Construction and application of a diaphragm exercise program in patients with mechanical ventilation in ICU

doi:10.3761/j.issn.0254-1769.2023.03.001

Abstract

Abstract:

Objective To construct a diaphragm exercise program for patients with mechanical ventilation in intensive care unit（ICU），and to explore its clinical application effect. Methods Based on literature analysis and expert meeting，a diaphragm exercise program of ICU patients with mechanical ventilation was constructed. A total of 69 adult patients with mechanical ventilation in our comprehensive ICU from October 2020 to October 2021 were randomly divided into an experimental group（35 cases） and a control group（34 cases）. The control group was given ICU routine rehabilitation nursing care and early activities，and the experimental group was given the diaphragm exercise on the basis of the interventions in the control group. End-inspiratory diaphragm thickness （DTei），end-expiratory diaphragm thickness（DTee），diaphragm thickening fraction（DTF） and diaphragmatic excursion（DE） were evaluated by ultrasound before and 24，48，72 and 120 hours after intervention. The success rate of weaning and the incidence of adverse events were compared and analyzed between the 2 groups. Results Repeated measures ANOVA showed that the time effect and interaction effect of DTei between the 2 groups were statistically significant（P<0.05）；the time effect of DTee in the 2 groups was statistically significant（P<0.05）；the time effect and interaction effect of DTF in the 2 groups were statistically significant（P<0.05）；the time effect and interaction effect of DE in the 2 groups were statistically significant（P<0.05）. The DTei of the experimental group was higher than that of the control group at 120 h after intervention；the DTF of the experimental group was higher than that of the control group at 72 h and 120 h after intervention；the DE of the experimental group was higher than that of the control group at 120 h after intervention；the differences were statistically significant（P<0.05）. The weaning success rate of the experimental group was higher than that of the control group，and the difference was statistically significant（P<0.05）. There were no adverse events such as sudden drop of oxygen saturation，tachycardia or musculoskeletal injury occurred in the 2 groups. Conclusion The diaphragm exercise program is safe and feasible for ICU patients with mechanical ventilation，which can improve diaphragm function，increase the success rate of weaning，and promote the rehabilitation of patients.

Key words: ICU, Mechanical Ventilation, Diaphragm Exercise, Rehabilitation Nursing

摘要：

目的构建ICU机械通气患者膈肌锻炼方案，并探讨其临床应用的效果。方法在文献分析和专家会议的基础上构建ICU机械通气患者膈肌锻炼方案。2020年10月—2021年10月，选取遵义市某三级甲等医院综合ICU的成人机械通气患者69例，随机分为试验组（35例）和对照组（34例）。试验组在常规康复护理及早期活动的基础上接受膈肌锻炼，对照组接受常规康复护理及早期活动。采用超声评估两组干预前和干预后24、48、72、120 h吸气末膈肌厚度、呼气末膈肌厚度、膈肌增厚分数、膈肌移动度；比较两组撤机成功率和不良事件发生率。结果试验组33例、对照组31例完成研究。重复测量方差分析显示，两组吸气末膈肌厚度的时间效应、交互效应具有统计学意义（P<0.05）；两组呼气末膈肌厚度的时间效应具有统计学意义（P<0.005）；两组膈肌增厚分数的时间效应、交互效应具有统计学意义（P<0.05）；两组膈肌移动度的时间效应、交互效应具有统计学意义（P<0.05）。干预后120 h，试验组吸气末膈肌厚度高于对照组，干预后72、120 h，试验组膈肌增厚分数高于对照组，干预后120 h试验组膈肌移动度高于对照组，差异具有统计学意义（P<0.05）。试验组撤机成功率高于对照组，差异具有统计学意义（P<0.05）。两组均未发生血氧饱和度骤降、心动过速、肌肉骨骼损伤等不良事件。结论 ICU机械通气患者膈肌锻炼方案是安全可行的，可改善患者膈肌功能，提高撤机成功率，促进患者康复。

关键词: 重症监护病房, 机械通气, 膈肌锻炼, 康复护理

LIU Xiu, LIU Binbin, QUAN Mingtao, ZHAN Weili, YANG Dengbi, ZHANG Jiaxin. Construction and application of a diaphragm exercise program in patients with mechanical ventilation in ICU[J]. Chinese Journal of Nursing, 2023, 58(3): 261-267.

刘秀, 刘滨滨, 权明桃, 詹炜丽, 杨登碧, 张佳薪. ICU机械通气患者膈肌锻炼方案的构建及应用研究[J]. 中华护理杂志, 2023, 58(3): 261-267.

Figures/Tables 6

Table 1 Diaphragm exercise program of mechanically ventilated patients in ICU

Table 2 Comparison of general data in the 2 groups

Table 3 Comparison of DTei between the 2 groups（mm，$\bar{x}±s$）

Table 4 Comparison of DTee between the 2 groups（mm，$\bar{x}±s$）

Table 5 Comparison of DTF between the 2 groups（%，$\bar{x}±s$）

Table 6 Comparison of DE between the 2 groups（mm，$\bar{x}±s$）

References 22

[1]	Goligher EC, Brochard LJ, Reid WD, et al. Diaphragmatic myotrauma:a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure[J]. Lancet Respir Med, 2019, 7(1):90-98. DOI PMID
[2]	Demoule A, Molinari N, Jung B, et al. Patterns of diaphragm function in critically ill patients receiving prolonged mechanical ventilation:a prospective longitudinal study[J]. Ann Intensive Care, 2016, 6(1):75. DOI URL
[3]	吴月红, 梁红霞, 席芳, 等. 体外膈肌起搏预防无创机械通气患者膈肌功能障碍的效果研究[J]. 中华护理杂志, 2022, 57(9):1029-1034. DOI URL
	Wu YH, Liang HX, Xi F, et al. Effect of external diaphragm pacer on prevention of ventilator-induced diaphragmatic dysfunction in patients with ICU non-invasive ventilation[J]. Chin J Nurs, 2022, 57(9):1029-1034. DOI URL
[4]	黄渝, 王增旭, 龚雨叶, 等. 膈肌锻炼促进肺癌病人肺康复的研究进展[J]. 全科护理, 2022, 20(2):187-191.
	Huang Y, Wang ZX, Gong YY, et al. Research progress of diaphragm exercise in promoting lung rehabilitation of lung cancer patients[J]. Chin Gen Pract Nurs, 2022, 20(2):187-191.
[5]	Nair A, Alaparthi GK, Krishnan S, et al. Comparison of diaphragmatic stretch technique and manual diaphragm release technique on diaphragmatic excursion in chronic obstructive pulmonary disease:a randomized crossover trial[J]. Pulm Med, 2019, 2019:6364376.
[6]	姚叶林, 陈康, 陶金好, 等. 超声引导下对撤机失败儿童进行膈肌手法干预的疗效观察[J]. 中国康复医学杂志, 2020, 35(7):813-819.
	Yao YL, Chen K, Tao JH, et al. The curative effect of diaphragm manipulation under the guidance of ultrasound on children with failure of weaning[J]. Chin J Rehabil Med, 2020, 35(7):813-819.
[7]	Rocha T, Souza H, Brandão DC, et al. The manual diaphragm release technique improves diaphragmatic mobility,inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease:a randomised trial[J]. J Physiother, 2015, 61(4):182-189. DOI URL
[8]	郑刚, 徐前纬, 杨开仁. 膈肌锻炼联合运动训练对脑卒中后疲劳的康复效果研究[J]. 浙江医学, 2019, 41(4):355-358.
	Zheng G, Xu QW, Yang KR. Rehabilitative effect of diaphragm muscle exercise combined with sport training on fatigue after cerebral infarction[J]. Zhejiang Med J, 2019, 41(4):355-358.
[9]	李琳琳, 郝世杰, 王万宏, 等. 膈肌松解技术联合吸气肌训练对脑卒中患者肺功能的影响[J]. 康复学报, 2018, 28(1):19-23.
	Li LL, Hao SJ, Wang WH, et al. Effect observation of diaphragm release technique combined with inspiratory muscle training on pulmonary function of stroke patients[J]. Rehabil Med, 2018, 28(1):19-23. DOI URL
[10]	张小玉, 黄营湘. 六字诀联合膈肌松解技术对脑卒中偏瘫患者肺功能的影响[J]. 中国医学创新, 2020, 17(1):40-43.
	Zhang XY, Huang YX. Effect of six-character formula com-bined with diaphragmatic muscle release technique on pulmonary function in stroke patients with hemiplegia[J]. Med Innov China, 2020, 17(1):40-43.
[11]	刘敏, 王兆, 笪苗, 等. AECOPD机械通气患者膈肌超声监测下吸气肌锻炼研究[J]. 护理学杂志, 2018, 33(19):18-21.
	Liu M, Wang Z, Da M, et al. Ultrasound-guided inspiratory muscle training for mechanically ventilated patients with acute COPD exacerbation[J]. J Nurs Sci, 2018, 33(19):18-21.
[12]	武亮, 郭琪, 胡菱, 等. 中国呼吸重症康复治疗技术专家共识[J]. 中国老年保健医学, 2018, 16(5):3-11.
	Wu L, Guo Q, Hu L, et al. Experts’ consensus on rehabilitation treatment technology of severe respiratory diseases in China[J]. Chin J Geriatr Care, 2018, 16(5):3-11.
[13]	杨玉洁, 刘桂英, 李若祎, 等. ICU机械通气患者吸气肌训练的研究进展[J]. 中国护理管理, 2020, 20(9):1436-1440.
	Yang YJ, Liu GY, Li RY, et al. Research progress of inspira-tory muscle training for intensive care patients with me-chanical ventilation[J]. Chin Nurs Manag, 2020, 20(9):1436-1440.
[14]	Turton P, Alaidarous S, Welters I. A narrative review of di-aphragm ultrasound to predict weaning from mechanical ven-tilation:where are we and where are we heading?[J]. Ultrasound J, 2019, 11(1):2. DOI PMID
[15]	刘晋豫, 王强, 汪晓蜜, 等. 膈肌超声评分预测机械通气撤机的价值探讨[J]. 临床超声医学杂志, 2020, 22(1):38-41.
	Liu JY, Wang Q, Wang XM, et al. Value of diaphragm ultrasound score scale in predicting mechanical ventilator withdrawal[J]. J Clin Ultrasound Med, 2020, 22(1):38-41.
[16]	邵蕾, 汪志方, 王飞飞, 等. 机械通气后大鼠膈肌和比目鱼肌的形态学变化[J]. 中华危重病急救医学, 2017, 29(1):11-15. PMID
	Shao L, Wang ZF, Wang FF, et al. Mechanical ventilation leads to remodeling of diaphragma and soleus in rats[J]. Chin Crit Care Med, 2017, 29(1):11-15. DOI PMID
[17]	Dot I, Pérez-Teran P, Samper MA, et al. Diaphragm dysfunction in mechanically ventilated patients[J]. Arch Bronconeumol, 2017, 53(3):150-156. DOI URL
[18]	姚丽, 杨琳, 杨丽平, 等. 机械通气患者吸气肌训练效果的Meta分析[J]. 中华护理杂志, 2020, 55(1):141-147. DOI URL
	Yao L, Yang L, Yang LP, et al. Inspiratory muscle training in patients with mechanical ventilation:a Meta-analysis[J]. Chin J Nurs, 2020, 55(1):141-147.
[19]	傅晓倩, 陶林花, 陆操, 等. 体外膈肌起搏治疗对颈髓损伤呼吸功能的影响[J]. 中国康复医学杂志, 2022, 37(4):532-534.
	Fu XQ, Tao LH, Lu C, et al. Effect of external diaphragm pacing therapy on respiratory function of cervical spinal cord injury[J]. Chin J Rehabil Med, 2022, 37(4):532-534.
[20]	何远超, 刘玲. 呼吸机相关膈肌功能障碍的主要发病机制[J]. 中华医学杂志, 2019, 99(46):3671-3674.
	He YC, Liu L. Main pathogenesis of ventilator-related diaphragm dysfunction[J]. Natl Med J China, 2019, 99(46):3671-3674.
[21]	伍松柏, 戴瑶, 何峻, 等. 超声测量膈肌增厚分数联合膈肌位移在预测机械通气成功撤机中的价值[J]. 实用医学杂志, 2021, 37(12):1592-1597.
	Wu SB, Dai Y, He J, et al. Predictive value of ultrasonic measurement of diaphragmatic thickening fraction combined with diaphragmatic displacement in weaning success of mechanical ventilation[J]. J Pract Med, 2021, 37(12):1592-1597.
[22]	Magalhães PAF, Camillo CA, Langer D, et al. Weaning failure and respiratory muscle function:what has been done and what can be improved?[J]. Respir Med, 2018, 134:54-61. DOI PMID