運用俯臥通氣改善非急性呼吸窘迫症候群相關之嚴重低血氧的呼吸照護經驗之個案報告

Successful prone ventilation treatment in a severe hypoxemic patient without acute respiratory distress syndrome - A case report

郭詩毓(Shih-Yu Kuo) ； 吳佳宜(Chia-I Wu) ； 郭鈞瑋(Chin-Wei Kuo)

《呼吸治療》 18卷1期 (2019/07) Pp. 71-78

https://doi.org/10.6269/JRT.201907_18(1).0007

摘要

俯臥通氣是一種應用廣泛且安全改善氧合的方法，過去的研究多著墨於俯臥通氣在急性呼吸窘迫症候群病患的應用，對於不是因為急性呼吸窘迫症相關的嚴重低血氧的病人，俯臥通氣的使用並沒有被建立。本個案為86歲男性無特殊過去病史，此次意識不清、呼吸窘迫及休克被送至急診，追蹤病患血液動脈血分析有低血氧合併呼吸和代謝酸中毒，當下給予放置氣管內管及機械通氣治療，而胸腔X光和電腦斷層並無急性呼吸窘迫症候群之表現，臨床診斷為感染性腹瀉導致之敗血性休克及呼吸衰竭。三天後，病人血液氧合濃度變差，胸部X光除了輕微肺塌陷外並沒有發現急性呼吸窘迫症候群之典型影像學表現，其他臨床檢查也並無肺栓塞之證據。為改善低血氧，照顧團隊決定為病人執行俯臥通氣，俯臥通氣半小時後的動脈血液氣體分析有大幅的改善，而其改善氧合的效應也能持續到俯臥通氣結束後。俯臥通氣透過改善區域通氣、改變正壓呼吸及神經肌肉阻斷劑使用下的橫膈肌運動以達到減少通氣灌流的不平衡等方式來改善氧合，這些改變並不只發生在急性呼吸窘迫症候群病患身上。本個案的照顧經驗可當做呼吸治療師同仁對於此類病人低血氧原因的臨床分析的參考，以及給予俯臥通氣在非急性呼吸窘迫症候群的嚴重低血氧病人的治療依據及不同的思維。

關鍵字

俯臥通氣 ； 非急性呼吸窘迫症 ； 嚴重低血氧

並列摘要

The use of prone ventilation has been mostly limited to patients with acute respiratory distress syndrome (ARDS). Few studies have focused on the effects of prone ventilation treatment for patients not clinically diagnosed with ARDS. Here, we report the case of an 86-year-old male without a specific systemic underlying disease who had been sent to our emergency department due to a change in consciousness, respiratory distress, and shock. A laboratory survey initially showed severe hypoxemia and metabolic acidosis, and a chest radiograph and computerized tomography results revealed no evidence of ARDS. The tentative diagnosis was infectious-diarrhea-associated septic shock and respiratory failure, and thus mechanical ventilator support and a vasopressor were given. The oxygenation of this patient worsened three days later, and a chest radiograph showed mild basal lung atelectasis but not the typical characteristics of ARDS. A bedside ultrasound survey did not show signs of pulmonary embolism. His severe hypoxemia improved 30 minutes after prone ventilation. Prone ventilation improves oxygenation via the following mechanisms: lung recruitment, improved regional ventilation, change of diaphragm movement under positive ventilation and neuromuscular blockage agent use, and optimization of ventilation-perfusion mismatch. We emphasis that these effects are not limited to ARDS patients.

並列關鍵字

Prone ventilation ； Non-acute respiratory distress syndrome ； Severe hypoxemia