Branson Richard D
Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA.
Respir Care. 2007 Oct;52(10):1328-42; discussion 1342-7.
Secretion management in the mechanically ventilated patient includes routine methods for maintaining mucociliary function, as well as techniques for secretion removal. Humidification, mobilization of the patient, and airway suctioning are all routine procedures for managing secretions in the ventilated patient. Early ambulation of the post-surgical patient and routine turning of the ventilated patient are common secretion-management techniques that have little supporting evidence of efficacy. Humidification is a standard of care and a requisite for secretion management. Both active and passive humidification can be used. The humidifier selected and the level of humidification required depend on the patient's condition and the expected duration of intubation. In patients with thick, copious secretions, heated humidification is superior to a heat and moisture exchanger. Airway suctioning is the most important secretion removal technique. Open-circuit and closed-circuit suctioning have similar efficacy. Instilling saline prior to suctioning, to thin the secretions or stimulate a cough, is not supported by the literature. Adequate humidification and as-needed suctioning are the foundation of secretion management in the mechanically ventilated patient. Intermittent therapy for secretion removal includes techniques either to simulate a cough, to mechanically loosen secretions, or both. Patient positioning for secretion drainage is also widely used. Percussion and postural drainage have been widely employed for mechanically ventilated patients but have not been shown to reduce ventilator-associated pneumonia or atelectasis. Manual hyperinflation and insufflation-exsufflation, which attempt to improve secretion removal by simulating a cough, have been described in mechanically ventilated patients, but neither has been studied sufficiently to support routine use. Continuous lateral rotation with a specialized bed reduces atelectasis in some patients, but has not been shown to improve secretion removal. Intrapulmonary percussive ventilation combines percussion with hyperinflation and a simulated cough, but the evidence for intrapulmonary percussive ventilation in mechanically ventilated patients is insufficient to support routine use. Secretion management in the mechanically ventilated patient consists of appropriate humidification and as-needed airway suctioning. Intermittent techniques may play a role when secretion retention persists despite adequate humidification and suctioning. The technique selected should remedy the suspected etiology of the secretion retention (eg, insufflation-exsufflation for impaired cough). Further research into secretion management in the mechanically ventilated patient is needed.
机械通气患者的分泌物管理包括维持黏液纤毛功能的常规方法以及清除分泌物的技术。湿化、患者活动和气道吸引都是管理通气患者分泌物的常规操作。术后患者早期下床活动和通气患者常规翻身是常见的分泌物管理技术，但几乎没有疗效方面的支持证据。湿化是护理标准，也是分泌物管理的必要条件。可使用主动湿化和被动湿化。所选的湿化器和所需的湿化水平取决于患者的病情和预期的插管持续时间。对于分泌物浓稠且量大的患者，加热湿化优于热湿交换器。气道吸引是最重要的分泌物清除技术。开路吸引和闭路吸引的效果相似。文献不支持在吸引前滴注生理盐水以稀释分泌物或刺激咳嗽。充分湿化和按需吸引是机械通气患者分泌物管理的基础。间歇性分泌物清除治疗包括模拟咳嗽、机械性松解分泌物或两者兼具的技术。用于分泌物引流的患者体位摆放也被广泛使用。叩击和体位引流已广泛应用于机械通气患者，但未显示可降低呼吸机相关性肺炎或肺不张的发生率。手动过度充气和吹入 - 呼出法试图通过模拟咳嗽来改善分泌物清除，已在机械通气患者中有所描述，但两者都未得到充分研究以支持常规使用。使用专门的床进行持续侧方旋转可减少部分患者的肺不张，但未显示可改善分泌物清除。肺内叩击通气将叩击与过度充气和模拟咳嗽相结合，但机械通气患者肺内叩击通气的证据不足以支持常规使用。机械通气患者的分泌物管理包括适当湿化和按需气道吸引。当尽管进行了充分湿化和吸引但仍存在分泌物潴留时，间歇性技术可能会发挥作用。所选技术应纠正分泌物潴留的可疑病因（例如，对于咳嗽功能受损者采用吹入 - 呼出法）。需要对机械通气患者的分泌物管理进行进一步研究。
