其病理生理机制[J]. 中华肺部疾病杂志(电子版), 2020, 13(4): 479-483. doi: 10.3877/cma.j.issn.1674-6902.2020.04.010 HU M L, DAI S H, YU S Y. Imaging characteristics and pathophysiological mechanisms of cardiogenic pulmonary edema[J]. Chinese Journal of Lung Diseases (Electronic Edition), 2020, 13(4): 479-483. doi: 10.3877/cma.j.issn.1674-6902.2020.04.010
[8]	汪佳伟, 顾莺, 徐培红, 等. 俯卧位手术患儿体位管理的最佳证据应用[J]. 护理学杂志, 2020, 35(15): 103-106. https://www.cnki.com.cn/Article/CJFDTOTAL-HLXZ202015033.htm WANG J W, GU Y, XU P H, et al. Application of best evidence on position management of pediatric prone position operations[J]. Journal of Nursing Science, 2020, 35(15): 103-106. https://www.cnki.com.cn/Article/CJFDTOTAL-HLXZ202015033.htm
[9]	刘美兰, 肖力, 肖成伟, 等. 密闭式吸痰联合俯卧位通气对重症腺病毒肺炎患儿的影响[J]. 护理实践与研究, 2020, 17(8): 108-110. https://www.cnki.com.cn/Article/CJFDTOTAL-HLSJ202008042.htm LIU M L, XIAO L, XIAO C W, et al. Effect of closed sputum suction combined with prone position ventilation for children patients with severe adenovirus pneumonia[J]. Nursing Practice and Research, 2020, 17(8): 108-110. https://www.cnki.com.cn/Article/CJFDTOTAL-HLSJ202008042.htm
[10]	郑晓倩, 李爱丹, 陈王峰, 等. 改良式俯卧位通气对ARDS患者压力性损伤的影响[J]. 温州医科大学学报, 2020, 50(6): 489-492. https://www.cnki.com.cn/Article/CJFDTOTAL-WZYX202006012.htm ZHENG X Q, LI A D, CHEN W F, et al. The effect of modified prone position ventilation on pressure injury in ARDS patients[J]. Journal of Wenzhou Medical University, 2020, 50(6): 489-492. https://www.cnki.com.cn/Article/CJFDTOTAL-WZYX202006012.htm
[11]	李海燕, 赵广云, 彭万胜. 改良式胸部叩击联合无创吸痰技术在婴儿急性毛细支气管炎治疗中的效果[J]. 中华全科医学, 2022, 20(7): 1162-1165. doi: 10.16766/j.cnki.issn.1674-4152.002548 LI H Y, ZHAO G Y, PENG W S. Effect of modified chest percussion combined with non-invasive sputum suction technique in the treatment of infants with acute bronchiolitis[J]. Chinese Journal of General Practice, 2022, 20(7): 1162-1165. doi: 10.16766/j.cnki.issn.1674-4152.002548
[12]	吴念念, 朱玲. 机械排痰联合不同翻身时间在急性呼吸窘迫综合征患儿中的应用[J]. 当代护士(上旬刊), 2020, 27(6): 101-103. https://www.cnki.com.cn/Article/CJFDTOTAL-DDZT202006045.htm WU N N, ZHU L. Application of mechanical expectoration combined with different turning time in children with acute respiratory distress syndrome[J]. Modern Nurse, 2020, 27(6): 101-103. https://www.cnki.com.cn/Article/CJFDTOTAL-DDZT202006045.htm
[13]	彭小贝, 贺连香, 陈嘉. 急性呼吸窘迫综合征病人仰卧位、俯卧位通气联合振动排痰的疗效比较[J]. 护理研究, 2018, 32(9): 1387-1392. https://www.cnki.com.cn/Article/CJFDTOTAL-SXHZ201809016.htm PENG X B, HE L X, CHEN J. Comparison of the curative effect of supine position and prone position ventilation combined with vibration sputum in patients with acute respiratory distress syndrome[J]. Chinese Nursing Research, 2018, 32(9): 1387-1392. https://www.cnki.com.cn/Article/CJFDTOTAL-SXHZ201809016.htm
[14]	张东旭, 周鹏飞. 呼气末正压通气联合俯卧位通气对ARDS患者血流动力学的影响[J]. 安徽医学, 2020, 41(1): 56-59. https://www.cnki.com.cn/Article/CJFDTOTAL-AHYX202001019.htm ZHANG D X, ZHOU P F. Effect of positive end-expiratory pressure ventilation combined with prone ventilation on hemodynamics of ARDS patients[J]. Anhui Medical Journal, 2020, 41(1): 56-59. https://www.cnki.com.cn/Article/CJFDTOTAL-AHYX202001019.htm
[15]	郑云鹏, 朱望君, 冯群英, 等. 俯卧位通气在新冠肺炎引起的急性呼吸窘迫综合征患者通气策略中的应用[J]. 齐鲁护理杂志, 2020, 26(5): 19-21. https://www.cnki.com.cn/Article/CJFDTOTAL-QLHL202005006.htm ZHENG Y P, ZHU W J, FENG Q Y, et al. Application of prone position ventilation in patients with acute respiratory distress syndrome induced by COVID-19[J]. Journal of Qilu Nursing, 2020, 26(5): 19-21. https://www.cnki.com.cn/Article/CJFDTOTAL-QLHL202005006.htm
[16]	郭艳侠, 梁珣, 朱文, 等. 我国住院患者压疮现患率及医院获得性压疮现患率的Meta分析[J]. 中国护理管理, 2018, 18(7): 907-914. https://www.cnki.com.cn/Article/CJFDTOTAL-GLHL201807014.htm GUO Y X, LIANG X, ZHUW, et al. The prevalence of pressure ulcer and hospital acquired pressure ulcer in hospitalized patients in China: a Meta-analysis[J]. Chinese Nursing Management, 2018, 18(7): 907-914. https://www.cnki.com.cn/Article/CJFDTOTAL-GLHL201807014.htm
[17]	ELSAGH A, LOTFI R, AMIRI S, et al. Comparison of massage and prone position on heart rate and blood oxygen saturation level in preterm neonates hospitalized in neonatal intensive care unit: a randomized controlled trial[J]. Iran J Nurs Midwifery Res, 2019, 24(5): 343-347.
[18]	杨净月, 徐美玉, 吴尤佳, 等. 芬太尼联合咪达唑仑在早产儿机械通气中的镇静镇痛效果[J]. 中国临床医学, 2022, 29(6): 939-944. https://www.cnki.com.cn/Article/CJFDTOTAL-LCYX202206008.htm YANG J Y, XU M Y, WU Y J, et al. Sedative and analgesic effects of fentanyl combined with midazolam in mechanical ventilation of premature infants[J]. Chinese Journal Of Clinical Medicine, 2022, 29(6): 939-944. https://www.cnki.com.cn/Article/CJFDTOTAL-LCYX202206008.htm
[19]	郭昆, 张红英, 彭四萍. 每日唤醒与舒适化镇痛镇静两种方案在ICU机械通气患者中的应用比较[J]. 中华危重病急救医学, 2018, 30(10): 950-952. https://www.cnki.com.cn/Article/CJFDTOTAL-YJYX202104014.htm GUO K, ZHANG H Y, PENG S P. Comparison of two schemes of daily arousal and comfort analgesia and sedation in patients on mechanical ventilation in intensive care unit[J]. Chinese Critical Care Medicine, 2018, 30(10): 950-952. https://www.cnki.com.cn/Article/CJFDTOTAL-YJYX202104014.htm
[20]	张先敏, 伍中华. 运动康复在支气管哮喘儿童中的应用效果观察[J]. 吉林医学, 2020, 41(8): 2027-2030. https://www.cnki.com.cn/Article/CJFDTOTAL-JLYX202008111.htm ZHANG X M, WU Z H. Observation on the effect of exercise rehabilitation on children with bronchial asthma[J]. Jilin Medical Journal, 2020, 41(8): 2027-2030. https://www.cnki.com.cn/Article/CJFDTOTAL-JLYX202008111.htm