肠内营养支持对慢性阻塞性肺病急性加重期机械通气患者营养和预后的影响

doi:10.3969/j.issn.1004-583X.2022.06.005

摘要/Abstract

摘要：

目的探讨营养支持对改善慢性阻塞性肺病急性加重期(AECOPD)机械通气患者营养状况和预后的作用。方法采用随机对照法,将初期入选的100例AECOPD机械通气患者分成治疗组(n=50)和对照组(n=50)。治疗组于机械通气后48 小时内开始给予肠内营养混悬液(能全力^®)肠内营养(enteral nutrition,EN)支持,对照组给予自制流食支持治疗。观察并监测两组治疗前及治疗7 d和14 d后的营养指标:血清清蛋白(ALB)、前清蛋白(PA)、血红蛋白(Hb)、氮平衡(NB);营养状况:体重指数(BMI)、肱三头肌皮褶厚度(TSF)、上臂中间点周径(AMC);免疫指标:免疫球蛋白(IgA);临床指标:2周内脱机成功率、机械通气时间、入住ICU时间、呼吸机相关肺炎(VAP)的发生率,APACHE II评分以及观察肠内营养不耐受性:胃潴留、反流、误吸,导管相关感染等不良事件的发生情况;同时对未到达终点(死亡或放弃治疗)的患者做退出处理。结果治疗14 d后,治疗组血清ALB、PA、NB、IgA各指标均明显提高,与治疗前及对照组相比,差异均有统计学意义(P<0.05);治疗组BMI、TSF和AMC较治疗前明显改善,与治疗前及对照组比较差异均有统计学意义(P<0.05);APACHE II评分较治疗前明显好转,也优于同期对照组,差异有统计学意义(P<0.05)。机械通气时间、入住ICU时间和VAP的发生率,治疗组明显低于对照组(P<0.05),2周内脱机成功率明显高于对照组(P<0.05)。2组均有不良事件的发生,但差异无统计学意义。2组均有退出患者,治疗组4例;对照组10例,所有退出患者均未进行相关指标的比较。结论能全力^®EN支持治疗是AECOPD机械通气患者的一项重要措施,可改善患者的营养状况,能更好地促进蛋白质合成,提高机体免疫力,综合提高患者的治疗效果及改善患者的预后。

关键词: 肺疾病, 慢性阻塞性, 机械通气, 肠内营养, 营养状况

Abstract:

Objective To investigate the effect of nutritional support on nutritional status and prognosis of patients with mechanical ventilation(MV) in acute exacerbation of chronic obstructive pulmonary disease(AECOPD). Methods Using randomized method,100 MV patients in AECOPD were divided into treatment group and control group. In 48 hours after MV, the treatment group(n=50) was given enteral nutrition (EN) ; the control group(n=50) were given self-made liquid food. The nutritional indicators were monitored before treatment and days 7 and 14 days of treatment, including arm muscle circumference (AMC), serum albumin (ALB), prealbumin (PA), hemoglobin (Hb), nitrogen balance (NB).The nutritional status was assesses including body mass index (BMI), triceps fold thickness (TSF), arm muscle circumference (AMC); The immunological parameters were observed including immunoglobulin A (IgA). The clinical indicators were evaluated including weaning success rate, MV time, ICU time, the incidence of ventilator-associated pneumonia (VAP). The APACHE Ⅱ score and intolerance to EN were recorded, including the incidence of gastric retention, regurgitation, and aspiration, catheter-related infection, and the incidence of other related adverse events. At the same time, patients who did not reach the endpoint (death occurred or abandoned treatment) were withdrawn from treatment. Results Compared with before treatment, the serum ALB, PA, Nb and IgA of the patients in the treatment group were significantly higher than those in control group on day 14 of treatment (all P<0.05); BMI, TSF and AMC in the treatment group were significantly improved (all P<0.05); APACHE Ⅱ score in the treatment group was significantly improved (all P<0.05). Compared with the control group, the MV time, ICU time and the incidence of VAP in the treatment group were significantly lower (P<0.05); and the weaning success rate within 2 weeks in the treatment group was significantly higher (P<0.05). Adverse events occurred in both groups, but there was no statistical significance. There were patients with withdrawal from both group, four in the treatment group and 10 in the control group. No comparison of relevant indicators was conducted among all patients with withdrawal. Conclusion For MV patients in AECOPD, EN is an important measure. It can improve the nutritional status, better promote protein synthesis, improve the body immunity, comprehensively improve the therapeutic effect and improve the prognosis of patients.

Key words: pulmonary disease, chronic obstructive, mechanical ventilation, enteral nutrition, nutritional status

中图分类号:

张志萍, 张宝民, 秦伟, 高凌杰, 陈冬. 肠内营养支持对慢性阻塞性肺病急性加重期机械通气患者营养和预后的影响[J]. 临床荟萃, 2022, 37(6): 510-514.

Zhang Zhiping, Zhang Baomin, Qin Wei, Gao Lingjie, Chen Dong. Clinical application of nutritional support on mechanical ventilation in acute exacerbation of chronic obstructive pulmonary disease[J]. Clinical Focus, 2022, 37(6): 510-514.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.06.005

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I6/510

图/表 3

参考文献 15

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组别	例数	ALB(g/L)^△	PA(mg/L)^△	Hb(g/L)^△	NB(g/L)^△	IgA(g/L)^△	APACHE Ⅱ评分^△
对照组	40
治疗前		40.72±3.74	180.56±10.46	124.95±7.48	19.17±2.70	1.85±0.34	22.32±3.43
治疗后第7 d		31.39±2.93	142.54±6.83	105.81±10.78	1.67±0.42	1.29±0.24	20.11±2.53
治疗后第14 d		40.50±4.72	171.89±9.43	112.57±7.55	6.25±0.44	1.71±0.28	15.31±2.01
治疗组	46
治疗前		45.01±3.28	191.85±17.58	128.87±8.19	18.08±4.25	1.80±0.12	23.17±3.81
治疗后第7 d		34.79±3.17	198.99±18.81	119.88±4.83	3.73±1.60	2.01±0.13	16.76±3.06
治疗后第14 d		49.67±4.15	331.81±39.71	124.55±5.10	13.95±3.52	2.39±0.12	12.54±2.98
组间		F=53.34, P<0.01	F=263.24, P<0.01	F=66.34, P<0.01	F=174.54, P<0.01	F=45.36, P<0.01	F=36.22, P<0.01
不同时点		F=65.72, P<0.01	F=145.33, P<0.01	F=57.32, P<0.01	F=183.33, P<0.01	F=78.22, P<0.01	F=67.54, P<0.01
组间·不同时点		F=120.32, P<0.01	F=123.55, P<0.01	F=96.22, P<0.01	F=134.26, P<0.01	F=82.46, P<0.01	F=101.43, P<0.01

组别	例数	ALB(g/L)^△	PA(mg/L)^△	Hb(g/L)^△	NB(g/L)^△	IgA(g/L)^△	APACHE Ⅱ评分^△
对照组	40
治疗前		40.72±3.74	180.56±10.46	124.95±7.48	19.17±2.70	1.85±0.34	22.32±3.43
治疗后第7 d		31.39±2.93	142.54±6.83	105.81±10.78	1.67±0.42	1.29±0.24	20.11±2.53
治疗后第14 d		40.50±4.72	171.89±9.43	112.57±7.55	6.25±0.44	1.71±0.28	15.31±2.01
治疗组	46
治疗前		45.01±3.28	191.85±17.58	128.87±8.19	18.08±4.25	1.80±0.12	23.17±3.81
治疗后第7 d		34.79±3.17	198.99±18.81	119.88±4.83	3.73±1.60	2.01±0.13	16.76±3.06
治疗后第14 d		49.67±4.15	331.81±39.71	124.55±5.10	13.95±3.52	2.39±0.12	12.54±2.98
组间		F=53.34, P<0.01	F=263.24, P<0.01	F=66.34, P<0.01	F=174.54, P<0.01	F=45.36, P<0.01	F=36.22, P<0.01
不同时点		F=65.72, P<0.01	F=145.33, P<0.01	F=57.32, P<0.01	F=183.33, P<0.01	F=78.22, P<0.01	F=67.54, P<0.01
组间·不同时点		F=120.32, P<0.01	F=123.55, P<0.01	F=96.22, P<0.01	F=134.26, P<0.01	F=82.46, P<0.01	F=101.43, P<0.01

组别	例数	BMI(kg/m²)^△	TSF(mm)^△	AMC(cm)^△
对照组	40
治疗前		18.85±3.97	7.20±1.95	19.56±4.06
治疗后第7 d		13.92±3.18	6.94±2.54	17.13±3.12
治疗后第14 d		19.73±3.44	8.07±2.75	21.34±3.85
治疗组	46
治疗前		19.12±3.86	8.64±3.41	21.07±3.87
治疗后第7 d		15.17±3.75	7.48±3.02	17.58±3.79
治疗后第14 d		22.21±3.92	10.71±3.67	25.90±3.11
组间		F=42.32, P<0.01	F=93.45, P<0.01	F=35.44, P<0.01
不同时点		F=33.25, P<0.01	F=64.29, P<0.01	F=36.22, P<0.01
组间·不同时点		F=51.21, P<0.01	F=88.46, P<0.01	F=45.20, P<0.01

组别	例数	BMI(kg/m²)^△	TSF(mm)^△	AMC(cm)^△
对照组	40
治疗前		18.85±3.97	7.20±1.95	19.56±4.06
治疗后第7 d		13.92±3.18	6.94±2.54	17.13±3.12
治疗后第14 d		19.73±3.44	8.07±2.75	21.34±3.85
治疗组	46
治疗前		19.12±3.86	8.64±3.41	21.07±3.87
治疗后第7 d		15.17±3.75	7.48±3.02	17.58±3.79
治疗后第14 d		22.21±3.92	10.71±3.67	25.90±3.11
组间		F=42.32, P<0.01	F=93.45, P<0.01	F=35.44, P<0.01
不同时点		F=33.25, P<0.01	F=64.29, P<0.01	F=36.22, P<0.01
组间·不同时点		F=51.21, P<0.01	F=88.46, P<0.01	F=45.20, P<0.01

组别	例数	机械通气时间 (d)	2周内脱机成功率[例(%)]	入住ICU时间 (d)	VAP发生率 [例(%)]	不良事件[例(%)]
组别	例数	机械通气时间 (d)	2周内脱机成功率[例(%)]	入住ICU时间 (d)	VAP发生率 [例(%)]	胃潴留	误吸	反流	导管相关感染
对照组	40	12.2±3.8	17(42.50)	17.3±4.2	13(32.50)	1(2.50)	0(0.0)	1(2.50)	3(7.50)
治疗组	46	8.9±3.2	31(67.39)	12.6±2.8	6(13.04)	3(6.52)	1(2.17)	2(4.35)	1(2.17)
t/χ²值		30.23	5.38	27.45	4.71	-	-	-	-
P值		<0.01	0.02	<0.01	0.03	0.62	1.00	1.00	0.33