重症卒中患者早期不同气道开放方式对肺部感染及气管插管的影响

doi:10.3969/j.issn.1673-5765.2023.03.009

摘要/Abstract

摘要：

目的研究重症卒中患者早期应用口咽通气管或鼻咽通气管的临床应用效果。
方法连续纳入2020年6月—2022年6月首都医科大学附属北京天坛医院急诊抢救室收治的重症卒中患者，根据患者留置口咽通气管、鼻咽通气管、未留置口/鼻咽通气管分为口咽通气管组、鼻咽通气管组、对照组，对其临床资料进行回顾性分析。比较各组间临床特征、入院7 d内肺部感染发生情况、序贯气管插管转化率及转化时间。
结果共纳入213例重症卒中患者，男性123例，脑出血119例，脑梗死94例。鼻咽通气管组79例，口咽通气管组68例，对照组66例。鼻咽通气管组入院7 d内误吸发生率低于对照组（10.13% vs. 19.70%，P=0.034）及口咽通气管组（10.13% vs. 22.06%，P=0.021）。鼻咽通气管组入院7 d内肺部感染发生率低于对照组（32.91% vs. 59.09%，P=0.018）与口咽通气管组（32.91% vs. 45.59%，P=0.023）。鼻咽通气管组、口咽通气管组、对照组三组7 d院内全因死亡率（30.38% vs. 32.35% vs. 34.84%，P=0.660）整体差异无统计学意义。鼻咽通气管组7 d内气管插管转化率低于口咽通气管组（12.66% vs. 44.12%，P=0.022）与对照组（12.66% vs. 43.94%，P=0.031）。鼻咽通气管组气管插管转化时间较口咽通气管组[（6.72±2.15）d vs.（4.12±1.23）d，P=0.022]、对照组[（6.72±2.15）d vs.（3.12±1.33）d，P=0.011]延长。入院7 d血气分析可见鼻咽通气管组[（83.56±8.31）mmHg vs.（76.34±8.63）mmHg，P=0.007]及口咽通气管组[（84.56±5.84）mmHg vs.（76.34±8.63）mmHg，P=0.003]血氧分压高于对照组，而鼻咽通气管组[（37.67±11.22）mmHg vs.（48.56±9.62）mmHg，P=0.012]及口咽通气管组[（36.45±17.53）mmHg vs.（48.56±9.62）mmHg，P=0.009]二氧化碳分压低于对照组。
结论重症卒中早期给予口咽通气管或鼻咽通气管开放气道能改善呼吸道不畅，提高血氧分压、降低二氧化碳潴留。但鼻咽通气管与口咽通气管相比，可减少卒中后误吸的发生，降低肺部感染概率，延缓气管插管转化时间，降低气管插管转化率，缩短住院时间。

文章导读：

鼻咽通气管开放气道能够降低重症卒中患者气管插管转化率，延长气管插管转化时间。

关键词: 重症卒中；气管插管；口咽通气管；鼻咽通气管

Abstract: Objective To study the clinical effects of early oropharyngeal ventilation tube or nasopharyngeal ventilation tube in patients with severe stroke.
Methods The consecutive patients with severe stroke admitted to the emergency room of Beijing Tiantan Hospital, Capital Medical University from June 2020 to June 2022 were included in the study. Patients were divided into oropharyngeal airway group, nasopharyngeal airway group and control group according to the use of oropharyngeal airway, nasopharyngeal airway, and non-use of oral/nasopharyngeal airway. Their clinical data were collected. The clinical features, incidence of pulmonary infection within 7 days after admission, conversion rate and time of sequent tracheal intubation were compared among all groups.
Results A total of 213 patients with severe stroke were included, including 123 males (57.7%), 119 cases of cerebral hemorrhage and 94 cases of cerebral infarction. There were 68 cases in oropharyngeal airway group, 79 cases in nasopharyngeal airway group, and 66 cases in control group. The incidence of aspiration in nasopharyngeal airway group was lower than that in the control group (10.13% vs. 19.70%, P=0.034) and oropharyngeal airway group (10.13% vs. 22.06%, P=0.021). The incidence of pulmonary infection within 7 days after admission in nasopharyngeal airway group was lower than that in control group (32.91% vs. 59.09%, P=0.018) and oropharyngeal airway group (32.91% vs. 45.59%, P=0.023). There was no statistical difference in in-hospital all-cause mortality (30.38% vs. 32.35% vs. 34.84%, P=0.660) among the three groups within 7 days after admission. The conversion rate of endotracheal intubation in nasopharyngeal airway group was lower than that in oropharyngeal airway group (12.66% vs. 44.12% P=0.022) and control group (12.66% vs. 43.94%, P=0.031). The conversion time of endotracheal intubation in nasopharyngeal airway group delayed compared to that in oropharyngeal airway group [(6.72± 2.15) d vs. (4.12±1.23) d, P=0.022] and control group [(6.72±2.15) d vs. (3.12±1.33) d, P=0.011]. Blood gas analysis at 7 days after admission showed that the blood oxygen partial pressure of nasopharyngeal airway group [(83.56±8.31) mmHg vs. (76.34±8.63) mmHg, P=0.007] and oropharyngeal airway group [(84.56±5.84) mmHg vs. (76.34±8.63) mmHg, P=0.003] was higher than that of the control group, while the carbon dioxide partial pressure of nasopharyngeal airway group [(37.67±11.22) mmHg vs. (48.56±9.62) mmHg, P=0.012] and oropharyngeal airway group [(36.45±17.53) mmHg vs. (48.56±9.62) mmHg, P=0.009] was lower than that in control group.
Conclusions In the early stage of severe stroke, oropharyngeal ventilation tube or nasopharyngeal ventilation tube can improve airway obstruction, increase blood oxygen partial pressure and reduce carbon dioxide retention. However, compared with oropharyngeal ventilation tube, nasopharyngeal ventilation tube can reduce the occurrence of aspiration after stroke, reduce the risk of pulmonary infection, delay the conversion time of endotracheal intubation, reduce the conversion rate of endotracheal intubation, and shorten the length of hospital stay.

Key words: Severe stroke; Tracheal intubation; Oropharyngeal ventilation tube; Nasopharyngeal ventilation tube

霍洁, 刘京铭, 冀瑞俊, 徐玢, 郭伟. 重症卒中患者早期不同气道开放方式对肺部感染及气管插管的影响[J]. 中国卒中杂志, 2023, 18(03): 295-300.

HUO Jie, LIU Jingming, JI Ruijun, XU Bin, GUO Wei.

Effects of Early Different Airway Opening Mode on Pulmonary Infection and Tracheal Intubation in Patients with Severe Stroke

[J]. Chinese Journal of Stroke, 2023, 18(03): 295-300.

参考文献

[1] 中华医学会神经病学分会，中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志，2018，51（9）：662-682.
[2] 中华医学会神经病学分会，中华医学会神经病学分会脑血管病学组. 中国脑出血诊治指南2019[J]. 中华神经科杂志，2019，55（12）：994-1005.
[3] 中国医师协会神经外科学分会神经重症专家委员会，上海卒中学会，重庆市卒中学会. 脑卒中病情监测中国多学科专家共识[J]. 中华医学杂志，2021，101（5）：317-326.
[4] MANN G，HANKEY G J，CAMERON D. Swallowing disorders following acute stroke： prevalence and diagnostic accuracy[J]. Cerebrovasc Dis，2000，10（5）：380-386.
[5] CORDONNIER C，DEMCHUK A，ZIAI W，et al. Intracerebral haemorrage：current approaches to acute management[J]. Lancet，2018，392（10154）：1257-1268.
[6] 杨璐晖. 口咽通气管吸痰在脑梗塞舌后坠合并肺部感染患者的应用效果[J]. 中外医疗，2020，39（18）：142-144.
[7] 代辉，樊青珠，李燕爽，等. 鼻咽通气道通气和面罩通气对术前置入鼻胃管患者全身麻醉诱导期通气效果的影响[J]. 中国实验诊断学，2021，25（7）：1020-1023.
[8] 张为民，方强，程旭萍，等. 重症脑卒中早期开放人工气道的临床价值评价研究[J]. 中国全科医学，2010，13（16）：1757-1759，1762.
[9] 叶向红，许冰茹，王慧君，等. 重症病人早期肠内营养误吸风险评估表的构建[J]. 肠外与肠内营养，2019，26（6）：346-350.
[10] KIMOFF R J，SFORZA E，CHAMPAGNE V，et al. Upper airway sensation in snoring and obstructive sleep apnea[J]. Am J Respir Crit Care Med，2001，164（2）：250-255.
[11] JOHNSON M，MISKOVIC A，RAY S，et al. The nasopharyngeal airway：Estimation of the nares-to-mandible and nare-to-tragus distance in young children to assess current clinical practice[J/OL]. Resuscitation，2019，140：50-54[2022-10-01]. https://doi.org/10.1016/j.resuscitation. 2019.04.039.
[12] 蓝凤薇，果基木果，何建芳，等. 改良鼻咽通气道给氧联合体位管理对脑出血并发舌后坠患者的影响研究[J]. 赣南医学院学报，2022，42（2）：190-193.

[1]	梁晓燕, 侯峰, 刘小青, 倪钦帅, 郭云良, 张睿. 神经调节素1β通过激活Sirt1信号通路抑制自噬改善大鼠脑缺血再灌注损伤研究[J]. 中国卒中杂志, 2023, 18(03): 301-314.
[2]	《卒中相关非运动症状多学科管理专家共识》编写委员会. 卒中相关非运动症状多学科管理专家共识[J]. 中国卒中杂志, 2023, 18(03): 315-334.
[3]	陈悦薇, 徐群. 脑小血管病的外周标志物及其多组学研究进展[J]. 中国卒中杂志, 2023, 18(03): 340-346.
[4]	刘阳, 程丝, 吕天节, 王誉博, 王孟, 许喆, 石延枫, 李子孝, 王拥军. 基于单细胞转录组的围产期卒中性别差异原因探究[J]. 中国卒中杂志, 2023, 18(02): 169-174.
[5]	赵曼曼, 程丝, 李嫣然, 李昊, 王拥军. 单细胞测序技术解析动脉粥样硬化巨噬细胞异质性的研究进展[J]. 中国卒中杂志, 2023, 18(02): 180-184.
[6]	宋晓微, 桑振华, 侯朵朵, 陈文文, 张红亮, 郑卓肇, 赵锡海, 李睿, 武剑. 血压昼夜节律变化与颅内动脉粥样硬化斑块特征的相关性研究[J]. 中国卒中杂志, 2023, 18(01): 61-67.
[7]	王孟, 王春娟, 李子孝, 谷鸿秋. 阶梯整群随机试验[J]. 中国卒中杂志, 2023, 18(01): 114-122.
[8]	林庆金, 杨雅玲, 卢武生. 寰椎变异致反复脑梗死1例报道[J]. 中国卒中杂志, 2022, 17(11): 1252-1256.
[9]	王一轻, 刘平国, 沈佳慧, 蔡增林. 脑穿支动脉病变梗死类型和神经影像学研究进展[J]. 中国卒中杂志, 2021, 16(09): 877-882.
[10]	赵桐, 康帅, 王安心, 黄义炳, 吕寿祝, 高晓艳. 神经学科青年医师人才培养策略探讨[J]. 中国卒中杂志, 2021, 16(06): 631-634.
[11]	曹风雅, 邓江山, 赵玉武. 急性缺血性卒中与血糖波动关系的研究进展[J]. 中国卒中杂志, 2018, 13(10): 1114-1117.
[12]	赵莹莹, 武珊珊, 陈珺, 丁永芹, 高凤玲, 张伟, 赵静洁, 李继梅. 下肢动脉硬化闭塞症患者颅内/外动脉狭窄的特点及危险因素[J]. 中国卒中杂志, 2018, 13(05): 450-454.
[13]	刘炫君, 杨国帅, 林海丽, 周艳辉, 程启慧, 周律, 张艳君, 胡裕洁, 郝海珍, 王强. 亚低温联合丁基苯酞对溶栓时间窗外急性大脑中动脉闭塞患者预后的影响[J]. 中国卒中杂志, 2018, 13(05): 463-468.
[14]	苏兆萍，杨寓玲，刘长城，赵晶，孟维静，杨光，王素珍. 急性缺血性卒中合并颈动脉斑块患者神经功能损伤与血浆氧化低密度脂蛋白水平相关性研究[J]. 中国卒中杂志, 2017, 12(04): 309-313.
[15]	楼敏，张旭婷. 卒中中心的区域化建设[J]. 中国卒中杂志, 2015, 10(06): 457-460.