摘要目的 比较智能化撤机和经验性撤机两种撤机方法对机械通气撤机困难患者的疗效.方法 采用前瞻性随机对照研究,按平衡指数最小的原则进行简易的临床试验随机化分组,将62例综合ICU内的撤机困难患者随机分入智能化Smart Care组(SC组,30例)和同步间歇指令通气联合压力支持通气组(SP组,32例)进行撤机试验,两组患者的疾病构成、年龄、性别、入ICU时急性生理慢性健康状况评分(APACHE)Ⅱ以及撤机前机械通气时间差异均无统计学意义.两组患者除撤机方法不同外,其他处理均相同,观察两组的撤机时间、再插管率和机械通气相关并发症的发生率以及ICU滞留率.结果 SC组神经肌肉病变患者、术后呼吸支持患者和呼吸系统疾病患者的撤机时间分别为(49±13)、(67±37)和(25±96)h,明显少于SP组[分别为(223±38)、(106±34)和(502±91)h,X~2值分别为8.33、4.77和4.43,均P<0.05].SC组神经肌肉病变患者、术后呼吸支持患者的ICU滞留时间分别为(9.0 ±1.7)和(7.3±1.9)d,明显低于SP组的(20.8±5.1)和(14.6±1.7)d(X~2值分别为6.74和7.68,均P<0.05).SC组平均调节呼吸机次数为(5±1)次/人明显低于SP组的(13±3)次/人(t=2.73,P<0.05).两组的再插管率、气管切开率、气胸发牛率、呼吸机相关性肺炎(VAP)发生率和皮下气肿发生率比较差异均无统计学意义.结论 CDW智能化撤机法应用于撤机困难患者能够有效地缩短撤机时间,减少ICU滞留时间,并可以减少医生调节呼吸机的负担而节约医疗资源.

abstractsObjective To evaluate if the computer-driven weaning (CDW) with a closed-loop knowledge-based system introduced in a ventilator is superior to physician-directed weaning (PDW) in difficult-to-wean patients in the intensive care unit (ICU). Methods Sixty-two difficult-to-wean patients were randomized into 2 groups: weaning with Smart Care/PS (SC group, n=32 ) or with synchronize intermittent mandatory ventilation add positive support ventilation (SP group, n = 30). In the SC group, the automated system titrated pressure support, conducted a spontaneous breathing trial and provided notification of success (separation potential). In the SP group, weaning from ventilators was carried out by gradually decreasing respiratory support. The length of mechanical ventilation and stay in ICU, the rate of ventilator-associated pneumonia (VAP), the retubing rate in 48 h, manual ventilator setting changes before extubatlon were compared between the 2 groups. Results In the SC group, the weaning time was (49±13 ) h, (67±37) h, and (254± 96 ) h, respectively in patients with neuromuscular diseases, for post-operative respiratory support and patients with respiratory diseases; while in the SP group, the weaning time was (223 ± 38 ) h, ( 106 ±34) h and ( 502 ± 91 ) h, respectively; the difference between the 2 groups being and (7.3 ±1.9 ) d in the SC group for patients with neuromuscular diseases and patients with post-operative respiratory support, respectively, while that was (20. 8 ±5. 1 ) d and (14.6±1.7) d in the SP group,respectively. Time of stay in ICU was significantly shorter in the SC group ( X~2 = 6. 74, 7.68, both P <than that of the SP group (13:1:3, t =2.73, P <0.05). There were no significant differences between the SC and the SP groups in the rate of re-intubation, the rate of traeheotomy, the incidence of pneumothorax,the incidence of VAP and the incidence of subcutaneous emphysema. Conclusion The CDW method used in patients with difficult weaning from ventilators was shown to shorten the weaning time, reduce stay in ICU,and decrease the need for manual adjustment of ventilators.