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中华重症医学电子杂志 ›› 2021, Vol. 07 ›› Issue (01): 21 -27. doi: 10.3877/cma.j.issn.2096-1537.2021.01.004

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临床研究 上一篇    下一篇

侧卧位通气治疗新型冠状病毒肺炎重症患者的临床研究
周岐龙 1, 潘鹏飞 2, 卢花 3, 岳希 3, 赵建新 3, 陈建国 3, 刘超 3, 熊芳 3, 黄霞 3, 于湘友 4 , ( )   
  1. 1. 404100 重庆大学附属三峡医院(重庆三峡中心医院)重症医学科
    2. 404100 重庆大学附属三峡医院(重庆三峡中心医院)重症医学科;830054 新疆医科大学第一附属医院重症医学科
    4. 830054 新疆医科大学第一附属医院重症医学科
  • 收稿日期:2020-05-09 出版日期:2021-02-28
  • 通信作者: 于湘友
  • 基金资助:
    重庆市万州区科技计划项目(wzstc-2020004)

Clinical study of lateral position ventilation in severe coronavirus disease 2019 patients

Qilong Zhou 1, Pengfei Pan 2, Hua Lu 3, Xi Yue 3, Jianxing Zhao 3, Jianguo Chen 3, Chao Liu 3, Fang Xiong 3, Xia Huang 3, Xiangyou Yu 4 , ( )   

  1. 2. Department of Critical Care Medicine, Three Gorges Hospital of Chongqing University/Chongqing Three Gorges Center Hospital, Chongqing 404100, China; Department of Critical Care Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
    3. Department of Critical Care Medicine, Three Gorges Hospital of Chongqing University/Chongqing Three Gorges Center Hospital, Chongqing 404100, China
    4. Department of Critical Care Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
  • Received:2020-05-09 Published:2021-02-28
  • Corresponding author: Xiangyou Yu
目的

探讨侧卧位通气对重症新型冠状病毒肺炎(COVID-19)患者的临床价值。

方法

采用回顾性研究,收集2020年1月20日至3月7日在重庆三峡中心医院重症应急病区住院的41例COVID-19并中、重度急性呼吸窘迫综合征(ARDS)患者的临床资料。在经鼻高流量湿化氧疗(HFNC)或无创通气(NIV)的基础上,按是否进行侧卧位通气将患者分为侧卧位组(24例)和仰卧位组(17例)。统计2组患者的性别、年龄、急性生理与慢性健康状况(APACHEⅡ)评分和合并基础疾病情况,比较治疗前及治疗后第1、3、5天的心率(HR)、呼吸频率(RR)、氧合指数(PaO2/FiO2)、二氧化碳分压(PaCO2)、平均动脉压(MAP),以及轻症化率、HFNC或NPPV时间、气管插管发生率、住院时间、压疮发生情况等预后指标。

结果

41例患者中,男性21例,女性20例;年龄43~79岁,平均(60.9±11.1)岁。2组患者年龄、性别、APACHEⅡ评分、合并基础疾病,以及治疗前RR、PaO2/FiO2、PaCO2和MAP等比较,差异均无统计学意义(P均>0.05)。2组患者治疗后HR、RR、MAP较治疗前下降,而PaCO2、PaO2/FiO2上升,其中PaO2/FiO2在第5天较治疗前明显改善[侧卧位组:(166.4±45.4)mmHg vs(253.0±66.0)mmHg,仰卧位组:(183.8±54.4)mmHg vs(227.4±62.8)mmHg,P均<0.05,1 mmHg=0.133 kPa]。2组间比较,侧卧位组在治疗后第1天RR较仰卧位组降低(P=0.006);侧卧位组的中、重度ARDS患者PaO2/FiO2在治疗后第5天较仰卧位组改善,差异有统计学意义[(260.8±58.5)mmHg vs (221.6±64.9)mmHg,P=0.043]。2组HFNC或NIV时间和气管插管发生率比较,差异无统计学意义(P均>0.05),而侧卧位组总住院时间明显短于仰卧位组,差异有统计学意义[(15.5±7.2)d vs (21.5±9.8)d,P=0.028],ICU住院时间也短于仰卧位组,差异有统计学意义[(10.3±6.3)d vs (16.9±11.0)d,P=0.021],侧卧位组病死率低于仰卧位组,差异有统计学意义(8.3 % vs 23.5 %,P = 0.047)。

结论

侧卧位通气能改善COVID-19并中、重度ARDS患者的氧合,缩短住院时间,降低病死率,提高疗效,促进患者康复。

Objective

To investigate clinical effects of lateral position ventilation in the patients with severe coronavirus disease 2019 (COVID-19).

Methods

Retrospectively collecting data of 41 COVID-19 patients with moderate and severe acute respiratory distress syndrome (ARDS) hospitalized in the critical emergency ward of Chongqing Three Gorges Central Hospital from January 20 to March 7, 2020. The patients treated with high-flow nasal canula therapy (HFNC) or noninvasive ventilation (NIV) were divided into two groups: lateral position group (n=24) and supine position group (n=17). The gender, age, acute physiology and chronic health evaluation (APACHE) Ⅱ score,comorbidities of the two groups were compared. Respiratory rate (RR), oxygenation index (PaO2/FiO2), partial pressure of carbon dioxide (PaCO2) and mean arterial pressure (MAP) of the two groups were compared before and on the first, third and fifth day of treatment. The amelioration rate, duration of HFNC or NPPV, incidence of tracheal intubation, length of stay in hospital and occurrence of bedsore of the two groups were compared too.

Results

Among 41 patients, 21 were male and 20 were female, with an average age of (60.9±11.1) years (43-79 years). There was no significant difference in age, gender, APACHE Ⅱ score, comorbidities, RR, PaO2/FiO2, PaCO2and MAP before treatment between the two groups (P all>0.05). HR, RR and MAP decreased after treatment in both groups,while PCO2 and PaO2/FiO2 increased. PaO2/FiO2 improved significantly on the 5th day in both groups [(166.4±45.4) mmHg vs (253.0±66.0) mmHg in lateral position ventilation group and (183.8±54.4) mmHg vs (227.4±62.8) mmHg in supine position ventilation group, P all<0.05, 1 mmHg=0.133 kPa]. Compared with supine position ventilation group, RR was lower in the lateral position ventilation group on the first day after treatment (P=0.006); PaO2/FiO2 increased significantly in moderate and severe ARDS patients in lateral position group on the 5th day after treatment [(221.6±64.9) vs (260.8±58.5) mmHg, P=0.043],compared with supine position ventilation. There was no significant difference in duration of HFNC or NIV and the incidence of endotracheal intubation between the two groups (P all>0.05). Compared with the supine position ventilation group, the length of stay in hospital and in ICU was significantly shorter in the lateral position ventilation group [(15.5±7.2) d vs (21.5±9.8) d, P=0.028; (10.3±6.3) d vs (16.9±11.0) d, P=0.021], and the mortality was also lower in lateral position ventilation group (8.3% vs 23.5%, P=0.047).

Conclusion

Lateral position ventilation can improve oxygenation, reduce length of stay in hospital and ICU, mortality in COVID-19 patients with moderate and severe ARDS.

表1 2组COVID-19患者一般情况比较(例)
表2 2组COVID-19患者各时间点HR、MAP和呼吸参数的比较(
x ˉ
±s
表3 2组COVID-19患者各时间点RR、PaO2/FiO2比较(
x ˉ
±s
表4 2组COVID-19患者预后的指标比较(
x ˉ
±s
图1 1例COVID-19患者胸部CT的变化。图a为患者入院时胸部CT示双肺多发性磨玻璃样渗出病变,中外带为主;图b为实施侧卧位下无创通气治疗8 d,胸部CT示双肺渗出病灶逐步吸收;图c为出院前胸部CT示病灶明显吸收,少许纤维条索样改变
1
Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [J]. Lancet, 2020, 395(10223): 497-506.
2
International Committee on Taxonomy of Viruses. The virus causing the current outbreak of coronavirus disease has been named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2)[EB/OL]. (2020-02-13)[2020-02-12].

URL    
3
国家卫生健康委. 新型冠状病毒感染的肺炎诊疗方案(试行第七版) [EB/OL]. (2020-3-4).

URL    
4
Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin definition [J]. JAMA, 2012, 307(23): 2526-2533.
5
Zhu N, Zhang DY, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019 [J]. N Engl J Med, 2020, 382(8): 727-733.
6
Zhou P, Yang XL, Wang XG, et al.A pneumonia outbreak associated with a new coronavirus of probable bat origin [J].Nature,2020, 579(7798): 270-273 .
7
World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV)[EB/OL].

URL    
8
World Health Organization. Consensus document on the epidemiology of severe acute respiratory syndrome (SARS)[EB/OL].

URL    
9
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in china: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention [J]. JAMA, 2020, 323(13): 1239-1242.
10
Zhou F, Yu T, Du RH, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [J] Lancet, 2020, 395: 1054-1062.
11
Lei J, Li J, Li X, et al. CT Imaging of the 2019 novel coronavirus (2019-nCoV) pneumonia [J]. Radiology, 2020, 295(1): 18.
12
Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID- 19 associated with acute respiratory distress syndrome [J]. Lancet Respir Med, 2020, 8(4): 420-422.
13
刘茜, 王荣帅, 屈国强, 等. 新型冠状病毒肺炎死亡尸体系统解剖大体观察报告[J].法医学杂志, 2020, 36(1): 21-23.
14
Tian S, Hu W, Niu L, et al. Pulmonary pathology of early-phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer [J]. J Thorac Oncol, 2020, 15(5): 700-704.
15
Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States [J]. N Engl J Med, 2020, 382(10): 929-936.
16
Lin S, Shen RN, Guo XS. Molecular modeling evaluation of the binding abilities of ritonavir and lopinavir to Wuhan pneumonia coronavirus proteases [J]. bioRxiv preprint, 2020.01.31.
17
Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro [J]. Cell Res, 2020, 30(3): 269-271.
18
Chen L, Xia HF, Shang Y, et al. Molecular mechanisms of ventilator-induced lung injury [J]. Chin Med J, 2018, 131(10): 1225-1231.
19
Fan E, Brodie D, Slutsky AS. Acute respiratory distress syndrome: advances in diagnosis and treatment [J]. JAMA, 2018, 319(7): 698-710.
20
Lee JM, Bae W, Lee YJ, et al. The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: updated study-level meta-analysis of 11 randomized controlled trials [J]. Crit Care Med, 2014, 42(5): 1252-1262.
21
Staudinger T, Kofler J, Müllner M, et al.Comparison of prone positioning and continuous rotation of patients with adult respiratory distress syndrome: results of a pilot study [J]. Crit Care Med, 2001, 29(1): 51-56.
22
Kim MJ, Hwang HJ, Song HH. A randomized trial on the effects of body positions on lung function with acute respiratory failure patients [J]. Int J Nurs Stud, 2002, 39(5): 549-555.
23
Chechenin MG, Voevodin SV, EIu P, et al. Kinetic therapy for acute respiratory distress syndrome [J]. Anesteziol Reanimatol, 2004, 370(6): 8-12.
24
于湘友, 杨春波, 王毅. 侧卧位通气治疗肺内/肺外源性急性呼吸窘迫综合征的对比观察[J].中华急诊医学杂志, 2012, 21(3): 249-251.
25
Wieslander B, Ramos JG, Ax M, et al. Supine, prone, right and left gravitational effects on human pulmonary circulation [J]. J Cardiovasc Magn Reson, 2019, 21(1): 69.
26
钱民, 李建国. 侧卧位通气对急性呼吸窘迫综合征患者影响的研究 [J]. 现代中西医结合杂志, 2015, 14(11): 1158-1160, 1164.
27
Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China [J]. JAMA, 2020, 323(11): 1061-1069.
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