慢病人群呼吸机依赖精准干预体系的构建及实施路径

doi:10.3877/cma.j.issn.2096-1537.2026.01.005

呼吸机依赖已成为重症医学领域亟待破解的关键难题，慢性疾病（简称慢病）人群因合并多系统基础疾病，其呼吸机依赖发生率、脱机失败率及病死率均显著高于普通人群，且消耗大量医疗资源。现有干预策略存在系统性不足、个体化欠缺及预见性薄弱等问题。本文基于多维临床数据与人工智能（AI）技术，提出“风险识别-分层干预-动态监测-随访管理”全链条精准干预体系框架，明确体系核心模块、技术支撑与实施路径，通过标准化数据采集、可解释性AI模型构建、表型导向模块化干预及多中心验证，实现从风险预测到临床落地的闭环管理，为改善慢病人群呼吸机依赖预后、优化医疗资源配置提供理论与实践参考。

关键词: 呼吸机依赖, 慢性疾病, 精准干预, 表型分型

Ventilator dependence has become a critical challenge in the field of critical care medicine. Among patients with chronic diseases, who often have multiple underlying systemic conditions, the incidence of ventilator dependence, weaning failure, and mortality are significantly higher than those in the general population, along with substantial medical resource consumption. Existing intervention strategies suffer from insufficient systematization, lack of individualization, and weak predicative capability. Based on multidimensional clinical data and AI technology, this paper proposes a full-chain precision intervention framework consisting of four components: risk identification, stratified intervention, dynamic monitoring and follow-up management. By integrating standardized data collection, construction of explainable AI models, phenotype-oriented modular interventions, and multicenter validation, it enables closed-loop management from risk prediction to clinical practice, providing theoretical and practical guidance for improving prognosis of ventilator-dependent patients with chronic diseases and optimizing medical resource allocation.

Key words: Ventilator dependence, Chronic diseases, Precision intervention, Phenotype classification

图1 慢病人群呼吸机依赖精准干预体系“四维一体”核心架构

表1 不同表型的精准干预模块组合^{[17,18,19，21,22,23,24,25,26,27,28,29,30,31,32,33,34,35]}

干预模块	呼吸肌功能衰竭型（膈肌功能障碍为主）	颅脑功能受累型（颅脑功能损伤）	心功能不全型（心功能障碍）	多器官功能受累型（多系统功能障碍）	基础功能紊乱型（基础疾病+内分泌 / 营养异常为主）
个体化通气策略	PSV+膈肌保护性通气（Pplat≤28 cmH₂O），根据EIT调整PEEP	控制性通气（小潮气量+低流速）+脑保护通气策略（避免高碳酸血症 / 低氧血症）	NIPPV+心功能导向的通气调整（避免过度正压影响心输出量）	SIMV+液体管理优化（PiCCO指导）	个体化通气（根据基础肺功能调整）+内分泌紊乱相关通气调整（如甲状腺功能异常者调整呼吸频率）
呼吸肌功能训练	体外膈肌起搏（2次/d，30 min/次）+吸气肌训练（负荷从30%最大吸气压递增）	被动呼吸肌训练（家属 / 治疗师辅助胸廓活动）+意识恢复后渐进式主动呼吸训练	低强度呼吸肌训练（腹式呼吸为主）+心功能耐受下的呼吸训练	早期被动肢体活动+渐进式呼吸训练	基础疾病稳定后启动低强度呼吸肌训练（如慢性肾脏病患者采用坐位呼吸训练）
营养支持	高蛋白[1.8 g/（kg·d）]+支链氨基酸补充，空肠营养泵入	高能量密度营养（促进脑代谢）+氨基酸平衡配方（含牛磺酸等脑营养物质）	低盐低脂高蛋白营养+心功能支持型营养制剂（添加左旋肉碱）	低热卡[20 kcal/（kg·d）]+肝肾保护型营养制剂	基础疾病适配营养（如糖尿病患者低糖营养）+内分泌调节型营养（如甲状腺功能减退者补充碘和酪氨酸）
多器官功能保护	重点保护膈肌功能，避免过度镇静	脑保护（亚低温治疗+神经营养药物）+颅内压监测	心功能保护（正性肌力药物+利尿剂优化）+心肌营养支持	心肾协同保护（利尿剂+血管活性药物优化）	基础疾病靶器官保护（如慢性肝病患者保肝治疗）+内分泌轴调节（如肾上腺功能不全者激素替代）
心理干预	认知行为疗法+家属参与式康复指导	认知功能训练（记忆/ 注意力训练）+情绪管理（抗焦虑抑郁药物辅助）	心理支持（心因性焦虑疏导）+疾病认知教育	焦虑抑郁筛查+放松训练	慢病管理心理支持（正念减压）+营养/ 内分泌知识宣教

表1 不同表型的精准干预模块组合^{[17,18,19，21,22,23,24,25,26,27,28,29,30,31,32,33,34,35]}

干预模块	呼吸肌功能衰竭型（膈肌功能障碍为主）	颅脑功能受累型（颅脑功能损伤）	心功能不全型（心功能障碍）	多器官功能受累型（多系统功能障碍）	基础功能紊乱型（基础疾病+内分泌 / 营养异常为主）
个体化通气策略	PSV+膈肌保护性通气（Pplat≤28 cmH₂O），根据EIT调整PEEP	控制性通气（小潮气量+低流速）+脑保护通气策略（避免高碳酸血症 / 低氧血症）	NIPPV+心功能导向的通气调整（避免过度正压影响心输出量）	SIMV+液体管理优化（PiCCO指导）	个体化通气（根据基础肺功能调整）+内分泌紊乱相关通气调整（如甲状腺功能异常者调整呼吸频率）
呼吸肌功能训练	体外膈肌起搏（2次/d，30 min/次）+吸气肌训练（负荷从30%最大吸气压递增）	被动呼吸肌训练（家属 / 治疗师辅助胸廓活动）+意识恢复后渐进式主动呼吸训练	低强度呼吸肌训练（腹式呼吸为主）+心功能耐受下的呼吸训练	早期被动肢体活动+渐进式呼吸训练	基础疾病稳定后启动低强度呼吸肌训练（如慢性肾脏病患者采用坐位呼吸训练）
营养支持	高蛋白[1.8 g/（kg·d）]+支链氨基酸补充，空肠营养泵入	高能量密度营养（促进脑代谢）+氨基酸平衡配方（含牛磺酸等脑营养物质）	低盐低脂高蛋白营养+心功能支持型营养制剂（添加左旋肉碱）	低热卡[20 kcal/（kg·d）]+肝肾保护型营养制剂	基础疾病适配营养（如糖尿病患者低糖营养）+内分泌调节型营养（如甲状腺功能减退者补充碘和酪氨酸）
多器官功能保护	重点保护膈肌功能，避免过度镇静	脑保护（亚低温治疗+神经营养药物）+颅内压监测	心功能保护（正性肌力药物+利尿剂优化）+心肌营养支持	心肾协同保护（利尿剂+血管活性药物优化）	基础疾病靶器官保护（如慢性肝病患者保肝治疗）+内分泌轴调节（如肾上腺功能不全者激素替代）
心理干预	认知行为疗法+家属参与式康复指导	认知功能训练（记忆/ 注意力训练）+情绪管理（抗焦虑抑郁药物辅助）	心理支持（心因性焦虑疏导）+疾病认知教育	焦虑抑郁筛查+放松训练	慢病管理心理支持（正念减压）+营养/ 内分泌知识宣教

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Construction and implementation pathway of a precision intervention system for ventilator-dependent patients with chronic diseases

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Construction and implementation pathway of a precision intervention system for ventilator-dependent patients with chronic diseases