Nurse-Led Diaphragm-Guided Weaning Protocol Optimizing Sequential Oxygen Therapy After Extubation in High-Risk Mechanically Ventilated Patients: A Randomized Controlled Trial

作者：董钰源，赵延波，杨会梅，王启萍，邓冰^*

十堰市人民医院（湖北医药学院附属人民医院）急诊科湖北十堰

^*通信作者：邓冰；单位：十堰市人民医院（湖北医药学院附属人民医院）急诊科湖北十堰

精准护理研究, 2025, 3(1), 5-10;

提交日期 : 2025年08月27日丨录用日期 : 2025年09月28日

课题资助：2024年十堰市科研引导性项目（编号：24Y115）

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摘要：
目的：探讨由护士主导，基于自主呼吸试验（SBT）联合膈肌超声（DUS）早期识别撤机高风险患者，并制定个体化拔管后序贯氧疗方案的有效性与安全性，为优化撤机流程、改善患者预后提供循证护理依据。方法：采用前瞻性随机对照研究设计。选取2024年1月至2024年9月在ICU接受有创机械通气、拟行撤机拔管的患者。通过SBT初步筛查撤机潜力，并联合DUS评估膈肌功能：膈肌移动度（DE）、膈肌收缩速度（DCV）。将符合纳入标准且经评估为撤机高风险（如DE基线值偏低或改善不佳、DCV减慢等）的100例患者，按随机数字表法分为干预组（n=50）和对照组（n=50）。对照组拔管后接受常规氧疗支持方案（根据医嘱调整鼻导管/面罩吸氧，必要时按标准流程启动无创通气）。干预组则由研究护士团队主导实施膈肌导向的序贯氧疗方案：拔管后立即使用经鼻高流量湿化氧疗（HFNC），根据实时血气分析、SpO2及患者舒适度，精准调节氧流量（初始35-60 L/min）、氧浓度（FiO2 35%-60%）、气体温度（31-37℃）和湿度；设定严格转换标准（如氧合恶化、呼吸窘迫），必要时无缝切换至无创正压通气（NIV，迈瑞无创呼吸机），参数（EPAP/IPAP，FiO2）由护士依据膈肌保护策略进行个体化设置。所有患者均接受标准化基础治疗（抗感染、营养支持等）。比较两组患者拔管后24小时、48小时的血气分析指标（PaO2, PaCO2）、膈肌功能指标（DE, DCV）、撤机相关不良事件发生率（再插管、高碳酸血症、呼吸窘迫、误吸、谵妄、鼻面部损伤等）、机械通气总时间、ICU住院时间及总住院时间。结果：两组患者基线资料均衡可比（P>0.05）。拔管后24小时，干预组PaO2显著高于对照组（75.44±4.24 mmHg vs. 70.29±4.24 mmHg, P<0.05），PaCO2显著低于对照组（41.29±6.86 mmHg vs. 55.26±5.02 mmHg, P<0.05）。干预组膈肌移动度（DE）显著优于对照组（12.87±2.21 mm vs. 9.97±2.87 mm, P<0.001）。干预组总体不良事件发生率低于对照组（14.0% vs. 20.0%），虽差异未达统计学意义（P>0.05），但再插管率（4.0% vs. 6.0%）与谵妄发生率（2.0% vs. 4.0%）呈现降低趋势。干预组机械通气总时间显著短于对照组（4.32±2.42 d vs. 5.66±3.83 d, P<0.05），ICU住院时间显著短于对照组（中位数 6.56 d vs. 7.73 d, P<0.05），总住院时间亦短于对照组（中位数 26.92 d vs. 27.68 d, P<0.05）。结论；护士主导的、基于SBT联合膈肌超声早期识别撤机高风险患者并实施的膈肌导向序贯氧疗方案，能有效改善患者拔管后的氧合状态与通气效率，促进膈肌功能恢复，显著缩短机械通气时间及ICU住院时间，并展现出降低撤机相关不良事件发生率的潜力。该方案整合了客观的生理学评估（DUS）与精准的呼吸支持技术（HFNC/NIV），体现了重症护理在呼吸治疗中的核心价值，为高风险患者撤机拔管后的呼吸管理提供了优化路径，具有重要的临床推广意义。

关键词：膈肌超声；自主呼吸试验；撤机高风险；序贯氧疗；经鼻高流量氧疗；重症护理

Abstract:
Objective: To evaluate the efficacy and safety of a nurse-led diaphragm-guided weaning protocol (NLDGP) integrating spontaneous breathing trial (SBT) and diaphragm ultrasound (DUS) for sequential oxygen therapy in high-risk patients after extubation. Methods: In this single-center RCT, 100 high-risk patients (identified by DUS criteria: diaphragmatic excursion [DE] <10mm or diaphragmatic thickening fraction <20%) were randomized to intervention (n=50) or control (n=50). The intervention group received NLDGP-protocolized sequential oxygen therapy (HFNC → NIV transitioned by nurses based on predefined criteria), while controls received conventional oxygen therapy. Primary outcomes included blood gas parameters (PaO₂/PaCO₂), DE, and ventilation duration. Results: At 24h post-extubation, the intervention group showed significantly higher PaO₂ (75.44±4.24 vs 70.29±4.24 mmHg, P<0.05) and lower PaCO₂ (41.29±6.86 vs 55.26±5.02 mmHg, P<0.05). Improved DE was observed in the intervention group (12.87±2.21 vs 9.97±2.87 mm, P<0.001). Total mechanical ventilation time (4.32±2.42 vs 5.66±3.83 days, P<0.05) and ICU stay (median 6.56 vs 7.73 days, P<0.05) were significantly reduced. Conclusion: NLDGP enhances oxygenation, promotes diaphragmatic recovery, and shortens ventilator dependence in high-risk patients, demonstrating the pivotal role of nurses in advanced weaning management.

Keywords: Diaphragmatic ultrasonography；Spontaneous breathing trial；High-risk weaning；Sequential oxygen therapy；Nurse-led protocol；Critical care nursing

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