VIETHAM MEDICAL JOURHAL Wl - FEBRUARY - 2017
NGHIEN CU'U TINH TRANG ROI LOAN THONG KHI PHOI 6" BENH N H A N CHAN THU'aNG TU^ SONG CO LIET TUY
T O M T A T
Nghien ctfu 35 b§nh nhin chan thtfdng cot sdng CO liet tuy ttf mtfc D12 trd Ien dang dtfdc dieu trj tai Tmng t i m Phuc hoi chtfc ning Benh viin Bach Mai ttf thing 09/2011 den thing 04/2012 nharh xic djnh tlnh trang va mtfc dp mi Io?n tiiong khi phoi theo vj trf, mut dp ^ n thUdng txiy song d benh nhan chan thuWng c6t song co liet tuy. Phudng phip: NghiSn ctfu mo t i cat ngang. Kit qua: O ttf th§ ngoi, khong CO benh nhan nao co r^ loan thong khf ^ c ngheni Binh nhan ton thtfdng bjy co va tuy ngtfc cao (ttf D6 trd len) co r^ lo^n tiiong khi han che. B$nh nhan ton thuWng toy ngut thap (D7-D12) khong co roi loan thong khi; benh nhan ton thtfdng tuy ra cao (C4 trd len) co^roi loan thong khi han d i § mtfc dp vtfa; binh nhan ton thtfdng tuy cd thap va ngtfc cao (C5-D6) co ra Joan thong khf mtfc dp nhe. Oitfc nang thong khf phoi d benh nhan chin thtfdng tuy sdng co liet tuy khong phu thupc v i o mtfc dp l»n tiitfdng tuy song m i phu thupc vao vj tri ton thtfdng tuy song. Kit lu$n:
Chut ning ho hap co xu hudng cang giim ^ n khi vj tri ton OiuWng tuy cang cao. Qiut nang thdng khi phdi cua binh nhan chan tiitfdng tuy song c6 liet tuy khong phu tiiupc vao mu'c dp ton thtfdng m i phu thuoc v i o vj tri ton thuWng tuy song.
Tit khoa: ton tiitfdng tuy song, chtfc nang hd hap, tiiong khf phoi.
SUMMARY
STUDY THE S I T U A T I O N OF THE V E N H L A T I O N PULMONARY I N SPINAL
CORD I N J U R Y PATIENTS . The research was conducted on on 35 patients with spinal coni injury, who had paralyzed from D12 and above were treating at tiie RehabilitaHon Center of Bach Mai Hospital from 09/2011 to 04/2012 to determine the situation and the level of pulmonary ventilation disorders by location and level of lesion in spinal rord injury patients. Methods: cross-secdonal desaiptive study. Resulfln the sitting position, there were no patient with obstmcdve ventilatory disonjers.
The cenflcal spinal cord injury patients and high dorsal spinal cord injury (from D6 and above) with restilctive ventilatory disorders. Low dorsal spinal cord injury patients (D7-D12) has no ventilatory disorders; the
* Tn^g Dal hoc YHa Hdi
Chju trich nhiem chinh: l>iguyen Thi Kim Lien Email: [email protected]
Ngiy nhan b i i : 13.11.2016 Ngiy phan biin khoa hpc: 28.12.2016 Ngiy duyet b i i : 9.01.2017
Nguyin Thf Kim Lien*, Ngo X u ^ TnroBj
patieiits, who had the cen/ical spinal cord injury (C4' above) with restrictive ventilatory disorder were moderate level; the patient, who had cervical spin cord injury from C5 to D6 were in miid ventiiato disorders. The respiratory function of the patien^ wl had cervical spinal cord injury was not dependedj the injury lerel, but it was depended on the p t s ^ injury of spinal cord injury patients. Q^nciusiM The higher Injury location the lower of respir?^
function was. Pulmonary ventilation was not depeiiffl on the injury level, but it was depended on % position Injury of spinal conJ injury patients. '^
Keywords: spinal cord injury, respiratoi function, pulmonary ventilation. :
I.OATVXNDE
Ho hap la mpt hoat dpng cd ban dam bS chtfc nang song cua cd the. Bien chtfng suy h hap la nguyen nhan pho bien gay ttf vong sau dra thutJng tuy song. Cac bien chutig ve ho hap ph' thupc vao vj b-i tSn thtfdng tuy song, trong do tSi thudng vung co gay anh htfcfng nhieu nhat. '
Trong cac phtfdng phap tham do chi!it nani ho hap, do chtfc riang thong khf phoi (hay coi gpi la h6 hap ky) la mot phtfdng phap co gia ti quan trpng vdi nhieu du diCTn: ddn gian, mai moc khong dat tien, ket qua dang tin cay. Ttf ai ket qua do chpn Itf^ cac ki thuat phuc hoi cM\
nang, vat ly tri lieu thfch hdp v^ co hieu qua cht benh nhan [1]. Tuy nhiSn cf Viet Nam cho dei nay co rat it nghien ctfu ve van de nay, chin^ly the nghiSn ciki nay dude tien hanh nhSm m tiSu: Xac dinh tinh bang va mut do rot ban timnt khi pha theo vf tii, mut dp ton thudi^ tiiy s&^ i benh nhan chan thut^cdtsong CO l^t tuy. -.
II. DOI TUQNG vA PHU0NG PHAP N G H I I N J 1. Ooi tiring: 35 benh nhan chan thtil cot song co liet tuy tu* mu'c D12 trcf l§n^^
dtfdc dieu trj tai Trung tam Phuc hoi chd<f%
Benh vien Bach Mai ttf thang 09/2011 d i r i l
04/2012. ^ - Tieu chuan chgn: Benh nhan ddd&i
doan xac dinh chSn thtfdng rot s5ng co l i | ^ 9 miJc D12 trcf len, bao gom ca diSu tri bao t''"
diSu tn phau thu$t. Benh nhan da ngoi;d(|
tien hanh do chijt hang ho hap d ttf t h ^ ^ i ^ - Tiiu diuin loai bih Cac t r t f c ^ M thtfdng tuy song do cac,nguyen nhankfiS
48
TAP CHi Y HQC VIET NAM TAP 451 - T H A N G 2 - s g 1 - 2017
trong glai doan choang tuy; co ton thtfdng ph5i hdp chan thutfng sp nao, nghien ma tu^?, nghien niau, benh ly tam than co giam hoac mSt tri giac; co nhiem khuan ho hap cap hoac co tien sd b! benh ho hap man tfnh trtfdc khi hi chan thudng cot song, bj gay xtfdng don, xtfdng stfdn.
2. Phifdhg phap nghien cu'u: Nghien cu'u dtfdc tlSn hanh theo phtfdng phap mo ta, cat ngang. So lieu dtfcfc thu thap theo mlu benh an nghien cufu dtfdc chuan bj trtfdc gom cac thong tin: benh stf, kham Icim sang. €)o chtfc nang thong khi ph6i cQa b|nh nhan bang may do dung tich phoi SPM 300 Cardiotouch 3000 d ttf the ngol.
3. Xuflysoli$u: theo phtfdng phap thong ke y hpc bang phan mem SPSS 16.0.
4. Bao d&c ti'ong nghien cihj: Nghien ctfu dtfdc thiet ke dam bao van de y dtfc trong nghien ctfu, khong co bat ky can thiep g! anh htfcfng den stfc khoe va hieu qua dieu trj cua ngtfdi bSnh; mpi thong tin iien quan den benh nhan diidc gitf kin, benh nhan va ngtfdi nha
benh nhSn dtfdc glai thich ro rang va dong y tham gia nghien culj.
Ml. K ^ Q U A NGHllN CCrU
1. B$c diem b$nh nham Trong so 35 benh nhan nghien cu'u, phan ldn trong dp tuoi Iao dpng (18-60), chiem 91,4%, chi co 3 benh nhan tren 60 tuoi, chiem 8,6%. Ty ie benh nhan nam chiem 88,6% va chi co 11,4% nff, hay ty Ie nam/nff la 7,75/1.
Nguyen nhan dan den ton thtfdng tuy song chu yeu la tai nan giao (48,57%), tai nan lao d6ng (17,14%) va tai nan sinh hoat (34,29%).
VS vi trf ton thtfdng, co 2 benh nhan (5,71%) nhom I, 19 benh nhan (54,29%) nhom II va 14 benh nhan (40,0%) nhom I I I . WSc do tdn thtfdng tuy song theo ASIA: mu'c A cd 19 benh nhan (54,3%), mtfc B co 2 benh nhan (5,7%), mtfc C aS 8 benh nhan (22,9%) ya mtfc D CO 6 benh nhan (17,1%). Khong co benh nhan nao ton thtfdng d mtfc E. T'/ l | bSnh nhan bj Iiet cd hoan toan chiem 60% (21 benh nhan), liet cd khong hoan toan 40% (14 benh nhan).
2. Cacdtisodii^cnang tiiong khf phm
• Phan lo9i titeo vi tif td'n thifdng tuy
Bang 3.1. Cac chi sS tiidng Ichi phoi theo vi tif ton thifdng tuy' C h i s o ( A ± S U ) ~ Nhom
Nhom I : Ton thu'dng tu*/ co^cao
% FVC (O/o)
o/o F E V l (O/o) F E V l / F V C (O/o)42,27 47,44
95,10
Nhom I I : Ton thu'dng
tuy CO thap va ngu'c cao 57,59±10,72
Nhom I I I : Ton thu'dng
tuy ngu'c thafp 14 85,80±13,57 79,39±11,60
"(Ghi chu: '= So vdJ 70%, P<0,05; " : So vdi 60%, P>0,05; *": so vdi 80%, P>0,05).
Chi so % FVC, % FB/1 co xu hulSng t§ng dan khi
\^ tri dn thuWng tuy' thSp cSn, hay vj tri ^ n thudng tuy cang cao, cac chi so tiiong khf cang thap.
Chi so FEVl/i=VC (%) cua nhom II va nhom III deu Idn hdn 70% (p<0,05), cho thay d 2 nhom nay khong cd hpi chtfhg ^c nghen.
Chi so % F=VC cf nhom I I so vdi gia tr| 60%
khong cd stf khac biet co y nghTa thdng ke (p=0,201) cho thay niidm II cd roi loan thong
khf han che d mdc dp nhe. Chi so % FVC cf nhdm III khong cd stf khac biet co y nghia thong ke khi so sanh vdi gia trj 80% (p=0,83) nen nhdni III khong cd roi loan thong khf.
6 nhdm I, ca 2 benh nhan deu cd chi so % FEVl/FVC >70% (92,80% va 97,40%) nen khong cd benh nhan nao cd hdi chtfng roi loan thong khi tac nghen. Ca 2 benh nhan deu cd
4 0 % < % FVC< 6 0 % (43,42% va 41,12%) chothay benh nhan cd hpl chtfng roi loan thong khi han che mtfc do \/da.
-Ph Ban STT
1 2
an lo^i theo mu'c dp li$t ctf:
a 3.2. Chi so thong ichiphcn theo mitc do iiSt cd Nh6in
Liet ai hoan toan Uet cd khong hoan toan
n 21 M
o/oFVC (O/o) 71,72 ± 19,98 62,08 ± 13,24
P
0,189
Chi so %FVC gitfe 2 nhdm Net cd hoan toan va liet cd khong hoan toan khong cd stf khac biet cd
y nghTa thong ke (p > 0,05).
VIETHAM MEDICAL JOURHAL N'l - FEBRUARY - 2017
IV. BAN LUAN
1. Oac diem benh nhan
Trong nghien ctfu cua chung toi thay ti le nam: nff la 7,75:1, so benh nhan trong d6 tuoi lao dpng la cao nhat (65,7%) va nguyen nhan gay ra chlin thtfdng tuy song chu yeu la do tai nan giao thong (48,6%). Bac diem nay nam trong tinh hinh djch t l chung cua chan thtfdng tuy song. Theo nliieu tac gia khac, tije nam/ nff la 3:1 hoac 4:1, chu yeu trong dp tuoi lao dpng, con nguyen nhan thi moi tac gia lai cd nhffng thong ke khac nhau. Theo thong ke tinh hinh chan thtfdng tu^ song tai Hoa Kj' nam 2010, nguyen nhan gay chan tiitfdng pho bien nhat la tai nan giao thong vdi ty le 36,5% cac trtfdng hdp [2].
Trong so nhffng benh nhan tham gia nghien cull cua chung toi chi cd 2 benh nhan ton thtfdng tuy co ttf C4 trd len (chiem 5,71%).
Thong thtfdng ^ n thtfcftig tuy cd cao ttf C4 trcf len thtfdng gay ra ttf vong cho benh nhan ngay sau tai nan hoac tren dtfdng van chuyen do Net cd ho hap nen nhOtig benh nhan nay gap dtfdc t?i Trung tam Phuc hoi chtfc nang la rat ft. 2 benh nhan tren trong nghien ctfu cua chung toi ciing phai dtfdc ho trd ho hap trong qua trinh dieu tri tai khoa cho den khi tinh trang on dinh mdi cd the tip luyen, do chtfc nang ho hap.
Cot song d l bj ton tiitfdng d nhutig vj tri di dpng, dac biet klii viing do sat ngay vdi phafi k^m di dpng [3]. 6 co, cot song co C5, C6, C7 la hay ton thtfdng nhat vi day la doan di dpng ngay tren cot song ngtfc duOc co djnii vthig chac bdi khung xtfdng stfdn. Khi chan tlitfdng c6t song thi hiem khi gay ton thtfdng tuy cat ngang ma ton thtfdng thtfdng lan doc len mpt vai khoanh tuy so vdi vj tri nang nheit. I^oi dot tuy lai cao hdn dot tu'/ cj!ing ten. Nhtf vay thi mtfc tuy C5, C6 la hay ton thtfdng nhat. Trong ket qua nghien ctfu cua chung toi, doan tuy co C5, C6 chiem 68,42%
trong so nhffng benh nhan ton thtfdng tuy co.
Cung ttfdng id, dot tiiy D i l , D12 tuy khong ttfdng tfng vdi cot song Itfng D i l , D12 la doan chuyen tiep giii^ viling cot song Itfng co dinh va doan cdt song that Itfng di dpng Ll, L2 nhtfng do dac diem vung ton thtfdng thtfdng lan dpe len mpt vai khoanh tuy nen lai thtfdng la mii'c tuy tSn thtfdng hay gap nhat. Trong nghien cii'u cua chung toi, vj tri ton thtfdng doan tuy O i l , D12 chiem ti le kha ldn (60%) trong so benh nhan ton thtfdng tu'/ Itfng.
Trong nghien cffu cua chung tdi cd 60% ton thudng than kinh ASIA-A va ASIA-B, 22,9% mtfc
ASIA-C va chi 17,1% ASIA-D. Ket qua cua chung toi cung nSm trong tinh hinh djch te chung, Nghien ctfu cua Hu X va cong stf tren 26 benli nhan chan thtfdng tuy song tai cong dong sau 18 nam ra vien vdi mtfc do ASIA-D chiem ty le cao nhat 42,3%; ASIA-C (26,9%); ASIA-A ( 2 3 , 1 | ^ ASIA-B (7,6%); khdng cd benh nhan nao mtfc dof- ASIA-E[4].
Trong nghien ctfu cua chung toi khong gap benh nhan nao co mtfc ton thtfdng nao /VSiA-E' bdi day la mtfc ton thtfdng chi gap dutfc ^ danh gia benh nhan ra vien. I«lat khac, ASIA-E % mffc ton thirdng nhe nen benh nhan thtfdng diSf tri ngoai tru.Vi vay chung toi se khong du^ mu'c ASIA-E vao nhfjYig nhan xet ve chtfc nang li[
hap cua nhdm li$t cd ktiong hoan toan.
2. Cac tiiong so chii'c nang ho hap ^ Chung tdi nhSn thay trong tat ca cac nhoiiS chi so FEVl/FVC deu > 70 % nen khong «^
nhdm benh nhan nao cd roi loan thdng khf tac nghen. Nhdm ton thtfdng tuy co cao (C4 trd len) va nhdm ton thtfdng tuy co thap va ngtfc cao (C5--D6) cd roi loan thong khf han che, nhom twi thtfdng tuy ngtfc thap (D7-Di2) khong cd rcS'
loan thong khi. ^ Ddt tuy CO cao (C4 trcf len) chi phdi cho cd 1 ^
hap cua dpng tac hft vao ma quan trpng nhat la cd hoanh. £>ot tuy co thap va ngtfc cao (C5-D^
chi phoi cac cii ho hap cho ddng tac hft vao gan^
stfc: cd lien stfdn ngoai va cac cd ho heip phu' khac (cd ngtfc Idn, cd Itfng rpng, aS rang cda..).
Cdn cac dot tu9 ngtfc thap (D7-D12) chi phdi cho dgng tac thd ra thdng qua stf co cac cd bung va cd lien stfdn trong ep cac tang trong bung va cd hoanh len trSn, trong dd vai tro chfnh la cua cac cd bung. Mat l^ac, khi do chi so FVC va FEVl^l benh nh3n phai thtfc hien bao gdm cac ddng tac.' hft vao va thd ra gang stfc nen ket qua do phu thupc vao ca cac cd hft vao va cd thd ra. Khi ton thtfdng tuy song, cac cd nay bj liet hoac yeu khien cho ddng tac hft vao va thd ra gang stfc \A., han che nen FVC va FEVl se bi giam. Tuy nhieni do FEVl va FVC ddng thdi cung giam nen chi s5 FEVl/FVC van binh thtfdng (>70%), trong khi dp, FVC giam n§n benh nhan liet tuy thtfdng khong^
cd hdi chtfng rdi loan thdng khi tac nghen ma co hpi chtfng roi loan thdng khf han che. Ket qua nay cung ttfdng ttf nhtf nghien ctfu ciia Chai (1990) tren 31 benh nhan cho thay chi so' FEVl/FVC la binh thtfdng d tat ca cac benh nhari*
va rdi loan thdng khi han che la dien hinh d benh
nhan ton thtfdng tuy song [5].
TAP CHi Y HOC VIET HAM TAP 451 • T H A N G 2 - SO 1 - 2017
Chung ldi rihan thay rang chi so % FVC cd xu LTdng tang dan khi vj t r i t o n thtfdng tuy thap an. Cu the hdn khi xet % FVC thay d nhdm tdn IUdng tuy co cao (C4 t r d len) cd rdi loan thdng hi han che mtfc do v t o , nhdm ton thtfdng tuy 3 thap va ngtfc cao (C5-D6) cd roi loan thdng hi han che mu'c dp nhe, va nhdm ton tiitfdng jy ngtfc thap (D7-D12) khdng cd rdi loan thdng hi. Nhtf vay, nghien cffu nay cho thay chtfc ang hd hap cua benh nhan iiet tuy giam dan Idii I tri ton thtfdng tuy cang cao.
Khi ton thtfdng tuy thtfdng tuy" song d mpt vj rf till dtfdng dan truyen than kinh tai vi h i ' do ung bj gian doan, nen chtfc nang cua cac dot UV' ben dtfdi mtfc l^n thtfdng cung bi anh itfdng, cho nen v| t r i ton thtfdng tuy cang cao hi mffc dp anh hu^ng den sd Itfdng cd tham gia 10 hap cang nhieu, dan den chtfc nang hd hap ang giam. Nghien cffU Baydur (2001) khi lap jhtfdng trinh ttfdng quan tuyen b'nh giuS FVC va nffc tuy tdn thtfdng cung cho cac ket qua ttfdng tf: FVC cang tang khi vj trf ton thtfdng cang liap. Dong thcfi cung cho ket qua bat dau tff 'ijng ton thtfdng tuy ngtfc thap % FVC cd gia b i :tf 80% trd len nghTa la bat daiJ ttf mtfc ton htfdng nay thi khdng cd rdi loan thdng khi.
Chung tdi danh gia gian tiep anh htfdng cua nffc dp ton thudng tuy sdng tdi chtfc nang hd lap tiidng qua mtfc do liet cd hd hlip cua benh ihSn. Tff nh$n xet cac nhdm tienh nhan dSu didng cd ren loan thdng khi t i c nghen nhtf tren, :hung tdi tien hanh phan loai cac benh nhan iianh hai nhdm liet cd hoan toan va khdng hoan loan, sau dd so sanh chi so % FVC cua 2 nhdm i i tim hieu cd stf khac biet g i i i ^ chtfc nang hd iiap glQ^ hai nhdm nay hay khdng. Khdng cd stf khac biet ve chtfc nang thdng khf phdi giffa hai ihdm tdn thudng tuy liet cd hoan toan va ton thtfdng tu'/ liet cd khdng hoan toan (p=0,189).
Linn (2000) va Baydur (2001) khi tien hanh cac nghidn cffu chffe nang hd hap tren benh nhan liet tuy so sanh giCici cac nhdm nay cung cho ket qua ttfdng ttf [ 6 ] , [ 7 ] . Nhtf v$y, viec anh htfdng cua liet cd hoan toan hay khdng hoan toan tdi chtfc nang hd hap khac biet khdng cd y nghTa thdng ke. Hay ndi each khac, chtfc nang hd hap khong phu thupc vao mffc dp liet tuy.
^ Tff ket qua nghien cffu nay, chung tdi cho rang, vi t n ton thtfdng tuy cd y" nghTa quyet djnh i5en clitfc nang hd hap ciia benh nhan liet tiiy, ddng thcfi can o5 thai dp quan tam nhtf nliau ve
phuWig dien hd hap ddi v6l nhuhg benh nhan liet tuy d bilt ki mu'c dp nao.
Dili da dat dtfdc mot so ket qua song nghidn cffu nay cdn han che ve so Itfdng benh nhan do thdi gian cd han va trong qua trinh thtfc hien chung tdi gap kho Idian vi cd nhffng liic true trac ve may mdc thiet bj, nen can cd them nhffng nghien cffu vdi thdi gian, sd Itfdng benh nhan nhieu hdn, nhat la vdi nhdm ton thtfdng tuy co cao (C4 t r d len) de thay ro dtfdc mtfc dp anh htfdng cua ton thtfdng t u y t d i chtfc nang hd hap.
V. K^ LUAN
Qua qua trinh nghieri culi chffe nang ho hap d 35 benh nhan chan thffdng tuy song cd l i f t tuy, chung tdi rut ra nhffng ket luan sau:
- 0 ttf the ngdi, khdng cd benh nhan nao cd rdi loan thdng khi tac nghen. Benh nhan ton thtfdng tuy co va tuy ngtfc cao (tff D6 t r d len) cd rdi loan thdng khf han che; benh nhan tdn thtfdng tuy n g u t thap (D7-D12) khdng cd roi loan thdng khi. Chtfc nang hd hap cd xu htfdng giam dan khi vj trf tdn thtfdng tuy cang cao.
- Chtfc nang thdng khf phdi cua benh nhan chan thtfdng tuy sdng cd liet tuy khdng phii thudc vao mffc dp tdn thtfdng ma phu thudc vao vi t r i ton thtfdng tuy sdng.
TAI LIEU THAIVI KHAO
1. U Thj Tuygt U n (2005). Ho hip k^
(s/jirometry). Nha xuat ban y hpc - chl nhanh tiianh pho , 7 - 4 5 .
2. National Spinal Cord I n j u r y Statistical Center (2014). Spinal cord injury Fads and figures at a glance. J Spinal Cord Med, 37(1), 117-118.
3. Ha Kim Trung (2001). Phlu thu$t benh 1^ cot sdng. Tap chingoaiIdioa, {so 3/200i), 13-19.
4 . Hu X, Zhang X, Gosney ] . E , e t al (2012).
Analysis of functional status, quality of life and community ontsgratlon in earthquake sun/ivors with spinal cord injury at hospital discharge and onfr^year follow-up In the community. J Rehabil fifed, 44, 200-205.
5. Chen C F., Lien I . N., and Wu M. C (1990).
Respiratory function in patjents virith spinal cord irijurlGs:
effects of poSure. Para{^0a, 28 (2), RJ. 81-6.
6. Unn WS, Adidns, et al (2000). Pulmonary function in chronic spinal cord injury: a cross-^ctronal sunrey of 222 Southern California adult ou^tients. Ardi Ph^ M&l Rdiabil, 81 (6), 757-63.
/ . Baydur A, Adidns RH, e t al (2001). Lung mechanics in individuals with spinal cord injury:
effecte of injury level and posture. J Applied Physiology, 90 (2), 405-411.
