Lytra Elena, Kokkoris Stelios, Poularas Ioannis, Filippiadis Dimitrios, Cokkinos Demosthenes, Exarhos Dimitrios, Zakynthinos Spyros, Routsi Christina
1st Department of Intensive Care, Medical School, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.
Radiology Department, Evangelismos Hospital, Athens, Greece.
J Intensive Med. 2024 Jan 4;4(2):202-208. doi: 10.1016/j.jointm.2023.11.008. eCollection 2024 Apr.
Compared to conventional oxygen devices, high-flow oxygen treatment (HFOT) through the nasal cannulae has demonstrated clinical benefits. Limited data exist on whether such effects are also present in HFOT through tracheostomy. Hence, we aimed to examine the short-term effects of HFOT through tracheostomy on diaphragmatic function and respiratory parameters in tracheostomized patients on prolonged mechanical ventilation.
A randomized, crossover, physiological study was conducted in our ICU between December 2020 and April 2021, in patients with tracheostomy and prolonged mechanical ventilation. The patients underwent a 30-min spontaneous breathing trial (SBT) and received oxygen either via T-piece or by HFOT through tracheostomy, followed by a washout period of 15-min breathing through the T-piece and receipt of 30-min oxygen with the other modality in a randomized crossover manner. At the start and end of each session, blood gasses, breathing frequency (f), and tidal volume (V) via a Wright's spirometer were measured, along with diaphragm ultrasonography including diaphragm excursion and diaphragmatic thickening fraction, which expressed the inspiratory muscle effort.
Eleven patients were enrolled in whom 19 sessions were uneventfully completed; eight patients were studied twice on two different days with alternate sessions; and three patients were studied once. Patients were randomly assigned to start the SBT with a T-piece (=10 sessions) or with HFOT (=9 sessions). With HFOT, V and minute ventilation (V) significantly increased during SBT (from [465±119] mL to [549±134] mL, <0.001 and from [12.4±4.3] L/min to [13.1±4.2] L/min, <0.05, respectively), but they did not change significantly during SBT with T-piece (from [495±132] mL to [461±123] mL and from [12.8±4.4] mL to [12.0±4.4] mL, respectively); f/V decreased during HFOT (from [64±31] breaths/(min∙L) to [49±24] breaths/(min∙L), <0.001), but it did not change significantly during SBT with T-piece (from [59±28] breaths/(min∙L) to [64±33] breaths/(min∙L)); partial pressure of arterial oxygen increased during HFOT (from [99±39] mmHg to [132±48] mmHg, <0.001), but it decreased during SBT with T-piece (from [124±50] mmHg to [83±22] mmHg, <0.01). In addition, with HFOT, diaphragmatic excursion increased (from [12.9±3.3] mm to [15.7±4.4] mm, <0.001), but it did not change significantly during SBT with T-piece (from [13.4±3.3] mm to [13.6±3.3] mm). The diaphragmatic thickening fraction did not change during SBT either with T-piece or with HFOT.
In patients with prolonged mechanical ventilation, HFOT through tracheostomy compared with T-piece improves ventilation, pattern of breathing, and oxygenation without increasing the inspiratory muscle effort.
Clinicaltrials.gov ldentifer: NCT04758910.
与传统吸氧装置相比，经鼻高流量氧疗（HFOT）已显示出临床益处。关于经气管切开的高流量氧疗是否也有同样效果的数据有限。因此，我们旨在研究经气管切开的高流量氧疗对长期机械通气的气管切开患者膈肌功能和呼吸参数的短期影响。
2020年12月至2021年4月在我们的重症监护病房对气管切开且长期机械通气的患者进行了一项随机、交叉、生理学研究。患者进行30分钟的自主呼吸试验（SBT），通过T形管或经气管切开的高流量氧疗吸氧，随后有15分钟的洗脱期，期间通过T形管呼吸，然后以随机交叉的方式接受另一种方式的30分钟吸氧。在每个阶段开始和结束时，测量血气、呼吸频率（f）和通过赖特肺活量计测得的潮气量（V），以及膈肌超声检查，包括膈肌移动度和膈肌增厚分数，后者表示吸气肌力量。
纳入11例患者，顺利完成19个阶段；8例患者在两个不同日期进行了两次研究，交替进行不同阶段；3例患者进行了一次研究。患者被随机分配以T形管（=10个阶段）或高流量氧疗（=9个阶段）开始自主呼吸试验。采用高流量氧疗时，自主呼吸试验期间潮气量（V）和分钟通气量（V）显著增加（分别从[465±119]mL增至[549±134]mL，P<0.001；从[12.4±4.3]L/min增至[13.1±4.2]L/min，P<0.05），但采用T形管进行自主呼吸试验时无显著变化（分别从[495±132]mL降至[461±123]mL，从[12.8±4.4]L/min降至[12.0±4.4]L/min）；高流量氧疗期间f/V降低（从[64±31]次/（分钟·升）降至[49±24]次/（分钟·升），P<0.001），但采用T形管进行自主呼吸试验时无显著变化（从[59±28]次/（分钟·升）增至[64±33]次/（分钟·升））；高流量氧疗期间动脉血氧分压升高（从[99±39]mmHg升至[132±48]mmHg，P<0.001），但采用T形管进行自主呼吸试验时降低（从[124±50]mmHg降至[83±22]mmHg，P<0.01）。此外，采用高流量氧疗时，膈肌移动度增加（从[12.9±3.3]mm增至[15.7±4.4]mm，P<0.001），但采用T形管进行自主呼吸试验时无显著变化（从[13.4±3.3]mm增至[13.6±3.3]mm）。采用T形管或高流量氧疗进行自主呼吸试验期间，膈肌增厚分数均无变化。
在长期机械通气的患者中，与T形管相比，经气管切开的高流量氧疗可改善通气、呼吸模式和氧合，而不增加吸气肌力量。
Clinicaltrials.gov标识符：NCT04758910。
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