序贯侧卧位管理对慢性创面合并肺部并发症患者效果的前瞻性RCT

尹希; 常菲; 邵丽佳; 曹洁; 沙薇

doi:10.3760/cma.j.cn501225-20250222-00080

序贯侧卧位管理对慢性创面合并肺部并发症患者效果的前瞻性RCT

doi: 10.3760/cma.j.cn501225-20250222-00080

尹希¹,
常菲¹,
邵丽佳¹,
曹洁¹,
沙薇^2, ,

1.
苏州大学附属张家港医院烧伤整形（修复重建）科,苏州　215600
2.
苏州大学附属张家港医院护理部,苏州　215600

基金项目:

张家港市卫生青年科技项目 ZJGQNKJ202203

张家港市科技计划项目 ZKYL2407

详细信息

通讯作者:
沙薇,Email：592505793@qq.com

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出版历程
- 收稿日期: 2025-02-22

Efficacy of sequential lateral position management in patients with chronic wounds and pulmonary complications: a prospective RCT

Yin Xi¹,
Chang Fei¹,
Shao Lijia¹,
Cao Jie¹,
Sha Wei^{2
, ,}

1.
Department of Burns and Plastic (Reconstructive) Surgery, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou 215600, China
2.
Department of Nursing, Zhangjiagang Hospital Affiliated to Soochow University, Suzhou 215600, China

Funds:

Zhangjiagang Health Youth Science and Technology Project ZJGQNKJ202203

Zhangjiagang Science and Technology Plan Project ZKYL2407

More Information

Corresponding author: Sha Wei, Email: 592505793@qq.com

摘要

摘要: 目的探讨序贯侧卧位管理对慢性创面合并肺部并发症患者的效果。方法该研究为前瞻性随机对照试验（RCT）。2023年1月—2024年12月,苏州大学附属张家港医院烧伤整形（修复重建）科收治48例符合入选标准的慢性创面合并肺部并发症患者,采用信封法随机分为对照组[24例,其中男13例、女11例,年龄（76±12）岁]和试验组[24例,其中男12例、女12例,年龄（76±12）岁],分别行常规体位管理和在常规体位管理方案的基础上实施序贯侧卧位管理,周期均为7 d。统计2组患者体位管理第1天和第7天的血气分析指标[动脉血氧分压（PaO₂）、动脉血氧饱和度（SaO₂）、动脉血二氧化碳分压（PaCO₂）]、安全性指标（呼吸频率等）及体位管理第1~7天的痰液量分度（轻度、中度、重度）、并发症与不良事件（误吸、心律失常、皮肤损伤、气管导管移位、意外拔管等）次数。结果与对照组相比,试验组患者体位管理第7天与第1天的PaO₂差值、SaO₂差值、PaCO₂差值变化,差异均有统计学意义（F值分别为15.50、18.79、10.13,P<0.05）。体位管理第7天,试验组患者的PaO₂为（102±24）mmHg（1 mmHg=0.133 kPa）,高于对照组的（79±16）mmHg。与对照组相比,试验组患者体位管理第7天与第1天的呼吸频率差值变化,差异有统计学意义（F=15.17,P<0.05）。体位管理第1~7天,2组患者痰液量分度比较,差异无统计学意义（P>0.05）。2组患者均未发生误吸、心律失常、皮肤损伤、气管导管移位、意外拔管等相关并发症或不良事件。结论该RCT显示,对于慢性创面合并肺部并发症患者,行序贯侧卧位管理可改善肺通气功能,改善氧合,纠正低氧血症,降低呼吸频率,促进患者肺康复且安全可靠。
- 肺疾病 /
- 随机对照试验 /
- 引流,体位 /
- 序贯侧卧位 /
- 体位管理 /
- 慢性创面 /
- 肺部并发症
Abstract: Objective To investigate the efficacy of sequential lateral position management in patients with chronic wounds and pulmonary complications. Methods This study was a prospective randomized controlled trial (RCT). From January 2023 to December 2024, 48 patients with chronic wounds and pulmonary complications who met the inclusion criteria were admitted to the Department of Burns and Plastic (Reconstructive) Surgery of Zhangjiagang Hospital Affiliated to Soochow University. They were randomly divided into control group (n=24, 13 males and 11 females, aged (76±12) years) and experimental group (n=24, 12 males and 12 females, aged (76±12) years) using an envelope method, and underwent conventional position management and sequential lateral position management based on conventional position management protocol, respectively, with a period of 7 days. On the 1^st and 7^th day of body position management, blood gas analysis parameters (including partial pressure of arterial oxygen (PaO₂), arterial oxygen saturation (SaO₂), and partial pressure of arterial carbon dioxide (PaCO₂)) as well as safety indicators such as respiratory rate in both groups of patients were statistically analyzed. Additionally, from the 1^st to 7^th days of body position management, sputum volume grading (mild, moderate, and severe), along with the frequency of complications and adverse events (aspiration, arrhythmia, skin injury, endotracheal tube displacement, and unplanned extubation, etc.) were statistically analyzed. Results Compared with those in control group, the differences in PaO₂, SaO₂, and PaCO₂ between the 7^th day and the 1^st day of body position management of patients in experimental group were statistically significant (with F values of 15.50, 18.79, and 10.13, respectively, P<0.05). On the 7^th day of body position management, the PaO₂ of patients in experimental group was (102±24) mmHg (1 mmHg=0.133 kPa), which was higher than (79±16) mmHg in control group. Compared with that in control group, the respiratory rate difference between the 7^th day and the 1^st day of body position management of patients in experimental group was statistically significant (F=15.17, P<0.05). From the 1^st to 7^th days of body position management, there was no statistically significant difference in sputum volume grading between the two groups of patients (P>0.05). No related complications or adverse events such as aspiration, arrhythmia, skin injury, endotracheal tube displacement, and unplanned extubation occurred in the two groups of patients. Conclusions The RCT shows that for patients with chronic wounds and pulmonary complications, sequential lateral position management can improve pulmonary ventilation function, improve oxygenation, correct hypoxemia, reduce respiratory rate, promote pulmonary rehabilitation of patients, and is safe and reliable.
- Lung diseases /
- Randomized controlled trial /
- Drainage, postural /
- Sequential lateral position /
- Body position management /
- Chronic wound /
- Pulmonary complications
尹希：研究设计、数据分析、论文撰写；常菲：研究指导；邵丽佳：数据收集、统计学分析；曹洁：数据收集；沙薇：研究指导、论文修改、经费支持

所有作者声明不存在利益冲突

经过17年的实验与前期临床探索,该研究团队提出了一种基于自体组织的面部预构新概念,以应对全面部修复这一整形外科领域的挑战。为评估该技术的长期疗效并最终确立标准化术式,团队进行了一项单中心的回顾性研究,纳入了2005—2022年间接受全面部修复的32例患者。该技术体系的关键在于分阶段手术,首先在胸前区预构皮瓣,移植带血供的筋膜组织并置入组织扩张器,以培育出面积充足、质地优良的薄型皮瓣。随后在Ⅱ期手术中将预构好的皮瓣整体移植至面部,并借助吲哚菁绿血管造影精准指导眼、口等面部裂隙的开口设计。对24例完成随访的患者（平均随访5.6年）数据分析显示,所有患者在生活质量（尤其是SF-36量表中的社会功能与情绪稳定维度）、面部美学与功能评分上均有显著提升,高达92%的患者重返工作岗位。该研究证实,这一系统化的面部预构与移植策略能为适用患者提供安全且效果持久的修复方案,在功能和外观上均取得了令人满意的长期结果。

克利夫兰诊所Dane J. Genther博士和美国面部整形与修复外科协会主席Patrick J. Byrne教授随刊发表的专题评论指出,该技术体系的核心突破在于利用预埋筋膜瓣增强血供,使扩张皮瓣能够以带蒂方式转移至面部；结合多血管蒂设计与术中灌注监测,安全实现眼、鼻、口等面部亚单位的精细重建。长期随访显示,所有患者的生活质量、社交功能及情绪健康均获显著改善。尽管该技术目前主要适用于软组织及软骨缺损的修复,尚难以修复涉及骨骼或表情肌的复杂性缺损——此类情况仍需依赖异体面部移植,但其通过完全规避终身免疫抑制治疗,为特定患者群体提供了一种安全、有效且效果持久的重建新范式,标志着自体组织修复技术迈入了系统性整合与精准化设计的新阶段。

顾舒晨,编译自JAMA Otolaryngol Head Neck Surg,2024,150(8):695-703；昝涛,审校

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参考文献(42)

[1]	国家卫生健康委办公厅.国家卫生健康委办公厅关于加强体表慢性难愈合创面(溃疡)诊疗管理工作的通知:国卫办医函〔2019〕865号[A/OL].(2019-12-02)[2025-02-22]. https://www.nhc.gov.cn/yzygj/c100068/201912/b2d0a4dcf77348cfb9abaa8f908574c6.shtml. https://www.nhc.gov.cn/yzygj/c100068/201912/b2d0a4dcf77348cfb9abaa8f908574c6.shtml
[2]	MartinengoL, OlssonM, BajpaiR, et al. Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies[J]. Ann Epidemiol, 2019,29:8-15. DOI: 10.1016/j.annepidem.2018.10.005.
[3]	BlairMJ, JonesJD, WoessnerAE, et al. Skin structure-function relationships and the wound healing response to intrinsic aging[J]. Adv Wound Care (New Rochelle), 2020,9(3):127-143. DOI: 10.1089/wound.2019.1021.
[4]	王丽薇, 刘冰川, 曲音音, 等. 多学科诊疗模式在慢性难愈合创面诊疗中的临床应用[J].北京大学学报(医学版),2025,57(1):185-191. DOI: 10.19723/j.issn.1671-167X.2025.01.028.
[5]	豆哲, 张国安. 系统综述我国烧伤患者吸入性损伤的流行病学特征[J].中华烧伤杂志,2021,37(7):654-660. DOI: 10.3760/cma.j.cn501120-20200306-00129.
[6]	中国老年医学学会烧创伤分会,中华医学会烧伤外科学分会重症学组,《中华烧伤与创面修复杂志》编辑委员会. 成人吸入性损伤临床诊疗专家共识更新(2025版)[J]. 中华烧伤与创面修复杂志,2025,41(9):811-824.DOI: 10.3760/cma.j.cn501225-20250502-00202.
[7]	RenS, LiW, WangL, et al. Numerical analysis of airway mucus clearance effectiveness using assisted coughing techniques[J]. Sci Rep, 2020,10(1):2030. DOI: 10.1038/s41598-020-58922-7.
[8]	中国老年医学学会烧创伤分会, 中华医学会烧伤外科学分会重症学组. 成人烧伤俯卧位治疗全国专家共识(2022版)[J].中华烧伤与创面修复杂志,2022,38(7):601-609. DOI: 10.3760/cma.j.cn501120-20211208-00407.
[9]	González-SeguelF, Pinto-ConchaJJ, AranisN, et al. Adverse events of prone positioning in mechanically ventilated adults with ARDS[J]. Respir Care, 2021,66(12):1898-1911. DOI: 10.4187/respcare.09194.
[10]	Rodríguez-HuertaMD, Díez-FernándezA, Rodríguez-AlonsoMJ, et al. Nursing care and prevalence of adverse events in prone position: characteristics of mechanically ventilated patients with severe SARS-CoV-2 pulmonary infection[J]. Nurs Crit Care, 2022,27(4):493-500. DOI: 10.1111/nicc.12606.
[11]	AdelstenJ, GrønlykkeL, PedersenFM, et al. Use of prone position ventilation in patients with COVID-19 induced severe ARDS supported with V-V ECMO: a danish cohort study with focus on adverse events[J]. Perfusion, 2024,39(8):1549-1557. DOI: 10.1177/02676591231198798.
[12]	RadovanovićN, KrajncM, GorenjakM, et al. Adverse events during prone positioning of patients with COVID-19 during a surge in hospitalizations-results of an observational study[J]. Nurs Rep, 2024,14(3):1781-1791. DOI: 10.3390/nursrep14030132.
[13]	RoldánR, RodriguezS, BarrigaF, et al. Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients[J]. Ann Intensive Care, 2022, 12(1):13. DOI: 10.1186/s13613-022-00988-9.
[14]	AcostaCM, VolpicelliG, RudzikN, et al. Feasibility of postural lung recruitment maneuver in children: a randomized, controlled study[J]. Ultrasound J, 2020,12(1):34. DOI: 10.1186/s13089-020-00181-8.
[15]	谭谦, 徐晔. 慢性创面治疗的理论和策略[J].中华烧伤杂志,2020,36(9):798-802. DOI: 10.3760/cma.j.cn501120-20200728-00361.
[16]	葛均波,王辰,王建安.内科学[M].10版.北京:人民卫生出版社,2024:23-66.
[17]	冯国双. 临床研究中重复测量资料组间比较的样本量估算[J].慢性病学杂志,2022,23(9):1323-1325,1330. DOI: 10.16440/J.CNKI.1674-8166.2022.09.13.
[18]	陈丽云,李锦萍.内科护理[M].2版.北京:人民卫生出版社,2020:8.
[19]	付小兵. 进一步推进具有中国特色的创面防控创新体系建设[J].中华创伤杂志,2017,33(4):289-292. DOI: 10.3760/cma.j.issn.1001-8050.2017.04.001.
[20]	孟浩, 苏建隆, 王睿, 等. 889例体表慢性难愈合创面住院患者临床流行病学研究[J].解放军医学院学报,2022,43(3):253-258. DOI: 10.3969/j.issn.2095-5227.2022.03.003.
[21]	MauriT. Personalized positive end-expiratory pressure and tidal volume in acute respiratory distress syndrome: bedside physiology-based approach[J]. Crit Care Explor, 2021,3(7):e0486. DOI: 10.1097/CCE.0000000000000486.
[22]	ConstantinJ, GodetT, JabaudonM, et al. Recruitment maneuvers in acute respiratory distress syndrome[J]. Ann Transl Med, 2017,5(14):290. DOI: 10.21037/atm.2017.07.09.
[23]	KuenzelA, MarshallB, VergesS, et al. Positional changes in arterial oxygen saturation and end-tidal carbon dioxide at high altitude: Medex 2015[J]. High Alt Med Biol, 2020,21(2):144-151. DOI: 10.1089/ham.2019.0066.
[24]	朱峰, 郭光华. 烧伤相关肺损伤的呼吸治疗任重道远[J].中华烧伤与创面修复杂志,2024,40(11):1016-1023. DOI: 10.3760/cma.j.cn501225-20240802-00291.
[25]	BastonCM, CoeNB, GuerinC, et al. The cost-effectiveness of interventions to increase utilization of prone positioning for severe acute respiratory distress syndrome[J]. Crit Care Med, 2019,47(3):e198-e205. DOI: 10.1097/CCM.0000000000003617.
[26]	SweetDG, CarnielliV, GreisenG, et al. European consensus guidelines on the management of respiratory distress syndrome - 2019 update[J]. Neonatology, 2019,115(4):432-450. DOI: 10.1159/000499361.
[27]	ChenX, PengC, XiaoY, et al. Construction and application of prone position ventilation management scheme for severe COVID-19 patients[J]. Front Physiol, 2023,14:1152723. DOI: 10.3389/fphys.2023.1152723.
[28]	陈洁如, 王梦琪, 陈泓伯, 等. 不同体位对成人ARDS行机械通气患者影响的网状Meta分析[J].中华现代护理杂志,2021,27(31):4246-4255. DOI: 10.3760/cma.j.cn115682-20210421-01736.
[29]	D'AngeloE, BonanniMV, MicheliniS, et al. Topography of the pleural pressure in rabbits and dogs[J]. Respir Physiol, 1970,8(2):204-229. DOI: 10.1016/0034-5687(70)90016-2.
[30]	TusmanG, AcostaCM, BöhmSH, et al. Postural lung recruitment assessed by lung ultrasound in mechanically ventilated children[J]. Crit Ultrasound J, 2017,9(1):22. DOI: 10.1186/s13089-017-0073-0.
[31]	AgostoniE, D'AngeloE, BonanniMV. Topography of pleural surface pressure above resting volume in relaxed animals[J]. J Appl Physiol, 1970,29(3):297-306. DOI: 10.1152/jappl.1970.29.3.297.
[32]	CashaAR, CamilleriL, ManchéA, et al. Physiological rules for the heart, lungs and other pressure-based organs[J]. J Thorac Dis, 2017,9(10):3793-3801. DOI: 10.21037/jtd.2017.09.86.
[33]	BasfordJR. The Law of Laplace and its relevance to contemporary medicine and rehabilitation[J]. Arch Phys Med Rehabil, 2002,83(8):1165-1170. DOI: 10.1053/apmr.2002.33985.
[34]	EscolarJD, EscolarA. Lung hysteresis: a morphological view[J]. Histol Histopathol, 2004,19(1):159-166. DOI: 10.14670/HH-19.159.
[35]	AmatoMPB, MariniJJ. Pressure-controlled and inverse-ratio ventilation[M]. 3rd ed. New York: Mc Graw-Hill, 2013:227-251.
[36]	ÖstbergE, ThorissonA, EnlundM, et al. Positive end-expiratory pressure and postoperative atelectasis: a randomized controlled trial[J]. Anesthesiology, 2019,131(4):809-817. DOI: 10.1097/ALN.0000000000002764.
[37]	PelosiP, CaironiP, BottinoN, et al. Positive end expiratory pressure in anesthesia[J]. Minerva Anestesiol, 2000,66(5):297-306.
[38]	HuertaMDR, GiraltJAS, Díez-FernándezA, et al. Effects of routine postural repositioning on the distribution of lung ventilation and perfusion in mechanically ventilated patients[J]. Intensive Crit Care Nurs, 2025,87:103952. DOI: 10.1016/j.iccn.2025.103952.
[39]	WittensteinJ, ScharffenbergM, YangX, et al. Distribution of transpulmonary pressure during one-lung ventilation in pigs at different body positions[J]. Front Physiol, 2023,14:1204531. DOI: 10.3389/fphys.2023.1204531.
[40]	SacksM, RaidalS, CatanchinCSM, et al. Impact of sedation, body position change and continuous positive airway pressure on distribution of ventilation in healthy foals[J]. Front Vet Sci, 2022,9:1075791. DOI: 10.3389/fvets.2022.1075791.
[41]	Martínez-AlejosR, MartíJ, BassiGL, et al. Effects of mechanical insufflation-exsufflation on sputum volume in mechanically ventilated critically ill subjects[J]. Respir Care, 2021,66(9):1371-1379. DOI: 10.4187/respcare.08641.
[42]	RichardJ, DecailliotF, JanierM, et al. Effects of positive end-expiratory pressure and body position on pulmonary blood flow redistribution in mechanically ventilated normal pigs[J]. Chest, 2002,122(3):998-1005. DOI: 10.1378/chest.122.3.998.

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Table 1. 2组慢性创面合并肺部并发症患者一般资料比较

组别	例数	性别（例）		年龄（岁,x¯±s）	创面类型（例）
组别	例数	男	女	年龄（岁,x¯±s）	压力性损伤	术后感染性切口	糖尿病足	下肢静脉溃疡	撕脱伤伴感染	感染性创面	坏疽
对照组	24	13	11	76±12	12	3	2	2	2	2	1
试验组	24	12	12	76±12	10	4	4	3	1	2	0
统计量值		χ²=0.08		t=-0.23	—
P值		0.780		0.821	0.943
注：对照组患者行常规体位管理,试验组患者在常规体位管理方案的基础上实施序贯侧卧位管理；“—”表示无此项

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Table 2. 2组慢性创面合并肺部并发症患者各时间点血气分析指标比较（x¯±s）

组别	例数	PaO₂（mmHg）			SaO₂（%）			PaCO₂（mmHg）
组别	例数	第1天	第7天	差值	第1天	第7天	差值	第1天	第7天	差值
对照组	24	81±25	79±16	-2±32	93.5±2.5	93.3±3.9	-0.2±4.0	35±3	38±4	2±4
试验组	24	87±16	102±24	15±30	93.7±5.2	97.3±2.1	3.6±5.4	35±4	34±3	0±5
注：1 mmHg=0.133 kPa；PaO₂为动脉血氧分压,SaO₂为动脉血氧饱和度,PaCO₂为动脉血二氧化碳分压；第1、7天指患者行体位管理的时间；差值=第7天数值-第1天数值；对照组患者行常规体位管理,试验组患者在常规体位管理方案的基础上实施序贯侧卧位管理；PaO₂、SaO₂、PaCO₂的分组因素主效应,F值分别为38.04、46.28、7.48,P值分别为<0.001、<0.001、0.009；时间因素主效应,F值分别为1.78、4.34、2.02,P值分别为1.114、0.002、0.063；两者交互作用,F值分别为1.97、3.44、1.61,P值分别为0.080、0.009、0.145；2组间PaO₂差值、SaO₂差值、PaCO₂差值比较,F值分别为15.50、18.79、10.13,P值分别为<0.001、<0.001、0.003

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Table 3. 2组慢性创面合并肺部并发症患者各时间点安全性指标比较（x¯±s）

组别	例数	呼吸频率（次/min）		平均动脉压（mmHg）		心率（次/min）
组别	例数	第1天	第7天	第1天	第7天	第1天	第7天
对照组	24	20.3±1.5	20.1±1.1	96±11	101±7	88±15	92±14
试验组	24	19.8±0.9	18.7±1.0	95±14	100±13	88±16	94±17
注：1 mmHg=0.133 kPa；第1、7天指患者行体位管理的时间；对照组患者行常规体位管理,试验组患者在常规体位管理方案的基础上实施序贯侧卧位管理；呼吸频率、平均动脉压、心率的分组因素主效应,F值分别为92.38、0.37、0.04,P值分别为<0.001、0.548、0.851；时间因素主效应,F值分别为5.52、4.24、1.42,P值分别为<0.001、<0.001、0.219；两者交互作用,F值分别为2.87、0.27、0.19,P值分别为0.010、0.950、0.965；对照组与试验组呼吸频率差值（第7天数值-第1天数值）分别为（-0.5±1.9）、（-1.4±1.5）mmHg,两组间比较,F=15.17,P<0.001