探讨侧卧位与半卧位对脑卒中合并肺炎、呼吸衰竭患者预后的影响。

选择2015年1月至2017年7月哈尔滨医科大学附属第一医院重症医学科收治的因脑卒中合并肺炎、呼吸衰竭需要有创机械通气的患者68例，分为侧卧位组（37例）和半卧位组（31例）。记录两组患者的年龄、性别比、急性病生理学和长期健康评价（APACHE）Ⅱ评分、脑卒中类型等一般资料；比较两组患者机械通气期间的痰液量、氧合指数、临床病死率、脱呼吸机成功率、机械通气时间、ICU住院天数以及侧卧位组患者侧卧位前后心率和平均动脉压；采用Logistic回归分析影响脑卒中合并肺炎、呼吸衰竭患者预后的相关因素。

机械通气第3、5天时，侧卧位组患者的痰液量分别为（41 ± 18）、（35 ± 16）mL，半卧位组患者的痰液量分别为（66 ± 30）、（57 ± 29）mL，两组比较，差异均有统计学意义（t=4.179、2.776，P均< 0.05）；机械通气第5天时，侧卧位组患者的氧合指数较半卧位组显著升高[（288 ± 43）mmHg vs.（254 ± 32）mmHg；t=2.802，P=0.008]。侧卧位组患者侧卧位前5 min和侧卧位后5、15 min的心率分别为（92 ± 16）、（100 ± 17）、（96 ± 17）次/min，平均动脉压分别为（109 ± 12）、（115 ± 11）、（112 ± 11）mmHg，结果显示，侧卧位后5、15 min患者心率及平均动脉压均较侧卧位前5 min明显升高（P均<0.001）。两组患者机械通气时间比较，侧卧位组患者较半卧位组显著降低[4（4，7）d vs. 6（5，10）d，χ²=2.601，P=0.009]。将体位、性别、年龄、APACHEⅡ评分和脑卒中类型纳入Logistic回归分析，发现年龄[OR=0.921，95%CI（0.860，0.985），P=0.017]是脑卒中合并肺炎、呼吸衰竭患者预后的保护因素，APACHEⅡ评分[OR=1.357，95%CI（1.162，1.584），P<0.001]是脑卒中合并肺炎、呼吸衰竭患者预后的危险因素。

侧卧位可以明显减少脑卒中合并肺炎、呼吸衰竭患者每日痰液量，改善氧合指数，缩短机械通气时间，但对于患者病死率无影响。

To explore the effect of lateral and semi-recumbent positions on the prognosis of stroke patients with pneumonia and respiratory failure.

A total of 68 stroke patients with pneumonia and respiratory failure requiring invasive mechanical ventilation were selected from January 2015 to July 2017 in the Department of Intensive Care Unit of First Affiliated Hospital of Harbin Medical University, who were divided into the lateral position group (37 cases) and semi-recumbent group (31 cases). The age, sex ratio, acute physiology and chronic health evaluation (APACHE) Ⅱ score, stroke type and other general data were recorded in both groups. The sputum volume, oxygenation index, clinical mortality, success rate of deventilator, duration of mechanical ventilation, ICU length of hospital stay between the two groups during mechanical ventilation, as well as the heart rate and mean arterial pressure before and after lateral position in the lateral position group, were compared. Prognostic factors of stroke patients with pneumonia and respiratory failure were analyzed by Logistic regression.

On the 3rd and 5th days of mechanical ventilation, the sputum volume was (41 ± 18) and (35 ± 16) mL for patients in the lateral position group and (66 ± 30) and (57 ± 29) mL for patients in the semi-recumbent position group, respectively. The differences between the two groups were both statistically significant (t=4.179, 2.776; all P < 0.05). On the 5th day of mechanical ventilation, the oxygenation index of patients was significantly higher in the lateral position group than in semi-recumbent position group [(288+43) mmHg vs. (254+32) mmHg; t=2.802, P=0.008]. The heart rates 5 min before and 5 min and 15 min after lateral position in the lateral position group were (92 ± 16), (100 ± 17) and (96 ± 17) times/min, and the mean arterial pressure were (109 ±12), (115 ± 11) and (112 ±11) mmHg, respectively. The results showed that the heart rate and mean arterial pressure were significantly higher in the 5 min and 15 min after lateral position than in the 5 min before lateral position (all P<0.001). The duration of mechanical ventilation in the lateral position group was significantly lower than that in the semi-recumbent position group [4 (4, 7) d vs. 6 (5, 10) d; χ²=2.601, P=0.009]. The position, sex, age, APACHEⅡscore and stroke type were included in Logistic regression analysis. It found that age [OR=0.921, 95%CI (0.860, 0.985), P=0.017] was a protective factor for prognosis in stroke patients with pneumonia and respiratory failure, and the APACHEⅡ score [OR=1.357, 95%CI (1.162, 1.584), P<0.001] was a risk factor.

The lateral position can significantly reduce the amount of sputum per day, improve the oxygenation index and shorten mechanical ventilation time in stroke patients with pneumonia and respiratory failure, but it has no effect on the mortality of patients.