B Y T TRNG I HC Y H NI PHM TH TR GIANG ĐáNH GIá CáC YếU Tố TIÊN LƯợNG THấT BạI CủA THÔNG KHí NHÂN TạO KHÔNG XÂM NHậP TRONG ĐợT CấP BệNH PHổI TắC NGHẽN MạN TíNH Chuyờn ngnh: Hi sc cp cu Mó s: CK 62723101 LUN VN BC S CHUYấN KHOA CP II Ngi hng dn khoa hc: PGS.TS NGUYN T ANH H NI - 2015 Li cm n hon thnh lun ny, tụi xin trõn trng cm n: - ng y, Ban Giỏm hiu Trng i hc Y H Ni, Phũng o to Sau i hc Trng i hc Y H Ni - ng y, Ban Giỏm c Bnh vin Bch Mai, khoa Cp cu, phũng K hoch tng hp Bnh vin Bch Mai - ng y, Ban Giỏm c cựng th khoa Cp cu Bnh vin Thanh Nhn ó to mi iu kin thun li giỳp tụi quỏ trỡnh hc cng nh thc hin ti Vi lũng kớnh trng v bit n sõu sc, tụi xin chõn thnh cm n: GS.TS Nguyn Th D - Nguyờn giỏm c Trung tõm Chng c, bnh vin Bch Mai ó dnh thi gian c v cho tụi nhng ý kin quý bỏu hon thnh lun PGS.TS Nguyn t Anh, ch nhim B mụn Hi sc cp cu Trng i hc Y H Ni, trng khoa cp cu A9 bnh vin Bch Mai ó tn tỡnh dy d, giỳp , ch bo tụi nhng kin thc v hng dn tụi vic chn ti nghiờn cu v to iu kin cho tụi c thc hin ti ti khoa Cp cu bnh vin Bch Mai PGS.TS ng Quc Tun, phú ch nhim B mụn Hi sc cp cu Trng i hc Y H Ni, phú trng khoa Hi sc tớch cc bnh vin Bch Mai, ngi thy ó giỳp tụi vic thc hin ti ny Tụi xin chõn thnh cỏm n cỏc Giỏo s, Phú giỏo s, Tin s hi ng khoa hc bo v lun tụt nghip ó dnh nhiu thi gian c v úng gúp cho tụi nhng ý kin quý bỏu nõng cao cht lng lun Tụi xin chõn thnh cm n cỏc thy cụ giỏo b mụn Hi sc cp cu, cỏc bỏc s khoa Cp cu bnh vin Bch Mai ó giỳp tụi hon thin ti ny Tụi xin by by t li cm n chõn thnh n gia ỡnh, bn bố cựng cỏc ng nghip ó dnh cho tụi s quan tõm, khuyn khớch, ng viờn tụi sut quỏ trỡnh hc v nghiờn cu hon thnh lun ny Xin trõn trng cm n! H Ni, ngy 20 thỏng 11 nm 2015 Hc viờn Phm Th Tr Giang LI CAM OAN Tụi xin cam oan ti: ỏnh giỏ cỏc yu t tiờn lng tht bi ca thụng khớ nhõn to khụng xõm nhp t cp bnh phi tc nghn mn tớnh l ti tụi thc hin di s hng dn khoa hc ca PGS.TS Nguyn t Anh v ó c s ng ý ca khoa Cp cu bnh vin Bch Mai, phũng K hoch tng hp bnh vin Bch Mai cho phộp s dng cỏc thụng tin h s bnh ỏn Cỏc s liu nghiờn cu l hon ton trung thc v cha tng c cụng b bt k nghiờn cu no H Ni, ngy 20 thỏng 11 nm 2015 Hc viờn Phm Th Tr Giang DANH MC CH VIT TT CH VIT TT TING VIT BN Bnh nhõn CNHH Chc nng hụ hp HA Huyt ỏp HATB Huyt ỏp trung bỡnh HPQ Hen ph qun SHH Suy hụ hp TKMP Trn khớ mng phi TKNT Thụng khớ nhõn to TKNTKXN Thụng khớ nhõn to khụng xõm nhp TKNTXN Thụng khớ nhõn to xõm nhp CH VIT TT TING ANH A/C Assists/Control APACHE Acute Physiology Chronic Health Evaluation ATS American Thoracic Society BiPAP Bilevel positive airway pressure COPD Chronic obstructive pulmonary disease CPAP Continuous positive airway pressure EIP End Inspiratory Pause EPAP Expiratory Positive Airway Pressure FEV1 Forced Expiratory Volume in second FiO2 Fractional inspired Oxygen FVC Forced Vital Capacity GOLD Global Initative for Chronic Obstructive Lung Disease IPAP Inspiratory Positive Airway Pressure PEEP Positive End-Expiratory Pressure PSV Pressure Support Ventilation SAPS Simplified Acute Physiology Score SIMV Synchronize Intermitted Mandatory Ventilation MC LC T VN Chng 1: TNG QUAN 1.1 i cng v COPD 1.1.1 nh ngha 1.1.2 Nguyờn nhõn v c ch bnh sinh 1.1.3 Chn oỏn COPD 12 1.2 iu tr t cp COPD 16 1.2.1 Mc ớch 16 1.2.2 Cỏc bin phỏp c th 16 1.3 Thụng khớ nhõn to khụng xõm nhp t cp COPD 17 1.3.1 Nguyờn lớ v k thut 17 1.3.2 Cỏc phng thc TKNTKXN ỏp lc dng 17 1.3.3 Ch nh v chng ch nh thụng khớ nhõn to khụng xõm nhp 20 1.3.4 Cỏch tin hnh thụng khớ nhõn to khụng xõm nhp 21 1.3.5 u nhc im ca thụng khớ nhõn to khụng xõm nhp so vi thụng khớ nhõn to xõm nhp 22 1.3.6 Tỏc dng ph v bin chng thụng khớ nhõn to khụng xõm nhp 23 1.4 Thụng khớ nhõn to khụng xõm nhp t cp COPD 24 1.4.1 Hiu qu t cỏc nghiờn cu 24 1.4.2 Tht bi thụng khớ nhõn to khụng xõm nhp iu tr t cp COPD v cỏc yu t d bỏo 24 Chng 2: I TNG V PHNG PHP NGHIấN CU 29 2.1 i tng nghiờn cu 29 2.2 Phng phỏp nghiờn cu 30 2.3 Tiờu chun ỏnh giỏ kt qu iu tr 30 2.4 Cỏc bc tin hnh nghiờn cu 31 2.5 Phng tin nghiờn cu 35 2.6 Phõn tớch s liu 35 Chng 3: KT QU NGHIấN CU 36 3.1 c im lõm sng cn lõm sng bnh nhõn suy hụ hp t cp bnh phi t c ngh n mn tớnh c thụng khớ nhõn to khụng xõm nhõp 36 3.1.1 M t s c im chung ca i tng nghiờn cu 36 3.1.2 Cỏc c im lõm sng cn lõm sng 37 3.2 ỏnh giỏ cỏc yu t tiờn lng tht bi ca thụng khớ nhõn to khụng xõm nhp 44 3.3 Cỏc yu t liờn quan n kt qu TKNTKXN 51 Chng 4: BN LUN 54 4.1 c im lõm sng cn lõm sng bnh nhõn suy hụ hp cp t cp bnh phi t c ngh n mn tớnh c TKNTKXN 54 4.1.1 Tui v gii 54 4.1.2 Bnh kốm theo 55 4.1.3 Yu t bnh nguyờn 56 4.1.4 Yu t kh i phỏt t cp 57 4.1.5 Tỡnh trng dinh dng 58 4.1.6 Cỏc thang im tiờn lng 59 4.1.7 Cỏc thụng s cn lõm sng 61 4.1.8 Phng thc th mỏy 62 4.2 ỏnh giỏ cỏc yu t tiờn lng tht bi ca TKNTKXN bnh nhõn suy hụ hp cp t cp bnh phi t c ngh n mn tớnh 63 4.2.1 Din bin trc vo vin thi gian nm khoa cp cu 63 4.2.2 Bin chng quỏ trỡnh TKNTKXN 64 4.2.3 M t s yu t liờn quan n tiờn lng tht bi ca TKNTKXN 65 KT LUN 70 KIN NGH 72 TI LIU THAM KHO PH LC DANH MC BNG Bng 3.1 Phõn b bnh nhõn theo nh m tui 36 Bng 3.2 Cỏc yu t bnh nguyờn 37 Bng 3.3 T l cỏc bnh l kốm theo COPD 38 Bng 3.4 Cỏc triu chng lõm sng 39 Bng 3.5 Cỏc thụng s v dinh dng 40 Bng 3.6 Tỡnh trng dinh dng ca BN theo ch s Albumin nhúm thnh cụng, tht bi 40 Bng 3.7 Cỏc nguyờn nhõn kh i phỏt t cp mt b 41 Bng 3.8 c im chung v khớ mỏu trung tõm hụ hp 41 Bng 3.9 Cỏc thang im tiờn lng l c vo vin 42 Bng 3.10 Kt qu iu tr chung 42 Bng 3.11 Cỏc bin chng sau thụng khớ nhõn to khụng xõm nhp 43 Bng 3.12 Cỏc ch s ỏnh giỏ sau gi Bng 3.13 Giỏ tr ca cỏc thụng s sau gi tiờn lng tht bi sau nh m bnh nhõn 44 TKKXN 45 Bng 3.14 ỏp ng ca bnh nhõn trc v sau can thip TKNTKXN 47 Bng 3.15 Cỏc ch s ỏnh giỏ 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York, NY: McGraw-Hill Co, 427-453 86 Anders Bastiansen (2014), Predicting Failure of Non-invasive Ventilation in a Mixed Population, Journal of Anesthesia Clinical Research 5(1), 6155-6148 BNH N NGHIấN CU I HNH CHNH Mó bnh ỏn: S bnh ỏn: H tờn BN: Tui: Gii: Nam N a ch: Ngh nghip: Ngy vo vin: Ngy vin: S ngy nm vin: II TIN S Yu t nguy c H t thuc: Tip x c vi khớ c hi: Gia ỡnh c ngi b COPD: Triu ch ng bnh COPD Ho kộo di: Cú Khụng Khc m kộo di: C Khụng Kh th : Khi ngh ngi Khi g ng sc Chn oỏn COPD: C Khụng iu tr trỡ: C Khụng Trung bỡnh nhp vin:ln/nm ó c th mỏy: C Khụng Cỏc bnh lớ khỏc: Bnh tim: Tng HA: Tiu ng: Hen PQ: Gión ph qun Tõm ph mn ao III TRIU CHNG LM SNG Lớ v o vin Kh th Khc m tng St Ho Din bin trc v o vin Thi gian t kh i phỏt-vo vin: Nguyờn nhõn mt bự Cú Khụng Nhim tr ng hụ hp Suy tim Ri lon nc in gii Khỏc C nng Ho tng: C Khụng Khc m tng: C Khụng Mu s c m: Tr ng Vng S lng m tng: C Khụng Kh th : Tng Phi ngi dy m m Ton thõn St i n i: Ph Tớm tỏi Cõu di Gan to Cõu ng n Vó m hụi Tng t Ng n tay d i trng Th c th : í thc: Tnh - Kớch thớch ng ngc hỡnh th ng: - Co kộo c hụ hp ph: - Ran rớt, ran ngỏy: - Ran n m: m - Nghe phi im l ng: Ting tim bnh lớ: Giai on COPD: III IV Mc suy hụ hp: - Nhp th : SpO2: - Tớm: Rỳt lừm: Triu chng khỏc: IV Cn lõm s ng: Khớ mỏu: Gi H 1-4h H 4-12 H 12-24 H 24-48 >48h pH PaCO2 PaO2 HCO3 CTM: BC: NEU: HC: Hb: HCT: SHM: Ure: Creatinin: Glucose: Na: K: Ca: Protein: Albumin: CRP: Procalcitonin: FEV1: FEV1/FVC: Cy mỏu: oi vi khun: V KT QU Kt u TKNTKXN: Thnh cụng Tht bi Hp tỏc th mỏy: Tt Trung bỡnh Khụng Thi gian iu tr TKKXN: Nguyờn nhõn tht bi: Co th t PQ n ng Ho khc yu tng tit m Khụng chu c m t n Huyt ng khụng n nh Ri lon nhp tim Nguyờn nhõn khỏc Tỏc dng ph v bin ch ng ca TKNTKXN Bin chng ca TKNTKXN: Chng hi d dy Hoi t gc mi Trn khớ mng phi S c dch v oột ming Rũ khớ m t n Xung huyt kt mc da tip x c Bin chng khỏc: Viờm phi Suy tim Suy thn R in gii Sc nhim khun Suy a tng XHTH Khỏc: Thay i v ch s sinh tn Trc Sau 1h Sau 4h Sau 24h Mch HA TT HA TTr Nhp th SpO2 S ng y iu tr: S ngy iu tr chung: S ngy iu tr ti khoa cp cu ICU: Kt u iu tr chung: Ra vin Chuyn tuyn di Sau 48h Kt thỳc Xin v cht T vong Thay i v khớ mỏu ng mch Trc Sau 1h Sau 4h Sau 24h Sau 48h Kt th c pH PaCO2 PaO2 HCO3 PaCO2/FiO2 Cỏc thụng s mỏy th Trc Sau 1h Sau 4h Sau 24h Sau 48h Kt th c IPAP EPAP I/E FiO2 TS th mỏy Mode: CPAP BiPAP M t n: Mi Ming C hai PEEP/CPAP/EPAP: PS/IPAP: FiO2: PH LC Thang im SAPS II [86] Thụng s Hỡnh thc nhp vin Tui Nhit Huyt ỏp tõm thu Nhp tim Nc tiu 24h Chi tit i m Phu thut theo h n N i khoa Phu thut khụng theo h n