气管切开时机对急性呼吸窘迫综合征患者通气功能与临床结局的影响

Influence of tracheotomy timing on ventilation function and clinical outcome in patients with acute respiratory distress syndrome

摘要

目的：探讨不同气管切开时机在急性呼吸窘迫综合征（ARDS）患者中的临床应用效果及其对通气功能、用药情况和预后指标的影响。方法：回顾性分析2020年1月至2023年1月武汉大学人民医院重症医学科收治的33例ARDS患者，根据患者自气管插管并接受机械通气之日起至实施气管切开的时间计算，分为早期组（≤7 d，n=19）与晚期组（>7 d，n=14）。比较两组在重症监护病房（ICU）住院时长及28天死亡率、呼吸机相关性肺炎发生率、镇静药、镇痛药、升压药使用时间、机械通气时间、气管切开时长、血气指标、血常规及凝血功能等方面的差异。根据数据分布采用独立样本t检验、Mann-Whitney U检验与Fisher精确检验进行统计分析。结果：与晚期组比较，早期组的28天死亡率明显降低（P<0.05），但ICU住院期间死亡率差异无统计学意义（P>0.05）。早期组呼吸机相关性肺炎发生率及镇静药使用时间显著少于晚期组（P<0.05），两组间的镇痛药、升压药使用时间、机械通气时间及气管切开时长的差异均无统计学意义（P>0.05）。早期组动脉血二氧化碳分压（PaCO₂）显著下降（P<0.05），晚期组D-二聚体水平下降（P<0.05）；两组间动脉血氧分压及凝血指标PLT、INR及FIB差异均无统计学意义（P>0.05）。结论：早期气管切开可显著降低ARDS患者28 d病死率，减少呼吸机相关性肺炎发生率及镇静药物使用天数，并改善通气效能（PaCO₂下降更明显），提示其在短期预后及感染防控方面具有优势。

Abstract

Objective: To evaluate the clinical impact of different tracheostomy timing in patients with acute respiratory distress syndrome (ARDS), with emphasis on ventilatory function, medication use, and prognostic outcomes. Methods: A retrospective analysis was conducted on 33 patients with ARDS admitted to the Department of Critical Care Medicine, Renmin Hospital of Wuhan University, between January 2020 and January 2023. Based on the interval from endotracheal intubation and initiation of mechanical ventilation to tracheostomy, patients were categorized into an early group (≤7 days, n=19) or a late group (>7 days,n=14). Differences between the two groups were assessed in terms of ICU length of stay, 28-day mortality, incidence of ventilator-associated pneumonia, duration of sedative, analgesic, and vasopressor use, duration of mechanical ventilation, duration of tracheotomy, arterial blood gas parameters, complete blood count, and coagulation function. Statistical analyses were performed with independent-samples t tests, Mann-Whitney U tests, and Fisher's exact tests, as appropriate, according to data distribution. Results: Compared with the late group, the early group had a significantly lower 28-day mortality rate (P<0.05), while ICU mortality showed no significant difference between the two groups (P>0.05). The incidence of ventilator-associated pneumonia and the duration of sedative use were also significantly lower in the early group (P<0.05). There were no statistically significant differences between the two groups in the duration of analgesic and vasopressor use, mechanical ventilation time, or tracheotomy duration (P>0.05). Arterial PaCO₂ significantly decreased in the early group (P<0.05), whereas D-dimer levels decreased significantly in the late group (P<0.05). No significant differences were found in PaO₂, platelet count (PLT), international normalized ratio (INR), or fibrinogen (FIB) between groups (all P>0.05). Conclusion: Early tracheostomy significantly reduces 28-day mortality, the incidence of ventilator-associated pneumonia and the duration of sedative use in ARDS patients, and improves ventilatory efficiency, as reflected by a more pronounced decrease in PaCO₂, suggesting potential benefits in short-term prognosis and infection control.

关键词

急性呼吸窘迫综合征 / 气管切开 / 早期干预 / 通气功能 / 血气分析

Key words

Acute Respiratory Distress Syndrome / Tracheotomy / Early Intervention / Ventilatory Function / Blood Gas Analysis

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基金资助

新发突发与重大传染病防控国家科技重大专项(2025ZD01902600)

武汉大学人民医院交叉创新人才项目(JCRCYG-2022-005)

广东省二十一世纪教育基金会(2023HX0074)