摘要目的 探讨胸肺物理治疗(CPT)对机械通气(MV)患者的疗效.方法 采用前瞻性随机对照研究(RCT)方法,选择2014年12月至2016年10月遵义医学院附属医院综合重症加强治疗病房(ICU)收治的68例有创MV时间≥48 h的成人重症患者,按随机数字表法分为CPT组(37例)和对照组(31例).对照组实施常规物理治疗;CPT组在对照组的基础上实施手法膨肺、振动排痰、早期功能锻炼等综合CPT.观察两组患者治疗前后急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、氧合指数(PaO2/FiO2),以及CPT治疗前后呼吸功能和生命体征的变化;并记录两组治疗后实验室指标、并发症发生情况及MV时间和ICU住院时间.结果 CPT组呼吸机相关性肺炎(VAP)发生率明显低于对照组(5.4%比25.8%,P<0.05);对照组患者还存在肺不张、下肢深静脉血栓形成等并发症,而CPT组无上述并发症发生.CPT组MV时间(h:77.4±41.0比133.9±117.2)和ICU住院时间(h:134.4±71.4比207.4±177.7)均较对照组明显缩短(均P<0.05).两组患者治疗前APACHEⅡ评分及PaO2/FiO2无明显差异.两组治疗2 d起APACHEⅡ评分呈降低趋势,以CPT组降低更为显著,治疗4 d已显著低于对照组(分:8.6±3.9比12.5±5.3,P<0.05).两组治疗后PaO2/FiO2呈升高趋势;CPT组治疗3 d PaO2/FiO2即较治疗前显著升高〔mmHg(1 mmHg=0.133 kPa):278.1±79.0比224.2±98.9,P<0.05〕,而对照组治疗4 d才出现显著升高(mmHg:302.3±93.1比232.3±116.7,P<0.05).CPT组治疗后除脉搏血氧饱和度(SpO2)较治疗前显著升高外(0.985±0.016比0.978±0.018,P<0.05),其余生命体征及潮气量(VT)、呼吸频率(RR)、气道峰压(Ppeak)、平均气道压(Pmean)等呼吸功能指标均无明显变化,说明CPT治疗不会对患者呼吸功能和生命体征造成波动.CPT组治疗后血乳酸明显低于对照组(mmol/L:1.10±0.79比1.32±1.09,P<0.05),说明CPT治疗,尤其是早期功能锻炼,能改善患者氧供和四肢循环情况.结论 CPT治疗对预防MV患者发生VAP等并发症有一定作用,可以缩短MV时间和ICU住院时间,促进患者早日康复.

abstractsObjective To investigate the effect of chest physiotherapy (CPT) on patients undergoing mechanical ventilation (MV).Methods A prospective randomized controlled trial (RCT) was conducted. Sixty-eight adult patients undergoing invasive MV over 48 hours admitted to intensive care unit (ICU) of Affiliated Hospital of Zunyi Medical College from December 2014 to October 2016 were enrolled, and they were divided into CPT group (n = 37) and control group (n = 31) by random number table. The patients in control group received routine physical therapy; while those in the CPT group received comprehensive CPT including manual lung inflation, vibration expectoration and early functional exercise etc. on the basis of the treatment in control group. Acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and oxygenation index (PaO2/FiO2) before and after the treatment in both two groups were observed as well as the respiratory function and vital signs before and after CPT. The laboratory indicators after treatment, incidence of complications, duration of MV and the length of ICU stay in the two groups were recorded.Results The incidence of ventilator associated pneumonia (VAP) in the CPT group was significantly lower than that of control group (5.4% vs. 25.8%,P < 0.05), the patients in control group also had atelectasis, deep vein thrombosis and other complications, while no such complications were found in the CPT group. The duration of MV (hours: 77.4±41.0 vs. 133.9±117.2) and the length of ICU stay (hours: 134.4±71.4 vs. 207.4±177.7) in CPT group were significantly shorter than those of the control group (bothP < 0.05). There was no significant difference in APACHE Ⅱ score and PaO2/FiO2 before treatment between the two groups. After treatment for 2 days, the APACHE Ⅱ score in both groups was gradually decreased, and that in CPT group was more significantly, it was significantly lower than that of control group after treatment for 4 days (8.6±3.9 vs. 12.5±5.3,P < 0.05). The PaO2/FiO2 in the two groups was gradually increased after treatment. PaO2/FiO2 in CPT group was significantly increased at 3 days after treatment as compared with that before treatment [mmHg (1 mmHg = 0.133 kPa): 278.1±79.0 vs. 224.2±98.9], while PaO2/FiO2 in the control group did not appear significantly increased until after 4-day treatment (mmHg: 302.3±93.1 vs. 232.3±116.7, both P < 0.05). There was no significant difference in vital signs andrespiratory function parameters including tidal volume (VT), respiratory rate (RR), peak airway pressure (Ppeak) and mean airway pressure (Pmean) before and after treatment in CPT group excepting pulse oxygen saturation (SpO2) was significantly higher than that before treatment (0.985±0.016 vs. 0.978±0.018,P < 0.05), indicating that CPT treatment did not cause fluctuations in respiratory function and vital signs. Blood lactate in CPT group was significantly lower than that of control group (mmol/L: 1.10±0.79 vs. 1.32±1.09, P < 0.05), indicating that CPT treatment, especially early functional exercise, could improve the oxygen supply and limb circulation.Conclusion CPT treatment has some effect on prevention of VAP and other complications in patients undergoing MV, which could shorten the duration of MV and the length of ICU stay, and promote the recovery of patients.