外科重症患者使用不同脫離呼吸器模式的呼吸參數、能量消耗與三大營養素及能量攝取之相關性

The association of ventilator parameters, energy expenditure and dietary energy and macronutrients intakes using different modes of ventilator weaning in patients with surgical intensive care unit

陳家榛(Chia-Chen Chen)

指導教授 ： 黃詩茜

中山醫學大學/健康管理學院/營養學系/碩士(2020年)

https://doi.org/10.6834/csmu202000250

摘要

使用呼吸器之重症患者之生理狀況、呼吸肌肉已能克服自行呼吸的需求時，會嘗試進行脫離呼吸器，但臨床上約有20-30%患者在初步嘗試脫離呼吸器會失敗，這可能與能量攝取不足與營養不良有關。因此，本研究目的為了解不同呼吸器脫離模式的耗能情形，以得知重症患者在脫離呼吸器的進程中，是否依不同呼吸器脫離模式給予患者足夠營養需求，以協助患者能成功脫離呼吸器。本研究於2017年10月至2019年5月期間，自臺中榮民總醫院外科加護病房收集62位外科重症患者，記錄患者之醫療紀錄、體位測量、生命徵象與脫離呼吸器進程。當患者進行呼吸器脫離時，依隨機方式先後進行兩種呼吸器支持模式測定：壓力支持模式 (pressure support ventilation; PS，PSV=12cmH2O) 與同步間歇強制通氣模式 (synchronized intermittent mandatory ventilation＋pressure support; SIMV＋PS，RR:6 bpm；PSV=12cmH2O) ，兩種模式皆持續進行監測一小時，模式轉換中需有一小時改回強制通氣模式，以避免干擾兩種模式測量之數據。利用氧氣濃度及二氧化碳分析儀測量之，並紀錄每分鐘通氣量、呼吸次數等相關呼吸參數，再將測得呼吸參數帶入Weir Equation計算能量消耗，進而比較患者在兩種模式下的能量消耗。患者身體質量指數為23.6 ± 4.7 kg/m2，屬正常體位，APACHE Ⅱ score為22.2 ± 5.4，脫離呼吸器天數為9.7 ± 7.1天。患者在SIMV＋PS模式的能量消耗顯著高於PS模式 (1540.2 ± 722.9 kcal vs 1367.8 ± 648.7 kcal，p＜0.05) ，在VO2、VCO2和RQ方面皆有顯著差異。而脫離呼吸器當天和脫離呼吸器前三天之平均熱量皆未達建議熱量1606 kcal且低於實際消耗熱量(1580.5 ± 726.2 vs 1394.8 ± 663.3, p <0.05)。臨床常見虛弱無力的患者是無法直接使用壓力支持模式來進行脫離，而必須採用循序漸進的方式，先使用同步間歇強制通氣模式開始進行訓練起。當外科重症患者進行同步間歇強制通氣模式時，更需積極監控患者脫離呼吸器前三天能量攝取情形；若是使用壓力支持模式，則需留意脫離呼吸器當天之蛋白質，以利於患者成功脫離呼吸器。SIMV+PS與PS兩種模式的脫離呼吸器當天和脫離呼吸器前三天之平均熱量的MV與Cdyn與三大營養素攝取狀況也有顯著相關性結果。此研究結果也代表著營養攝取對呼吸系統的重要性。

關鍵字

外科重症患者 ； 呼吸器 ； 自主性呼吸試驗 ； 脫離呼吸器參數 ； 能量消耗

並列摘要

Extubation is a necessary process to help critical patient wean from the ventilator once the breathing was improved. However, we observed that about 20-30% of patients will fail in their initial attempts to extubate, which may be related to the insufficient calorie intake and malnutrition. Therefore, the purpose of this study is to understand the energy consumption of extubation in different types of mode of mechanical ventilation, and we can provide adequate nutrition support based on different modes of mechanical ventilation to help critical patient wean successfully. This study collected 62 critically patients from the Surgery Intensive Care Unit of Taichung Veterans General Hospital from October 2017 to May 2019. We recorded their medical records, anthropometric data, vital signs, and the process of extubation. When the patient is working on detaching from the ventilator, we will measure by two types of ventilator mode randomly. One is PS mode (pressure support ventilation, PSV = 12 cm H2O), and another one is SIMV+PS mode (synchronized intermittent mandatory ventilation + pressure support; SIMV) + PS, RR: 6 bpm; PSV = 12 cm H2O). We will continue to monitor for one hour during the process of extubation, and it will take one hour to change back to assist control ventilation mode during the mode conversion to avoid interference with the data measured by the two modes. We used the oxygen analyzer and ETCO2 analyzer to measure the breathing, and record the data of FIO2, FEO2, ETCO2, the breaths per minute and other parameters from the ventilator. We used the Weir Equation to calculate the energy consumption, and compared the energy consumption in these two modes. The average age of the subjects was 68.0 ± 15.3 years old, the body mass index was 23.6 ± 4.7 kg/m2, and they were in regular body type. The average APACHE II score was 22.2 ± 5.4, and the number of days on the ventilator was 9.7 ± 7.1 days. The energy consumption of the patient in the SIMV + PS mode was significantly higher than that in the PS mode (1540.2 ± 722.9 vs 1367.8 ± 648.7 kcal, p <0.05). The average calories on the day of weaning from the ventilator and the three days before the weaning of the ventilator did not reach the recommended calories of 1606 kcal and were lower than the actual calories consumed (1580.5 ± 726.2 vs 1394.8 ± 663.3, p <0.05).We can start with synchronized intermittent mandatory ventilation mode on these patients are unable to use pressure support mode for weaning plan in the beginning of training. We could provide higher calorie than the pressure support mode when the surgical critically ill patients use the synchronized intermittent forced ventilation mode. This change might be possible to shorten the weaning process. The MV and Cdyn of the average calories on the day of extubation and the average of three days before extubation in the two modes of SIMV+PS and PS have a significant correlation with the intake of the three major nutrients. The results of this study also represent the importance of nutritional intake to the respiratory system.

並列關鍵字

surgical critically ill patients ； ventilator ； spontaneous breathing test ； weaning parameters ； energy expenditure

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