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中国循证儿科杂志

中国循证儿科杂志 ›› 2023, Vol. 18 ›› Issue (2): 91-95.DOI: 10.3969/j.issn.1673-5501.2023.02.002

• 论著 • 上一篇    下一篇

多学科诊疗模式对儿童长期机械通气过渡为家庭机械通气的质量改进研究

杜俐佳1,5，秦妍1,5，杜岩1，柳宇鑫1，刘盼1，陶金好1，陈超2，王素娟3，高萱4，陆国平1，张铮铮1，陈伟明1
  

  1. 复旦大学附属儿科医院上海，201102；1 重症医学科，2 耳鼻喉科，3 康复科，4 营养科，5 共同第一作者
  • 收稿日期:2022-11-11 修回日期:2022-12-13 出版日期:2023-04-25 发布日期:2023-05-19
  • 通讯作者: 张铮铮，陈伟明

The transition from pediatric prolonged mechanical ventilation to home mechanical ventilation by a multidisciplinary approach: A quality improvement study

DU Lijia1,5, QIN Yan1,5, DU Yan1, LIU Yuxin1, LIU Pan1, TAO Jinhao1, CHEN Chao2, WANG Sujuan3, GAO Xuan4, LU Guoping1, ZHANG Zhengzheng1, CHEN Weiming1   

  1. Children's Hospital of Fudan University, Shanghai 201102, China; 1 Department of Critical Care Medicine, 2 Department of Otorhinolaryngology, 3 Department of Rehabilitation, 4 Department of Nutrition, 5 Co-first author
  • Received:2022-11-11 Revised:2022-12-13 Online:2023-04-25 Published:2023-05-19
  • Contact: ZHANG Zhengzheng, email: 6710916@163.com; CHEN Weiming, email: 13817556013@163.com

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摘要： 背景：对于危重症医疗团队而言，长期机械通气（PMV）患者的撤机管理和后续向家庭机械通气（HMV）治疗模式转变一直是复杂的挑战。 目的：探索多学科诊疗模式（MDT）在PICU呼吸机依赖患儿诊治中的应用，分析其对于实施个体化撤机方案和指导从PMV过渡为HMV的临床价值以及推广意义。 设计：质量改进研究。 方法：以PICU中呼吸机依赖的PMV病例为观察对象，以2020年7月时点前后各18个月的PMV病例分为对照组和干预组。我院PMV诊疗措施主要包括：呼吸机相关肺炎预防，镇静、镇痛，液体管理，营养支持，早期康复，个体化撤机方案，PMV过渡为HMV的宣教，随访。对照组以PICU中不同医生或团队经验性的采用PMV诊疗措施，干预组以PMVMDT团队采用PMV诊疗措施，以重症医学科为平台，PMVMDT团队包括兼职联络员、核心团队成员（呼吸治疗师、康复科医生、五官科医生、营养科医生等）和原发病专科医生，并建立HMV专病随访门、急诊。 主要结局指标：①PMV过渡为HMV的情况，②个体化撤机方案的应用情况。 结果：干预组和对照组PMV患儿分别纳入124例和101例，两组性别、年龄、体重和导致PMV的原发疾病等差异无统计学意义。对照组院内死亡36例，遵医嘱出院67例（成功拔管撤离呼吸机44例，仍依赖机械通气14例，仍依赖人工气道无需机械通气7例），放弃治疗出院21例。干预组院内死亡26例，遵医嘱出院64例（成功拔管撤离呼吸机38例，仍依赖机械通气19例，依赖人工气道无需机械通气7例），放弃治疗出院11例（死亡9例，仍需机械通气1例，成功拔管脱离呼吸机1例）。干预组较对照组实施膈肌超声（97.0% vs 12.7%）、膈肌电活动监测（5% vs 0）和体外膈肌起搏技术（26.7% vs 0）差异均有统计学意义；两组纤维支气管镜检查例数差异无统计学意义，食道压监测、神经调节辅助通气在干预组首次开展。干预组HMV 19例，其中3例因病情加重（气道廓清不规范导致肺部感染加重）在HMV急诊随访由PICU绿色通道再入院，死亡1例，余均存活随访中，仍坚持HMV；对照组HMV 14例，均失访。干预组依赖人工气道无需机械通气7例，其中1例出院3个月人工气道拔除，余均存活随访中；对照组依赖人工气道无需机械通气7例，均失访。两组存活出院、出院时拔管脱离呼吸机、出院时无法脱离呼吸机、仍依赖人工气道无需机械通气例数、PICU住院时间和机械通气时间差异均无统计学意义。 结论：PMVMDT模式能尽早给予呼吸机依赖患儿系统及个体化的临床诊疗及撤机方案。MDT团队还能为PMV患儿过渡至HMV提供出院前家庭照护培训和出院后定期随访，保证PMV患儿治疗策略的连续性和有效性。

关键词: 长期机械通气, 儿童, 多学科诊疗, 纤维支气管镜检查, 膈肌超声, 家庭机械通气

Abstract: Background：Weaning management of patients with prolonged mechanical ventilation （PMV） and subsequent transition to home mechanical ventilation have been complex challenges for critical care teams. Objective：To explore the application of multidisciplinary treatment (MDT) model in the diagnosis and treatment of pediatric PMV and to analyze its clinical value and the significance of promotion for individualized weaning plan and transition from PMV to HMV. Design：Quality improvement. Methods：Patients with PMV in PICU were observed, and were divided into control group and intervention group according to 18 months before and after July 2020. The diagnosis and treatment measures of PMV in our hospital mainly include: prevention of ventilatorassociated pneumonia, sedation, analgesia, fluid management, nutritional support, early rehabilitation, individualized weaning program, education and followup of PMV transition to HMV, and establishment of outpatient and emergency followup for HMV specific diseases. The control group was empirically treated by different doctors or teams in the PICU. In the intervention group, the PMVMDT team led the treatment. Taking the PICU as the platform, PMVMDT parttime liaisons and core team members (respiratory therapists, rehabilitation physicians, ent physicians, nutrition physicians, etc.) were set up. The HMV special followup and emergency clinics were established. Main outcome measures：PMV transition to HMV and the application of individualized weaning technology. Results：There were 101 cases of PMV in the intervention group and 124 cases in the control group. There was no statistical difference in gender, age, weight and the primary disease causing PMV between the two groups. In the control group, 36 cases died in hospital, 67 cases were improved and discharged (44 cases discharged after weaning and extubation , 14 cases still dependent on mechanical ventilation, and 7 cases still dependent on artificial airway without mechanical ventilation), and 21 patients gave up treatment. In the intervention group, 26 cases died in hospital, 64 cases were improved and discharged (38 cases discharged after weaning and extubation, 19 cases still dependent on mechanical ventilation, and 7 cases still dependent on artificial airway without mechanical ventilation), and 11 patients gave up treatment (9 deaths, 1 case still dependent on mechanical ventilation, 1 case successfully extubated). Compared with the control group, there were more use of diaphragm ultrasound (97.0% vs 12.7%), diaphragm electrical activity monitoring technology (5% vs 0) and external diaphragm pacer (26.7% vs 0) in the intervention group, and the differences were statistically significant. There was no significant difference in the number of cases of bronchoscopy between the two groups. The esophageal pressureguided strategy and neurally adjusted ventilator assist (NAVA) mode were the first of their kind. Among 19 HMV patients in the intervention group, 3 cases were readmitted by green channel due to aggravation of pulmonary infection caused by irregular airway clearance, 1 case died, and the rest of them still insisted on HMV during followup. Fourteen cases with HMV in control group were lost to followup. In the intervention group, there were 7 cases dependent on artificial airway without mechanical ventilation, of which 1 case were extubation 3 months after discharge, and the rest were all alive during followup. There were 7 cases dependent on artificial airway without mechanical ventilation, and they were all lost to followup. There was no statistical difference between the two groups in the number of patients discharged from hospital, extubation at discharge, dependent on mechanical ventilation at discharge, dependent on artificial airway without mechanical ventilation, length of stay in ICU and duration of mechanical ventilation. Conclusions：PMVMDT model can provide systematic and individualized clinical diagnosis, treatment and weaning plan for children with ventilator dependent as early as possible. It also provides home care training before discharge and regular followup after discharge for children with HMV. All these can ensure the effectiveness and continuity of treatment strategies for children with longterm mechanical ventilation.

Key words: Prolonged mechanical ventilation, Child, Multidisciplinary treatment, Bronchoscopy, Diaphragm ultrasound, Home mechanical ventilation