Efficiency of bedside flexible bronchoscope supported by high flow oxygen therapy
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摘要:目的 探讨高流量氧疗支持下床旁可弯曲支气管镜的应用效果。方法 选取27例鼻导管/面罩吸氧组患者(A组)及51例高流量吸氧组患者(B组)，分析2组患者术前及术中平均动脉压(MAP)、心率(HR)的变化，以及2组患者术前、术后的氧合指数[p(O2)/FiO2]和二氧化碳分压[p(CO2)]的变化。结果 2组术中MAP均较术前升高，其中B组ΔMAP为(12.1±4.7) mmHg, A组ΔMAP为(16.3±5.2) mmHg，差异有统计学意义(P=0.001)。2组术中HR均较术前升高, B组ΔHR为(21.2±11.2)次/min, A组ΔHR为(26.7±11.3)次/min, 差异有统计学意义(P=0.045)。2组术后p(O2)/FiO2均较术前降低，其中B组Δp(O2)/FiO2绝对值为(-9.5±19.5) mmHg, 低于A组Δp(O2)/FiO2绝对值(-23.6±12.2) mmHg, 差异有统计学意义(P=0.002)。2组术后p(CO2)均较术前升高, B组Δp(CO2)为(2.7±4.7) mmHg, 低于A组Δp(CO2) (5.0±3.0) mmHg, 差异有统计学意义(P=0.02)。结论 经鼻高流量氧疗可能减少床旁可弯曲支气管镜检查中MAP、HR变异率，降低检查风险，提高患者对检查的耐受性。Abstract:Objective To explore the clinical effect of bedside flexible bronchoscope supported by high flow oxygen therapy.Methods Totally 27 cases with nasal catheter/mask oxygen inhalation were selected as group A and 51 cases with high flow oxygen inhalation were selected as group B. Changes of mean arterial pressure (MAP) and heart rate (HR) before and during operation were analyzed, and the changes of oxygen index [p(O2)/FiO2] and partial pressure of carbon dioxide [p(CO2)] before and after operation were analyzed as well.Results The intra-operative MAP in both groups was higher than that before operation. The ΔMAP in group B was (12.1±4.7) mmHg, while that in group A was (16.3±5.2) mmHg, and there was a significant difference between two groups (P=0.001). The intra-operative HR in both groups was higher than that before operation. The ΔHR in group B was (21.2±11.2) times per minute, and that in group A was (26.7±11.3) per minute, and there was a significant difference between two groups (P=0.045). Postoperative p(O2)/FiO2 in both groups was lower than that before operation. The absolute value of Δp(O2)/FiO2 in group B was (-9.5±19.5) mmHg, which was lower than (-23.6±12.2) mmHg in group A, and there was a significant difference between two groups (P=0.002). Postoperative p(CO2) in both groups was higher than that before operation. The Δp(CO2) in group B was (2.7±4.7) mmHg, which was lower than (5.0±3.0) mmHg in group A, and there was a significant difference between two groups (P=0.02).Conclusion Transnasal high flow oxygen therapy may reduce the variation rates of MAP and HR in patients with bedside flexible bronchoscope, reduce the risk of examination and improve the patient′s tolerance to examination.
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Keywords:
- hypoxemia /
- high flow oxygen therapy /
- flexible bronchoscope /
- oxygenation index /
- variation rate
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应用床旁可弯曲支气管镜时，低氧血症是常见的并发症，是检查失败的重要原因之一[1]。氧疗是治疗低氧血症的主要手段。高流量氧疗可以保证患者吸入的氧浓度精确并且稳定[2-3]。本院2016年4月—2019年4月在呼吸重症监护病房(RICU)开展高流量氧疗支持下床旁可弯曲支气管镜吸痰，取得了显著的效果，现报告如下。
1. 资料与方法
1.1 一般资料
本研究78例患者均具备可弯曲支气管镜检查指征并排除禁忌证，其中鼻导管/面罩吸氧组(A组)27例，男20例，女7例，平均年龄(69.4±6.4)岁; 高流量吸氧组(B组)51例，男35例，女16例，平均年龄(72.6±5.9)岁。2组性别、年龄无显著差异(P>0.05)。2组患者术前均有不同程度的呼吸困难，所有患者氧合指数[p(O2)/FiO2]不低于150 mmHg。2组患者术前p(O2)/FiO2、动脉血二氧化碳分压[p(CO2)]比较无显著差异(P>0.05)。见表 1。
表 1 2组患者临床资料比较(X±s)临床资料 A组(n=27) B组(n=51) 年龄/岁 69.4±6.4 72.6±5.9 男 20/7 35/16 女 7 16 术前平均动脉压/mmHg 97.0±15.8 96.9±18.1 术前心率/(次/min) 82.4±6.4 83.7±6.3 术前p(O2)/FiO2/mmHg 329.6±55.2 315.7±55.5 术前p(CO2)/mmHg 54.9±9.9 56.6±9.7 术中平均动脉压/mmHg 113.2±14.4 109.0±18.7 术中心率/(次/min) 109.1±14.5 104.9±10.6 术后p(O2)/FiO2/mmHg 306.0±58.8 305.8±58.7 术后p(CO2)/mmHg 60.0±9.1 59.2±10.7 1.2 检查方法
采用局部浸润麻醉，以2%利多卡因雾化吸入，术中根据情况予2%利多卡因局部喷洒，总量不超过30 mL。A组患者经鼻导管或面罩吸氧, B组患者经鼻高流量氧疗。术中常规进行脉氧饱和度(SpO2)监测和心电监测。根据患者SpO2调整吸入氧气浓度和流量，维持患者术中SpO2不低于90%。
1.3 观察指标
比较2组患者术前(可弯曲支气管镜进入声门前5 min内)和术中(可弯曲支气管镜经过声门120 s)平均动脉压(MAP)、心率(HR)等生命体征变化; 比较2组患者术前(可弯曲支气管镜进入声门前5 min内)和术后(可弯曲支气管镜退出声门)的p(O2)/FiO2和p(CO2)变化。
1.4 统计学方法
采用SPSS 22.0统计软件进行分析，计量资料以平均值±标准差表示，计数资料以(%)表达，两组计量资料比较应用独立样本t检验，计数资料比较应用χ2检验，检验水准均为α=0.05。
2. 结果
2.1 2组患者术前及术中ΔMAP、ΔHR值比较
2组术中MAP均较术前升高，其中B组ΔMAP为(12.1±4.7) mmHg, A组ΔMAP为(16.3±5.2) mmHg, 差异有统计学意义(P=0.001)。2组术中HR均较术前升高, B组ΔHR为(21.2±11.2)次/min, A组ΔHR为(26.73±11.3)次/min, 差异有统计学意义(P=0.045)。上述结果说明高流量氧疗能改善床旁可弯曲支气管镜检查过程中MAP和HR的波动。
2.2 2组患者术前及术后Δp(O2)/FiO2、Δp(CO2)值比较
2组术后p(O2)/FiO2均较术前降低，其中B组Δp(O2)/FiO2绝对值为(-9.5±19.5) mmHg, 低于A组Δp(O2)/FiO2绝对值(-23.6±12.2) mmHg, 差异有统计学意义(P=0.002)。2组术后p(CO2)均较术前升高, B组Δp(CO2)为(2.7±4.7) mmHg, 低于A组Δp(CO2) (5.0±3.0) mmHg, 差异有统计学意义(P=0.02)。上述结果说明高流量氧疗能改善床旁可弯曲支气管镜检查过程中缺氧及二氧化碳潴留。
3. 讨论
可弯曲支气管镜检查是呼吸系统疾病临床诊断和治疗的重要手段[4]。在重症监护病房，通过床旁可弯曲支气管镜下吸痰可明显减少气管插管次数，镜下防污染毛刷检查可以提高下呼吸道病原学检测的敏感性和特异性，为目标性抗感染治疗提供依据，明显降低重症肺部感染患者的抗生素使用强度(DDD)[5-6]。可弯曲支气管镜检查可以协助诊治并明确重症患者的病因，做到早诊断、早治疗[7-8]。但术中低氧血症限制了可弯曲支气管镜在呼吸重症病房的使用。
床旁可弯曲支气管镜检查可以诱发低氧血症，主要机制有: ①可弯曲支气管镜经过大气道，并刺激声门导致声门水肿，增高大气道阻力，降低术中通气量; ②诱发迷走神经兴奋、小气道痉挛、肺泡通气量下降[9]; ③术中负压吸引导致肺泡陷闭，导致动静脉分流[10]; ④部分患者术中肺泡灌洗，导致肺泡水肿[11-12]。严重低氧血症可以诱发心律失常、血压升高等严重并发症[13-15], 因此限制了可弯曲支气管镜的应用。
目前常规氧疗的氧输送系统分为低流量、贮氧器和高流量氧疗系统。低流量氧疗系统包括鼻导管、面罩吸氧等，特点是一旦吸气流量大于系统给予的流量，氧就会被稀释，吸气流量越大，氧浓度越低[16]。高流量系统给氧时，一般系统流量大于患者自主流量，所以给予的氧浓度就较为固定[17-18]。使用贮氧器在理论上也能获得固定的氧浓度，但前提是贮氧器存储的气量要等于或者大于患者的潮气量且系统没有漏气。本院使用的经鼻高流量氧疗装置的另一个特点是可以产生一定的吸气末正压，具有预防肺泡塌陷和促进肺泡复张的作用，使更多的肺泡发挥气体交换的功能。因此，高流量氧疗装置这2项特点决定了B组患者的术后p(O2)/FiO2及p(CO2)值均高于A组。总之，经鼻高流量氧疗可以降低床旁可弯曲支气管镜检查的风险，提高患者对检查的耐受性。
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表 1 2组患者临床资料比较(X±s)
临床资料 A组(n=27) B组(n=51) 年龄/岁 69.4±6.4 72.6±5.9 男 20/7 35/16 女 7 16 术前平均动脉压/mmHg 97.0±15.8 96.9±18.1 术前心率/(次/min) 82.4±6.4 83.7±6.3 术前p(O2)/FiO2/mmHg 329.6±55.2 315.7±55.5 术前p(CO2)/mmHg 54.9±9.9 56.6±9.7 术中平均动脉压/mmHg 113.2±14.4 109.0±18.7 术中心率/(次/min) 109.1±14.5 104.9±10.6 术后p(O2)/FiO2/mmHg 306.0±58.8 305.8±58.7 术后p(CO2)/mmHg 60.0±9.1 59.2±10.7 
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1. 何智群，郭栋伟，户海宁，张华玲，唐文富. 经鼻高流量氧疗用于呼吸衰竭患者无痛支气管镜检查的前瞻性研究. 中国医学装备. 2022(07): 107-111 . 
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