梁娟+胡雪慧
[摘要] 目的 探討不同吸痰深度密閉式吸痰法在外科ICU機械通氣患者中的應(yīng)用效果。 方法 選擇2015年5月~2016年12月于第四軍醫(yī)大學(xué)西京醫(yī)院外科綜合ICU接受機械通氣治療的患者150例,采取隨機數(shù)字表法分為三組,每組50例。A組吸痰管插入深度等于氣管插管長度;B組吸痰管插入氣道遇阻力后上提1~2 cm;C組吸痰管插入深度達氣管插管長度后再插入1 cm,比較三組患者24 h吸痰次數(shù)、血氧飽和度恢復(fù)時間、痰鳴音改善評分及并發(fā)癥發(fā)生情況。 結(jié)果 三組患者24 h吸痰次數(shù)、血氧飽和度恢復(fù)時間、痰鳴音改善評分比較,差異有統(tǒng)計學(xué)意義(P < 0.05)。三組患者心率變化、嗆咳及痰中帶血發(fā)生率比較,差異有統(tǒng)計學(xué)意義(P < 0.05)。 結(jié)論 吸痰管置入深度達氣管插管刻度后繼續(xù)深入1 cm可有效清除接受機械通氣治療患者的氣道分泌物,對氣道黏膜損傷小,安全性高。
[關(guān)鍵詞] 機械通氣患者;密閉式吸痰護理;吸痰深度;吸痰并發(fā)癥
[中圖分類號] R473.5 [文獻標(biāo)識碼] A [文章編號] 1673-7210(2017)03(a)-0159-04
Application effect comparison of different sputum suction methods in ICU patients with mechanical ventilation
LIANG Juan1 HU Xuehui2
1.Department of Pediatrics, Xijing Hospital of the Fourth Military Medical University, Shaanxi Province, Xi′an 710032, China; 2.Department of Nursing, Xijing Hospital of the Fourth Military Medical University, Shaanxi Province, Xi′an 710032, China
[Abstract] Objective To investigate application effect of different sputum suction methods in ICU patients with mechanical ventilation. Methods 150 patients with mechanical ventilation in Surgical Intensive Care Unit of Xijing Hospital of the Fourth Military Medical University from May 2015 to December 2016 were selected. All patients were divided into three groups by using random number table method. Each group of 50 cases. The depth of sputum suction tube was equal to the length of tracheal intubation in group A, the sputum suction tube was inserted into the airway for 1 to 2 cm in group B, the depth of the sputum suction tube was inserted to 1 cm after tracheal intubation in group C. The number of 24 h sputum suction, the recovery time of blood oxygen saturation, the improvement score of sputum sound and incidence of complication among three groups were compared. Results The number of 24 h sputum suction, the recovery time of blood oxygen saturation, the improvement score of sputum sound among three groups were compared, with statistical differences (P < 0.05). Incidence rate of heart rate change, cough and sputum with blood among three groups were compared, with statistical differences (P < 0.05). Conclusion The depth of suction tube is extended to 1 cm after intubation can effective removal of airway secretion in patients receiving mechanical ventilation, has small airway mucosal damage and high safety.
[Key words] Patients with mechanical ventilation; Closed tracheal suction; Depth of sputum suction; Complication caused by sputum suction
1979年機械通氣技術(shù)首先應(yīng)用于患者至今已40年,隨著機械通氣技術(shù)的跨越發(fā)展,這一技術(shù)對護理人員的職業(yè)要求越來越高[1]。氣管內(nèi)吸痰(ETS)是對已經(jīng)建立機械通氣患者最常見的護理方法之一,ETS包含支氣管治療和防止機械通氣引起的肺部阻塞[2]。美國呼吸護理學(xué)會(AARC)發(fā)表的氣管內(nèi)吸痰指南中對吸痰操作規(guī)范與實際臨床護理應(yīng)用存在較大差異,且具體吸痰深度界定模糊[3-4]。如何能夠根據(jù)患者情況明確吸痰管深度范圍,保證氣道通暢的同時最大程度減少吸痰帶來的一系列不良反應(yīng),最終提高機械通氣患者臨床護理質(zhì)量十分重要[5-6]。本研究調(diào)查對象為外科ICU機械通氣患者,采用三種臨床常用密閉式吸痰方法,比較不同吸痰深度的吸痰效果及并發(fā)癥發(fā)生情況,明確最佳吸痰方法及深度范圍,在保證安全性的前提下提高機械通氣患者護理質(zhì)量。
1 資料與方法
1.1 一般資料
選取西京醫(yī)院外科綜合ICU 2015年5月~2016年12月需接受機械通氣治療患者150例為研究對象,采取密閉式吸痰護理方法,其中男114例,女36例;平均年齡(52.1±1.5)歲;基本情況為呼吸窘迫綜合征66例,窒息48例,昏迷36例。所有患者按照隨機數(shù)字表法分為A、B、C組,各50例。三組患者性別、年齡、身高、急性生理學(xué)及慢性健康狀況(APACHEⅡ)評分比較,差異無統(tǒng)計學(xué)意義 (P > 0.05),具有可比性。見表1。本研究經(jīng)西京醫(yī)院倫理委員會討論通過,所有入選患者均簽署知情同意書。
1.2 方法
所有患者采用密閉式吸痰護理[7]。吸痰操作由經(jīng)過培訓(xùn)的ICU護理人員進行。吸痰前先評估患者氣道的一般情況[8]。臨床選擇常用規(guī)格為12~14號吸痰管。吸痰負壓為200~300 mmHg[9]。具體操作方法為護理人員一手握住可旋轉(zhuǎn)接頭,另一手拇指及食指將吸痰管緩慢插入患者氣管套管內(nèi)達到所需深度后,按下負壓閥進行吸痰[10],吸痰時間不超過15 s[11]。如患者氣道內(nèi)分泌物較黏稠,可經(jīng)沖水孔注入2~3 mL的無菌生理鹽水,再實施上述吸痰操作[12]。三組患者選擇不同的吸痰深度:A組吸痰管插入深度與氣管插管刻度保持一致;B組吸痰管插入氣管插管深部,遇阻力后上提1~2 cm;C組吸痰管置入深度達氣管插管刻度后繼續(xù)深入1 cm。吸痰前后分別提高呼吸機氧濃度10%,時間持續(xù)1~2 min,提升患者的血氧飽和度(SpO2)[13]。
1.3 觀察指標(biāo)
①吸痰效果:24 h吸痰次數(shù)、SpO2恢復(fù)時間以及痰鳴音改善評分。其中痰鳴音改善情況以評分方式計算[14]:完全消失為3分;明顯減輕為2分;依然存在為1分。②并發(fā)癥情況:心率變化、嗆咳以及痰中帶血。吸痰前監(jiān)測基礎(chǔ)心率,吸痰時如心率加快超過基礎(chǔ)心率的20%,停止吸痰后5 min降至基礎(chǔ)心率,則為心率變化。
1.4 統(tǒng)計學(xué)方法
采用SPSS 19.0統(tǒng)計軟件對數(shù)據(jù)進行分析和處理,計量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,采用單因素方差分析,計數(shù)資料采用χ2檢驗,以P < 0.05為差異有統(tǒng)計學(xué)意義。
2 結(jié)果
2.1 三組患者吸痰效果比較
三組患者24 h吸痰次數(shù)、SpO2恢復(fù)時間、痰鳴音改善評分比較,差異有統(tǒng)計學(xué)意義(P < 0.05)。見表2。
2.2 三組患者吸痰并發(fā)癥情況比較
三組患者心率變化、嗆咳及痰中帶血發(fā)生率比較,差異有統(tǒng)計學(xué)意義(P < 0.05)。見表3。
3 討論
隨著機械通氣技術(shù)的跨越式發(fā)展,針對外傷患者術(shù)后呼吸治療已成為急危重癥患者重要的治療手段[15]。外科ICU患者在呼吸治療過程中,氣道內(nèi)環(huán)境變化較大,分泌物增多,術(shù)后傷口疼痛、感染、意識障礙長期臥床等情況的出現(xiàn)易導(dǎo)致咳嗽排痰困難,出現(xiàn)痰液滯留、痰痂堵管等現(xiàn)象,所有這些現(xiàn)象在外科ICU護理工作中十分常見[16]。
2010年AARC發(fā)表的氣管內(nèi)吸痰指南中對吸痰的操作指導(dǎo)與臨床護理操作存在較大不同[17],AARC指南推薦兩種吸痰方法,一種為吸痰管刻度與氣管插管保持一致,另一種為吸痰管在遇阻力后上提1~2 cm[18]。這兩種吸痰方法在臨床工作中十分常見,但該指南并沒有對患者一般情況進行限定,如外科機械通氣患者的吸痰操作是否與內(nèi)科患者類似[19]。在外科ICU實際工作中,我們發(fā)現(xiàn)當(dāng)吸痰管和氣管導(dǎo)管刻度一致后在深入1 cm可以保證吸痰有效性,同時減少吸痰并發(fā)癥的發(fā)生,在回顧外文文獻時發(fā)現(xiàn)報道多集中于吸痰時機的判斷,而對于吸痰管深度及相關(guān)并發(fā)癥的報道相對較少[20]。
臨床護理實踐中如果外科機械通氣患者采取指南推薦的第二種方式進行吸痰[21]?;颊邌芸劝l(fā)生率較高,劇烈且持續(xù)時間較長,嗆咳導(dǎo)致短時間內(nèi)氣道壓力急劇上升,特別是在機械通氣患者使用密閉通氣管道,過高的氣道壓損傷氣道黏膜導(dǎo)致血性分泌物增多,最常見的表現(xiàn)為痰中帶血的發(fā)生,在吸痰過程中損傷氣道黏膜更加不利于患者呼吸功能的恢復(fù)[22-23]。如果使用指南推薦的第一種方法,患者吸痰并發(fā)癥發(fā)生率明顯降低,但24 h吸痰次數(shù)顯著增多和SpO2恢復(fù)時間顯著延長,增加了單位時間對患者氣道的侵擾次數(shù)及吸痰過程中的缺氧風(fēng)險。最終使用吸痰管置入深度達氣管插管刻度后繼續(xù)深入1 cm的吸痰方法,不但可以減少不良反應(yīng)的發(fā)生,同時24 h吸痰次數(shù)、SpO2恢復(fù)時間及痰鳴音改善評分得到顯著改善。
綜上所述,吸痰管置入深度達氣管插管刻度后繼續(xù)深入1 cm的吸痰方法能夠在有效清除患者呼吸道分泌物的同時,減少對患者氣道的刺激及損傷,減少侵擾次數(shù),同時對患者心率、氣道黏膜影響較小,具有較好的有效性以及安全性。然而本實驗沒有將內(nèi)科ICU患者納入比較,同時樣本量規(guī)模較小,如果能夠在多家醫(yī)療機構(gòu)展開多中心研究及增加樣本量會使本研究更加完善。
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